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. Shock Inadequate tissue perfusion, with the mechanism identified from the examination and history. Cool peripheries and a narrow pulse pressure with a bleeding source fits.
2. Neurogenic shock Hypotension with bradycardia and warm peripheries after a spinal cord injury. Cool peripheries and a narrow pulse pressure with a bleeding source makes it distinct.
3. Haemorrhage Ongoing blood loss as the specific cause of hypovolaemic shock. Cool peripheries and a narrow pulse pressure with a bleeding source makes the source the priority.
4. Anaphylaxis Vasodilation and airway or breathing compromise minutes after a trigger, often with a rash. Cool peripheries and a narrow pulse pressure with a bleeding source raises it.
5. Hypovolaemic shock correct Correct. Cool clammy peripheries, tachycardia and a narrow pulse pressure with a maintained systolic, from a penetrating abdominal wound. This is compensated haemorrhagic shock in a young patient.

The point: Shock is inadequate tissue perfusion, and it is classified by mechanism. Hypovolaemic shock from bleeding or fluid loss gives cool peripheries, tachycardia, a narrow pulse pressure, and hypotension only late, because young patients compensate until they suddenly do not. Distributive shock (sepsis, anaphylaxis, neurogenic) gives warm peripheries and vasodilation. Cardiogenic shock gives a raised jugular venous pressure and pulmonary oedema. Obstructive shock (tension pneumothorax, tamponade, massive pulmonary embolism) gives a raised jugular venous pressure with clear or unilateral lungs. Treat the cause and restore perfusion: control haemorrhage and give blood in haemorrhagic shock; fluids and early antibiotics in sepsis; adrenaline in anaphylaxis. Lactate and its clearance track the response. In trauma, permissive hypotension and balanced blood product resuscitation apply until bleeding is controlled.

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 an acute coronary event. Cool peripheries and a narrow pulse pressure with a bleeding source makes it appropriate.
2. Assess perfusion, temperature of the peripheries and pulse pressure correct Correct. The cool peripheries and narrow pulse pressure are what classify this as hypovolaemic rather than distributive, and they are elicited immediately.
3. Focused ultrasound (FAST or echo) Identifies free fluid in trauma, a pericardial effusion, or poor cardiac function at the bedside. Cool peripheries and a narrow pulse pressure with a bleeding source makes it useful.
4. Venous or arterial blood gas with lactate A raised lactate quantifies hypoperfusion, and its clearance tracks the response to resuscitation. Cool peripheries and a narrow pulse pressure with a bleeding source makes it decisive.
5. Blood cultures and a septic screen For distributive shock from infection, before antibiotics. Cool peripheries and a narrow pulse pressure with a bleeding source indicates it.

The point: Shock is inadequate tissue perfusion, and it is classified by mechanism. Hypovolaemic shock from bleeding or fluid loss gives cool peripheries, tachycardia, a narrow pulse pressure, and hypotension only late, because young patients compensate until they suddenly do not. Distributive shock (sepsis, anaphylaxis, neurogenic) gives warm peripheries and vasodilation. Cardiogenic shock gives a raised jugular venous pressure and pulmonary oedema. Obstructive shock (tension pneumothorax, tamponade, massive pulmonary embolism) gives a raised jugular venous pressure with clear or unilateral lungs. Treat the cause and restore perfusion: control haemorrhage and give blood in haemorrhagic shock; fluids and early antibiotics in sepsis; adrenaline in anaphylaxis. Lactate and its clearance track the response. In trauma, permissive hypotension and balanced blood product resuscitation apply until bleeding is controlled.

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 Within an hour, alongside cultures and lactate, in septic shock. Cool peripheries and a narrow pulse pressure with a bleeding source demands it.
2. Control external haemorrhage and give blood In haemorrhagic shock, stopping the bleeding and transfusing blood products rather than crystalloid alone. Cool peripheries and a narrow pulse pressure with a bleeding source makes it the priority.
3. Needle decompression or chest drain for tension pneumothorax For obstructive shock from a tension pneumothorax, before imaging. Cool peripheries and a narrow pulse pressure with a bleeding source demands it.
4. Inotropes or vasopressors in a critical care setting For cardiogenic or refractory distributive shock not responding to fluids. Cool peripheries and a narrow pulse pressure with a bleeding source indicates it.
5. Balanced blood product resuscitation and permissive hypotension in trauma correct Correct. Blood products in balance rather than large volumes of crystalloid, and permissive hypotension until the bleeding is surgically controlled.

The point: Shock is inadequate tissue perfusion, and it is classified by mechanism. Hypovolaemic shock from bleeding or fluid loss gives cool peripheries, tachycardia, a narrow pulse pressure, and hypotension only late, because young patients compensate until they suddenly do not. Distributive shock (sepsis, anaphylaxis, neurogenic) gives warm peripheries and vasodilation. Cardiogenic shock gives a raised jugular venous pressure and pulmonary oedema. Obstructive shock (tension pneumothorax, tamponade, massive pulmonary embolism) gives a raised jugular venous pressure with clear or unilateral lungs. Treat the cause and restore perfusion: control haemorrhage and give blood in haemorrhagic shock; fluids and early antibiotics in sepsis; adrenaline in anaphylaxis. Lactate and its clearance track the response. In trauma, permissive hypotension and balanced blood product resuscitation apply until bleeding is controlled.

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