Shock and Haemorrhage

Question 1

What is shock?

Answer 1

A syndrome in which tissue perfusion is inadequate for the tissue’s metabolic requirement.

Question 2

What are surrogate markers for tissue perfusion?

Answer 2

Blood pressure
Consciousness (Brain perfusion)
Urine output (Renal perfusion)
Lactate (General tissue perfusion) – quite a late sign of general tissue hypoperfusion and hypoxia

Question 3

MAP=

Answer 3

CO x SVR

Question 4

5 types of shock?

Answer 4

hypovolaemic 
cariogenic 
distributive (e.g. septic, anaphylactic, neurogenic)
obstructive 
endocrine

Question 5

What is the most common cause of shock?

Answer 5

sepsis

Question 6

Explain what causes re-perfusion injury?

Answer 6

multifactorial

due to inflammatory response to shock, haemodynamic changes, loss of vascular reactivity and myocardial dysfunction

Question 7

What sign is most frequently associated with all types of shock?

Answer 7

hypotension

Question 8

What additional signs may be present in someone with cariogenic shock?

Answer 8

signs of myocardial failure

Question 9

What additional signs may be present in someone with distributive shock?

Answer 9

raised JVP, pulses paradoxes, signs of the cause
e.g. if sepsis, pyrexia, rapid cap refill, hypotension
anaphylactic- vasodilatation, erythema, bronchospasm, oedema

Question 10

Describe some clinical monitoring you can do for shock?

Answer 10

Examination – Pale, cold skin, prolonged capillary refill.

Urine output – Sensitive indicator of renal perfusion

Neurological – Disturbed consciousness a good indicator of cerebral hypoperfusion

Biochemical – Acidosis, lactate levels

Question 11

Overview of management of shock?

Answer 11

Prompt diagnosis, and treatment critical

ABC approach

Establishment of reliable, wide bore IV access and resuscitate while investigating

Identify – and treat – underlying cause

Question 12

Describe what is a good fluid challenge for someone with suspected shock?

Answer 12

Rapid administration of a fluid, with an assessment of response

Rapid enough to get a response, but not so fast as to provoke a stress response.

Typically – 300-500ml over 10-20 mins.

Question 13

Describe the 3 types of fluid?

Answer 13

Crystalloids (normal salines, hartmans/ ringers lactate) – Convenient, cheap, safe (basically water and salts)
But: Rapidly lost from circulation to extravascular spaces, need significantly larger volumes than loss.

Colloids (isoplex, albumin) – Cheap(ish), reduce volumes required
But: Can cause anaphylaxis, no evidence of benefit vs crystalloids

Blood (technically a colloid but a special colloid) – oxygen carrying capacity, will stay in circulation.
But: a scarce resource, and multiple risks

Question 14

When is pharmacological management for shock considered?

Answer 14

in severe cases

when fluids dont work or stop working

Question 15

List some examples of drugs that may be used for pharmacological management of shock?

Answer 15

adrenaline
noradrenaline (first choice in most circumstances)
vasopressin 
dopamine 
dobutamine/ dopamine

Question 16

What are the side effects of fluid resuscitation?

Answer 16

Resucitation associated with significant (sometimes massive!) fluid administration and positive balances

Volume delivered never remains intra-vascular

Extra-vascular overload, in an intra-vascularly
“dry” patient.

Sub-cutaneous oedema obvious

Less obvious – “wet” lungs/ARDS, bowel oedema, etc

> it is important to remove extra fluid from a patient once their shock has resolved - either spontaneously (ie they pee it out) or with diuretics or dialysis

Question 17

Give an overview of what a massive haemorrhage protocol looks like?

Answer 17

call blood bank and state massive haemorrhage
send urgent samples for crossmatch and other blood tests
blood bank will issue 4 units red cells, 4 units FFP, 1 unit platelets
resus patient with ABCDE approach, call for senior help, transfuse the platelets and red cells
treat underlying cause

Question 18

Explain the blood component support of a massive haemorrhage?

Answer 18

Red cells- maintain tissue oxygenation
FFP- replace coagulation factors and help maintain coagulation close to normal
Platelets
Crytoprecipitate- replace fibrinogen
Aim 2 RBC: 1 FFP in first instance and 1:1 in trauma

Question 19

Specific management of PPH?

Answer 19

tranexamic acid
identify cause- like uterine atony
give uterotonics e.g. syntocinon
pay specific attention to fibrinogen which should be higher in pregnant women so there is a lower threshold for replacement

Question 20

Specific management of pelvic trauma?

Answer 20

Imaging – where is he bleeding from
Pelvic binder to support pelvis
Tranexamic acid
Surgical involvement
1:1 ratio to red cells and FFP for trauma
Worried about DIC/ TIC risk from massive trauma

Question 21

Specific management of variceal bleed?

Answer 21

Resus- consider intubation, high flow O2, intravenous access, blood transfusion, antibiotics, terlipressin
Endoscopy
Variceal band ligation, balloon tamponade if cant control bleeding
TIPS- transjugular intrahepatic portosystemic shunt
Prophylaxis- beta blockers

Question 22

Specific management of ruptured AAA?

Answer 22

CT then surgery

Blood support is used to get the patients to theatre