SHOCK

Question 1

Define shock

Answer 1

• Shock is a life threatening condition of inadequate circulatory functioning
• Inadequate tissue perfusion resulting in impaired cellular metabolism and functioning
• potentially life-threatening

Question 2

Discuss the pathophysiology relating to the four stages of shock

Answer 2

Initial stage:

• hypo-perfusion begins
• imbalance between supply and demmand
• anaerobic metabolism begins
• cellular acidosis is developing

Compensatory stage:

• Compensatory mechanisms activated (decreased CO stimulates baroreceptors and chemoreceptors –> adrenaline and noadrenaline released)
• Blood flow to the heart lungs and brain is maintained (decreased blood flow to the kidneys, RAAS activated, ADH released)

Progressive stage:

• compensatory mechanisms fail
• Decreased ATP production
• Hypoxia of vital organs
• decreased cellular perfusion and tissue ischaemia
• Failure of sodium-potassium pump
• Altered cell membrane permeability
• Metabolic acidosis
• Decreased CO
• Myocardial Ischaemia
• Increased gastric ulcers and GI bleeding
• Increased risk of disseminated intravascular coagulation
• Acute renal failure
• Aggressive management required to prevent MODS

Irreversible/Refractory stage:

• Compensatory mechanisms overwhelmed
• severe tissue hypoxia with ischaemia, necrosis and death of cell
• build up of toxins
• MODS
• recovery unlikely

Question 3

Identify the clinical manifestations of the four stages of shock

Answer 3

• hypotension
• hypoxia
• tachy/bradycardia
• decreased UO
• diaphoresis

Question 4

Identify the four classifications of shock

Answer 4

• Cardiogenic
• Hypovolaemic
• Distributive
• Obstructive

Question 5

Identify the three types of distributive shock

Answer 5

• Septic shock
• Anaphylactic shock
• Neurogenic shock

Question 6

List the causes of the types of distributive shock

Answer 6

• Septic shock (infection - inflamm)
• Anaphylactic shock (allergic reaction - allergen)
• Neurogenic shock (lesions or pressure on the spinal cord)

Question 7

Discuss ‘cold’ shock

Answer 7

• Usually a late and ominous stage of septic shock
• Generally irreversible and indistinguishable from terminal hypovolaemic shock
• Characterised by a decreased cardiac output, low temperature, and low WCC

Question 8

Discuss ‘warm’ shock

Answer 8

• Usually 1st phase of septic shock preceding cold shock
• characterised by high cardiac output and low peripheral vascular resistance
• fluid begins to shift into third spaces

Question 9

Identify the three primary aims in the management of shock

Answer 9

• fluid replacement
• reperfuse
• identify and treat cause
• prevent MODS

Question 10

Outline the aims of ED management for Hypovolaemic shock

Answer 10

Airway - assess and secure
Breathing - Maximise O2 carrying capacity
 - Assess RR/WOB/SpO2/ABG’s (PaO2>80mmHg)
 - apply O2T
 - appropriate ventilation
Circulation - 
Assess:
– Source of fluid loss,
– HR, BP, Cap refill, Peripheral pulses, U/O, ECG/CCM
Interventions:
– Control external bleeding
– Two large bore IVC
– Fluid resuscitation
– CVC
– Artline
– IDC
– Where indicated adrenaline NOT NORADRENALINE

Question 11

Compare the administration of crystalloid and colloid for fluid resuscitation

Answer 11

Crystalloids:

• salts and electrolytes
• commonly used for intravascular expansion
• low molecular weight
• inexpensive
• readily available
• short half-life
• extravascular space expander

Colloids:

• large molecules
• provide oncotic pressure as well as intravascular volume
• longer half life
• risk of anaphylaxis
• not readily available
• intravascular space expander

Question 12

Discuss the administration of blood products to a patient in a shock state

Answer 12

• Blood products are most suitable in a hypovolaemic shock from an origin of blood loss
• blood products should be used cautiously as it is a colloid solution and cannot pass through the membrane. Therefore could cause fluid overload.

Question 13

Define systemic inflammatory response syndrome (SIRS)

Answer 13

Systemic inflammatory response syndrome (SIRS) is an inflammatory state affecting the whole body. It is the body’s response to an infectious or noninfectious insult. Although the definition of SIRS refers to it as an “inflammatory” response, it actually has pro- and anti-inflammatory components.

