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Module 14 > Management of Shock > Flashcards

Management of Shock Flashcards

1
Q

what are the fluid compartments

A
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2
Q

what are the cations and anions of the ECF

A

cations: sodium
anions: chloride, bicarbonate

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3
Q

what are the cations and anions of the ICF

A

cations: potassium
anions: phosphate, protein

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4
Q

what is responsible for the osmolarity of the fluid in the body

A

electrolytes

~300 mOsm/l in dogs

~310 mOsm/l in cats

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5
Q

what are the reasons to give fluids (6)

A

1. dehydration

2. shock

  1. provide maintenance requirements
  2. treat electrolyte imbalances
  3. maintain oncotic pressure (colloids)
  4. diuresis
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6
Q

what fluid deficit is dehydration

A

deficit in total body water

loss of water but often used clinically to refer to isotonic and hypotonic losses as well

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7
Q

what is the maintenance requirement in cats a dog

A

50 ml/kg/day

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8
Q

what is dehydration due to

A
  1. low consumption
  2. pathological fluid losses
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9
Q

what are clinical signs of dehydration

A
  1. skin tenting
  2. dry mucous membranes
  3. sunken eyes
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10
Q

what is circulatory shock

A

global energy deficit at cellular level

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11
Q

what is the most common shock

A

hypovolemic

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12
Q

what are the types of shock

A
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13
Q

what fluid loss is hypovolemic shock

A

loss of intravascular volume

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14
Q

what are the causes of hypovolemic shock

A
  1. dehydration
  2. blood loss
  3. 3rd spacing of fluids (pleura, peritoneum)
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15
Q

what is cardiogenic shock caused by (3)

A
  1. heart disease
  2. cardiac tamponade
  3. arrhythmias
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16
Q

why must cardiogenic shock be differentiated from other types of shock

A

large fluid volume is contraindicated

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17
Q

how do you differentiate cardiogenic shock from other types (3)

A
  1. signalment & history
  2. thoracic auscultation (heart murmurs, pulmonary edema heard as crackles)
  3. ascites/jugular distention
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18
Q

what is distributive shock

A

cardiac function and blood volume are not affected but there is a failure of the vascular tree to allow appropriate delivery

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19
Q

what does distributive shock cause

A
  1. loss of vascular tone: sepsis/endotoxemia, anaphylaxis
  2. venous blockage of blood (obstructive shock): GDV, pulmonary thromboembolism
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20
Q

can you treat distributive shock where there is loss of vascular tone due to sepsis/endotoxemia with fluid

A

yes –> vasodilation –> BP will drop

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21
Q

what are the classic clinical signs of hypovolemic shock (7)

A
  1. tachycardia (sympathetic response)
  2. poor pulse quality due to vasoconstriction and lack of blood volume
  3. decreased extremity temperature
  4. pale mucous membranes
  5. prolonged CRT
  6. decreased mentation due to inadequate brain perfusion
  7. tachypnea to increase oxygen uptake (not always evident)
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22
Q

list areas you can feel a pulse

A
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23
Q

in mild/compensated hypovolemia what would you expect the HR, MM colour, CRT, pulse amplitude, pulse duration, metatarsal pulse palpable to be

A

HR: 130-150

MM colour: normal/pinker

CRT: <1 sec

pulse amplitude: increased

pulse duration: mildly decreased

metatarsal pulse palpable: easily

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24
Q

in moderate hypovolemia what would you expect the HR, MM colour, CRT, pulse amplitude, pulse duration, metatarsal pulse palpable to be

