3+ conditions Flashcards
Aetiology, pathophys, epidemiology, risks, clinical features, Hx, exam, DDx, investigations, management (61 cards)
1
Q
Define shock
A
State of cellular and tissue hypoxia due to reduced oxygen delivery and/or increased O2 consumption or inadequate O2 utilisation.
- Circulatory failure
2
Q
What is undifferentiated shock?
A
Shock with an unknown cause
3
Q
4 types of shock
A
- Distributive
- Cardiogenic
- Hypovolaemic
- Obstructive
4
Q
Shock with more than one cause/category
A
Multifactorial shock
5
Q
What happens if shock is not recognised and treated early?
A
- Irreversible organ dysfunction
6
Q
What type of shock is septic shock?
A
Distributive
7
Q
Define septic shock
A
- Distributive shock
- Most common shock seen in ICU (62%)
- Dysregulated response to infection - leads to life threatening organ dysfunction
8
Q
Mortality of septic shock
A
40-50%
9
Q
What happens to lactate in septic shock
A
- Elevated - >2mmol/L
10
Q
Describe distributive shock
A
Severe peripheral vasodilation
11
Q
Name 6 types of distributive shock
A
- Septic shock
- SIRS
- Neurogenic shock
- Anaphylactic shock
- Drug and toxin induced shock
- Endocrine shock
12
Q
What is SIRS?
A
Systemic inflammatory response syndrome
13
Q
Causes of septic shock (4 groups)
A
- GPB = pneumonoccus, enterococcus (most common)
- MRSA
- GNB = pseudomonas, klebsiella, enterobacter
- Fungi - candida
14
Q
SIRS - 2 broad groups
A
Infectious and non-infectious
15
Q
Non-infectious causes of SIRS
A
- Burns
- Pancreatitis
- Amniotic fluid/air/fat embolism
- Post-MI
16
Q
Define neurogenic shock
A
- Disruption to autonomic pathways - decreases vascular resistance
- Severe traumatic brain injury, spinal cord injury
17
Q
Define anaphylactic shock
A
- IgE allergic reaction
- Many other symptoms
18
Q
Examples of drug and toxin induced shock
A
- Overdoses
- Bites
- Transfusion reactions
- Poisoning (eg. heavy metal)
- ** Also includes infections - toxic shock syndrome (Streptococcus, Escherichia)
19
Q
Two types of endocrine shock
A
- Addisonian crisis
- Myxedema
20
Q
Define Addisonian crisis in terms of endocrine shock
A
- Altered vascular tone
- Hypovolaemia
21
Q
Define Myxedema in terms of endocrine shock
A
- Myocardial depression
- Pericardial effusion
22
Q
Define cardiogenic shock
A
- Intracardiac cause
- Cardiac pump failure leads to reduced cardiac output
23
Q
3 groups of cardiac failure causing cardiogenic shock
A
- Cardiomyopathic
- Arrythmic
- Mechanical
24
Q
Define cariomyopathic cardiogenic shock
A
- MI - involves >40% of LV myocardium
- Ischaemia
- Severe RV infarction
- Myocarditis
- Myocardial depression
- Dilated cardiomyopathy
- Hypertrophic cardiomyopathy and diastolic heart failure rarely cause cardiogenic shock (lead to decreased BP and other types of shock)
25
Define arrythmic cardiogenic shock
- Atrial and ventricular tachy/bradyarrythmias - induce a decrease in BP
- CO compromised due to rhythm disturbances
- No ACO = cardiac arrest
26
Define mechanical cardiogenic shock
- Severe aortic/mitral valve insufficiency
- Acute valvular defects (rupture)
- Retrograde dissection - ascending aorta
- Ventricular septal defects
- Atrial myxoma
- Ruptured ventricular aneurysm - decrease CO (also features of obstructive shock as bleeding into sack, and haemorrhagic shocok as bleeding out)
27
Define hypovolemic shock
Reduced intravascular volume - reduced pre-load - reduced CO
28
2 subgroups of hypovolemic shock
Haemorrhagic and non-haemorrhagic
29
Causes of haemorrhagic hypovolemic shock
- Trauma
- Upper/lower GI blood loss
- Intra/post operative bleeding
- Ruptured AAA
- Iatrogenic
30
Causes of non-haemorrhagic hypovolemic shock
- Fluid loss other than blood
- GI losses --> diarrhoea, vomiting
- Skin losses --> heat stroke, burns, SJS
- Renal losses --> drug-induced, diuresis, nephropathy
- 3rd space losses --> into extravascular space and body cavities - trauma, intestinal obstruction, crush injury, pancreatitis, cirrhosis)
31
Define obstructive shock
- Usually extracardiac causes of pump failure
| - Often associated with poor right ventricle output (pulmonary vascular and mechanical)
32
2 types of obstructive shock
- Pulmonary vascular
| - Mechanical
33
Define pulmonary vascular obstructive shock
