Distributive Shock ⬇️ PVR Flashcards
Aetiology of anaphylactic shock
Penicillin Nuts Animals Seafood Bees/wasp stings Dairy products
Signs and symptoms of anaphylactic shock
First-pruritus (severe itching), urticaria (rash) and flushing
Second-throat swelling, anxiety, breathing difficulties, SOB , chest tightness, stiridor and wheeze. Tachycardia and low BP
Third- altered mental state, respiratory distress and circulation collapse and fatigue
Signs of profound vasodilation
Warm extremities
Low BP
Tachycardia
Other symptoms Vomiting and diarrhoea Hypovolemia due to capillary leak Oedema in face and pharynx and larynx Bronchospasms and rhinitis
Treatment for anaphylactic shock
Adrenalin- epinephrine causes vasoconstriction so blood can circulate back to vital organs (500mcg IM 1:1000, 50mcg IV)
a-e -airway management oesophageal/ nasopharyngeal to increase perfusion
Anti-histamine-hydrocortisone (200mg)or chlorphenamine (10mg)
Corticosteroids- prednisone given after antihistamine to reduce worsening reaction
IV access
ECG to treat arrhythmias- can cause myocardial ischeamia
Fluid resuscitation- crystalloids (500-1000ml)
Intropic support- dopamine
Beta agonist- salbutamol
Time course for fatal anaphylactic shock
Food reaction respiratory arrest -30-35 minutes
Inspect sting collapse from shock - 10-15 minutes
Death by IM - within 5 minutes
Pathology of neurogenic shock
Caused by spinal/ central nervous system injury such as trauma anaesthetic or medication, which interfere with normal nervous control of blood vessel diameters.
There is no loss of motor, sensory and autonomic function and the spinal cord function will return in time
Blood pressure drops due to decreased SVR and peripheral vasodilation resulting in the pooling of blood within the extremities lacking sympathetic tone.
Heart rate drops due to unopposed vagal activity and is exacerbated by hypoxia and endobronchial suction as the sympathetic nerve pathways are blocked.
Treatment for neurogenic shock
ABCDE- Airway management- define whether oropharyngeal/naso, head brace or spinal board is needed
Fluid resuscitation- Vasopressors like ephedrine, norepinephrine
Inotropic support ( affect the strength of the contractions of the heart)- Dopamine ( causes more intense contractions)
Vasopressin (antidiuretic hormone)
Atropine if bradycardia is severe.
02 therapy – to increase perfusion
Steroids
Signs and symptoms of neurogenic shock
Hypotension- The inability of the blood vessels to constrict leads to low BP as a response to the alteration in the autonomic nervous system.
Bradycardia-The injury causes the walls of the blood vessels to relax thus slowing the heart rate.
Warm dry extremities
Peripheral vasodilation and venous pooling
Poikilothermic (cold body)
Hypothermia- The injury may result in the loss of sympathetic tone which can result in the inability to redirect the blood flow to the core circulation thus excessive heat loss and drop in temperature
Decreased cardiac output (with cervical or high thoracic injured)
Causes of neurogenic shock
Spinal trauma
Anaesthetic
Drugs
Pathology of septic shock
Caused by a severe infection in which bacterial toxins are released into the circulation.
These toxins provoke an inflammatory and immune response which released powerful mediators such as endotoxins and cytokines.
Cytokines damage the capillary walls causing them to leak into the interstitial space
Because the response is not controlled it causes multiple organ damage, hypotension because of wide spread vasodilation depression of myocardial contractility, poor tissue perfusion and tissue death
Signs and symptoms of severe sepsis
Systolic BP 40mmHg)
Lactate- More than 2mmol/L
Urine Output- Less than 0.5ml/kg/hr for 2 hours
New need for oxygen to keep SpO2 more than 90%
Platelets- Less than 100 x 109/l
INR – more than 1.5 or APTT more than 60s
Bilirubin- More than 34 μmol/L
Creatinine- More than 177 μmol/L
SIRS criteria
Temperature – Above 38.3 °C
Heart rate- Tachycardia above 90/min
White cell count – Less than 12 x109/l
Acutely altered mental status
Glucose: Hyperglycaemia: above > 7.7 mmol/l in the absence of diabetes Mellitus
Respiratory rate- Above 20/min
If patient is within one month of last chemotherapy treatment of is suspected neutropenic treat as neutropenic (Abnormally few neutrophils in the blood, increases susceptibility to infection, side effect of some cancer drugs) sepsis
Causes of septic shock
Lung infections such as pneumonia (50-60%) –Elderly/ COPD patients
Urinary tract infections (7-10%) Elderly/ young women, UTI, pyelonephritis
Soft tissues/joints (7-10%)- Cellulitis, septic arthritis
Iatrogenic (5-10%)-Catheters and venflons
Abdomen (20-20%)-Perforation, appendicitis, Cholangitis, anastomotic leak, post-op abcess
CNS (
Symptoms of multi organ failure in sepsis
Decreased mental stare Tachypnoea Decreased urine output Low BP Thrombocytopenia Metabolic acidosis increased lactate Decreased CRT
Sepsis= infection + 2 or more SIRS criteria, treatment
Do a clinical assessment and management A-E approach
Take blood cultures (x2)
Give broad spectrum antibiotics
Screen for severe sepsis
Sepsis 6;
OXYGEN- Give 15Ls of O2 via non-rebreathe bag (80-90%). Aim for SATS of 100%. Still may be appropriate for COPD patients
BLOODS- Take blood cultures (x2) also urine, CSF, wounds, sputum and other fluids.
ANTIBIOTICS- In the first hour of recognition, ideally after taking blood cultures, give broad spectrum until defined. As per adult treatment formulary chart.
FLUIDS- Start IV fluid resuscitation (Hartmann’s or equivalent) to reduce organ dysfunction/ failure/improve tissue/organ perfusion. 30mls/ kg in divided boluses (60ml/kg in shock). Crystalloid (500mls in 4 38%
CATHETHER-Place and monitor hourly urinary catheter. 0.5ml/kg/hr, average is 30ml/hr in the average adult. Kidneys are a good measure of co2 & is the first organ to fail.
