Shock Quiz! By Clare Di Bona

Transcription

1 Shock Quiz! By Clare Di Bona

2 Test Question What is Mr Burns full legal name?

3 Answer Charles Montgomery Plantagenet Schicklgruber Burns. (Season 22, episode 11)

4 Question 1. What is the definition of shock?

5 Answer 1. Shock occurs when 02 delivery to the tissues does not meet demand This leads to cellular hypoxia and damage ie cellular swelling and leakage Can progress to systemic effects ie altered ph, endothelial dysfunction, inflammatory processes This can progress to organ failure

6 Question 2. Is having a low BP necessary for the patient to be in shock?

7 Answer 2. No. Patients with chronic hypertension may have hypoperfusion at a lower BP

8 Question 3. By the bedside how can you examine for evidence of hypoperfusion?

9 Answer 3. Examine the conscious state Temperature of the limbs Urine output Heart rate and blood pressure JVP

10 Question 4. Name two investigations that are helpful in shock

11 Answer 4. ABG, lactate

12 Question 5. What are the signs and symptoms of shock

13 Answer 5. Hypotension, tacchycardia, SOB, restlessness/altered mental state, metabolic acidosis, oliguria, cool and clammy skin

14 Question 6. Common bloods used to investigate shock include: FBP, U&E, coags, troponin, ABG, lactate Are increased lactate levels associated with increased mortality?

15 Answer 6. Yes increased lactate is associated with increased mortality

16 Question 7. Systemic tissue perfusion is determined by CO or SVR or both MAP=CO X SVR CO=? X?

17 Answer 7. Cardiac Output=HRxSV Stroke volume is determined by preload, contractility and afterload SVR is determined by vessel length, blood viscosity and vessel diameter

18 Question 8. Name four different types of Shock

19 Answer 8. Hypovolaemic Cardiogenic Distributive Obstructive

20 Question 9A. Type of Shock HR JVP Peripheries Cardiogenic Raised or Cool Hypovolaemic Cool Distributive A? Obstructive B? cool

21 Answer 9A. In distributive shock the peripheries are initially warm then as shock progresses become cool

22 Question 9B

23 Answer 9B. In obstructive shock the JVP is markedly raised

24 Question 10. Name some causes for hypovolaemic shock

25 Answer 10. Blood loss (trauma, GIT, dissection) GIT (vomiting, diarrhoea) Third-space loss ie post-op, intestinal obstruction, pancreatitis Renal loss ie DKA Skin loss ie sweating, burns

26 Question 11. What is the basic physiological mechanism behind hypovolaemic shock

27 Answer 11. The reduction in preload leads to a reduction in stroke volume (CO). The SVR increases in an attempt to compensate

28 Question 12. What is the most common cause of cardiogenic shock?

29 Answer 12. Myocardial Infarction

30 Question 1 3. What are some other causes of cardiogenic shock?

31 Answer 13. IHD MI acute MR LV aneurysm/rupture Cardiomyopathy Trauma Myocardial contusion Infection Myocarditis LV outflow obstruction HOCM Aortic stenosis LV inflow obstruction Mitral stenosis Left atrial myxoma

32 Question 14. The vasoactive agent of choice in severely hypotensive patients in cardiogenic shock is?

33 Answer 14. NA because of its vasoconstrictor effects (increases diastolic pressure) which increases coronary perfusion pressure and flow

34 Question 15. What is the physiological mechanism behind cardiogenic shock?

35 Answer 15. There is pump failure (low CO) and SVR increases in an attempt to compensate

36 Question 16. Name the most common cause of distributive shock

37 Answer 16. Septic Shock

38 Question 17. By what physiological mechanism does distributive shock lead to decreased tissue perfusion?

39 Answer 17. Distributive shock occurs from peripheral vascular dilation which causes a fall in SVR The CO is generally increased in an effort to compensate

40 Question 18. What are some other causes of distributive shock?

41 Answer 18. Anaphylactic shock Neurogenic shock Acute adrenal insufficiency

42 Question 19. Give a definition of Sepsis and septic shock

43 Answer 19. Sepsis is infection with signs of an inflammatory response (tachycardia, tachypnoea, fever or hypothermia, leucocytosis or leucopaenia) Severe sepsis is sepsis plus evidence of inadequate tissue 02 delivery (confusion, oliguria, raised lactate, hypotension) Septic shock is severe sepsis plus hypotension unresponsive to fluid therapy

44 Question 20. Name examples of samples that can be sent for MC&S

45 Answer 20. Sputum, urine, wound swabs, blood cultures, line tips, catheter tip Two to three sets of blood cultures should be taken prior to antibiotics ( 10ml of blood should be placed in each bottle)

46 Question 21. What is the cornerstone of management of septic shock?

47 Answer 21. Early administration of fluid and antibiotics

48 Question 22. Certain patient groups will not exhibit tacchycardia in sepsis Give an example

49 Answer 22. Elderly, diabetic, patients on beta blockers

50 Question 23. What type of fluid should be administered to a patient in septic shock?

51 Answer 23 No advantage of colloid over crystalloid Crystalloid is cheaper and for that reason given more frequently 5% dextrose is not a good choice given is rapidly leaves the intravascular space

52 Question 24. Give your approach to fluids in septic shock

53 Answer 24. Crystalloids generally used 500ml boluses then check for clinical effects ie BP and tissue perfusion Generally 3-5L over 6hrs but it really depends on patient and care must be taken not to drive the patient into pulmonary oedema

54 Question 25. What vasopressor is used in septic shock?

55 Answer 25. NA

56 Question 26. Give some targets of initial resuscitation in a septic patient ie MAP >65

57 Answer 26. MAP >65 Urine output >0.5ml/kg/hr CVP 8-12 Central venous 02 sats (>70) Follow the lactate until it trends down

58 Question 27. According to therapeutic guidelines what antibiotics should be given for sepsis of unclear origin

59 Answer 27. Gentamicin 4-7mg/kg IV for the first dose plus Flucloxacillin 2g IV 4hrly

60 Question 28. Give examples of obstructive shock

61 Answer 28 Cardiac tamponade Tension PTX PE

62 Question 29 What is cardiac tamponade?

63 Answer 29 Cardiac tamponade is extracardiac obstructive shock, in which mechanical obstruction to cardiac filling exists Always consider cardiac tamponade when JVP is high and BP low The treatment is urgent pericardiocentesis

64 Question 30 Why do people die from a massive PE

65 Answer 30 The mode of death from a massive PE is cardiovascular failure from right heart failure Massive PE increases RV afterload, increases size of the RV Coronary perfusion and CO from R heart fail, decreased contractility and pump failure.

66 Question 31 Name a definitive mode of management for massive PE

67 Answer 31 IV thrombolysis with tissue plasminogen activator probably the treatment of choice Alternatives include surgical embolectomy As soon as the diagonosis is suspected all patients need therapeutic doses of heparin ie IV unfractionated heparin

68 References Gaieski, D. Shock in adults: Types, presentation, and diagnostic approach [Internet] [updated 2013 May 15; cited 2015 March 3]. Available from: Gomersall C, Joynt G, Cheng C, Yap F, Lam P, Lam K et al. Basic Assessment & Support in Intensive Care. Hong Kong: Dept of Anaesthesia & Intensive Care; Schmidt, G. Evaluation and management of severe sepsis and septic shock in adults [Internet] [updated 2015 Feb 25; cited 2015 March 3]. Available from: