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Haematology > Shock > Flashcards

Shock Flashcards

1
Q

Definition of shock

A

syndrome in which tissue perfusion not enough for body’s needs

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2
Q

Normal tissue perfusion relies on what 3 components?

A

heart - pump,
vascular bed - pipes,
circulating blood volume

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3
Q

Normal perfusion is difficult to measure, but what 4 surrogate markers do we use?

A

blood pressure,
consciousness,
urine output,
lactate

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4
Q

Measuring lactate measures perfusion of what?

A

General tissue perfusion

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5
Q

Measure consciousness measures perfusion of what?

A

Brain perfusion

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6
Q

Measuring urine output measures perfusion of what?

A

Renal perfusion

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7
Q

Mean arterial pressure =

A

CO x SVR

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8
Q

Why is blood pressure not always an accurate measurement of perfusion?

A

Because body can vary perfusion locally despite relatively constant BP

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9
Q

What are the 4(5) causes of shock?

A 
hypovolaemic, 
cardiogenic, 
distributive, 
obstructive, 
(endocrine)
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10
Q

Give 3 examples of causes of hypovolaemic shock?

A

acute haemorrhage (most common),
fluid depletion due to severe dehydration,
burns

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11
Q

How does hypovolaemic shock affect the MAP equation?

A

Volume depletion leads to reduced SVR,

reduced volume returning to heart leads to reduced pre-load so reduced CO

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12
Q

How does cardiogenic shock affect the MAP equation?

A

reduced CO due to reduced contractility (SV) or reduced HR

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13
Q

List 4 causes of cardiogenic shock, what is the most common

A

ischaemia induced myocardial dysfunction (most common),
cardiomyopathies,
valvular problems,
dysrhythmias

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14
Q

If cardiogenic shock is due to MI this suggests that >40% of what is involved?

A

left ventricle

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15
Q

Unless correctable pathology such as valve problem, mortality with cardiogenic shock is greater than what?

A

> 75%

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16
Q

What is obstructive shock?

A

Mechanical obstruction to normal cardiac output in otherwise normal healthy heart

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17
Q

What are two causes of obstructive shock? give two examples of each

A

direct obstruction to CO e.g. PE, air/fat/amniotic fluid embolism,
restriction of cardiac filling e.g. tamponade, tension pneumothorax

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18
Q

Distributive shock AKA vasoplegic is known as what kind of shock

A

“hot” shock

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19
Q

List 4 causes of distributive shock

A

sepsis,
anaphylaxis,
acute liver failure,
spinal cord injuries

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20
Q

What happens in distributive shock?

A

due to disruption of normal vascular auto regulation and profound vasodilatation

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21
Q

What does it mean that there are regional perfusion differences in someone in distributive shock?

A

They may be awake and talking but some organs are not getting perfused

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22
Q

What happens in terms of CO and vasodilatation/constriction in endocrine shock?

A

Reduced CO and vasodilation

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23
Q

What causes endocrine shock? (3)

A

severe uncorrected hypothyroidism,
addisonian crisis,
thyrotoxicosis

24
Q

List 4 types of shock in order of most common to least

A 
distributive shock, (septic) 
cardiogenic, 
hypovolaemic, 
distributive (nonseptic), 
obstructive
25
Q

List 2 types of response to shock

A

sympathy-adrenal response,

neuroendocrine response

26
Q

List 5 hormones that are released in shock

A 
ACTH, 
ADH, 
endogenous opioids, 
cortisol, 
glucagon
27
Q

What does cortisol release do in shock (2)

A

fluid retention,

antagonises insulin

28
Q

Inflammatory response in shock can occur as part of pathological process or consequences of and often both. Give example of pathological process its a part of and an example of a situation in which It is a consequence

A

pathological process - sepsis,

consequence of persisting hypo perfusion

29
Q

List 7 components of inflammatory response

A

activation of complement cascade,
cytokine release,
platelet activating factor,
lysosomal enzymes,
adhesion molecules,
endothelium derived mediators (e.g. nitric oxide),
imbalance between antioxidants and oxidants

30
Q

What does activation of complement cascade in inflammatory response cause?

