SHOCK & SEPSIS

Catherine Rowan F2

Aims & Objectives

To understand what shock is
To know about the different types of shock Initial management of shock To know the septic 6/ Surviving sepsis campaign ALL ACT TOPICS!!! TO HELP YOU PASS FINALS

Why is it important?
Not only essential for finals but...

....You WILL see this as an F1 and you MUST manage it ....Patients get SICK if you miss it ....Early recognition & management reduces mortality

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Image 1

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What is SHOCK?
Inadequate tissue perfusion and delivery of oxygen to the tissues of the body
Shock and hypotension do not have to coexist

Consequence of Shock
Hypoperfusion

Tissue Hypoxia Switch to anaerobic metabolism Lactic acidosis

Diagnosing shock
Clinical diagnosis Cool sweaty skin Decreased cap refill HR (beware of Beta blockers) RR urine output
BP

Stages of shock
Compensated Uncompensated Pre-terminal

Heart rate

Mild tachycardia (bounding pulse)

Diastolic Slight

Mod tachy (weak and thready pulse)

BP Marked

Extreme tachy/brady/ dysrhythmias

BP rate & volume

BP RR

Skin

CRT > 2s Cool, clammy (except early septic)

Reduced Mild agitation & Confusion

Cold, mottled

Pale

Urine output Level of consciousness

Anuric Confusion or unconsciousness

Anuric React to pain / unconscious

A bit of physiology...
MAP = Cardiac Output X Total Peripheral Resistance
Heart Rate Stroke Volume

Preload

Afterload Contractility

Hypovolaemic
LOSS OF VOLUME

Examples: 1. Haemorrhage
External- trauma, GI tract b. Itrathoracic / Intra-abdo (AAA) /Intra-pelvic (ectopic)
a.

2.
a.

Fluid loss
Diarrhoea & Vomiting b. Burns

MAP = Cardiac Output X Total Peripheral Resistance

Heart Rate Stroke Volume

Preload

Contractility

Afterload

Distributive shock
LOSS OF VASCULAR CONTROL (reduced

systemic resistance) Examples:

o Anaphylaxis o Septic shock o Neurogenic shock (not spinal shock)

MAP = Cardiac Output X Total Peripheral Resistance

Heart Rate Stroke Volume

Preload

Contractility

Afterload

Cardiogenic
HEART NOT WORKING PROPERLY Examples
o contractility- MI, Cardiac failure, Cardiomyopathy
o Mechanical dysfunction- Valvular o Arrhythmia- Bradycardia o Cardiotoxicity e.g. Beta blocker

MAP = Cardiac Output X Total Peripheral Resistance

Heart Rate Stroke Volume

Preload

Afterload Contractility

Obstructive
IMPAIRED VENTRICULAR FILLING OR

OUTFLOW OBSTRUCTION
Examples
o Tension pneumothorax

o Cardiac tamponade
o Massive Haemothorax o PE

MAP = Cardiac Output X Total Peripheral Resistance

Heart Rate Stroke Volume

Preload

Afterload Contractility

Dissociative
Something that does not allow O2 to reach the

cells/ Inability to release oxygen to the tissues

Examples
o CO poisoning
o Cyanide o Anaemia

Types of shock

Figure 1: Types of shock

Figure 2. Adapted from Shock Lecture by Dr Tim Lovells , Consultant anaesthetist, University of Bristol

CVP

Cardiac Output

Hypovolaemic
Distributive Cardiogenic Obstructive Dissociative

Peripheral Resistanc e

Distinguishing between type of shock

SHOCK Check JVP Raised Not raised

Bounding Cool Postural No lung pulse + peripheri hypotension signs warm skin es + wet + cool skin lung Hypovolaemic Cardiogenic Obstructive Septic

History
Trauma?

Pregnant?
Acute abdominal pain? Vomiting or Diarrhoea? Haematemesis? Fever? Focus of infection? Chest pain? Drugs/ allergies?

Initial management approach

A- ?stridor B- Oxygen, monitor sats, check for creps C Access, bloods, Fluid resuscitation (except

cardiogenic!!), ECG, monitor UO (catheter), ?JVP raised D- GCS E- ?rash ?blood ?DVT ?oedema ?Examination findings to point towards cause? Abdo exam Specific Rx of type of shock dealing with e.g. Thrombolysis, adrenaline in anaphylaxis RE-REVIEW patient Escalate- ?art line ?measure cardiac output ?need haemofiltration ?medications ?Central line

Investigations
Bedside- ECG, ABG- Lactate

Simple radiological- CXR

Bloods- FBC, electrolytes, ?cultures Special tests ?Echo

Drugs
Vasoconstrictors
For distributative
E.g. Noradrenaline

Inotropes
Low cardiac output states E.g. Adrenaline, dobutamine, dopamine, milidrone

