32 Questions
What is shock?
It is life threatening circulatory failure that results in cellular and tissue hypoxia
What happens when the cardiac output is low?
RAAS happened
What is the primary function of the RAAS system?
Renin converts angiotensinogen to angiotensin I. Angiotensin-converting enzyme (ACE) converts angiotensin I to angiotensin II, which then stimulates aldosterone release, vasoconstriction, and increases sodium and water retention.
What are the general signs of shock?
Tachycardia, tachypnea, hypotension, decreased peripheral perfusion, and altered mental status
whats Distributive shock
A maldistribution of circulation.
what is Hypovolaemic
A reduction in circulating blood volume
whats Cardiogenic
Pump failure (impaired contractility)
what is Obstructive shock
blockage of circulation to the tissues by impedance of outflow or filling in the heart.
Targeted therapies for hypovolemic shock
Treat underlying cause of hypovolaemia: Wound management/surgical intervention Endoscopy to assess gastrointestinal bleeds Intravenous fluid/blood products/tranexamic acid
target therapy for Cardiogenic shock
Electrocardiogram: assess cardiac rhythm Echocardiogram: assess for cardiac filling and pump failure Percutaneous coronary intervention Intra-aortic balloon pump
target therapy for Obstructive shock
Ultrasound/X-ray/echocardiogram: assess for the source cause Removal of pericardial fluid Needle decompression and chest tube Cardiac surgery
target therapy for Distributive shock
Sepsis: treat infection—use Sepsis 6 or Surviving Sepsis Campaign guidelines Neurogenic: CT scan; treat underlying cause and provide pain relief Anaphylactic: treat effects of antigen with adrenaline, antihistamines, steroids; follow local anaphylaxis algorithms and guidelines
Treatment of Shock
A-E: patient assessment and haemodynamic monitoring essential
Supportive Care: address the complications of shock e.g. mechanical ventilation, sedation, glucose control, renal replacement therapy, DVT prophylaxis and nutrition.
Directed Therapies:
• Distributive: antibiotics (Sepsis) and adrenaline (anaphylaxis)
• Cardiogenic shock: reperfusion therapy (ACS) and cardioversion (tachyarrhythmia)
• Obstructive: thrombolytics (PE), decompression (Tension pneumothorax) and pericardiocentesis (cardiac tamponade)
• Hypovolaemic: haemorrhage control and blood products (Haemorrhagic)
Fluid Resuscitation- CRISTAL Research and National Institute for Health and Care Excellence (NICE, 2017) guidelines
Vasoactive Medications- vaso-constriction, vasodilation and increase in contract
‘FASTHUG’
• F eeding (prevent malnutrition, promote adequate caloric intake)
• A nalgesia (reduce pain; improve physical and psychological wellbeing)
• S edation (titrate to the 3Cs – calm, cooperative, comfortable)
• T hromboembolic prophylaxis (prevent deep vein thrombosis)
• H ead of bed elevated (up to 45 degrees to reduce reflux and VAP)
• U lcer prophylaxis (to prevent stress ulceration)
• G lycaemic control (to maintain normal blood glucose levels)
Shock is a life-threatening circulatory ______ that results in cellular and tissue hypoxia.
failure
The hallmark sign of shock has been a systolic blood pressure (SBP) less than ______ mmHg.
90
Shock is initially ______ but can rapidly become irreversible, resulting in multi-organ failure and death.
reversible
Therapy aims to maintain oxygen delivery to vital organs and prevent ______ and cell death.
ischemia
Hypovolemic Shock is characterized by a reduction in ______ blood volume.
circulating
Cardiogenic Shock is characterized by pump ______ and impaired contractility.
failure
Obstructive Shock is characterized by blockage of circulation to the tissues by impedance of outflow or ______ in the heart.
filling
Fluid resuscitation follows ______ research and National Institute for Health and Care Excellence (NICE) guidelines.
CRISTAL
The FASTHUG mnemonic stands for Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, and ______.
Hydration and Usher out
Shock can be caused by a ______ output problem, leading to activation of the renin-angiotensin-aldosterone system (RAAS).
cardiac
Distributive shock is characterized by a maldistribution of ______, often due to vasodilation.
circulation
The Surviving Sepsis Campaign provides guidelines for the management of ______, emphasizing early antibiotic administration and supportive measures.
sepsis
Neurogenic shock occurs in the presence of acute spinal cord injury above ______, resulting in inhibited sympathetic outflow and dominance of the parasympathetic nervous system.
