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YEAR 5 ED > Shock and acute haemorrhage > Flashcards

Shock and acute haemorrhage Flashcards

1
Q

What are the types of shock?

A
  • mnemonic HCODE
  • H- hypovoleamic
  • C-cardiogenic
  • O-obstructive
  • D-distributive
  • E- endocrine
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2
Q

What is shock?

A

Circulatory shock: an abnormality of the circulatory system that results in redcued organ perfusion or tissue oxygenation

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3
Q

What can cause hypovolaemic shock?

A
  • Haemorrhage
  • Vomitting
  • Diarrhoea
  • Diuresis
  • Burns
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4
Q

Where are common sites for catastrophic haemorrhage?

A
  • External
  • Internal:
  • Chest
  • Abdo
  • Pelvis
  • Retroperitoneum
  • Long bones
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5
Q

What is Cullens sign?

A

Periumbilical bruising associated with acute pancreatitis but can be with any type of retro/intra periotenal haemorrhage

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6
Q

How would haemorrhage present?

A
  • cold perpheries
  • low BP
  • high HR
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7
Q

Causes of cardiogenic shock?

A
  • MI
  • Myocardial contusion
  • Myocarditis
  • Cardiac arrhythmia: unstable tachyarrhythmias, unstable bradyarrhythmias
  • Negatively inotropic drug overdose: Beta blockers, calcium channel blockers
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8
Q

Reversible causes of arrhythmias?

A
  • electrolyte disturbances: K+, Ca2+, Mg2+
  • hyperthyroidism
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9
Q

What are life-threatening features of an adult tachycardia? (4)

A
  • Shock
  • syncope
  • Myocardial ischaemia
  • Severe heart failure
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10
Q

What to do if a patient has life- threatening features of adult tachycardia? (i.e what management)

A
  • synchronised DC shock up to 3 attempts
  • Sedation or anaesthesis if conscious
  • If unsuccessful:
  • amiodarone 300mg IV over 10-20 min
  • Repeat synchronised DC shock
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11
Q

What to do if someone has an adult tachycardia that does NOT have life threatening features? (i.e what should you check on ECG)

A
  • Is the QRS complex narrow (<0.12 s)
  • Is it regular/ irregular
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12
Q

What to do if pt has:
Broad QRS, irregular tachycardia?

A
  • If polymorphic VT (e.g. torsades de pointes) give Mg 2g over 10 mins
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13
Q

How do you treat AF with bundle branch block?

A
  • As irregular narrow complex tachycardia
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14
Q

What to do if pt has:
Broad QRS, regular tachycardia?

A
  • If VT or uncertain rhythm
    -amiodarone 300 mg IV over 10-60 mins
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15
Q

What to do if pt has:
narrow QRS, regular tachycardia?

A
  1. Vagal manoeuvres
  2. If ineffective
    * give adenosine: 6mg rapid IV bolus, if unsuccessful give 2mg, if unsuccesful give 18mg,
    * monitor ECG
  3. If ineffective: verapamil, or beta blocker
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16
Q

What to do if pt has:
Narrow QRS, irregular tachycardia?

A

Possible AF
* control rate with beta blocker
* consider digoxin or amiodarone if evidence of HF
* anticoagulate if duration > 48 hrs

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17
Q

Obstructive shock causes?

A
  • Tension pneumothorax
  • Massive PE
  • Cardiac tamponade
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18
Q

Distributive shock causes?

A
  • septic shock
  • anaphylatic shock
  • neurogenic shock
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19
Q

What is neurogenic shock?

A
  • Traumatic injury or tumour on spine
  • Pt will be:
  • flushed from the level of injury down
  • Motor deficit from the level down
  • hypotensive and tachycardic
  • treat with: fluids, vasopressors and rehab
20
Q

What causes cardiac tamponade?

A
  • trauma
  • pericardial effusion
21
Q

How do you treat cardiac tamponade?

A
  • needle pericardiocentesis
  • clamshell thoracotomy within 15 mins of cardiac arrest
22
Q

Massive PE vs submassive PE?

A
  • Causes cardiovascular collpase- need to thrombolyse them
  • Submassive does not cause cardiovascular collapse- treat with DOACs/ heparins
22
Q

What type of shock does CO poisoning cause?

A
  • distributive
23
Q

How to diagnose CO poisoning?

A
  • Cherry red lips/ tongue
  • SATs probe and ABG
  • ABG: carboxyhb- up to 10% is normal
  • > 30% is v dicey
24
Q

Hx of shock in a pt?

A
  • Assessment of severity:
  • Dyspnoea
  • Confusion
  • Light-headness
  • Drowsiness
  • Oliguria/anuria
  • Symptoms of the cause
25
Q

A-E findings of the shocked patient?

A
  • Airway
    -May be compromised due to reduced conscious level
  • Breathing
    -hypoxia due to airway compromise or peripheral shut down may cause them to look hypoxic
    -Tachypnoea
    -Kussmauls’s breathing
  • Circulation
    -cold pale peripheries
    -prolonged cap refill
    -Tachycardia
    -Hypotension
    -Oliguria
    -Anuria
  • Disability
    -confusion
    -drowsiness
    -unconsciousness
  • signs of the cause
26
Q

What is Type 1 shock?

