Week 10

Question 1

Shock is

Answer 1

a syndrome characterised by tissue ischemia from decreased perfusion and impaired cellular metabolism

Generalized state of hypoperfusion
Inadequate substrate delivery
Catecholamines and other responses
Anaerobic metabolism
Cellular dysfunction
Cell death

Question 2

How to recognise shock

Answer 2

Alteration in LOC, anxiety 
tachypnea, shallow respirations
tachycardia
hypotension
decreased urine output 
cold, diaphoretic skin

Question 3

Hypovolaemic shock

Answer 3

‘Low Volume of Blood’
Can be any fluid.
Caused by : 	
Bleeding – internal/external
Diarrhoea / vomiting
Dehydration

Question 4

Treatment for hypovolaemic shock

Answer 4

Oxygen
Fluid replacement
Stop further loss

Question 5

How to locate the bleeding

Answer 5

Physical examination
diagnostic adjuncts to the primary survey, including chest x-ray, chest tube insertion, DPL, FAST (focused assessment ultrasonography in trauma), CT scan, pelvic x-ray

Question 6

What to do to stop bleeding

Answer 6

apply direct pressure 
operation 
reducing pelvic volume
splint fractures 
restore volume - Vascular access (catheter, sites), Warmed fluids (type)
Monitor response
prevent hypothermia

Question 7

How to evaluate a positive response to treatment

Answer 7

CNS: Improved level of consciousness
Renal:  urinary output
Skin: Warm, capillary refill
Respirations: Improved rate and depth
Vital signs: Return to normal

Question 8

Mild hypovolaemic shock

Answer 8

Responder
750mL BVL (15-30%)
slightly anxious
urine output 30mL/hr
heart rate <100/min
normal blood pressure
treated with crystalloid

Question 9

Moderate hypovolaemic shock

Answer 9

Transient or non responder
1500-2000mL BVL (30-40%)
respirations 30-40/min
confused, anxious
urine output 5-15mL/hr
heart rate >120/min
decreased pulse pressure
decreased blood pressure
treated with crystalloid, blood, operation

Question 10

Severe hypovolaemic shock

Answer 10

Non responder
>2000mL BVL (>40%)
confused, lethargic 
urine negligible 
respirations >35/min
heart rate >140/min
decreased pulse pressure
decreased blood pressure
treat with rapid fluids, blood, operation

Question 11

What are the pitfalls of shock

Answer 11

Equating BP with cardiac output
Hemoglobin, hematocrit levels
Age extremes
Hypothermia
Athletes
Pregnancy
Medications
Pacemaker

Question 12

The two types of shock are

Answer 12

External (haemorrhage/severe diarrhoea/vomiting/massive urination)

Internal (fluid shift into extravascular/interstitial space/third spacing – peritonitis/burns/ascites)

Question 13

Management of hypovolaemic shock

Answer 13

Medical management:
Treat underlying cause
Fluid/blood replacement
Redistribution of fluid
Pharmacologic therapy

Nursing management:
Haemodynamic monitoring
Maintaining arterial/venous lines/equipment
Patient assessment/vital signs/fluid balance
Oxygen
Safety/comfort/reassurance
positioning

Airway support:
Maximal oxygenation/ventilatory support
Vasoactive medication therapy:
Restore vasomotor/improve cardiac function
Adrenaline/vasopressin/dopamine

Fluid replacement
Restore intravascular volume
Nutritional support

Question 14

Fluid replacement

Answer 14

Crystalloids: (electrolyte solutions) - 0.9% saline (normal saline)/ Hartmans (CSL)
Colloids: (plasma proteins) – albumin/gelofusine/haemaccel
Blood components (primarily for hypovolaemic shock)
Large bore cannulae x 2 (16g) at ~ 1000ml/5 mins each via hand pump/pressure bag driven/rapid infusors
CVC/intraosseus

Question 15

Nutritional therapy

Answer 15

Nutritional support needed to meet increased metabolic, energy requirements prevent further catabolism, due to depletion of glycogen
Support with parenteral or enteral nutrition

Administration of glutamine:
Amino acid essential in injury/burns/trauma