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ATLS > Shock > Flashcards

Shock Flashcards

1
Q

Shock definition

A

Abnormality in circulatory system that results in inadequate organ perfusion

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2
Q

Types of shock

A

Hypovolaemic (Haemorrhagic)
Cardiogenic
Distributive (Septic, Anaphylactic)
Obstructive
Neurogenic

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3
Q

Most common cause of shock in trauma patients

A

Haemorrhage

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4
Q

Cardiac output equation

A

CO = Stroke volume x Heart rate

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5
Q

Factors contributing to stroke volume

A

Preload
Myocardial contractility
Afterload

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6
Q

Definition of preload

A

Volume of venous blood return to the left and right sides of the heart

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7
Q

Effect of haemorrhage on preload

A

Haemorrhage reduces preload

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8
Q

Starling’s law

A

Muscle fibre length of the myocardium is related to the myocardial muscle contractility

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9
Q

Effect of preload on myocardial contractility

A

Volume of preload determines myocardial muscle fibre length after ventricular filling at the end of diastole

(Starling’s law)

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10
Q

Afterload definition

A

Resistance to the forward flow of blood

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11
Q

Early physiologic responses to blood loss

A

Release of catecholamines

Increase peripheral vascular resistance and diastolic BP

Progressive vasoconstriction to preserve blood flow to kidneys, heart and brain

Increased HR to preserve cardiac output

Shift from aerobic to anaerobic cellular metabolism

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12
Q

Useful marker of severity of shock and to monitor response to treatment

A

Lactate
Base deficit

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13
Q

Focus of management for haemorrhagic shock

A

Locate and stop haemorrhage

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14
Q

Diagnostic adjuncts for identifying source of haemorrhage

A

CXR
Pelvic XR
FAST scan
Diagnostic Peritoneal Lavage
Bladder catheterisation

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15
Q

4 views in FAST scan

A

Pericardial view
RUQ view
LUQ view
Suprapubic view

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16
Q

RUQ view of fast scan

A

Liver
Interface between liver and diaphragm
Morrison’s pouch

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17
Q

Morrison’s pouch

A

Interface between liver and right kidney

(Hepatorenal fossa)

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18
Q

LUQ view of FAST scan

A

Spleen
Interface between spleen and diaphragm
Interface between spleen and left kidney

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19
Q

Suprapubic view of FAST scan

A

Area behind bladder looking for fluid

Fluid posterior to the bladder is abnormal

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20
Q

Pericardial view of FAST scan

A

Sub-xiphoid view
Parasternal view

Looking for tamponade

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21
Q

Major haemorrhage protocol ratio to give products for major trauma initially

A

RBC : Platelets : FFP
1:1:1

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22
Q

Major haemorrhage protocol ratio to give products for major trauma initially

A

RBC : Platelets : FFP
1:1:1

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23
Q

What guides ongoing blood products to give by monitoring coagulation

A

Where available:

Thromboelastography (TEG)

or

Rotational Thromboelastometry (ROTEM)

24
Q

Consequence of massive crystalloid resuscitation in haemorrhagic shock

A

Coagulopathy due to dilution of platelets and clotting factors

25
Q

Poiseuille’s law equation

A
26
Q

Interpretation of Poiseuille’s law

A

Flow rate of IV fluids through a cannula / tube is:
- Proportional to the Radius^4
- Inversely proportional to the length

27
Q

Ideal size and shape of a cannula according to Poiseuille’s law

A

Short and large calibre (diameter)

28
Q

Normal adult blood volume in Litres

A

Approximately 7% body weight in Kg
(ideal body weight in obese adults)

