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