1. 4 collapsed patients

2. Shock
Shock is a profound haemodynamic and metabolic disturbance characterised by failure of the circulatory system to maintain adequate perfusion to vital organs.

3. 4 Main types of shock Septicaemic Cardiogenic Anaphylactic
Hypovolaemic

5. Clinical features Features of end-organ under-perfusion e.g. Pallor
cold peripheries
oliguria
(urine output < 30ml/hour)
faints, confusion/agitation
skin colour - pallor, cyanosis, jaundice
pulse rate and volume - carotid pulse
blood pressure
heart and chest sounds
Signs of blood loss
Cerebral hypoperfusion

6. Case 1 A teenager aged 18 is found at home
Febrile and appears confused and is irritable

7. Examination Temperature 39.7 P 120 BP 90/50
Noted to have a faint rash on skin

8. Questions Which illnesses you consider?
What actions need to be undertaken
How quickly should any intervention be made?
What are the potential risks ?
Should any action be undertaken relating to friends or family?

9. Neiserria meningitidis

10. Meningococcal septicaemia
The typical presentations are:
meningitis
sepsis with rash
sepsis without rash
bacteraemia without sepsis (uncommon)
Any of the first three presentations are common, and sepsis without rash in particular is difficult to diagnose clinically.
Key manifestations of meningococcal infection include:
abrupt onset
very rapid progression
haemorrhagic rash, which may be petechial only

11. Septicaemic shock
Complicates 20% of cases of septicaemia. It is a state of profound tissue hypoperfusion with the following features:
evidence of infection
fever or hypothermia
hypotension
tachypnoea
mental confusion
It classically occurs following infection by Gram negative organisms, though in fact shock may also occur due to Gram positive infection as well as fungal infection.

12. Pathogeneisis Exposure to endotoxin
Lipopolysacchride component of bacterial cell wall
Triggers Monocytes, cytokine release, neutrophils and inflammatory mediators
Factor XII release promotes coagulation
Tissue damage
Capillary leakage
Vasodilatation
Intravascular coagulation
Tissue damage and organ failure

13. Treatment Reverse tissue hypoxaemia Circulatory support and monitoring
Monitor urine output
Treat underlying infection

14. Meningococcus
Gram negative
Different types A,B C
B and C commonest in UK
Group B main cause of life threatening septicaemia/meningitis
Vaccine covers A and C not B – who is vaccinated?
Carriage rate

15. Treatment and prophylaxis
IV Benzyl penicillin
Cefotaxime if allergic
Prophylaxis
RifampacinTreatment
Swabs
Notifiable

16. Case 2 A 62 year old man is found at home He is collapsed
He is confused but rousable
He is pale and noted to be sweating

17. Examination
BP 60
Unable to palpate wrist pulse
P 40
HS audible

18. Questions What are the possible causes of this picture?
What actions would you take when this man arrives in A/E?
What tests are available?
Which organs might be particularly at risk?
Actions?

21. Cardiogenic shock Extreme form of cardiac failure.
Characteristic features:
poor tissue perfusion:
poor cerebral function
cool extremeties
oliguria
hypotension
poor cardiac output
Cardiogenic shock is most commonly caused by myocardial infarction.
Mortality approaches 90%.

22. Management 100% O2 Analgesia Aspirin Thrombolysis PTCA/Stent
Correct bradycardia
Inotropic support
Monitor urine output

24. Case 3 A 22 year old student is our with friends for a curry
He suddenly collapses
He is noted to be pale and cold

25. Examination BP 70/50 P 100 Raised rash on trunk and legs
Swelling of lips
Audible wheeze

26. Questions What is the likely cause of this collapse?
What are the possible precipitants of the condition?
Why has this mans BP dropped?
What actions need to be taken?

27. Aetiology food is particularly significant in children
Most commonly encountered precipitants include food, drugs and venom
Relative significance of these factors varies with the age -
vaccines
drugs:
antibiotics
heparin
neuromuscular blocking agents
iron injections
anti-inflammatory analgesics
contrast media
hyposensitising agents
insect bites and stings- wasp, bee
blood products
certain foods, for example peanuts, almonds,walnut, fish,milk
food is particularly significant in children
drugs being a much more common cause in the elderly.
it is more likely to occur after parenteral injections. The reaction is likely to be more severe if the patient is re-exposed.
although atopic patients are more susceptible, why some individuals should react so markedly to this repeat exposure to an antigen is not understood.

31. Case 4
A jockey is thrown from his horse on the racecourse at Newmarket
When the doctor arrives he is responding to pain
His radial pulse cannot be felt

32. Examination Noisy respiration Responding to pain
P 120 carotid but not palpable at wrist
Sweating

33. Questions What will kill this man first?
What does the doctor need to do first ?
What is the AVPU score?
What is the most likely reason for the tachycardia and the low BP?
Where in the body might he be loosing blood and how much?
What actions are required?

34. Hypovolaemic shock – early symptoms
Tachycardia (catecholamine release)
Skin pallor (vasoconstriction)
Hypotension (hypovolaemia)
Confusion, aggression, drowsiness, and coma (cerebral hypoxia and acidosis)
General weakness (hypovolaemia)
Thirst (hypovolaemia)
Reduced urine output (reduced perfusion)

35. Hypovolaemic shock Causes Blood loss overt Blood loss concealed
Hypovolaemia is assessed using urine output, pulse rate, blood pressure and capillary return.
These may be used to determine the grade of shock.
Capillary return is said to be decreased if the blanching of skin produced by pressure at an extremity remains longer than 2 seconds, or the time to say "capillary return".
A drop in blood pressure, i.e. grade III, is a late sign in shock and is often preterminal.
Causes
Blood loss overt
Blood loss concealed
Dehydration ( DKA, Vomiting and diarrhoea)

36. Grades of hypovolaemic shock
15% blood volume (~750 ml)
Mild resting tachycardia
Grade 2
% blood volume ( ml)
Moderate tachycardia, fall in pulse pressure, delayed capillary return
Grade 3
% blood volume ( ml)
Hypotension, tachycardia, low urine output
Grade 4
40-50% blood volume ( ml)
As above but with profound hypotension

38. Always think of the spleen

40. Signs to watch during fluid replacement
Peripheral oxygen saturations
Pulse
Respiratory rate
Urine output
Base deficit/lactate (from arterial blood)
Temperature
Mental state
Pulse pressure
Central venous pressure
Arterial pressure

41. Questions