Acute and emergency for PLAB 1

A 24 year old man is brought in after a stabbing to the abdomen. He is anxious and pale with cool, clammy peripheries. His pulse is 128 beats/minute and his blood pressure is 104/88 mmHg with a narrow pulse pressure. His abdomen is tender with a visible wound. His lactate is 4.2 mmol/L. His jugular venous pressure is not visible and his chest is clear. What is the SINGLE most likely diagnosis?

1. Obstructive shock A raised neck-vein pressure with lungs that are clear or affected on one side only, from a tension pneumothorax, a heart squeezed by fluid, or a large clot in the lungs. But cool skin and a narrow pulse pressure with a bleeding source does not point to it.
2. Neurogenic shock Low blood pressure with a slow pulse and warm hands and feet after a spinal cord injury. That does not match cool skin and a narrow pulse pressure with a bleeding source.
3. Haemorrhage Ongoing blood loss as the exact cause of hypovolaemic shock. Here, cool skin and a narrow pulse pressure with a bleeding source points elsewhere.
4. Anaphylaxis Widened blood vessels with trouble in the airway or breathing minutes after a trigger, often with a rash. It does not fit cool skin and a narrow pulse pressure with a bleeding source.
5. Hypovolaemic shock correct Correct. Cool, clammy skin, a fast pulse and a narrow pulse pressure with the top blood pressure number still holding up, after a stab wound to the abdomen. This is compensated shock from bleeding in a young patient.

The point: Shock means the organs are not getting enough blood, and doctors sort it into types by cause. Hypovolaemic shock (from bleeding or losing fluid) gives cool hands and feet, a fast pulse, a narrow gap between the top and bottom blood pressure numbers (pulse pressure), and a drop in blood pressure only late on, because young patients cope well until they suddenly stop coping. Distributive shock (seen in sepsis, anaphylaxis and nerve injury) gives warm hands and feet, because the blood vessels widen. Cardiogenic shock (from a failing heart) gives a raised neck-vein pressure (JVP) and fluid on the lungs. Obstructive shock (from a tension pneumothorax, a heart squeezed by fluid, or a large clot in the lungs) gives a raised neck-vein pressure with lungs that are clear or affected on one side only. Treat the cause and get the blood flowing properly again: stop the bleeding and give blood in bleeding-caused shock; give fluids and early antibiotics in sepsis; give adrenaline in anaphylaxis. Lactate, and how fast it falls, shows how well the treatment is working. In trauma, doctors let the blood pressure stay a little low on purpose (permissive hypotension) and give balanced blood products rather than a lot of plain fluid, until the bleeding is under control.

Source: Resuscitation Council UK — Advanced Life Support Resuscitation Council UK · tier 2, specialty society or college

A 24 year old man is brought in after a stabbing to the abdomen. He is anxious and pale with cool, clammy peripheries. His pulse is 128 beats/minute and his blood pressure is 104/88 mmHg with a narrow pulse pressure. His abdomen is tender with a visible wound. His lactate is 4.2 mmol/L. His jugular venous pressure is not visible and his chest is clear. What is the SINGLE most appropriate initial investigation?

1. ECG and troponin For suspected cardiogenic shock from a heart attack. Here, cool skin and a narrow pulse pressure with a bleeding source points elsewhere.
2. Assess perfusion, temperature of the peripheries and pulse pressure correct Correct. The cool skin and narrow pulse pressure are what mark this as hypovolaemic rather than distributive shock, and they are checked straight away.
3. Focused ultrasound (FAST or echo) Finds free fluid after trauma, fluid around the heart, or a weak-pumping heart, right at the bedside. It does not fit cool skin and a narrow pulse pressure with a bleeding source.
4. Venous or arterial blood gas with lactate A raised lactate shows how starved the tissues are of blood, and how fast it falls tracks how well the treatment is working. But cool skin and a narrow pulse pressure with a bleeding source does not point to it.
5. Blood cultures and a septic screen For distributive shock from an infection, sent before antibiotics. That does not match cool skin and a narrow pulse pressure with a bleeding source.