- RVF due to haemodynamically significant pulmonary embolism or severe pulmonary hypertension
- RV fails --> unable to generate enough pressure to overcome resistance
- Pulmonary vasoconstrictors --> serotonin and thromboxane
34
Define mechanical obstructive shock
- Presents clinically as hypovolemic - decreased preload
- Tension pneumothorax
- Pericardial tamponade
- Constrictive pericarditis
- Constrictive cardiomyopathy
35
Define ACS (abdominal compartment syndrome)
- Sustained intra-abdominal HTN
- Organ dysfunction
- Can exacerbate shock
- Primary cause = intra-abdominal injury
- Secondary cause = massive volumes given in resus
- Impairs cardiac function
36
Define the mechanism of shock
- Cellular hypoxia - due to reduced perfusion and delivery
- Leads to cell ion pump dysfunction, intracellular oedema, leakage of intracellular contents and inadequate regulation of cellular pH
- Acidosis (decreased pH)
- Endothelial dysfunction
- Stimulates inflammatory and anti-inflammatory cascades
37
Stages of shock
- Pre-shock (compensated shock/cryptic shock)
- Shock
- End-organ dysfunction
38
Define pre-shock
- Compensatory responses to decreased tissue perfusion
| - Tachycardia, peripheral vasoconstriction, mild hyperlactatemia
39
Symptoms of shock
- Tachycardia
- Dyspnoea
- Restlessness
- Diaphoresis
- Metabolic acidosis
- Decreased BP
- Oliguria
- Cool, clamy skin
--> Clinically evident when blood volume decreases 20-25%
40
Symptoms of end-organ dysfunctin
- Organ damage
- Multiorgan failure
- Death
- Anuria
- ARF
- Acidemia
41
Shock spidemiology
- Annual incidence of SEPTIC shock - 03.-0.7 per 1000
- Complicates MI in 7-9% of patients (cardiogenic)
- Hypovolaemic shock most common in children
42
Main goals/simple approach to shock
- Restore tissue perfusion
- Improve O2 delivery
- Reverse hypertension
- Prevent organ damage
43
First line treatment of shock
- Volume resuscitation (except anaphylaxis - IM adrenaline)
| - Further treatment guided by reponse to IV fluids and aetiology
44
Drugs to give people in shock
Vasopressors
- Alpha agonists
- Increase MAP
- Only give after adequate volume resuscitation
45
What type of shock needs special treatment?
Cardiogenic
46
Treating shock in all patients
- Assess ABC
- Treat underlying cause
- Vasopressor
47
Treating suspected cardiogenic shock
- MAYBE IV fluids
- Glyceryl trinitrate
- Inotropic support (force)
- Intra-aortic balloon pump
48
Treating shock that is NOT cardiogenic
- IV fluids
- Blood products
- Tranexamic acid (prevents blood lose)
49
Risk factors for shock
- Older age
- MI
- Cardiomyopathy
- Ruptured AAA
- Burns
- Heat stroke
- Anaphylaxis
- Spinal/brain injury
- Heart valve disease
- Arryhtmias
- Trauma
- GIT bleed
- GIT losses
- Pancreatitis
- Sepsis
- Poinsoning
- Endocrine disease
- PE
50
% of males who get gallstones
6%
51
% of females who get gallstones
9%
52
Define cholecystolithiasis
Stones in the gallbladder (not a disease until they cause symptoms)
53
Define gallstone disease
Gallstones that cause symptoms
54
Two subtypes of gallstones disease
Complicated and non-complicated
55
Name some gallstones related complications
- Cholcystitis
- Cholangitis
- Gallstone pancreatitis
- Gallstone ileus
- Mirizzi syndrome
56
Define Mirizzi syndrome
Common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct or Hartmann's pouch
57
Gallstone symptoms
Biliary colic
- intense, dull discomfort, RUQ and epigastric
- may radiate to the back or right shoulder blade
- often associated with diaphoresis and N/V
Post prandial pain
Nocturnal pain
Pain exacerbated on movement
Visceral pain
58
Atypical symptoms of gallstone disease
- Belching
- Early satiety
- Regurgitation
- Abdominal distension/bloating
- Epigastric or retrosternal burning
- Nausea and vomiting
- Chest pain
- Non-specific abdominal pain
59
Define cholecystitis
ACUTE
- Most common complication of gallstones
- RUQ pain
- Fever
- Leukocytosis/inflammation
CHRONIC
- Chronic inflammatory cell infiltration
- Minimal symptoms
60
Define choledocholithiasis
- Presence of stones in the CBD
| - Fever, jaundice, abdo pain --> due to biliary obstruction
61
Define acute gallstone pancreatitis
- Obstruction of flow from the pancreatic duct or obstruction of the ampulla - causes bile to reflux back into the pancreatic duct
- Presents with elevated bilirubin/APT/ALT
