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CP3 @ UoN - Medicine & Surgery > Surgery - Shock > Flashcards

Surgery - Shock Flashcards

1
Q

Define Shock

A

Acute circulatory failure that compromises tissue perfusion. If untreated will lead to irreversible organ damage and death due to cellular hypoxia

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2
Q

What are the main types of Shock?

A

Hypovolemic - due to haemmorhage or dehydration
Distributive - due to sepsis, anaphylaxis or neurogenic shock
Cardiogenic shock - direct pump failure
Obstructive shock - indirect pump failure

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3
Q

What are the essential features of Shock?

A

Fall in BP >40mmHg (SP usually <90mmHg)
Tachycardia (catecholamine release)
Tachypnoea (metabolic acidosis)

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4
Q

What are the specific features of hypovolemic/cardiogenic shock?

A

Patient is cold, clammy, pale
Rapid, thready pulse
Pulse pressure narrow (vasoconstriction)

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5
Q

What are the specific features of septic shock?

A

Patient is flushed, hot, sweaty
Rapid, bounding pulse
Pulse pressure wide (vasodilation)

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6
Q

What is the effect of shock on the cerebral system?

A 
Autoregulation over MAP 50-150mmHg
Below threshold pt becomes
-agitated
-confused
-drowsy
-unresponsive
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7
Q

What is the effect of shock on the cardiac system?

A

Reduced diastolic pressure –> inadequate myocardial perfusion –> ischaemic chest pain –> arrhythmias –> infarction

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8
Q

What is the effect of shock on the respiratory system?

A

Increased RR due to metabolic acidosis

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9
Q

What is the effect of shock on the renal system?

A

Autoregulation over MAP 70-170
Below threshold
-oliguria –> impaired renal funcn

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10
Q

What is the effect of shock on the GI system?

A

Decreased GI motility/nutrient absorption

Decreased ability to sustain flora –> infection susceptibility

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11
Q

What is the effect of shock on the skin?

A

Blood supply centralised –> cool/clammy/mottled peripheral skin

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12
Q

What is the main monitoring technique used to help diagnose/manage shock?

A

Modified Early Warning Score (MEWS)
>3 = urgent medical review
>5 = critical care teams involved

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13
Q

How is cardiac output calculated?

A

Stroke volume * Heart rate

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14
Q

How is BP calculated?

A

Cardiac output * Systemic vascular resistance

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15
Q

How is Mean Arterial Pressure calculated?

A

Diastolic BP + ((systolic/diastolic)/3)

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16
Q

What features suggest Systemic Inflammatory Response Syndrome?

A 
2+ from new:
   -temp >38.3o OR <36o
   -RR >20 OR pCO2 <4.3kPa
   -HR >90bpm
   -WCC <4 OR >12*10^9
OR
   -acutely altered mental state OR
   -glucose >7.7 in a non-diabetic
17
Q

What is sepsis?

A

SIRS + a suspected site of infection

18
Q

What defines severe sepsis?

A

Sepsis + hypotension OR evidence of end organ dysfunction

  • oliguria
  • confusion
  • lactate >2
  • SpO2 <94%
19
Q

What is septic shock?

A

Severe sepsis w/ hypotension NOT responding to fludi resus

-results from overactivation of immune system to infective causes

20
Q

What is the acute management of septic shock?

A

SEPSIS SIX + SENIOR REVIEW

  • O2, 15L/min via non-rebreathe (aim 94%)
  • IV fluids, 500ml crystalloid if hypotensive/lactate >2
  • IV a/b, according to local guidelines, w/i 1hr
  • serum lactate/Hb, blood gas (v/a), senior review if lactate >4
  • cultures, prior to a/b if poss, two pairs from separate sites + any indwelling lines + suspected source
  • catheterise, keep strict fluid balance
21
Q

What is anaphylactic shock?

A

Type IgE mediated hypersensitivity reaction

  • mast cells release vasoactive mediators
  • cause excessive vasodilation of venous system
  • bronchoconstriction & laryngeal oedema
22
Q

What is the acute management of anaphylactic shock?

A 
Secure airway
Remove cause
Adrenaline 0.5mg IM (0.5ml 1:1000), repeat every 5mins
Chlorphenamine 10mg IV
Hydrocortisone 200mg IV
Interval bloods for serum tryptase/histamine
If wheeze = treat as asthma
Raise legs
23
Q

What is the further management of anaphylactic shock?

A

ITU admission
ECG monitoring
Epi-pen & skin prick testing

24
Q

What are the different categories of haemorrhagic shock?

A

Class I - 750ml, 15% circulating vol, HR <100
Class II - 750-1500ml, 30% circulating vol, HR >100, narrow pulse pressure
Class III - 1500-2000ml, 40% circulating vol, HR >120, hypotensive
Class IV - >2000ml, 40% circulating vol

25
Q

How do the management options for haemorrhagic shock differ b/w categories?

A

Class I - give crystalloids
Class II - consider giving blood
Class III - give blood, consider surgical management
Class IV - give blood, need surgical management

26
Q

When should the massive transfusion protocol be activated?

A

Haemorrhagic shock
Rapid blood loss
Impending haemorrhagic shock

27
Q

What does the massive transfusion protocol entail?

A 
Delivery of
   -packed cells
   -fresh frozen plasma
   -platelets
Give in 2:1:1 ratio
28
Q

What is the initial management of hypovolaemic shock?

A 
Identify/treat cause of fluid loss &amp; replace
Fluid boluses (250/500ml)
Ionotropes if persistently hypotensive
Permissive hypotension (in haemorrhagic)
   -titrate to 60-70mmHg
   -95-100mmHg if head injury
Tranexamic acid
29
Q

What is the initial management of cardiogenic shock?

A

IV diamorphine 2.5-5mg IV
Assess for pulmonary oedema
Consider Swan-Ganz catheter
-PCWP low = 100mg plasma expander every 15mins
-PCWP fine = ionotropic support, keep SBP >80mmHg
Renal dose dopamine via central line

30
Q

What is neurogenic shock?

A

Inhibition of sympathetic outflow from spinal cord

-vasodilation

31
Q

What are the causes of neurogenic shock?

A

Epidural anaesthesia

Spinal cord injury above T6

32
Q

How does neurogenic shock present?

A

Hypotension & bradycardia not responding to fluid resus

33
Q

How is neurogenic shock managed?

A

Fluid resus

Vasopressors

34
Q

What is spinal shock?

A

Transient concussion of spinal cord

  • flaccid areflexia (resolves as swelling decreases)
  • priapism
  • no reflexes below level of injury
35
Q

What is the ‘Triad of Death’ in trauma pts?

A

Interlinked factors (+ve feedback) suggesting poor outcome

  • coagulopathy
  • hypothermia
  • metabolic acidosis
36
Q

What other factors are responsible for bleeding disorders?

A

Disseminated intravascular coagulation

Haemodilution w/ crystalloids/colloids

CP3 @ UoN - Medicine & Surgery (135 decks)

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