The point: Shock means the organs are not getting enough blood, and doctors sort it into types by cause. Hypovolaemic shock (from bleeding or losing fluid) gives cool hands and feet, a fast pulse, a narrow gap between the top and bottom blood pressure numbers (pulse pressure), and a drop in blood pressure only late on, because young patients cope well until they suddenly stop coping. Distributive shock (seen in sepsis, anaphylaxis and nerve injury) gives warm hands and feet, because the blood vessels widen. Cardiogenic shock (from a failing heart) gives a raised neck-vein pressure (JVP) and fluid on the lungs. Obstructive shock (from a tension pneumothorax, a heart squeezed by fluid, or a large clot in the lungs) gives a raised neck-vein pressure with lungs that are clear or affected on one side only. Treat the cause and get the blood flowing properly again: stop the bleeding and give blood in bleeding-caused shock; give fluids and early antibiotics in sepsis; give adrenaline in anaphylaxis. Lactate, and how fast it falls, shows how well the treatment is working. In trauma, doctors let the blood pressure stay a little low on purpose (permissive hypotension) and give balanced blood products rather than a lot of plain fluid, until the bleeding is under control.

Source: Resuscitation Council UK — Advanced Life Support Resuscitation Council UK · tier 2, specialty society or college

A 24 year old man is brought in after a stabbing to the abdomen. He is anxious and pale with cool, clammy peripheries. His pulse is 128 beats/minute and his blood pressure is 104/88 mmHg with a narrow pulse pressure. His abdomen is tender with a visible wound. His lactate is 4.2 mmol/L. His jugular venous pressure is not visible and his chest is clear. What is the SINGLE most appropriate immediate management?

1. Early broad-spectrum antibiotics and fluids for sepsis Given within an hour, alongside blood cultures and a lactate, in septic shock. But cool skin and a narrow pulse pressure with a bleeding source does not point to it.
2. Control external haemorrhage and give blood In bleeding-caused shock, stopping the bleeding and giving blood products rather than plain fluid alone. Here, cool skin and a narrow pulse pressure with a bleeding source points elsewhere.
3. Needle decompression or chest drain for tension pneumothorax For obstructive shock from a tension pneumothorax, done before any scan. That does not match cool skin and a narrow pulse pressure with a bleeding source.
4. Intramuscular adrenaline for anaphylaxis The immediate treatment for shock from anaphylaxis, given with the patient lying flat. It does not fit cool skin and a narrow pulse pressure with a bleeding source.
5. Balanced blood product resuscitation and permissive hypotension in trauma correct Correct. Blood products given together in balance rather than large amounts of plain fluid, and letting the blood pressure stay a little low until surgery has stopped the bleeding.

The point: Shock means the organs are not getting enough blood, and doctors sort it into types by cause. Hypovolaemic shock (from bleeding or losing fluid) gives cool hands and feet, a fast pulse, a narrow gap between the top and bottom blood pressure numbers (pulse pressure), and a drop in blood pressure only late on, because young patients cope well until they suddenly stop coping. Distributive shock (seen in sepsis, anaphylaxis and nerve injury) gives warm hands and feet, because the blood vessels widen. Cardiogenic shock (from a failing heart) gives a raised neck-vein pressure (JVP) and fluid on the lungs. Obstructive shock (from a tension pneumothorax, a heart squeezed by fluid, or a large clot in the lungs) gives a raised neck-vein pressure with lungs that are clear or affected on one side only. Treat the cause and get the blood flowing properly again: stop the bleeding and give blood in bleeding-caused shock; give fluids and early antibiotics in sepsis; give adrenaline in anaphylaxis. Lactate, and how fast it falls, shows how well the treatment is working. In trauma, doctors let the blood pressure stay a little low on purpose (permissive hypotension) and give balanced blood products rather than a lot of plain fluid, until the bleeding is under control.

Source: Resuscitation Council UK — Advanced Life Support Resuscitation Council UK · tier 2, specialty society or college