Shock & Sepsis

Question 1

What is cardiogenic shock and what is it defined as?

Answer 1

Failure of the pump action of the heart, leading to a decrease in cardiac output and reduced perfusion to the tissues and organs. Despite there being an adequate volume of fluid, the tissues/organs become hypoxic.

• Sustained hypotension (systolic <90mmHg for >30minutes)
• Decreased urine output (<30ml/hour)

Question 2

What is cardiogenic shock most commonly caused by? What are the other causes?

Answer 2

MI
Arrhythmias 
PE
Tension pneumothorax
Cardiac tamponade 
Myocarditis 
Aortic dissection

Question 3

What are the signs of cardiogenic shock?

Answer 3

Pale mottled skin with weak peripheral pulses
Hypotension
Oliguria
Altered mental state
Raised JVP
Tachycardia

Question 4

If the cause of cardiogenic shock is MI, how do you manage this?

Answer 4

Prompt reperfusion therapy is vital (PCI/ thrombolysis)

Question 5

How do you investigate a patient with cardiogenic shock?

Answer 5

ECG
U&E
Troponin
ABG
CXR
Pulmonary pressures (LAP) high

Question 6

How do you monitor a patient in cardiogenic shock?

Answer 6

CVP
BP
ABG
ECG
Urine output 
Cardiac telemetry

Question 7

What is the management of cardiogenic shock?

Answer 7

1) Oxygen. Sats of 94-98%. (If COPD sats of 88-92%)
2) Diamorphine 1.25-5mg IV
3) Investigations and monitoring
4) Correct arrhythmias/U&E abnormalities/acid-base
5) Clinical assessment of filling pressure (JVP/pulse/BP)
6) Underfilled = plasma expander, 100mL every 15min IV
Overfilled = Inotropic support e.g. dobutamine

Question 8

How do you work out MAP?

Answer 8

CO x SVR

Question 9

How do you work out CO?

Answer 9

SV x HR

Question 10

What is the management of hypovolaemic shock?

Answer 10

Large bore IV access 2 cannulas
Check ECG rate and rhythm
Identify and treat underlying cause
Raise the legs
Give fluid bolus 10-15mL/kg crystalloid via large peripheral line 
If shock improves, repeat

Question 11

What are the investigations of hypovolaemic shock?

Answer 11

Hb, U&E, LFT
Blood gases (may show metabolic acidaemia from poor perfusion)
Urine output 
CVP 
ECG for rate and rhythm

Question 12

What are the classes of haemorrhagic shock?

Answer 12

1 = <15%. <750mL. Normal/anxious

2 = 15-30%. 750-1500mL. Anxious/hostile

3 = 30-40%. 1500-2000mL. Anxious/confused

4 = >40%. >2000mL. Confused/unresponsive

Question 13

What are the three stages of hypovolaemic shock?

Answer 13

1) Compensated shock: Baroreceptor reflexes result in an increase in myocardial activity, tachycardia and vasoconstriction. They maintain cardiac output and BP (release renin, aldosterone etc)
2) Decompensated. Failure of vasomotor reflexes resulting in increased capillary permeability and thrombosis. Lactic acidosis
3) Irreversible shock. Failure of vital organs with no chance of recovery

Question 14

What procedure can be used for haemorrhage in shock?

Answer 14

Resuscitative endovascular balloon occlusion of the aorta (REBOA)

Introducing a balloon in the femoral artery into the aorta which is then inflated and cuts off the blood supply above the haemorrhaging point

Question 15

What is the management of haemorrhagic shock?

Answer 15

Stop bleeding
If still shocked despite 2L crystalloid or Class 3 shock:

Crossmatch blood
Give FFP with red cells
Consider tranexamic acid

Question 16

What is the management of hypovolaemic shock due to heat exhaustion?

Answer 16

Tepid sponging and fanning
Resuscitate with 0.9% saline and hydrocortisone 100mg IV
Lorazepam may be used to stop shivering

Stop cooling when core temperature <39 degrees

Question 17

What is the definition of sepsis?

Answer 17

Life threatening organ dysfunction caused by a dysregulated host response to infection

Question 18

What is the definition of septic shock?

Answer 18

Sepsis in combination with;

Either lactate >2mmol/L despite adequate fluid resuscitation
OR the patient is requiring vasopressins to maintain MAP >65mmHg

Question 19

What is the management of sepsis in adults?

Answer 19

1) Assess: consider sepsis in anyone with infective signs, altered mental state, feeling generally unwell,
2) Assess: PMH, capillary refill, mottled skin, conscious level, lactate, temperature, ECG, HR, BP, urine output/cultures
3) Assess risk: high/moderate-high/low
4) Treatment: broad spectrum ABx within 1hr.
Give fluids within 1hr if SBP <90, AKI or lactate >2. Give
500mL crystalloid boluses with 0.9% saline
Oxygen

Noradrenaline as a vasopressor to maintain MAP >65
PEEP for ARDS

Question 20

What is the SIRS criteria, sepsis criteria and severe sepsis criteria?

Answer 20

Temp >38 or <36
HR > 90
RR > 20
WBC > 12 000 or <4 000

If an infective source is present then that is the criteria for sepsis

If there is lactic acidosis or SBP <90 then that is the criteria for severe sepsis

Question 21

What is ARDS (acute respiratory distress syndrome)?

Answer 21

Respiratory failure characterised by widespread inflammation in lungs
SOB, rapid breathing and skin discolouration occurs
Sepsis may cause this

Impairs the lungs ability to exchange O2 and CO2
Mechanical ventilation may be needed

Question 22

What is the Sepsis 6?

Answer 22

1) Give O2 to keep sats >94%
2) Take blood cultures
3) Give IV ABx
4) Give a fluid challenge
5) Measure lactate
6) Measure urine output

Question 23

What is the qSOFA score?

Answer 23

A score used to see if patients with infection are at risk of heightened mortality:
RR >22
BP <100
Altered mentation