Inflammation, DIC and Shock

Question 1

What is SIRS

Answer 1

Systemic Inflammatory Response Syndrome

Question 2

What is a shock

Answer 2

It is a state in which there is diminished cardiac output or reduced circulating blood volume impairs tissue perfusion, leading to cellular hypoxia

Question 3

What is septic shock

Answer 3

It is a sub category of shock, it is caused by infectious organism, by their by products, by the inflammatory cytokines that are released in response to the presence of microbes. This induces SIRS in the body, which if not inhibited can lead to death of the patient. Important note: The organism doesnt have to be in the blood stream

Question 4

What is the golden hour

Answer 4

Time by which hypoxia has to be reversed to avoid irreversible injury. For brain, it is about 4 minutes

Question 5

Describe the different kinds of shock

Answer 5

1. Cardiogenic shock: failure of the left ventricle of the heart 2. Hypovolemic shock: there is not enough blood volume 3. Septic shock: caused by microbe or its by product

Question 6

What are the clinical staging of a shock

Answer 6

1. Non-progressive phase: Hypoxia is induced and there are compensatory mechanisms to temporarily deal with hypoxia such as anaerobic metabolism pathways. 2. Progressive phase: There is accumulation of lactic acid due to persistent hypoxia 3. Irreversible phase or stagnant phase

Question 7

Explain the clinical staging of shock in detail

Answer 7

Normal circulation 1. AV shunts are controlled 2. Good tissue perfusion 3. Sphincters are controlled 4. Minimal hypoxia and drop of pH across capillary beds

Question 8

What happens next?

Answer 8

Reversible or non progressive phase: 1. Peripheral vasoconstriction due to epinephrine and increase in activity of PS in ANS 2. Hemodilution: interstitial fluid in vascular spaces 3. Drop in pH across capillary bed 4. AV shunts open to redirect more blood to the heart and brain, renal output declines

Question 9

What happens in the next phase

Answer 9

Progressive phase:

1. The decrease in blood pressure and cardiac output continues
2. Lactic acidosis results
3. Decreased capillary bed perfusion causes the endothelial cells to die
4. Once the endothelial cells die, sludging and clothing begins.

The patient can still be saved but we are towards the end of the golden hour

Question 10

What is one way to diagnose whether the patient died in shock

Answer 10

In the autopsy we can see corticomedullary shunting in the kidneys

Question 11

What happens in the next phase

Answer 11

Irreversible phase

1. Arterioles give up - there is vasodilation
2. This causes a dramatic increase in hydrostatic pressure in the capillary bed, causing edema
3. Severe lactic acidosis that is not reversible
4. Decreased function of vital organs and death

Question 12

What is DIC

Answer 12

Diseminated Intravascular Coagulation, cloths forms in the vessels, may block blood flow into the organs

Question 13

What bacterium most commonly release LPS which is detected by the body as a biomarker for bacterial infection

Answer 13

Gram negative bacterium

Question 14

Some facts about septic shock

Answer 14

Most common cause of deaths in tertiary hospitals, mortality is about 20%, can be caused by bacteria, fungi or viruses such as Ebola virus

Question 15

How do endothelial cells repsond when the body is in a state of shock

Answer 15

They are induced such that they increase the tendency of the blood to cloth which results in DIC

Question 16

Explain SIRS

Answer 16

SIRS is caused by massive release of cytokines in the blood, what Fishback calls a cytokine storm. Mortality is high and its treatment with monoclonal antibodies has been ineffective.

Important to note that infectious organisms from the blood are isolated only 20% of the time, which implies that the microbes are not present in the blood but they have resided at some other place in the body

Question 17

Explain DIC

Answer 17

It is a condition where platelets and clothing factors are consumed extensively in massive intravascular coagulation events that happen intravascularly. This leads to uncontrolled hemorrhage in other areas of the body. This causes uncontrolled bleeding in other parts of the body.

Question 18

What are some of the other names of DIC

Answer 18

Consumption coagulopathy and microangiopathic hemolytic anemia

Question 19

How do you fix DIC

Answer 19

Once temperory way to treat DIC is to give platelets and clothing factors to the patient to stop the bleeding. However clothing factors and platelets will be consumed quickly and so this is not the permanent solution. DIC can only be solved by solving the underlying problem, if it is an infection then the patient has to be administered antibodies to kill the microbe, if it is due to a pregnency complication then a C section would have to be done

Question 20

Why does amniotic fluid causes clothing

Answer 20

Amniotic fluid has thromboplastin in it which causes widespread clothing

Question 21

What is the pathophysiology of DIC

Answer 21

It is marked by intrinsic or extrinsic activation of cascade of events that causes massice intravascular clothing. It can also be caused by different factors that cause damage to the epithelium or both of these events can happen at the same time

Question 22

Answer 22

Arrows point to the fibrin meshwork that has formed due to DIC, which can be seen as consistent pink patches

Question 23

Answer 23

DIC

PTH stains fibrin black

Question 24

Answer 24

Schistocytes or helmet cells which are fragmented RBCs, diagnostic of DIC

Question 25

What is Waterhouse Friderichson Syndrome

Answer 25

When a patient goes into a shock, the adrenal glands infarct. The adrenal glands die as a result so there is nothing in the body producing cortisol and epinephrine. Patients experiencing this condition develops low blood pressure and do not respond when IV fluids are administered so they also have to be given drugs that would performs the function of cortisol and epinephrine so they respond to IV fluids.

Question 26

Answer 26

Waterhouse Frederichson Syndrome

Question 27

Answer 27

Shock lung

Alveolar cells starts to die due to hypoxia, which are replaced by hyaline layer, air cannot pass through hyaline which leads to further complications.

Arrows point to dark pink spots which are hyaline deposits.

Question 28

Answer 28

Nutmeg liver or shock liver.

Congestion of rbcs around the central veins.

Question 29

Steps to treat DIC

Answer 29

1. IV fluids, saline solution or anything will work
2. Pressors such as dopamine to increase blood pressure
3. Antibiotics if bacterial sepsis is suspected
4. Corticosteroids if Waterhouse Frederichson Syndrome is suspected
5. Ventillary support to provide oxygen and prevent hypoxia
6. Other therapy such as providing them with platelet factors

There is only 1 way to treat shock or DIC which is to fix the underlying cause