A
  • Blood loss ml: < 750
  • Blood loss %: <15
  • Pulse rate: < 100
  • Blood pressure: normla
  • Respiratory rate: 14-20
  • Urine output: > 30ml
  • Symptoms: normal
27
Q

What are the parameters for Type 2 shock

A
  • Blood loss ml: 750-1500ml
  • Blood loss %: 15-30%
  • Pulse rate: >100
  • Blood pressure: Normal
  • Respiratory rate: 20-30
  • Urine output: 20-30ml
  • Symptoms: Anxious
28
Q

What are the parameters for type 3 shock

A
  • Blood loss ml: 1500-2000ml
  • Blood loss %: 30-40%
  • Pulse rate: >120
  • Blood pressure: Decreased
  • Respiratory rate: 30-40
  • Urine output: 5-15ml
  • Symptoms: Confused
29
Q

What are the parameters for type 4 shock

A
  • Blood loss ml: >2000ml
  • Blood loss %: >40%
  • Pulse rate: >140ml
  • Blood pressure: Decreased
  • Respiratory rate: >35
  • Urine output: <5ml
  • Symptoms: Lethargic
30
Q

Investigation in shock?

A
  • Bloods incl blood gas to check pH and lactate
  • ECG
  • CXR
  • Echo
  • In trauma
    -Pelvic xr, CT CAP, FAST
31
Q

Causes of haemorrhage?

A
  • PPH
  • Varices
  • AAA
  • Epistaxis
32
Q

A pt with known varices presents with haematemesis and shock. How would you manage this patient?

A
  • A-E
    -patients should be resuscitated prior to endoscopy
    -blood transfusion may be needed
    -correct clotting: FFP, vitamin K, platelet transfusions may be required
  • terlipressin
  • prophylactic IV antibiotics have been shown to reduce mortality in patients with liver cirrhosis
    quinolones are typically used
  • endoscopy: endoscopic variceal band ligation is superior to endoscopic sclerotherapy. NICE recommend band ligation
  • Sengstaken-Blakemore tube if uncontrolled haemorrhage
  • Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail connects the hepatic vein to the portal vein exacerbation of hepatic encephalopathy is a common complication
33
Q

AAA presentation?

A
  • severe, central abdominal pain radiating to the back
  • pulsatile, expansile mass in the abdomen
  • patients may be shocked (hypotension, tachycardic) or may have collapsed
34
Q

AAA management?

A
  • ruptured AAA is a surgical emergency - patients with a suspected ruptured AAA require an immediate vascular review with a view to emergency surgical repair (w/o CT )
  • frail patients- terminal event and put then on end of life pathway
  • Patients who are haemodynamically stable may be sent for a CT angiogram where the diagnosis is in doubt - this may also assess the suitability of endovascular repair.
35
Q

If a pt has a haemorrhage and is in hypovolaemic shock, what do you do?

A
  • identify source of bleeding and achieve haemorrhage control e.g. direct compression, pelvic binder, splinting of long bone fractures, surgical ligation of bleeding vessles
  • Restore of adequate circulating volume: cross match blood and activate Major haemorrhage protocol (+/- fluid challenge)
  • Correct coagulopathy by transfusion of platelets, FFP and cryoprecipitate
  • Give FFP early with RBC
  • Cryo if fibrinogen is < 1.5
36
Q

What is the NEWS2 score?

A
  • Identify seriously unwell patients
  • Identify deteriorations
37
Q

What parameters does the NEWS2 score take into account?

A
  • RR
  • Sp02
  • Systolic BP
  • Pulse rate
  • Level of consciousness or new confusion
  • Temp
38
Q

What is sepsis?

A
  • life- threatneing organ dysfunction is associated with infection
39
Q

What is qSOFA?

A
  • quick SOFA score
  • Provides one way to assess for sepsis
40
Q

Outline qSOFA?

A

Consider sepsis and commence treatment as appropriate if any one (or more) of the following is present:
* RR> 22 breaths/ min
* Systolic BP < 100mmHg
* Altered mental state

Pts scoreing 2/3 have been shown to have increased mortality

high lactate is helpful in identifying sepsis (not specific)

41
Q

Sepsis 6?

A

Take:
* Blood cultures
* lactate
* urine output
Give:
* O2
* Fluids
* Abx

42
Q

What bloods to take in sepsis?

A
  • FBC- for WCC
  • CRP- inflammation marker
  • U&Es- for any AKI
  • LFTs- ensure no concurrent liver damage
  • Lactate- marker of infection/ dysfunction

If lactate is > 2mmol/L, repeat the level in 2 hr

43
Q

How to manage a septic pt?

A
  1. Obtain senior/ ICU assistance immediately
  2. ABC- high flow o2 with SpO2 target of 90-96%
  3. IV access and take bloods
  4. Look for obvious sources of infection
  5. Take blood cultures before starting abx if this doesn’t delay the administration of abx
  6. IV crysalloid according to response ( be careful in COVID19 as lots of fluid can worse ARDs)
  7. Start vasopressors for persistent hypotension in order to main a mean arterial BP of >65mmHg
44
Q
A

YEAR 5 ED (11 decks)

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