Shock

Question 1

What is the definition of shock?

Answer 1

Inadequate peripheral tissue perfusion which leads to decreased oxygen and nutrient provision for tissue cells

Question 2

What are the 4 stages of shock?

Answer 2

1. Initial
2. Compensatory
3. Progressive
4. Refractory

Question 3

What is the initial state?

Answer 3

1. Hypoxia which leads to decreased ATP produced by the mitiochondria
   - this damages the cell membranes and they start to leak into the extra-cellular fluid
   - anaerobic respiration occurs and pyruvic acid and oflactic is produced

Question 4

What is the compensatory state?

Answer 4

• neural, hormonal, biochemical mechanisms occur to reverse the initial stage
• hyperventilation occurs to get rid of the carbon dioxide to corrector the pH
• cushings reflex (increased blood pressure) because increase in adrenaline(increases heart rate) and noradrenaline(causing vasoconstriction)
• the renin-angiotensin axis which conserves fluid
• this is all to divert fluid to the heart, brain and lungs

Question 5

What is the progressive state?

Answer 5

• compensatory mechanisms fail
• anaerobic metabolism continues and there is potassium effluent and and sodium influx
• metabolic acidosis leads to blood pooling in the capillaries
• the increase of hydrostatic pressure and histamine release leads to leakage of fluid and protein into the surrounding area
• prolonged vasoconstriction leads to vital organ compromise

Question 6

What is the refractory state?

Answer 6

1. Vital organs fail and shock cannot be reversed

Question 7

What are the 6 types of shock?

Answer 7

1. Hypovolaemic
2. Cardiogenic
3. Neurogenic
4. Obstructive
5. Septic
6. Anaphylactic

Question 8

What is hypovolaemic shock?

Answer 8

• Decreased volume circulating through the blood

- causes include haemorrhage, ruptured ectopic pregnancy, burns, acute pancreatitis

Question 9

What is cardiogenic shock?

Answer 9

• inability of the heart to pump effectively

- associated with myocardial infarction, cardiomyopathy, arrythmias

Question 10

What is neurogenic shock?

Answer 10

-trauma to spinal cord leading to loss of motor and autonomic reflexes

Question 11

What is obstructive shock?

Answer 11

The flow of blood is stopped so this impedes circulation

• cardiac tamponade
• tension pneumothorax
• pulmonary embolism
• aortic stenosis

Question 12

What is septic shock?

Answer 12

Severe sepsis and hypotension that cannot be reversed with fluids

Question 13

What is the criteria for septic shock?

Answer 13

1. Systolic BP of less than 90 mmHg or mean arterial BP of less than 60 mmHg
2. Tachypnoea>20 breaths per minute
3. WCC of less than 4000 cells or more than 12000 cells
4. HR>90 beats per minute
5. Temp: >38 degrees and <36 degrees

Question 14

What does the pneumonic OVERS mean?

Answer 14

1. Oxygen administration and airway
2. Volume resus: crystalloids and colloids
3. Early antibiotic administration
4. Rapid source identification and control
5. support major organ dysfunction

Question 15

When should we start AB treatment if the patient is in septic shock?

Answer 15

At least an hour into the sepsis

• broad spectrum
• do blood culture before you administer AB

Question 16

What is the management for Hypovolaemic shock?

Answer 16

1. Full blood count-Haematocrit
2. U&E
3. Creatinine
4. Troponin T(cardiac enzymes)
5. Arterial blood gas(metabolic acidosis)
6. CVP line to check fluid resus
7. Give fluid-1L crystalloid over 1 hour

Question 17

What is the management for cardiogenic shock?

Answer 17

1. ECG

2. Troponin T

Question 18

What is the Mx for obstructive shock?

Answer 18

1. Tension pneumothorax-insert 14G cannula in the 2nd intercostal space midclavicular line
2. Cardiac tamponade: 500ml normal saline IVI, IV dopamine infusion 5mcg/kg/min, pericardiocentesis
3. Pulmonary embolism: FBC,U&E,ECG,ABG, Pain relief, fluid resus and inotropic support, IV 5000U of heparin bolus, gold standard=pulmonary angiogram

Question 19

What is cardiac tamponade/pericarditis?

Answer 19

Fluid or effusion surrounding the heart presenting with

• muffled heart sounds
• jugular venous distension
• diffuse ST elevation
• hypotension

Question 20

What is the management of neurogenic shock?

Answer 20

1. Manage the site of trauma
2. Do neuro exam
3. Do C-spine X-ray up to C7/T1 for swimmers view/open mouth view if C1/2 injury
4. Thoracivc and lumbar spine X-ray
5. CT scan
6. MRI scan later
7. Fluid resus and compare and titrations according to urine output
8. Use vasopressors if the fluid resus is not working
9. Refer to neuro/ortho

Question 21

What is the management of anaphylactic shock?

Answer 21

1. Stop the allergen
2. Gastric lavage and activated charcoal if drug was ingested
3. Obtain airway by intubation
4. Give fluids-hartmans solution of normal saline 2L
5. Give adrenaline
6. Give glucagon if adrenaline has failed or if adrenaline is contra-indicated-IHD, pregnancy, severe HPT
   IV/IM 0,5-1mg
7. Give an anti-histamine- Promethazinee 25mg IM/IV
8. Cimetidine 200/400mg IV bolus if above does not work
9. Salbutamol
10. Hydrocortisone (corticosteroid) 200-300 mg IV bolus

Question 22

What is the management of septic shock?

Answer 22

1. Identify site of infection
2. FBC, U&E,Creatinine,ABG,ECG,CXR, Urine C/S
3. Rapid infusion 1-2L crystalloids and CVP line insertion
4. Give antibiotics- 3rd generation cephalosporin- 1g IV ceftriaxone or quinolone (ciprofloxacin 200 mg)

Question 23

What is a CVP line?

Answer 23

• can be placed at 3 different points: jugular, subclavian and femoral
• can be used to give fluids, medication, chemotherapy and for longer operations

Question 24

Give an example of an aminoglycoside

Answer 24

-gentamycin

Question 25

Give an example of a quinolone

Answer 25

-ciprofloxacin

Question 26

Define angioedema?

Answer 26

- edema of the deeper layers of the skin - usually non-pruritic - can be/without numbness and pain

Question 27

What is urticaria?

Answer 27

-oedematous and pruritic plaques with raised edges and a pale center