A

attraction and activation of leucocytes

31
Q

What does release of platelet activating factor in inflammatory response cause? (2)

A

increased vascular permeability (leaky),

platelet aggregation

32
Q

What does release of lysosomal enzymes in inflammatory response cause? (2)

A

myocardial depression,

coronary vasoconstriction

33
Q

List 5 haemodynamic changes in shock

A

vascular abnormalities (dilation or constriction), distribution of of blood flow messed up,
microcirculatory abnormalities (capillary beds flow interrupted),
inappropriate activation of coagulation systemic -> DIC,
reperfusion injuries

34
Q

The loss of vascular reactivity (failure of vascular smooth muscle constriction) in shock is mostly caused by what?

A

Huge increase in release of nitric oxide

35
Q

Myocardial dysfunction in shock is mostly caused by reduced coronary blood flow. T/F?

A

False!! its caused by
cytokines on myocardium,
beta receptor down regulation,
decreased cardiomyofilament calcium sensitivity

36
Q

What symptom is almost always present in all types of shock?

A

Hypotension (usually)

37
Q

Cardiogenic shock presentation (5)

A 
cold, 
clammy, 
chest pain, 
oedema, 
not very tachycardic
38
Q

Distributive shock presentation (3)

A

raised JVP,
pulsus paradoxus,
signs of cause

39
Q

Distributive shock septic presentation (4)

A 
pyrexia, 
vasodilatation, 
rapid cap. refill, 
warm and red
hypotension
40
Q

Distributive shock anaphylaxis presentation (4)

A

profound vasodilatation,
erythema,
bronchospasm,
oedema

41
Q

Assessment of shock (7)

A 
exam (skin temp, CRP), 
blood pressure monitoring,
pulse contour analysis for CO, 
urine output, 
neurological, 
acidosis, 
lactate levels
42
Q

Gold standard management for monitoring cardiac output?

A

thermodilution with a PA catheter but no one really happens

43
Q

Management of shock

A

ABCDE,
wide bore IV access and treat underlying cause,
fluids,
noradrenaline

44
Q

Biggest components of oxygen delivery (3) and how does this affect treatment aims

A 
Hb, 
SpO2, 
CO 
Hb -> correct anaemia, 
ensure O2 normal, 
optimise CO
45
Q

Why should you be careful with fluids in shocked patients

A

shocked patients more susceptible to pulmonary oedema due to microvascular dysfunction

46
Q

Typical fluids for shock

A

300-500ml over 10-20 mins

47
Q

MAP range target? but can vary depending on clinical picture

A

65-75

48
Q

Pros and cons of crystalloids

A

convenient cheap and safe, but rapidly lost from circulation

49
Q

Pros and cons of colloids

A

can cause anaphylaxis

50
Q

What does noradrenaline do

A

predominantly alpha agonist so vasoconstrictions

51
Q

Cardiogenic shock severe when drugs fail

A

balloon pumps,
L-VADs,
R-VADs
severe: VA-ECMO

52
Q 
Shock of blood loss <15% 
HR, 
BP, 
Cap refill, 
UO ml/hr, 
Mental state
A 
HR <100, 
BP normal, 
Cap refill normal, 
UO ml/hr >30, 
Mental state normal
53
Q 
Shock of blood loss 15-30% 
HR, 
BP, 
Cap refill, 
UO ml/hr, 
Mental state
A 
HR >100, 
BP normal, 
Cap refill >2sec, 
UO ml/hr 20-30, 
Mental state anxious
54
Q 
Shock of blood loss 30-40% 
HR, 
BP, 
Cap refill, 
UO ml/hr, 
Mental state
A 
HR >120, 
BP low, 
Cap refill >2sec, 
UO ml/hr 10-20, 
Mental state confused
55
Q 
Shock of blood loss >40% 
HR, 
BP, 
Cap refill, 
UO ml/hr, 
Mental state
A 
HR >140, 
BP low, 
Cap refill >2sec, 
UO ml/hr anuric, 
mental state lethargic

Haematology (25 decks)

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