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Emergency Medicine > Shock > Flashcards

Shock Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Definition of Shock

A

Hypotension (Systolic

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2
Q

Cellular consequences of shock

A

Anaerobic metabolism causes lactic acidosis
Membrane permeability increases - Na & water enter cells causing them to swell leading to death
Treatment is aimed at restoring cellular normality

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3
Q

Clinical signs of shock

A

Tachycardia & Vasoconstriction

Cardiac output drops –> Narrow pulse pressure, MAP drops, blood flow to organs decreases

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4
Q

Cases where shock may not be shock (6)

A

At extremes of age
Athletes or Pregnant women
Certain medications or OD
Hypothermia or people with pacemakers

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5
Q

Causes of Shock

A

Haemorrhagic –> Hypovolaemic due to internal or external bleeding
Non-haemorrhagic –> Tension pneumothorax, cardiogenic, neurogenic or septic shock

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6
Q

Tension pneumothorax

A

A surgical emergency where increasing pressure of air in the pleural space causes lung collapse and mediastinal shift compressing the Vena cava reduces CO by blocking venous return –> HR+RR+JVP up, BP down
Absent breath sounds, hyper-resonant with tracheal shift

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7
Q

Cardiogenic Shock (6,4)

A

Acute Pump Failure - most commonly MI but also HF, myocardial contusion, tamponade, Air embolus, cardiomyopathy
Investigate with ECG, cardiac enzymes, echo and CVP

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8
Q

Neurogenic shock

A

Due to spinal cord injury and loss of sympathetic tone - BP drops without increase in HR - warm peripheries
Will not respond to fluid resuscitation

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9
Q

Septic shock

A

Focus of infection which has spread systematically - cytokine storm causing BP crash with tachy and wide pulse pressure
Warm peripheries - treat with fluid and abx

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10
Q

Haemorrhagic shock

A

Loss of blood (no shit) - normal blood volume is 7% of body weight in adult and 9% in children
Classed I-IV - management guided by pt’s response

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11
Q

Class I haemorrhage

A

15% of volume/ 750mls
BP, HR, RR, urine output all normal. Slightly anxious
Like donating blood - no treatment required/crystalloid

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12
Q

Class II haemorrhage

A

15-30%/ 750-1500mls
HR/RR up, pulse pressure down, urine output down
CNS - anxiety & hostility - Tx crystalloid & maybe blood

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13
Q

Class III haemorrhage

A

30-40%/1500-2000ml
HR/RR up, systolic pressure and urine output down
Anxious and confused - Tx with crystalloid and blood

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14
Q

Class IV haemorrhage

A

> 40% lost/ >2000ml
Immediately life threatening - HR, RR & BP drop or v. high
Olgiouric, Confused and lethargic
Treat with lots of blood and surgical intervention

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15
Q

Management of shock

A

A+B- oxygenate and ventilate to preserve organ perfusion
C - Control blood loss and replace volume
D - focus on maintaining brain & kidney perfusion
E - Prevent hypothermia by using warmed fluids, treat any secondary injuries

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16
Q

Assessment of shock

A

Need significant vascular access - 2 big IV lines, central lines, IO line –> cross match blood
Rapid warmed fluid bolus - 1-2L hartmanns for adults and 20mls/kg hartmanns for children –>monitor response

17
Q

Volume replacement in shock

A

Warmed crystalloid is main - hartmanns or saline
Crossmatched RBCs if possible or O-ve blood
Management is directed by response to fluid challenge

18
Q

Acid-base changes in shock

A

Use ABGs to monitor acidosis - acidosis in adults is due to poor perfusion, in children poor ventilation
Treat –> control bleeding, oxygenate and ventilate, restore volume - Do not give bicarbonate

19
Q

A rapid responding patient

A

<20% blood loss - responds to inital fluid bolus

Remains stable afterwards - still needs surgical assessment and regular monitoring

20
Q

A transiently responding patient

A

20-40% blood loss - initially improves but deteriorates after initial fluid bolus –> needs continued fluid and blood and surgical intervention to stop ongoing haemorrhage

21
Q

A non-responding patient

A

> 40% blood loss - does not response to bolus or ongoing therapy - requires immediate transfer to theatre
Must exclude non-haemorrhagic causes

22
Q

Skin temperature in shock

A

Cold peripheries –> hypovolaemic, cardiogenic,

Warm peripheries –> septic and neurogenic

23
Q

Fluid shift in shock

A

External loss or internal loss (pelvis, lungs, abdomen)

Tissue fluid

24
Q

Inotropes in shock management

A 
Adrenaline
Noradrenaline
Ephedrine
Dobutamine
Dopexamine
Dopamine
25
Q

Adrenaline

A

It is a non-specific adrenoreceptor agonist and cause be used in Cardiac arrest, anaphylaxis, asthma, croup, LAs
SE: palpitations, tachycardia, arrhythmias, anxiety, panic attacks, tremor, HTN, headaches and pulmonary oedema

26
Q

Noradrenaline

A

Used as a vasopressor to treat critical hypotension – acting on Alpha receptors – at high doses it can lead to limb ischemia - used in septic and neurogenic shock as it has fewer side effects than dopamine.

27
Q

Ephedrine

A

Increase BP and act as bronchodilators. But it can cause tachycardia, arrhythmias, angina, vasoconstriction and HTN.

28
Q

Dobutamine

A

A sympathomimetic used in HF and septic or cardiogenic shock – it directly stimulates B1 receptors. Powerful Inotropic action so is not useful in IHD. Can cause HTN, angina, arrhythmia (cautious if AF present) and tachycardia.

29
Q

Dopexamine

A

A dopamine analogue and Beta-agonist which can be used as an inotrope in shock especially septic shock as it is a powerful splanchnic vasodilator so it protects the bowels.

30
Q

Dopamine

A

Used in severe hypotension or bradycardia.at the cardiac dose (5-10ug/kg/min) acts as an inotrope but at 10-20ug/kg/min it acts as vasoconstrictor which can be useful in septic shock but can also lead to kidney damage or arrhythmias.

31
Q

ECG changes in Hypothermia

A

Will be bradycardic with a ‘J’ or osborne wave - a hump at the end of the QRS complex. Can also have 1st degree heart block, long QT interval and atrial/ventricular arrhythmias.

32
Q

Symptoms of allergic reactions

A

Mild - urticara, angio-oedema, conjunctivitis (nausea, abdo pain, burning or itching in the lips/mouth/throat)
Moderate - Bronchospasm, tachy, pallor (coughing, sweating, irritable, loose bowel motions)
Severe - S. Bronchospasm, Laryngeal oedema, shock Arrest (collapse, difficulty in breathing, vomiting, uncontrolled shitting)

33
Q

Doses of Adrenaline in anaphylaxis

A

12yrs - 500mg (0.5ml 1/1000)

34
Q

Mortality of acute respiratory distress syndrome

A

50-75% overall
Pneumonia 86%
Trauma 38%

Emergency Medicine (9 decks)

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