Shock :o

Question 1

What treatment can be done in an uncoscious patient without an obvious cause?
Clue: possible drug/alcohol causes

Answer 1

IV thiamine (pabrinex) if diagnosis unclear and wenicke's encephalopathy possible (alcohol)
Trial of naloxone

Question 2

You are called to a shocked patient, whose BP is unrecordable - what should be done immediately?

Answer 2

Call the cardiac arrest team - 2222

Question 3

Clinical signs of SIRS?

Answer 3

2 of the following:

1. Temp <36 or >38
2. Tachycardia
3. RR >20 or PaCO2 <4.3
4. WCC >1.2 x 10^10 or <4x10^9

Question 4

Red flag signs for sepsis?

Answer 4

SBP <90 despite fluid challenge
Lactate >2 mmol/L
HR >130/min
RR >25
O2 <91%
Altered consciousness
Purpuric rash

Question 5

Management of sepsis in first hour?

Answer 5

BUFALO - complete within 1 hour

Blood cultures
Urine output - monitor hourly
Fluid challenge - 500-1000ml bolus hartmann's
Abx - empirical (tazocin) then targeted
Lactate + Hb (via ABG)
O2

Question 6

Additional management of sepsis in first 6 hours?

Answer 6

Vasopressors - for hypotension that does not respond to initial fluid challenge

If persistent hypotension or lactate >4 at intial presentation:
CVP
central venous oxygen saturation
Remeasure lactate

Question 7

Causes of hypovolemic shock?

Answer 7

Blood loss = most common

Burns and dehydration

Question 8

What class of haemorrhagic shock has a drop in blood pressure?

Answer 8

III and IV

Question 9

How much blood is lost in each class of hypovolemic shock?

Answer 9

I - <750ml (15%)
II - 750-1500ml (15-30%)
III - 1500-2000ml (30-40%)
IV - >2000ml (40%+)

Question 10

What clinical changes might you see in class II hemorrhagic shock?

Answer 10

Postural hypotension

Reduction in UO (20-30mlhr)

Question 11

What clinical changes might you see in class III hemorrhagic shock?

Answer 11

Hypotension
HR>120-140
Tachypnoea
UO <20ml/hr
Patient is confused

Question 12

What clinical changes might you see in class IV hemorrhagic shock?

Answer 12

Marked hypotension
HR>140
RR>35
No urine output
Comatosed state

Question 13

Investigations for hypovolaemic shock?

Answer 13

ABCDE
IV access x 2 wide bore cannula - bloods: 
FBC and clotting
 x-match and group and save
U+E's and LFTs

Coag screen
ABG, UO
US imaging to assess bleeding site
CVP if evidence of shock

Question 14

Management of hypovolaemic shock?

Answer 14

ABCDE
O2 NRBM 15L
Fluid resus and bloods
TXA 1g IV within 1 hour of bleeding within 3 hours of bleeding, additional 1g over next 8 hours

Surgery - definitive for stopping bleeding
Ionotropes and vasopressors available in HDU

Question 15

Transfusion in hypovolemic shock?

Answer 15

Aim for Hb >8g/dL

Severe blood loss:
Request massive transfusion pack (8 RBC and 4 FFP)

Adminsiter transfusion pack Red cells ASAP
Keep patient warm

Administer Fresh frozen plasma (FFP) ASAP - use separate IV access to RBC

Question 16

Features of anaphylactic shock?

Answer 16

Symptoms start 30 minutes post ingestion

rash, utricaria, angio-oedema
Laryngeal oedema (chocking/stridor, coughing)
Severe bronchospasm
Hypotension - most common sign in allergy to anaesthetic
N+V, diarrhoea
Rhinitis
Tachycardia

Question 17

Management of anaphylactic shock?

Answer 17

ABCDE
Secure airway and call anaesthetist 
O2
IV access and bloods (including glucose and calcium)
Raise legs and secure circulation

Adrenaline 0.5ml 1:1000 IM (repeat as necessary every 5 mins)
Chlorphenamine 10mg slowly
Hydrocortisone 200mg
Fluid bolus - 500ml-1L of warmed hartmann’s over 10 mins
If audible wheeze treat with nebs
ICU for inotropes