Shock

Question 1

What is the definition of shock

Answer 1

life threatening failure of delivery of oxygen to the tissues

Question 2

what is the diagnostic triad of shock

Answer 2

raised lactate
low blood pressure
signs of reduced perfusion (altered mental state, reduced uring output, reduced cap refill)

Question 3

what determines blood pressure

Answer 3

cardiac output x systemic vascular resistance

Question 4

what determines cardiac output

Answer 4

stroke volume x beats per min

Question 5

what makes up stroke volume

Answer 5

end diastolic volume - end systolic volume

Question 6

what modulates end diastolic volume

Answer 6

preload and compliance

Question 7

what modulates end systolic volume

Answer 7

contractility

afterload

Question 8

what are the 4 main categories of shock

Answer 8

Distributive
Hypovolaemic
Cardiogenic
Obstructive

Question 9

what is hypovolaemic shock

Answer 9

insufficient blood volume in intravascular compartment

decreased cardiac output

Question 10

what are signs of hypovolaemic shock

Answer 10

Leads to hypotension, dehydration, altered mental state, cool peripheries, mottled skin and increased cap refill

Question 11

why is it important to manually palpate the pulse in hypovolaemic shock

Answer 11

pulse may be irregular and the equipment will mismeasure it

also gives you more info on volume, rhythm and character

Question 12

what are the subtypes of hypovolaemic shock

Answer 12

haemorrhagic
anaphylactic
septic

Question 13

what are the classifications of haemorrhagic shock

Answer 13

1 
<750ml lost 
<100 bpm 
RR 14-20 
>30ml/hr urine output  
Normal BP 
Slightly anxious  

2 
750-1500ml lost 
100-120 bpm  
Normal BP 
Decreased pulse pressure 
20-30RR 
20-30ml/hr urine output 
Mildly anxious  

3 
1500-2000ml lost  
30-40% lost  
120-140 BPM  
Decreased BP 
Decreased pulse pressure  
30-40 RR  
5-15ml/hr urine output 
Anxious/confused  

4 
>2000ml 
>40% 
>140 BPM 
Decreased pulse pressure 
Decreased blood pressure 
>35RR  
Negligible urine output 
Confused/lethargic

Question 14

what is the treatment for anaphylactic shock (adults)

Answer 14

Remove stimulus 
IM Adrenaline 0.5ml 1:1000 (500mcg) 
IV fluid bolus 500ml 
10mg IM/slow IV chloramphenamine
200mg IM/slow IV hydrocortisone 

escalation

Question 15

what is the treatment for septic shock

Answer 15

Sepsis 6 3 in, 3 out

3 in - fluid bolus, oxygen, broad spectrum Abx

3 out - catheter, 2 blood cultures, ABG (lactate)

escalation

Question 16

what is distributive shock

Answer 16

widespread vasodilation due to toxins or loss of sympathetic tone

Question 17

what are the signs of distributive shock

Answer 17

general shock triad - raised lactate, low BP, signs of reduced perfusion

warm peripheries, flushed complexion

Question 18

what are the types of distributive shock

Answer 18

anaphylactic
septic
neurogenic

Question 19

what causes neurogenic shock

Answer 19

spinal cord injury above T61

Question 20

what is the treatment of neurogenic shock

Answer 20

fluids
vasopressors - adrenaline
inotropes - adrenaline, dopamine
chromotropes - corrects bradycardia, atropine/dopamine/adrenaline

Question 21

what is cardiogenic shock

Answer 21

failure of heart to pump

Question 22

what causes cardiogenic shock

Answer 22

MI
cardiomyopathy
arrythmias
neurogenic shock

Question 23

what are signs of cardiogenic shock

Answer 23

General shock triad - raised lactate, hypovolaemic, signs of reduced perfusion

Cool and clammy – peripheral vasoconstriction

Commonly overloaded with fluid

Commonly tachy or brady cardic

Question 24

what is obstructive shock

Answer 24

blockage of blood flow causing preload, afterload or compliance issues

Question 25

what are some causes of obstructive shock

Answer 25

``` PE mediastinal compression of vena cava aortic dissection compression of heart compression of heart ```

Question 26

what are the signs of obstructive shock

Answer 26

shock triad - lactate, signs of reduced perfusion, hypovolvaemia peripheral shut down may be normal fluid status

Question 27

if shock is prolonged, what happens to the heart, kidney, brain, lungs,GI, gut and immune tissue

Answer 27

``` Heart - MI Kidney - AKI Brain - hypoxic brain injury Lungs - T1RF leading to ARDS Gut - bowel ischaemia immune - immune suppression ```

Question 28

how should you monitor someone in shock

Answer 28

A-E assessment – with regular reassessment ``` Standard observations RR SPO2 HR BP Temp AVPU Hourly output monitoring ``` Urgent investigations Blood gas For lactate and acid base - (Repetition may be helpful) Bloods If not responding Admit to HDU/ITU for advanced monitoring

Question 29

how do you manage cardiogenic shock

Answer 29

if reversible fix that (e.g. PCI for MI, cardiovert for arrythmia) HR too high - cardioversion HR too low - positive chronotropes (atropine, adrenaline) contractility low - inotropes (positive inotropes increased contractility e.g. NA avoid fluids