Shock and acute haemorrhage Flashcards
What are the types of shock?
- mnemonic HCODE
- H- hypovoleamic
- C-cardiogenic
- O-obstructive
- D-distributive
- E- endocrine
What is shock?
Circulatory shock: an abnormality of the circulatory system that results in redcued organ perfusion or tissue oxygenation
What can cause hypovolaemic shock?
- Haemorrhage
- Vomitting
- Diarrhoea
- Diuresis
- Burns
Where are common sites for catastrophic haemorrhage?
- External
- Internal:
- Chest
- Abdo
- Pelvis
- Retroperitoneum
- Long bones
What is Cullens sign?
Periumbilical bruising associated with acute pancreatitis but can be with any type of retro/intra periotenal haemorrhage
How would haemorrhage present?
- cold perpheries
- low BP
- high HR
Causes of cardiogenic shock?
- MI
- Myocardial contusion
- Myocarditis
- Cardiac arrhythmia: unstable tachyarrhythmias, unstable bradyarrhythmias
- Negatively inotropic drug overdose: Beta blockers, calcium channel blockers
Reversible causes of arrhythmias?
- electrolyte disturbances: K+, Ca2+, Mg2+
- hyperthyroidism
What are life-threatening features of an adult tachycardia? (4)
- Shock
- syncope
- Myocardial ischaemia
- Severe heart failure
What to do if a patient has life- threatening features of adult tachycardia? (i.e what management)
- synchronised DC shock up to 3 attempts
- Sedation or anaesthesis if conscious
- If unsuccessful:
- amiodarone 300mg IV over 10-20 min
- Repeat synchronised DC shock
What to do if someone has an adult tachycardia that does NOT have life threatening features? (i.e what should you check on ECG)
- Is the QRS complex narrow (<0.12 s)
- Is it regular/ irregular
What to do if pt has:
Broad QRS, irregular tachycardia?
- If polymorphic VT (e.g. torsades de pointes) give Mg 2g over 10 mins
How do you treat AF with bundle branch block?
- As irregular narrow complex tachycardia
What to do if pt has:
Broad QRS, regular tachycardia?
- If VT or uncertain rhythm
-amiodarone 300 mg IV over 10-60 mins
What to do if pt has:
narrow QRS, regular tachycardia?
- Vagal manoeuvres
- If ineffective
* give adenosine: 6mg rapid IV bolus, if unsuccessful give 2mg, if unsuccesful give 18mg,
* monitor ECG - If ineffective: verapamil, or beta blocker
What to do if pt has:
Narrow QRS, irregular tachycardia?
Possible AF
* control rate with beta blocker
* consider digoxin or amiodarone if evidence of HF
* anticoagulate if duration > 48 hrs
Obstructive shock causes?
- Tension pneumothorax
- Massive PE
- Cardiac tamponade
Distributive shock causes?
- septic shock
- anaphylatic shock
- neurogenic shock
What is neurogenic shock?
- Traumatic injury or tumour on spine
- Pt will be:
- flushed from the level of injury down
- Motor deficit from the level down
- hypotensive and tachycardic
- treat with: fluids, vasopressors and rehab
What causes cardiac tamponade?
- trauma
- pericardial effusion
How do you treat cardiac tamponade?
- needle pericardiocentesis
- clamshell thoracotomy within 15 mins of cardiac arrest
Massive PE vs submassive PE?
- Causes cardiovascular collpase- need to thrombolyse them
- Submassive does not cause cardiovascular collapse- treat with DOACs/ heparins
What type of shock does CO poisoning cause?
- distributive
How to diagnose CO poisoning?
- Cherry red lips/ tongue
- SATs probe and ABG
- ABG: carboxyhb- up to 10% is normal
- > 30% is v dicey
Hx of shock in a pt?
- Assessment of severity:
- Dyspnoea
- Confusion
- Light-headness
- Drowsiness
- Oliguria/anuria
- Symptoms of the cause
A-E findings of the shocked patient?
- Airway
-May be compromised due to reduced conscious level - Breathing
-hypoxia due to airway compromise or peripheral shut down may cause them to look hypoxic
-Tachypnoea
-Kussmauls’s breathing - Circulation
-cold pale peripheries
-prolonged cap refill
-Tachycardia
-Hypotension
-Oliguria
-Anuria - Disability
-confusion
-drowsiness
-unconsciousness - signs of the cause
What is Type 1 shock?
