Shock Flashcards by Sumaya L

What is shock?

Shock is the inadequate perfusion of vital organs.

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What is a late sign of shock in young and fit patients?

drop in BP

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When should resuscitation be performed in young and fit patients with shock?

Resuscitation should be performed prior to a drop in blood pressure.

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What should be done when BP is unrecordable in a patient with shock?

The cardiac arrest team must be bleeped, and basic life support should begin with chest compressions.

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What is the systolic BP threshold indicating low or falling BP that requires specialist support?

Systolic BP below 90, arrange specialist support like ICU

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List some differentials for shock.

Myocardial infarction
Aortic dissection
Cardiac arrhythmias
Valvular disease (e.g., ventricular septal defect post MI)
Drug overdose
Myocarditis

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What can hypovolemia be attributed to?

Fluid loss (diarrhoea, vomiting, polyuria, burns)
Adrenal failure

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What are the types of shock?

Haemorrhagic shock
Neurogenic shock
Cardiogenic shock
Anaphylactic shock

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What characterizes class II haemorrhagic shock?

. class II patients will appear anxious with normal BP.

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What is haemorrhagic shock associated with?

trauma causing internal/external bleeding, aortic dissection or aneurysm or trauma.

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What characterizes class I haemorrhagic shock?

Class I haemorrhagic shock will appear normal with normal BP.

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What characterizes class III haemorrhagic shock?

patients will appearance confused with decreased BP

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What characterizes class IV haemorrhagic shock?

Patients appear lethargic

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What is the management for haemorrhagic shock?

Control bleeding and maintain Hb of 7-8 in those with no risk factors for tissue hypoxia.

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What is the target Hb for blood transfusions in patients with risk factors?

Hb of 10

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What is the minimum arterial pressure required to obtain a palpable femoral pulse in trauma patients?

At least 65 mmHg.

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What is the most important drug in anaphylaxis?

Adrenaline.

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What is the best site for IM injection of adrenaline?

The anterolateral aspect of the middle third of the thigh. it is a 0.5-1MG dose repeated every 5 to 10 minutes depending on BP and pulse.

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What to do if bronchospasm does not subside in shock?

it should be treated like a severe asthma attack by giving salbutamol, aminophylline and intratracheal adrenaline.

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What to do if patients are severely hypotensive in anaphylaxis?

raise their legs and lie them flat.

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What is anaphylaxis?

Anaphylaxis is a severe life threatening type 1 hypersensitivity reaction that presents with skin redness, pruritis, urticaria, conjunctival infection, angio-oedema and rhinitis.

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What are common identified causes of anaphylaxis?

Food (e.g., nuts)
Drugs
Venom (e.g., wasp sting)

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What can obstructive shock occur from?

Cardiac tamponade
Pulmonary embolism
Tension pneumothorax

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What is neurogenic shock most often associated with?

Spinal cord transection, usually at a high level. The result is either decreased sympathetic tone or increased parasympathetic tone, the effect of which is a decrease in peripheral vascular resistance mediated by marked vasodilation.

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What is the physiological effects of neurogenic shock

decreased preload and thus decreased cardiac output (Starling's law). There is decreased peripheral tissue perfusion and shock is thus produced.

How is neurogenic shock uniquely managed?

In contrast with many other types of shock peripheral vasoconstrictors are used to return vascular tone to normal.

What is the main cause of cardiogenic shock?

Ischaemic heart disease For trauma patients, MI or contusion Treatment is supportive

What is the purpose of transthoracic echocardiography in cardiogenic shock?

To determine evidence of pericardial fluid or direct myocardial injury.

What does the ABCDE assessment for shock include?

* Airways * Breathing For RR * Circulation by checking cardiac rhythm and listening for new murmurs * Disability/neurology * Exposure/environment

How are airways managed in emergency?

give high flow oxygen by face mask and check both sides of the chest are rising (suspect tension pneumothorax). For unprotected or inadequate breathing, provide endotracheal tube mask which protects the airways. Laryngeal mask airway aids oxygenation but does not protect the airways.

What to do following ABCDE assessment?

Establish CPR and venous access. For non obvious cause of hypotension, do a rapid clinical examination. Give high flow oxygen Patients should be checked for temperature, capillary refill time, any evidence of blood around th mouth, swelling on the eyelids or lips

What are the investigations for shock?

ECG, chest x ray, FBC, U&Es, glucose, coagulation screen, LFTs, troponin and group and cross match, ABG’s, septic screen.

What is the septic screen?

Septic screen is blood, urine and sputum culture and viral swabs.

What is sepsis?

