shock Flashcards
what is the definitive parameters for shock ?
BP— systolic <90mmHg—or mean arterial pressure (MAP) <65mmHg—
with evidence of tissue hypoperfusion,
eg mottled skin,
urine output (UO) of <0.5mL/kg/h,
serum lactate >2mmol/L
what are the signs for shock ?
GCS/agitation,
pallor, cool peripheries, tachycardia,
slow capillary refill, tachypnoea,
oliguria.
what are the causes for shock ?
hypovolemic - trauma, vomitting ruptured aortic aneurysm, GI bleed burns
cardiogenic - ACS arrhythmias, aortic dissection, acute valve failure. secondary - PE , tension pneumothorax , cardiac tamponade
septic shock - Classically patients with sepsis are warm & vasodilated
pancreatitis
anaphylactic
neurogenic - spinal cord anesthesia
endocrine - addison disease , hypothyroidism
how can we categorise ALL the shock shock ?
class 1 blood loss less than 750ml HR <100bpm BP - normal pulse pressure - normal capillary refill - normal respiratory rate - 14-20/min urine output >30ml/h cerebral function - normal / anxious
class 2 blood loss less than 1500ml heart rate >100bpm BPnormal pulse pressure narrow capillary refill >2sec resp rate - 20-30/min urine out put - 20-30ml/h cerebral function - anxious / hostile
class 3 blood loss less than 2000ml hr >120-40bpm bp - low pulse pressure - narro capillary refill >2seconds resp rate >30/min urine output - 5-20ml/h cerebral function - anxious / confused
class 4 more than 2000ml hr >140bpm bp -unrecordable pulse pressure - v narrow / unrecognised capillary refill absent resp rate >35/min urine output - negligible pulse pressure - very narrow cerebral function - confused / unresponsive
what is the assessment of shock ?
call for help
brief history taking for or features suggestive of anaphylaxis—history, urticaria, angioedema, wheeze
A-E
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primarily dealing with C - (pulse oximetry , auscultate heart , bp)
2 x large bore iv access
check ECG for rate, rhythm
check bp of both arms - Difference between arms (>20mmHg)—aortic dissection
Cold and clammy suggests cardiogenic shock or fluid loss.
Decreased skin turgor, dry mucous membranes = hypovolemic
Warm and well perfused, with bounding pulse points to septic shock.
JVP or central venous pressure: If raised, cardiogenic shock likely.
Check abdomen :Any signs of trauma, or aneurysm
if not for suggesting hypovolemia
FAST scan = intra-abdominal hemorrhage
Focused Assessment with Sonography for Trauma
CDC , ABG , blood culture
urinary catheterisation
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Disability
Assess ‘level of consciousness’ with AVPU score (alert? responds to voice? to pain? unresponsive?);
check pupils
WHAT ARE THE places checked in fast scan ?
1) Perihepatic and hepatorenal space:
2. Perisplenic and splenorenal space:
3. Pelvis: suprapubic region
4. Pericardium:
eFAST: additional imaging of the right and left anterior hemithorax for signs of pneumothorax
Management of hypovolemic shock ?
Raise the legs.
Give fluid bolus 10–15mL/kg crystalloid via large peripheral line, if shock improves,
repeat, titrate to HR (aim <100), BP (aim SBP >90) and UO (aim >0.5mL/kg/h).
hemorrhagic stop the bleeding - put pressure crossmatch blood request O Rh–ve in an emergency Consider tranexamic acid 2g IV
what are the signs specific to SEPTIC shock ?
LACTATE >2MMOL/L DESPITE ADEQUATE fluid resuscitation
or patient needing vasopressors to maintain MAP > 65mmhg
what is the moderate to high risk criteria in sepsis?
reports of altered mental state
resp 21-24 (> 24 high risk )
systolic blood pressure = 91/100mmhg (<90 high risk)
HR - 91-130bpm (>130)
urine output - nil for 12-18hrs or 0.5-1ml/kg/hr if catheterised (>18hr , <0.5)
local signs of infection - redness , swelling , discharge
(cyanotic , non blanching skin)
rigors or temperature <36c
impaired immunity
recent surgery / trauma
high risk - 2 moderate or one high risk criterion
with lactate >2
what is the managmnet of septic shock ?
IV fluids WITHIN 1ST HOUR given if systolic blood pressure is below 90
AKI
lactate >2mmol/l (consider if less than 2)
if no improvement of two bolus ask for senior help
500ml boluses with 130-154 mmol/l sodium over 15 mins
persistent hypotension during or after fluid resuscitation
First-line: norepinephrine
If MAP is still low after norepinephrine:
Add vasopressin
oxygen
antibiotics - broad spectrum after blood cultures have been drawn
Vancomycin
PLUS one of the following:
Broad-spectrum carbapenem-
Meropenem
Extended-range penicillin/B lactamase inhibitor-
Piperacillin/tazobactam
Third-generation (or higher) cephalosporin -
Cefotaxime
=========== Immediately alert a consultant if, after 1h of antibiotics and fluids: • SBP <90 •RR >30 •Reduced GCS • Raised lactate not reduced by >20% Consider critical care referral.
what are the signs specific to anaphylactic shock ?
wheezing
cyanosis
edema of the larynx causing laryngeal obstruction , lids , tongue lips
urticaria - itching
dd for anaphylactic shock ?
carcinoids
pheochromocytoma
what is the management of anaphylactic shock ?
A-E
secure the airway jaw thrust oxygen bag or cpap nasopharyngeal/oropharyngeal, intubation, surgical cricothyroidotomy
raise the feet
give adrenaline - IM 0.5MG
repeat every 5 minutes until better
( NOT IV unless the patient is severely ill, or has no pulse. The IV dose is different: 100mcg/min—titrating with the response.)
If on a b-blocker, consider salbutamol IV in place of adrenaline.
secure IV access
chlorphenamine -10mg IV and hydrocortisone 200mgIV
fluid
if wheeze treat for asthma going through nebuliser salbutamol
If still hypotensive, admission to ICU and an IVI of adrenaline may be needed ± aminophylline and nebulized salbutamol
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Further management:
• Admit to ward. Monitor ECG
• Measure serum tryptase 1–6h after suspected anaphylaxis
(tryptase is the best biomarker to assess mast cell activation)
- Continue chlorphenamine 4mg/6h PO if itching
- Suggest a ‘MedicAlert’ bracelet naming the culprit allergen
• Teach about self-injected adrenaline (eg 0.3mg, Epipen®) to
prevent a fatal attack
• Skin-prick tests showing specific IgE help identify allergens
to avoid