29
Q

Normal paediatric blood volume in Litres

A

Approximately 8-9% body weight in Kg

30
Q

Classification of Haemorrhagic shock

A

Class I
Class II
Class III
Class IV

31
Q

Class I Haemorrhagic shock definition

A

Blood volume loss <15%
Eg someone who has donated 1 unit of blood

32
Q

Class I Haemorrhagic shock signs

A

Minimal tachycardia
Normal BP, pulse pressure, RR
Base deficit 0 to -2

33
Q

Class II Haemorrhagic shock definition

A

Blood volume loss 15 - 30%
Uncomplicated haemorrhage
Requires crystalloid fluid resuscitation

34
Q

Class II Haemorrhagic shock signs

A

Raised HR and RR
Decreased pulse pressure
Urine output 20 - 30 ml/hr
Base deficit -2 to -6
Subtle central nervous system signs (anxiety, fear)

35
Q

Class III Haemorrhagic shock definition

A

Blood volume loss 30 - 40%
Complicated haemorrhagic state
Requires blood replacement often, but minimum crystalloids

36
Q

Class III Haemorrhagic shock signs

A

Marked increased HR and RR
Changes in mental state
Significant hypotension
Inadequate perfusion
Base deficit -6 to -10

37
Q

Class IV Haemorrhagic shock definition

A

Blood volume loss >40%
Preterminal event
Patient will die within minutes unless aggressive measures taken

38
Q

Class IV Haemorrhagic shock signs

A

Marked tachycardia
Significant hypotension
Very narrow pulse pressure
Minimal Urine output
Cold, pale skin
Base deficit -10 or more

39
Q

Confounding factors that alter haemodynamic response

A

Age
Injury severity
Time lapse between injury and treatment
Prehospital fluid resus
Medications
Implanted cardiac devices
Athletes

40
Q

Causes of hypovolaemia with soft tissue injures

A

Blood loss at site of injury

Oedema in injured soft tissue from fluid shifts

41
Q

Methods for haemorrhagic control

A

Direct pressure
Splint fractures
Pelvic binder
Tourniquet
Surgery
Angio-embolisation

42
Q

Role of NG tube in trauma

A

For gastric decompression

Gastric distention can cause hypotension, dysrhythmia and increase aspiration risk

43
Q

How to deliver fluid / blood

A

Warmed and high flow rates via Belmont

44
Q

Balanced / Controlled resuscitation

A

Aka permissive hypotension

Refraining from aggressive fluid resuscitation until source is controlled to reduce further bleeding

Not acceptable for suspected head injuries

45
Q

Minimum urine output indicating adequate perfusion in Adults

A

0.5 ml/kg/hr

46
Q

Minimum urine output indicating adequate perfusion in Children

A

1 ml/kg/hr

47
Q

Minimum urine output indicating adequate perfusion in Infants

A

2 ml/kg/hr

48
Q

Categories of response to initial fluid bolus

A

Rapid response

Transient response

Minimal / No response

49
Q

Ongoing management of rapid response

A

No further bolus needed but can switch to maintenance regime

Have types and matched blood ready in case

50
Q

Ongoing management of transient response

A

Respond to initial bolus but then deteriorate again

  • Transfusion of blood and blood products
  • Consider major haemorrhage protocol
  • Obtain source control
51
Q

Ongoing management of minimal / no response

A

Massive haemorrhage protocol

Immediate, definitive intervention

52
Q

Most common cause for a transient response to fluid bolus

A

Undiagnosed source on bleeding

53
Q

Definition of massive transfusion

A

> 10 units packed cells in first 24 hrs

OR

> 4 units packed cells in 1 hr

54
Q

When to use tranexamic acid

A

Within 3 hours of injury give 1g TXA stat

Followed by 1g TXA infusion

55
Q

How common is coagulopathy in trauma patients

A

Occurs in 30% severely injured pts

Baseline clotting studies and platelets are useful

56
Q

Calcium replacement target range

A

Free / Ionised Calcium > 1.0

This figure is obtained on a blood gas

57
Q

Consideration of pregnancy and haemorrhage

A

Normal hypervolaemia masks perfusion abnormalities

Decreased foetal perfusion may indicate maternal hypovolaemia

ATLS (14 decks)

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