A

HR: 150-170

MM colour: pink

CRT: ~2 seconds

pulse amplitude: decreased

pulse duration: decreased

metatarsal pulse palpable: just

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25
in severe/decompensated hypovolemia what would you expect the HR, MM colour, CRT, pulse amplitude, pulse duration, metatarsal pulse palpable to be
HR: 170-200, may become bradycardic MM colour: white/grey CRT: \> 2 seconds pulse amplitude: severe decreased pulse duration: severe decrease metatarsal pulse palpable: absent
26
fill out this chart
27
what are exemptions to the rule of clinical signs (2)
1. septic (distributive) shock: due to vasodilation animals may have brick red mucous membranes and bounding pulses (of decreased duration) 2. cats: may have increased heart rates in early shock but frequently present with bradycardia in more severe shock
28
what are pathological consequences of hypovolemic shock (3)
1. low blood pressure causes activation of the sympathetic nervous system --\> tachycardia & vasoconstriction 2. the renin-angiotensin system is activated --\> vasoconstriction & fluid retention 3. hydrostatic pressure promotes movement of water by Starling's forces from the interstitium
29
what % of blood volume can healthy animals tolerate
30-40%
30
how can shock kill animals
1. lack of perfusion 2. cellular hypoxia --\> free radical generation --\> inflammatory mediators
31
what occurs to the GI tract during hypovolemic shock
sympathetic activation tends to shunt blood away from GIT --\> disproportionate hypoperfusion and inflammation may amplify SIRS may allow bacterial translocation causing sepsis
32
what is SIRS
a complex immune response follows involving activation of multiple inflammatory mediators throughout the body --\> may lead to systemic inflammatory response syndrome may lead to multiple organ dysfunction (MODS)
33
what are the aims of shock treatment
1. rapid yet judicious use of fluid therapy to restore vascular volume, normalize tissue perfusion and reduce secondary injuries 2. identification and control of any hemorrage is an important component of treatment in hypovolemic shock
34
what are the routes of administration of fluid therapy
expanding vascular space so --\> IV or intraosseous access is mandatory
35
what is intra-osseous cannulation suitable for
small puppies, kittens
36
what fluid is used for shock
isotonic crystalloids equilibrate quickly with interstitial fluids --\> therefore high volumes are needed "shock dose"
37
what is the shock dose for cats and dogs and what is normally done
dogs: 80-90 ml/kg/hr cats: 40-60 ml/lg/hr but giving entire shock dose is outdated concept --\> divide into 4 over 15 mins and check perfusion parameters (improvement of mentation, decrease in HR, pulse quality improved)
38
what are examples of isotonic replacement crystalloids and what are their components
39
which fluid has more Na (normal saline, ringer's, hartmann's)
normal saline \> ringer's \> hartmann's
40
which fluid has more K (normal saline, ringer's, hartmann's)
ringers and hartmann's have the same amount normal saline doesnt have any
41
which fluid has more Cl (normal saline, ringer's, hartmann's)
ringer's \> normal saline \> hartmann's
42
which fluid has more Ca (normal saline, ringer's, hartmann's)
hartmann's \> ringer's normal saline doesn't have any
43
which fluid has lactate? (normal saline, ringer's, hartmann's)
hartmann's
44
which fluid has the highest osmolarity (normal saline, ringer's, hartmann's)
ringer's \> normal saline \> hartmann's
45
which fluid would be of choice for a patient with metabolic acidosis
hartmann's because it is alkalinizing
46
when is hartmann's contraindicated (5)
1. cerebral edema (hyperosmotic so will cause additional fluid to enter cerebral cavity) 2. severe liver failure: lactate cannot be metabolized 3. severe abnormalities of sodium concentration 4. hyperkalemia (renal/post-renal failure) because it has K 5. contains Ca: cannot be mixed with blood products, sodium bicarbonate, or hypercalcemic animals
47
even though Hartmann's is contraindicated in hyperkalemia, explain why it is still okay to use in cats with uretheral blockage
it contains K but only 4mmol/l --\> still dilutional bicarbonate buffer normalizes acid bases status more rapidly than saline in cats with experiental urtheral blockage
48
what are the advantages of crytalloids (4)
1. cheap 2. physiological 3. few side effects 4. widely available
49
what are the disadvantages of crystalloids
1. only transiently expand the vascular compartment 2. don't provide a replacement for albumin (oncotic support) --\> important in hypoalbuminemic patients especially those with peripheral edema
50
what are colloid fluids and how to they expand intravascular volume
large molecules which don't cross the vascular endothelium high oncotic pressure act to expand and maintain intravascular volume
51
