Shock and fluid resus

Question 1

What is shock?

Answer 1

A state of insufficient blood flow to the tissues of the body as a result of problems with the circulatory system.

Question 2

What are the types of shock?

Answer 2

1. Cardiogenic
2. Hypovolaemic
3. Anaphylactic
4. Septic
5. Neurogenic
6. Obstructive
7. Distributive

Question 3

What are causes of obstructive shock?

Answer 3

Obstruction of outflow e.g. pulmonary embolus

Restricted cardiac filling

Question 4

What are distributive of obstructive shock?

Answer 4

vascular dilation
Sequestration
Arteriovenous shunting

Question 5

What are the clinical features of hypovolaemic shock?

Answer 5

1. Inadequate tissue perfusion:
   → Cold and clammy skin, oliguria, anuria, drowsiness, confusion and irritability
2. Increased sympathetic tone
   → Tachycardia (can deteriorate to brady), narrow pulse, sweating, hypotension
3. Metabolic acidosis
   → compensatory tachypnoea

Question 6

What are the clinical features of cardiogenic shock?

Answer 6

Signs of myocardial failure, e.g. raised jugular venous pressure (JVP), pulsus alternans, ‘gallop’ rhythm, basal crackles, pulmonary oedema

Question 7

What are the clinical features of obstructive shock?

Answer 7

1. Elevated JVP
2. Pulsus paradoxus and muffled heart sounds in cardiac tamponade
3. Signs of pulmonary embolism

Question 8

What are the clinical features of anaphylactic shock?

Answer 8

1. Signs of profound vasodilatation: warm peripheries, low BP, tachycardia
2. Erythema, urticaria, angio-oedema, pallor, cyanosis
3. Bronchospasm, rhinitis
4. Oedema of the face, pharynx and larynx
5. Pulmonary oedema
6. Hypovolaemia due to vascular leak

Question 9

What are the clinical features of septic shock?

Answer 9

Pyrexia and rigors, or hypothermia (unusual)  Nausea, vomiting
Vasodilatation, warm peripheries
Bounding pulse
Rapid capillary refill
Hypotension (septic shock)
Occasionally signs of cutaneous vasoconstriction

Question 10

What are the stages of shock?

Answer 10

1. Compensated shock
2. Progressive shock (widespread hypoxia)
3. Irreversible shock (widespread necrosis)

Question 11

What are the classes of Haemorrhagic Shock?

Answer 11

1. minimal blood loss, pulse <100, BP normal, RR normal, urine < 30, CNS normal
2. 15-30% blood loss, pulse > 100, BP decreased, RR 20-30, urine 20-30, CNS normal
3. 30-40% blood loss, pulse > 120, BP decreased, RR 30-40, urine 5-15 CNS confused
4. 40% > blood loss, pulse > 140, BP decreased, RR > 35, urine negligible, CNS lethargic

Question 12

Where do you look for causes of haemorrhagic shock?

Answer 12

On the floor and 4 more:

1. Chest
2. Abdomen
3. Pelvis
4. Long bones like femur

Question 13

How would you stabilise a haemorrhagic shock?

Answer 13

Direct pressure
Splinting
Operation

Question 14

What is your goal in fluid replacement in shock?

Answer 14

First and foremost: restore volume

Secondary: restore blood

Third: coagulation status

Question 15

What volume replacement would you give in haemorrhagic shock?

Answer 15

1. Warmed Isotonic crystalloid

250mL boluses at a time to 1L to keep SBP 90-100
Procoagulant: tranexamic acid (stops all types of bleeding) 1g x 10mins then 1g x 8hrs IVI.
Blood products.

Do not use tetrastarch for fluid resuscitation.

Question 16

How do most types of shock present?

Answer 16

Loss of consciousness, BP, GCS, anxiety, tachpnea, shallow respiration, tachycardia, hypotension, cold, diaphoret skin, dec urine output.

Question 17

What is the difference between neurogenic shock and other types of shock?

Answer 17

Patient is warm and dry!

Question 18

What is permissive hypotension in shock?

Answer 18

The aim is to allow a subnormal blood pressure to minimise haemorrhagic blood loss

Question 19

What is the use of Tranexamic acid?

Answer 19

Control significant haemorrhage following trauma