- Blood loss ml: < 750
- Blood loss %: <15
- Pulse rate: < 100
- Blood pressure: normla
- Respiratory rate: 14-20
- Urine output: > 30ml
- Symptoms: normal
What are the parameters for Type 2 shock
- Blood loss ml: 750-1500ml
- Blood loss %: 15-30%
- Pulse rate: >100
- Blood pressure: Normal
- Respiratory rate: 20-30
- Urine output: 20-30ml
- Symptoms: Anxious
What are the parameters for type 3 shock
- Blood loss ml: 1500-2000ml
- Blood loss %: 30-40%
- Pulse rate: >120
- Blood pressure: Decreased
- Respiratory rate: 30-40
- Urine output: 5-15ml
- Symptoms: Confused
What are the parameters for type 4 shock
- Blood loss ml: >2000ml
- Blood loss %: >40%
- Pulse rate: >140ml
- Blood pressure: Decreased
- Respiratory rate: >35
- Urine output: <5ml
- Symptoms: Lethargic
Investigation in shock?
- Bloods incl blood gas to check pH and lactate
- ECG
- CXR
- Echo
- In trauma
-Pelvic xr, CT CAP, FAST
Causes of haemorrhage?
- PPH
- Varices
- AAA
- Epistaxis
A pt with known varices presents with haematemesis and shock. How would you manage this patient?
- A-E
-patients should be resuscitated prior to endoscopy
-blood transfusion may be needed
-correct clotting: FFP, vitamin K, platelet transfusions may be required - terlipressin
- prophylactic IV antibiotics have been shown to reduce mortality in patients with liver cirrhosis
quinolones are typically used - endoscopy: endoscopic variceal band ligation is superior to endoscopic sclerotherapy. NICE recommend band ligation
- Sengstaken-Blakemore tube if uncontrolled haemorrhage
- Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail connects the hepatic vein to the portal vein exacerbation of hepatic encephalopathy is a common complication
AAA presentation?
- severe, central abdominal pain radiating to the back
- pulsatile, expansile mass in the abdomen
- patients may be shocked (hypotension, tachycardic) or may have collapsed
AAA management?
- ruptured AAA is a surgical emergency - patients with a suspected ruptured AAA require an immediate vascular review with a view to emergency surgical repair (w/o CT )
- frail patients- terminal event and put then on end of life pathway
- Patients who are haemodynamically stable may be sent for a CT angiogram where the diagnosis is in doubt - this may also assess the suitability of endovascular repair.
If a pt has a haemorrhage and is in hypovolaemic shock, what do you do?
- identify source of bleeding and achieve haemorrhage control e.g. direct compression, pelvic binder, splinting of long bone fractures, surgical ligation of bleeding vessles
- Restore of adequate circulating volume: cross match blood and activate Major haemorrhage protocol (+/- fluid challenge)
- Correct coagulopathy by transfusion of platelets, FFP and cryoprecipitate
- Give FFP early with RBC
- Cryo if fibrinogen is < 1.5
What is the NEWS2 score?
- Identify seriously unwell patients
- Identify deteriorations
What parameters does the NEWS2 score take into account?
- RR
- Sp02
- Systolic BP
- Pulse rate
- Level of consciousness or new confusion
- Temp
What is sepsis?
- life- threatneing organ dysfunction is associated with infection
What is qSOFA?
- quick SOFA score
- Provides one way to assess for sepsis
Outline qSOFA?
Consider sepsis and commence treatment as appropriate if any one (or more) of the following is present:
* RR> 22 breaths/ min
* Systolic BP < 100mmHg
* Altered mental state
Pts scoreing 2/3 have been shown to have increased mortality
high lactate is helpful in identifying sepsis (not specific)
Sepsis 6?
Take:
* Blood cultures
* lactate
* urine output
Give:
* O2
* Fluids
* Abx
What bloods to take in sepsis?
- FBC- for WCC
- CRP- inflammation marker
- U&Es- for any AKI
- LFTs- ensure no concurrent liver damage
- Lactate- marker of infection/ dysfunction
If lactate is > 2mmol/L, repeat the level in 2 hr
How to manage a septic pt?
- Obtain senior/ ICU assistance immediately
- ABC- high flow o2 with SpO2 target of 90-96%
- IV access and take bloods
- Look for obvious sources of infection
- Take blood cultures before starting abx if this doesn’t delay the administration of abx
- IV crysalloid according to response ( be careful in COVID19 as lots of fluid can worse ARDs)
- Start vasopressors for persistent hypotension in order to main a mean arterial BP of >65mmHg