what is the colloid shock dose
dogs: 20ml/kg/hr cats: 10ml/kg/hr 1/4 doses over 15 mins
52
what is the colloid maintanence of oncotic pressure dose
20ml/kg/day
53
what are common colloids
haemacel pentastarch/tetrastarch 6%
54
which colloid has larger molecule size (Haemacel or pentastarch/tetrastarch 6%)
haemacel: small molecular size (~25 kDa) pentastarch/tetrastarch 6%: larger molecule size (~200 kDa)
55
which colloid has a rapid volume expansion (Haemacel or pentastarch/tetrastarch 6%)
Haemacel
56
which colloid has a longer duration of action (Haemacel or pentastarch/tetrastarch 6%)
pentastarch/tetrastarch 6% ~60% lost after 24hrs haemacel: ~80% lost after 24hrs
57
which colloid has a higher risk of coagulopathy (Haemacel or pentastarch/tetrastarch 6%)
pentastarch/tetrastarch 6% at high doses (\>20ml/kg/day or up to 50ml/kg/day with certain tetrastarches)
58
which colloid has a higher risk of anaphylaxis (Haemacel or pentastarch/tetrastarch 6%)
haemacel
59
what are the differences of crystalloids and colloids
no definitive evidence exists showing superiority of one over the other cyrstalloids seem effect despite physiological inferiority recent controversy with withdrawal of colloids in human med (renal complications)
60
when are colloids particularly useful
1. hypoalbuminemia 2. large patients 3. poor response to crystalloids
61
what is hypertonic saline
7.2% NaCl
62
how does hypertonic saline improve hypovolemia
high osmotic gradient draws interstitial fluid into the vascular space
63
what volume of hypertonic saline is needed
small volumes required 4ml/kg over 10 minutes
64
what does hypertonic saline cause
+ ionotropy and reduce inflammation
65
what is hypertonic saline useful for
hypovolemic patients with head trauma
66
when is hypertonic saline not to be administered
in already dehydrated patients
67
what must you follow up with once you give hypertonic saline
crystalloids to repay the debt can be mixed with colloids for shock resuscitation in severe cases
68
when are blood products not indicated
as first line treatment for shock as it cannot be administered fast enough while avoiding potential transfusion reactions animals in shock don't die of anemia --\> lack of vascular volume once initial resuscitation has been carried out, transfusion may be required to maintain a PCV of greater than 20-25%
69
what is hypotensive rescusitation
may be indicated in ongoing internal hemorrhage restores blood pressure to acceptable limits (60 mmHg) without "popping the clot" definitive volume restoration delayed until bleeding is surgically managed
70
what are additional shock therapies (5)
1. broad spectrum bacteriocidal antibiotics 2. GI protectants 3. vasopressors/iontropes (used is severe sepsis) 4. bicarbonate 5. glucocorticoids (but can cause immunosuppression + GI irritation, can be useful in septic shock)
71
what additional monitoring is needed
1. physical findings essential (mucous membranes, capillary refill time, pulse rate and quality, heart rate, respiratory rate) 2. urine output (\<1 ml/kg/hr could indicate hypovolemia and inadequate renal perfusion or renal failure) 3. arterial blood pressure: monitor trends 4. blood lactate: \< 2mmol/L normal
72
what are mild increases of lactate
2-5 mmol/L
73
what are moderate increases in lactate
5-8 mmol/L
74
what are severe increases in lactate
\>8 mmol/L
75
what are causes of increased plasma lactate concentrations (5)
type A 1. inadequate oxygen delivery 2. increased oxygen demand type B 3. inadequate oxygen utilization 4. drugs/toxin (list not exhaustive) 5. congenital errors of metabolism
76
how does inadequate oxygen delivery lead to increased lactate concnetrations (3)
1. inadequate tissue perfusion 2. low arterial oxygen saturation 3. low hemoglobin concentration
77
how does increased oxygen demand lead to increased lactate concnetrations (3)
1. exercise 2. shivering 3. seizures
78
how does inadequate oxygen utilization lead to increased lactate concnetrations (5)
1. sepsis 2. SIRS 3. neoplasia 4. renal failure 5. diabetes mellitus
79
what drugs/toxins lead to increased lactate concentrations (5)
1. ethylene glycol 2. cyanide 3. carbon monoxide 4. strychnine 5. acetaminophen
80
what are complications of fluid therapy (4)
1. iatrogenic electrolyte disturbances 2. overzealous use of fluids may lead to volume overload 3. catheter related tissues 4. complications associated with individual products (coagulopathy with colloids)
81
what are the signs of volume overload (7)
1. chemosis 2. serous nasal discharge 3. increased respiratory rate 4. effort and noise 5. restlessness 6. peripheral edema 7. polyuria 8. pulmonary and interstitial edema
82
what patients are more susceptible to volume overload
1. renal disease 2. cardiac disease 3. hypoalbuminemia 4. pulmonary contusions

Module 14 (29 decks)

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