Sepsis is life threatening organ dysfunction caused by dysregulated host response to infection

What are the features of sepsis?

body temperature outside 36 oC - 38 o C HR >90 beats/min respiratory rate >20/min WBC count >12,000/mm3 or < 4,000/mm3.

What are key areas for attention in sepsis management?

* Prompt administration of antibiotics in first hourto cover all likely pathogens coupled with a rigorous search for the source of infection in the first 6 hours. * Haemodynamic stabilisation * Modulation of the septic response. This includes manoeuvres to counteract the changes and includes measures such as tight glycaemic control. T

What is the aim for haemodynamically stabilisation in sepsis?

MAP >65mmHg and urine output over 0.5ml/kg/h

Which surgical groups are at risk for septic shock?

those with anastomotic leaks, abscesses and extensive superficial infections such as necrotising fasciitis.

What is the most common cause of sepsis?

pneumonia

What is the common causes of sepsis?

1) pneumonia 2) urinary tract 3) abdomen 4) skin, soft tissue, bone and joint

What is the NEWS score used for?

To assess for sepsis based on vital signs: Oxygen saturation, respiratory rate, pulse rate, systolic blood pressure, temperature and level of consciousness or new confusion.

How often should NEWs score be assessed?

NEWS score should be reassessed every 8 hours.

What is a low risk NEWS?

Low risk is a score of 0-4.

What is a low risk NEWS?

Low risk is a score of 0-4.

What is an intermediate risk?

Intermediate risk is 5-6 and there should be a prompt clinical review.

What is a high risk NEWs?

High risk is 7 or more and they should immediately be transferred to an emergency area. A single score of 3 or more in any parameter should prompt a clinical review.

How is patient consciousness assessed?

AVPU: Alert Verbally responsive Pain response Unconscious

What constitutes septic shock?

Severe sepsis with refractory hypotension below 65 mmHg despite adequate fluid resuscitation.

What is the SEPSIS SIX protocol?

* Give oxygen 15L via non-rebreathable mask * Give IV antibiotics * Give IV fluids 500-1000 mL For initial fluid bolus * Take blood cultures before antibiotics * Take lactate levels * Monitor urine output hourly and aim for over 0.5ml/kg/hour

What are potential complications of sepsis?

* ARDS * Ventilator-associated pneumonia

What assessss high risk patients not in ICU for sepsis?

QSOFA score is used to identify high risk patient for hospital mortality from infection in non ICU setting based on clinical symtpoms

What does QSOFA include?

It includes resp rate over 22, altered mental status and systolic BP under 100. 2 or more of these has a high mortality risk.

What is the SOFA score?

SOFA score is used in ICU and includes: bilirubin level blood pressure GCS creatinine urine output platelets oxygen saturation. A score of 2 or more is high risk.

What is associated with poor prognosis in sepsis?

Lactate

What is bactaeremia?

positive blood cultures

What is SIRS?

SIRS is systemic inflammatory response unrelated to infection. There will be at least two of the following: 38.3 Celsius or temp bleow 36 HR 90 bpm WCC over 12 x199 or less than 4

What requires urgent sepsis treatment?

new non-blanching rash mottled skin recent chemotherapy.

What is given for hypotension in shock?

vasopressors like noradrenaline or dobutamine. Vasopressin infusion can be added to noradrenaline.

How to prevent ARDS with ventilation?

giving low tidal volume, driving pressure and Inspiratory plateau pressure.

How to prevent veiltator associated pneumonia?

Patients on mechanical ventilation should have the bed in semi-upright position to prevent ventilator associated pneumonia and improve oxygenation by reducing workload on respiratory muscles. DVT prophylaxis should be given with low dose UFH or LMWH.

What is neutropenia sepsis?

Neutropenia sepsis is when neutrophil count is below 0.5 x 10^9 with fever or features consistent with sepsis. Coagulate negative gram positive bacteria are the most common cause especially staphylococcus epidermidis. It ocurrs due to chemotherapy after 7-14 days

Which drugs cause neutropenia sepsis?

Clozapine Hydroxyclorquinine, methotrexate, sulphasalazine, carbimazole, quinine monoclonal antibodies such as infliximan or rituximab.

What is the management of neutropenia sepsis?

immediate antibiotics with tazaocin ( piperacillin with tazobactam)

What is the difference between bolus and infusion?

Bolus is a rapid infusion that is given Infusion is a fixed rate of fluid given over a period of time.

What is the definition of oliguria?

Urinary output of <400 mL per day in adults.

What is a sign of moderate dehydration in adults?

Prolonged CRT, sunken eyes, reduced skin turgor, oliguria

What are symptoms of moderate dehydration?

Lightheadedness, headache & muscle cramp

What are common blood test abnormalities seen in dehydration?