SEPSIS

SIRS
2 or more of: Temp >38or <36 HR >90bpm Respiratory rate > 20 or PaCO2 <4.3kPa WCC >12 or <4 x 109 cells/L

Can get SIRs from pancreatitis, trauma, burns

Severe Sepsis

Figure 3

Recognising the septic patient

Initially vasodilation- warm extremities. Later

stages cold. Increased vascular permeability- relative hypovolaemia Not necessarily pyrexial

Initial Assessment & Management

Airway Breathing- RR Sats Chest clear? Administer oxygen, ?ABG Circulation- HR, BP, CRT, IV access, Bloods incl Cultures, VBG, Fluid resuscitation, urine output Disability- BM Exposure- temp? Source? ANTBIOTICS!! Initial Ix- CXR, Urine dip ?Catheter ?abscess need draining

Image 4

The septic six or BUFALO

Blood cultures

Urine output
Fluids

Antibiotics
Lactacte Oxygen
...Within

1 hour

Fluid resuscitation ?CVP Oxygen +/- ventilation Vasopressors Inotropic agents

Monitor and Minimise organ damage e.g. DIC

Therapeutic goals
CVP 8-12mmHg

MAP 65mmHg
Urine output >0.5ml/hr Central venous saturations >50%

Complications & Outcomes

ARDS

Circulatory failure
Acute renal failure Haemostatic failure- DIC Severe sepsis mortality rate 20-30%1. Depends

on age and co-morbidities.

Practice Questions
Q1. Part A An elderly gentleman presents to A&E with a 2 day history of cough with green sputum. Obs: temp 39 HR 120 BP 80/40 RR30 sats 90% on air. Chest examination: right basal crackles. What best defines this patients condition? a) Systemic inflammatory response syndrome (SIRS) b) Sepsis c) Severe sepsis d) Septic shock e) Multi-organ dysfunction syndrome (MODS)

Q. 1 Part B What is your first step in managing this patient? a) IV fluids b) Antibiotics c) Take blood cultures d) Supplementary oxygen e) Vasopressors

Q3.
a)

What is this?

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b) What antibiotics would you give?

Q4. You are called to see Mrs Jones; she has become acutely unwell. Obs: RR 30 HR 106 BP 86/54 Sats 92% on RA. On ascultation of her chest she has muffled heart sounds. This is her CXR. What does it suggest? What type of shock are they in?

X ray 1

Q5. Mr Taylor has become acutely SOB. He is clammy/ sweaty and peripherally shut down. RR 35 Sats 90% RA BP 90/60. a) What type of shock? b) What does his CXR suggest? c) How would you manage this?

Figure 4

X ray 2

Q6. You are called to review Mrs Gates rash a) What type of rash is it? She starts to look more unwell while you are with her and has difficulty breathing. Repeat obs: RR 30 sats 93% on RA BP 100/60 HR 110. On ascultation of the chest she has stridor.
b) How will you manage her?

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General tips for finals

OSCE- get in groups/ housemates and go

through scenarios Work together Dont get too worried by your peers...everyone has different areas of expertise They are looking for safe F1 doctors

Summary
The most important thing about shock is

RECOGNISING it SIRS is an important knowledge point Know the septic six Use ABCDE approach

Any questions?
Thank you

References
Davey, P. (2010) Medicine at a Glance. Third edn. Wiley-Blackwell Publishing 2. The ABCs of emergency medicine http://www.emergencymedicine.utoronto.ca/Assets/EmergeMed+Digital+Assets/education/ugra d/The+ABC$!27s+of+Emergency+Medicine.pdf [09/01/14] 3. Dellinger et al., (2012) Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock. Critical Care Feb2013 ,Vol 41 No.2 582-637 http://www.sccm.org/Documents/SSC-Guidelines.pdf 4. J. Wyatt et al., (2012) The Oxford Handbook of Emergency medicine. Oxford University Press Images 1. http://www.speareducation.com/spear-review/2013/08/anterior-resin-restorations-which-resindo-i-use/confused-dentist-2/ 2. http://www.bbc.co.uk/news/uk-wales-mid-wales-11380970 3. http://www.123rf.com/photo_9486907_portrait-of-smiley-medical-doctor-showing-thumbsup.html 4. Google Images 5. http://www.ocbmedia.com/meningitis/diagnosis.php Figures 1. Google Images 2. Adapted from Shock Lecture by Dr Tim Lovells , Consultant anaesthetist, University of Bristol. 3. http://nrsged.wikispaces.com/6.+SIRS+vs+Sepsis 4. http://www.survivingsepsis.org/Bundles/Documents/SSC_Bundle.pdf 5. http://medmnemonics.wordpress.com/2011/03/04/heart-failure-chest-x-ray-signs-2/ X rays 1. http://www.learningradiology.com/images/cardiacimages1/cardiacgallerypages/Pericardial%20e ffusion.html
1.

SAVE AS!!