Question 14

Define multiple organ dysfunction syndrome (MODS)

Answer 14

Medical Definition of multiple organ dysfunction syndrome.: progressive dysfunction of two or more major organ systems in a critically ill patient that makes it impossible to maintain homeostasis without medical intervention and that is typically a complication of sepsis and is a major factor in predicting mortality

Question 15

List the causes / predisposing factors for MODS

Answer 15

Sepsis and septic shock are most common causes
Other triggers:
– Burns,
– Acute pancreatitis
– Major surgery
– Severe trauma
– Circulatory shock
– ARDS
– Necrotic tissue

Question 16

Discuss pro-inflammatory and anti-inflammatory mediators

Answer 16

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Question 17

Discuss the mechanism of tissue injury in MODS

Answer 17

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Question 18

Discuss the ED management of a patient with MODS

Answer 18

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Question 19

Define the terms positive and negative inotrope

Answer 19

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Question 20

Define the terms ‘positive chronotrope’ and ‘negative chronotrope’

Answer 20

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Question 21

Define cholinergic transmission

Answer 21

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Question 22

List the two types of adrenergic receptors and their location

Answer 22

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Question 23

Describe the effects when adrenergic receptors are stimulated

Answer 23

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Question 24

List the location and action of dopaminergic receptors

Answer 24

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Question 25

Discuss the use of Adrenaline in the critically unwell patient

Answer 25

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Question 26

Discuss the use of Noradrenaline in the critically unwell patient

Answer 26

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Question 27

Discuss the use of Isoprenaline in the critically unwell patient

Answer 27

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Question 28

Discuss the use of Dopamine in the critically unwell patient

Answer 28

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Question 29

Discuss the use of Dobutamine in the critically unwell patient

Answer 29

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Question 30

Discuss the use of Metaramimimol in the critically unwell patient

Answer 30

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Question 31

Outline the risk factors that would increase your index of suspicion for a patient presenting with signs of shock

Answer 31

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Question 32

Describe the three main aims of shock management

Answer 32

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Question 33

Explain the interventions that are available in your ED to increase arterial oxygenation

Answer 33

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Question 34

Identify the interventions that are available to you in the ED to improve tissue perfusion

Answer 34

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Question 35

Provide an example of a colloid solution found in your department

Answer 35

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Question 36

Discuss fluid resuscitation, including type of fluid, for a patient in cardiogenic shock

Answer 36

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Question 37

Outline the benefits for using packed cells, plasma and platelets

Answer 37

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Question 38

Differentiate between an inotrope and a chronotrope

Answer 38

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Question 39

Specify where α-adrenergic receptors are located and when stimulated explain the effect

Answer 39

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Question 40

Specify where β-adrenergic receptors are located and when stimulated explain the effect

Answer 40

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Question 41

Specify where dopeminergic receptors are located and when stimulated explain the effect

Answer 41

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Question 42

Which receptor is stimulated when adrenaline is administered

Answer 42

– Catecholamine – Direct acting sympathomimetic – α and β agonist – Low doses β effects – e.g. increase HR – Higher doses – α effects – e.g. vasoconstriction – Maintains coronary and cerebral blood flow

Question 43

Which receptor is stimulated when noradrenaline is administered

Answer 43

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Question 44

Which receptor is stimulated when isoprenaline is administered

Answer 44

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Question 45

Which receptor is stimulated when dopamine is administered

Answer 45

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Question 46

Which receptor is stimulated when dobutamine is administered

Answer 46

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Question 47

Which receptor is stimulated when metaraminimol is administered

Answer 47

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Question 48

List the adverse reactions of adrenaline

Answer 48

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Question 49

List the adverse reactions of noradrenaline

Answer 49

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Question 50

List the adverse reactions of isoprenaline

Answer 50

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Question 51

List the adverse reactions of dopamine

Answer 51

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Question 52

List the adverse reactions of dobutamine

Answer 52

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Question 53

List the adverse reactions of metaraminimol

Answer 53

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Question 54

For each shock state identify which inotrope would be most appropriate and rationalise why

Answer 54

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Question 55

Discuss the nursing considerations when administering inotropes to a patient in a shock state

Answer 55

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Question 56

Explain the ED management of a patient presenting with anaphylactic shock

Answer 56

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Question 57

Discuss the ED management of a patient presenting in septic shock

Answer 57

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Question 58

Describe the complications of a persistent hypothermic state and how are they treated

Answer 58

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Question 59

Explain the mechanism of tissue injury in MODS

Answer 59

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Question 60

Discuss the supportive care of a patient with MODS

Answer 60

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Question 61

A 56 year old male presents to the ED complaining of spontaneous onset of severe back pain whilst watching TV. The patient has a past history of hypertension and obesity. On arrival the patient is diaphoretic, anxious and complaining of 6/10 back pain. His abdomen is hard and distended. An abdominal aortic aneurysm is suspected. On returning from an ultrasound the patient becomes difficult to rouse, responds only to verbal stimuli and BP is 80 systolic. Discuss your assessment management and rationale for this case

Answer 61

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Question 62

Outline the aims of ED management for Cardiogenic shock

Answer 62

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