* ↑ Urea Due to increased urea absorption via ADH * ↑ Albumin from decrease in intravascular fluid * ↑ Haematocrit from decrease in intravascular fluid * higher urea:creatinine ratio

What is the most common cause of hyperalbuminaemia?

Dehydration.

What is the recommended management for neutropenic sepsis?

Immediate antibiotics with tazocin (piperacillin with tazobactam).

What is the role of zinc supplementation in diarrhoea management?

It promotes regeneration of the intestinal lining and reduces the duration and severity of diarrhoeal episodes.

What happens to the Urea:Creatinine ratio in dehydration?

It will be increased due to greater increase in urea compared to creatinine.

How does eGFR appear in dehydration?

It will appear reduced due to increased creatinine.

Why does ↑Urea occur in dehydration?

Due to increased renal reabsorption of urea mediated by ADH.

What causes ↑Albumin in dehydration?

Serum concentration increases due to relative decrease in intravascular fluid.

What causes ↑Haematocrit in dehydration?

Serum concentration of RBCs increases due to relative decrease in intravascular fluid.

What does ORS contain?

* Glucose * NaCl * KCl * Sodium citrate

What is the antibiotic treatment for pneumonia?

Co-amoxicillin with clarithromycin or azithromycin or doxycycline.

What is the antibiotic treatment for hospital-acquired pneumonia?

Piperacillin and tazobactam + gentamicin or amikacin.

What is the antibiotic treatment for intra-abdominal sepsis?

Piperacillin and tazobactam + metronidazole + gentamicin or amikacin.

What is the antibiotic treatment for biliary tract sepsis?

Piperacillin and tazobactam + gentamicin or amikacin.

What is the antibiotic treatment for urinary tract sepsis?

Co-amoxiclav, ciprofloxacin, or fosfomycin.

What is the antibiotic treatment for skin/soft tissue sepsis?

Co-amoxiclav + flucloxacillin and clindamycin.

What is the antibiotic treatment for sore throat sepsis?

Benzylpenicillin.

What is the antibiotic treatment for meningitis sepsis?

Ceftriaxone and amoxicillin or vancomycin, rifampicin, or chloramphenicol.

What causes antibiotic treatment failure?

* Resistant organisms * Ongoing sepsis source * Advanced disease * Ongoing immunosuppression

What causes toxic shock syndrome?

Gram positive bacteria like staphylococci or streptococci, with illness caused by superantigen toxins from localised infection

What are the clinical features of toxic shock syndrome?

* Rapid onset of fever * Diffuse macular rash with desquamation * Hypotension * Diarrhoea and vomiting * Increased risk of DIC * Multi-organ failure

What is the treatment for toxic shock syndrome?

* Limiting toxin production * Draining focal collections * Antibiotic therapy with anti-staphylococcal agents

What is the fatality rate of streptococcal toxic shock syndrome?

50%.

What is Staphylococcal toxic shock syndrome related to?

Severe systemic reaction to staphylococcal exotoxins, notably TSST-1 superantigen toxin.

What are the Centers for Disease Control and Prevention diagnostic criteria for toxic shock syndrome?

* Fever: temperature > 38.9ºC * Hypotension: systolic BP < 90 mmHg * Diffuse erythematous rash * Desquamation of rash * Involvement of three or more organ systems

What is lactic acidosis?

Metabolic acidosis with serum lactate above 4 mmol/L and blood pH less than 7.35.

What are the two types of lactic acidosis?

* Type A: due to tissue hypoperfusion and hypoxia * Type B: occurs without evidence of tissue hypoxia or hypoperfusion

What are common causes of Type A lactic acidosis?

* Septic shock * Cardiogenic shock * Hypovolemic shock * Obstructive shock * Regional ischemia * Cardiopulmonary arrest

What are examples of conditions associated with Type B lactic acidosis?

Type B is when there is absence of tissue hypoxia or hypoperfusion * Biguanide therapy * Diabetic ketoacidosis * Trauma * Malignancies * Excessive exercise * Alcoholism * Toxic alcohols * Cyanide poisoning * HIV infection * Thiamine deficiency

What are some clinical signs of lactic acidosis?

* Shock * Kussmaul respiration * Tachypnoea * Cold peripheries

What receptors does adrenaline act on?

* B1 * B2 * Alpha

What is the effect of adrenaline on the body?

* Increases heart rate * Increases systemic volume

What receptors does dobutamine act on?

* B1 * B2

What is the effect of dobutamine?

It increases heart rate and systemic volume and acts as a vasodilator.

What is dopexamine?

A B2 agonist and dopamine agonist that increases heart rate and is a splanchnic vasodilator.

What is the effect of noradrenaline?

It is an alpha agonist that acts as a vasoconstrictor.

Shock Flashcards

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