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A messy on callA messy on call
Mr JamesMr James• Age 48 • Works as head lad
in racing• Vomited • Seen at home and
is drowsy but also noted that he has some coffee grounds in his vomit
QuestionsQuestions• What does the story suggest?• What might have caused this?• Can you think of possible causes?
Admitted to hospitalAdmitted to hospital• Seen in Accident
department• Examination• Slightly yellow• Dupytren’s
contracture• Spider naevi• Abdomen – looks
bloated• Tip of spleen is felt
QuestionsQuestions• What are the causes of the clinical
signs?• Why is his spleen enlarged?
QuestionsQuestions• What is portal hypertension and what
are the effects?• How can you tell clinically
Sudden deteriorationSudden deterioration• Collapses• Low blood pressure • Very drowsy• Passes very smelly
and black stools
QuestionsQuestions• What is this called?• Why has he collapsed?
ThenThen• Massive vomit• 2 litres of bright red fresh blood• BP now just palpable• Carotid pulse 120• Cannot feel radial pulse• Sweating
QuestionsQuestions• What might have happened now?• What would you need to do to help
him?• What investigations would you
arrange in the emergency department?
• What test might he need now?
OliguriaOliguria• What does this mean?• Why does this occur?• What is the risk if this is not treated?
ShockShock• What do we mean by shock?• What are the main types of shock?
WHAT IS SHOCK?WHAT IS SHOCK?
Inadequate Tissue Perfusion
Symptoms of ShockSymptoms of Shock
• Anxiety /Nervousness
• Dizziness• Weakness• Faintness• Nausea & Vomiting• Thirst• Confusion• Decreased UO
• Hx of Trauma / other illness
• Vomiting & Diarrhoea
• Chest Pain• Fevers / Rigors• SOB
General Symptoms Specific Symptoms
Signs of ShockSigns of Shock
Pale
Cold & ClammySweatingCyanosis
TachycardiaTachypnoea
Confused / AgitatedUnconsciousHypotensiveStridor / SOB
Circulatory HomeostasisCirculatory Homeostasis
BP = CO X PVR
CO – Cardiac OutputPVR – Peripheral Vascular resistance
Tissue perfusion is driven by blood pressure
What makes up blood What makes up blood volumevolume
Plasma
RBCs
WBCs
Platelets
What Alters Blood Volume?What Alters Blood Volume?• Haemorrhage
• Plasma Loss
• Redistribution of Extracellular Volume
Heart RateHeart Rate• Heart rate increases as a
compensatory response to Shock
• Rarely you get High Output failure
Heart rate too fast to allow adequate refilling of heart between beats
Peripheral Vascular ResistancePeripheral Vascular Resistance
PVR regulated by ARTERIOLAR tone.
Dilatation opens Arteriovenous
beds & increases volume of
circulatory system
What Alters PVR?What Alters PVR?• Circulation cytokines & Inflammatory
mediators (e.g. Histamine)
• Endotoxins
• Drugs (e.g. Nitrates)
Types of ShockTypes of ShockHypovolaemic
Cardiogenic
Redistributive
HypovolaemicHypovolaemic• Volume Loss
• Blood loss -HaemorrhagePlasma Loss -Burns / Pancreatitis
ECF Loss- V&D
CardiogenicCardiogenic• Pump Failure
May be due to • inability of heart to Contact• Inability of heart to pump blood
RedistributiveRedistributive• Decreased Peripheral Vascular
Resistance
• Septic Shock• Spinal / Neurogenic Shock• ANAPHYLACTIC shock