Case Eight - Case Two Flashcards
what is the shock index
heart rate / blood pressure
what is a normal shock index and suggests that a patient is haemodynamically stable
a shock index of 0.5/0.7 is normal
if a patient is in shock, what treatment do they need asap?
500ml sodium chloride 0.9% IV over 10 mins
what is the pneumonic to remember the different categories of shock
‘how fast you fill the pump and squeeze’
fast - heart rate
fill - blood volume
pump - heart
squeeze - blood pressure
what are the fast (heart rate) problems
extreme tachycardia of any cause (e/g.ventricular tachycardia) or bradycardia
what are the fill (blood volume) causes
haemorrhage or dehydration (from inadequate intake or vomiting / diarrhoea) will both cause a reduced blood volume
what are the pump (heart) problems
a primary cardiac problem such as an acute MI, aortic dissection, papillary muscle rupture) or something preventing the heart’s ability to pump blood out of the thorax (pneumothorax or PE or CT)
what are the squeeze (BP) problems
sepsis and anaphylaxis both involve capillary dysfunction which causes fluid from the blood vessels to leak out into the tissues
what does the term shock describe
used to describe the state that results when circulatory insufficiency leads to inadequate tissue perfusion and thus inadequate oxygen delivery to tissues. this shortage of oxygen means that aerobic metabolism cannot occur, resulting in organ dysfunction
what are some of the broad categories of types of shock
hypovolaemic
distributive
obstructive
cariogenic
neurogenic
what suggests hypovolaemic shock
suggested by signs of shock plus history or examination evidence of bleeding or fluid loss, cool peripheries, a good response to fluid or blood resuscitation
what suggests distributive shock
may be suggested by signs of shock plus peripheral vasodilation i.e warm, dilated peripheries
there may be clues in the history like a recent infection that has been getting worse (sepsis) or a known exposure to an allergen (anaphylaxis)
the patient may be febrile. it may respond to fluid resuscitation, but as this is not the underlying cause, your patient may remain hypotensive
what is obstructive shock suggested by
signs of shock plus signs go a problem inside the thorax that is impeding cardiac output
what are the three risk factors for obstructive shock
tension pneumothorax
cardiac tamponade
massive pulmonary embolism
what is cariogenic shock suggested by
the history; the patient will usually have presented with adverse cardiac features like chest pain, syncope, or signs of heart failure; their peripheries may be cold; their ECG may give clues
what is neurogenic shock
a specific syndrome that happens in trauma. it is different to spinal shock
when does neurogenic shock happen
happens in high (cervical or high thoracic) spinal cord injuries where the patient loses their sympathetic outflow hence their normal sympathetic responses to blood loss
instead of tachycardic, they will be bradycardia
instead of hypotension and peripherally vasoconstrictor/cold, they will be hypotensive but peripherally dilated/warm
what is the most common cause of shock in trauma
haemorrhage
what is the most common type of shock overall
sepsis
what is the initial treatment for severe sepsis and hypovolaemia
IV fluid.
what is there management for an Acute Upper GI bleed
recommend a risk assessment using the Glasgow Blatchford Score to determine who is likely to benefit from early endoscopy
what haemoglobin should you aim for
70-100g/L
what is rnhabdomylosis
a syndrome whereby there is breakdown and necrosis of damaged skeletal muscle, releasing its contents into the circulation
what are the contents of this damaged skeletal muscle
electrolytes, myoglobin, sarcoplasmic proteins such as creatinine kinase
what can rhabdomyolysis cause
multiple complications, including AKI as the myoglobin deposits in and obstructs the renal tubules
what is anaphylaxis
a type I hypersensitivity reaction, which causes comprise to the airway, breathing and circulation, with or without skin or mucosal changes
it is a medical emergency which requires immediate recognition and treatment
A 25 year old woman has been unwell with vomiting and diarrhoea for six days. For the last 24 hours she has been vomiting even sips of fluid. Her temperature is 36.7, RR 20, sats 98% RA, HR 125, BP 85/54. Her lips and tongue appear dry and her hands and feet are cold. Her central cap refill time is 3 seconds. She is drowsy.
What is the most appropriate initial treatment?
The patient is dangerously dehydrated and showing signs of hypovolaemic shock; NICE guidance on IV fluids tells us that, for resuscitation, we should prescribe 250-500mL of a crystalloid IV STAT/ over less than 15 minutes
A 60 year old man was at a restaurant when he collapsed. His colleagues were very concerned about him because after eating his starter he started drooling and his tongue appeared to swell out of his mouth then he went very pale. His temperature is 37.0, RR 28, sats 95% RA, HR 140, BP 70/40. He is scratching his arms and trunk, but the rash that appears when he scratches doesn’t last long and seems to move.
What is the most appropriate initial treatment?
IM adrenaline 0.5mL 1:1000
why?
the patient is shocked and the features of tongue swelling causing airway compromise and pallor suggesting severe illness/hypotension, as well as features of an urticarial rash and a possible food exposure in a restaurant, suggests that his shock is due to anaphylaxis
what is the treatment of anaphylaxis
IM adenaline 500mcg or 0.5mL of 1:1000
we use 1:1000IM because it is more concentrated, thus a smaller amount can be injected into the muscle.