T6
Adequate perfusion is achieved when Systolic BP is equal to ______ mm Hg.
90-100
Anaphylactic shock is a severe, whole body allergic reaction triggered by exposure to an ______.
allergen
Cardiogenic shock is defined by decreased ______ output (cardiac index).
cardiac
Define sepsis and septic shock according to Sepsis 3
Sepsis: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection.
Define sepsis and septic shock according to Sepsis 3
Septic Shock: Septic shock is a subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality.
What is the management of sepsis?
- Initial Resuscitation: Early goal-directed therapy within the first 3 hours. o Measure lactate levels. o Obtain blood cultures before administering antibiotics. o Administer broad-spectrum antibiotics. o Begin rapid administration of crystalloid fluids at 30 mL/kg for hypotension or lactate ≥ 4 mmol/L. o Apply vasopressors if hypotensive during or after fluid resuscitation to maintain a MAP ≥ 65 mmHg.
- Ongoing Management: o Reassess and adjust antimicrobial therapy based on culture results. o Monitor organ function and provide supportive care as needed (e.g., mechanical ventilation for respiratory failure, dialysis for renal failure). o Control the source of infection (e.g., surgery, drainage).
- Adjunctive Treatments: o Consider corticosteroids for patients with septic shock unresponsive to fluid and vasopressor therapy. o Manage blood glucose levels, targeting ≤180 mg/dL.
- Monitoring and Supportive Care: o Continuously monitor vital signs, urine output, and other parameters to guide ongoing treatment .
Study Notes
Shock and Its Types
- Shock is a life-threatening circulatory failure that results in cellular and tissue hypoxia.
- Hallmark sign: systolic blood pressure (SBP) less than 90 mmHg.
Types of Shock
- Distributive Shock: characterized by maldistribution of circulation, often due to vasodilation.
- Hypovolemic Shock: reduction in circulating blood volume due to hemorrhage or non-hemorrhagic causes.
- Cardiogenic Shock: characterized by pump failure and impaired contractility, with subtypes including cardiomyopathy, arrhythmias, and mechanical causes.
- Obstructive Shock: blockage of circulation to the tissues by impedance of outflow or filling in the heart, with subtypes including pulmonary embolism, pericardial tamponade, and tension pneumothorax.
- Septic Shock: a subset of sepsis with circulatory, cellular, and metabolic alterations associated with higher mortality.
- Neurogenic Shock: occurs in the presence of acute spinal cord injury above T6, resulting in inhibited sympathetic outflow and dominance of the parasympathetic nervous system.
- Anaphylactic Shock: a severe, whole-body allergic reaction triggered by exposure to an allergen.
Causes and Management of Shock
- Causes: cardiac output problem, vasodilation, and maldistribution of circulation.
- Management: initial assessment and hemodynamic monitoring, supportive care, and directed therapies targeting the underlying cause.
- Therapy aims to maintain oxygen delivery to vital organs and prevent ischemia and cell death.
Treatment of Shock
- Fluid resuscitation follows CRISTAL research and National Institute for Health and Care Excellence (NICE) guidelines, with consideration of Surviving Sepsis Campaign guidelines for septic shock.
- Vasoactive medications are used for vasoconstriction, vasodilation, and increased contractility.
- ‘FASTHUG’ mnemonic:
- Feeding: prevent malnutrition, promote adequate caloric intake
- Analgesia: reduce pain; improve physical and psychological wellbeing
- Sedation: titrate to the 3Cs – calm, cooperative, comfortable
- Thromboembolic prophylaxis: prevent deep vein thrombosis
- Head elevation: elevate head of bed to 30-45 degrees
- Upright: sit upright to improve oxygenation
Circulatory Failure in Shock
- Blood flow to tissues is not enough to maintain metabolic function, leading to an imbalance of oxygen supply and demand, resulting in hypoxia at the cellular level.
- Shock is not just about hypoxemia (low oxygen in the blood), but about hypoxia (low oxygen in the cells).
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