Septic Shock

SEPTIC SHOCK

Q. 1

The Reynold’s pentad of fever, jaundice, right upper quadrant pain, septic shock and mental status change in typical of:

 A

Cholangitis

 B

Hepatitis

 C

Cholecystitis

 D

Pancreatitis

Q. 1

The Reynold’s pentad of fever, jaundice, right upper quadrant pain, septic shock and mental status change in typical of:

 A

Cholangitis

 B

Hepatitis

 C

Cholecystitis

 D

Pancreatitis

Ans. A

Explanation:

Cholangitis is one of the two main complications of choledochal stones, the other being gallstone pancreatitis.

The most common presentation is fever, epigastric or right upper quadrant pain, and jaundice.

These classic symptoms, well known as Charcot’s triad, are present in about two thirds of patients. 

 
The illness may progress rapidly with septicemia and disorientation, known as Reynolds pentad (e.g., fever, jaundice, right upper quadrant pain, septic shock, and mental status changes). 
 
Ref: Oddsdottir M., Pham T.H., Hunter J.G. (2010). Chapter 32. Gallbladder and the Extrahepatic Biliary System. In F.C. Brunicardi, D.K. Andersen, T.R. Billiar, D.L. Dunn, J.G. Hunter, J.B. Matthews, R.E. Pollock (Eds), Schwartz’s Principles of Surgery, 9e.

Q. 2

You are about to give intraosseous infusion in a child. Which of the following need NOT be ruled out before giving the infusion?

 A

Osteoporosis

 B

Septic shock

 C

Osteogenesis imperfecta

 D

Fracture at the site of insertion

Q. 2

You are about to give intraosseous infusion in a child. Which of the following need NOT be ruled out before giving the infusion?

 A

Osteoporosis

 B

Septic shock

 C

Osteogenesis imperfecta

 D

Fracture at the site of insertion

Ans. B

Explanation:

Intraosseous transfusion may be required if intra vascular access is not available in conditions like severe burns, septic shock, prolonged status epilepticus, cardiopulmonary arrest etc.

Also know
Complications of intraosseous transfusion
a) Extravasation of fluids
b) Cellulilits
c) Osteomyelitis
d) Fat or bone micro embolism
 
Ref: Oxford Handbook Of Clinical Specialities, Edition 8, Page – 263.

Q. 3

Endotoxin causes –

 A

Diarrhea

 B

Muscle damage

 C

Septic shock

 D

None

Q. 3

Endotoxin causes –

 A

Diarrhea

 B

Muscle damage

 C

Septic shock

 D

None

Ans. C

Explanation:

Ans. is ‘c’ i.e., Septic shock 

  • Endotoxin induces release of IL-1 from macrophages and TNF from phagocytes, which induces severe septic shock.

Q. 4

Peripheral resistance is decreased in which type of shock –

 A

Hypovolemic shock

 B

Neurogenic shock

 C

Septic shock

 D

b and c

Q. 4

Peripheral resistance is decreased in which type of shock –

 A

Hypovolemic shock

 B

Neurogenic shock

 C

Septic shock

 D

b and c

Ans. D

Explanation:

Ans. is ‘b’ i.e., Neurogenic shock; ‘c’ i.e., Septic shock

 Septic shock has already been described —> in hyperdynamic stage there is vasodilation and TPR. Neurogenic shock

o Neurogenic shock occurs when there is Neurological injury as occur in head trauma or high cervical cord injury or cephalad migration of spinal anaesthesia.

o Interruption of sympathetic vasomotor input occurs that causes vasodilatation, decreased heart rate and Cardiac output and shock.

Then what is the difference between neurogenic shock and hyperdynamic stage of septic shock ?

o In septic shock, there vasodilatation ( TPR) due to NO with associated reflex sympathetic activity that increases heart rate and cardiac output.

o On the other hand, in neurogenic shock there is decreased sympathetic drive that leads to decrease in all, i.e., peripheral resistance, cardiac output and heart rate.


Q. 5

Following pathogenetic mechanisms operate in septic shock except –

 A

Increased peripheral vascular resistance

 B

Veno constriction

 C

Direct toxic endothelial injury

 D

Activation of complement

Q. 5

Following pathogenetic mechanisms operate in septic shock except –

 A

Increased peripheral vascular resistance

 B

Veno constriction

 C

Direct toxic endothelial injury

 D

Activation of complement

Ans. A

Explanation:

Ans. is ‘a’ i.e., Increased peripheral vascular resistance


Q. 6

All are true about septic shock in children except ‑

 A

1st response is TC.O. due to vasodilatation

 B

Hypotension is a late sign

 C

Heart rate remains same

 D

LPeripheral vascular resistance

Q. 6

All are true about septic shock in children except ‑

 A

1st response is TC.O. due to vasodilatation

 B

Hypotension is a late sign

 C

Heart rate remains same

 D

LPeripheral vascular resistance

Ans. C

Explanation:

Ans. is c’ i.e., Heart rate remains same

Septic shock in children

  • Septic shock is an inflammatory state resulting from systemic response to bacterial infection.

o Decrease in peripheral resistance (vasodilatation) is the hallmark of early (hyperdynamic) stage of septic shock, this feature distinguishes it from other types of shock. Decreased peripheral resistance (vasodilatation) leads to compensatory increase in cardiac output; therefore, cardiac output is maintained or some time increased despite of shock.

o Decreased peripheral resistance and increased cardiac output leads to increased blood flow and total oxygen delivery to the tissue. But, still the tissues lack 02 due to local microcirculatory changes produced as a result of sepsis which causes decrease tissue extraction of oxygen. So, increased blood flow and cardiac out are still inadequate to meet the total metabolic needs of the tissue which are increased in sepsis.

o As sepsis progresses, hypodynamic stage supervenes in which there is decreased cardiac output and increased peripheral resistance.

  • So, hemodynamic changes in septic shock occur in two characteristic patterns, Early hyperdynamic and late hypodynamic shock

1) Early hyperdynamic shock

          Hypotension is a late feature of septic shock and early hyperdynamic stage is characterized by normal or increased BP

          Other features are : ‑

o Tachycardia                                                            o Warm extremities

o Normal or increased cardiac output                          o Decreased systemic vascular resistance

o Tachypnea                                                           o Increased pulmonary vascular resistance

2) Late hypodynamic stage

o Decreased cardiac output                                       o Cool, mottled and often cyanotic extremities

o Hypotension                                                         o Oliguria, renal failure

o Increased vascular resistance                                 o Hypothermia


Q. 7

The most important cause of the death in septic shock is-

 A

DIC

 B

Respiratory failure

 C

Renal

 D

Cardiac

Q. 7

The most important cause of the death in septic shock is-

 A

DIC

 B

Respiratory failure

 C

Renal

 D

Cardiac

Ans. D

Explanation:

Ans. is ‘d’ i.e., Cardiac 

Hypotension is the cause of death.


Q. 8

Renal failure in patients with septic shock occurs primarily from:

 A

Acute tubular mecrosis

 B

Acute cortical necrosis

 C

Acute clomerulonephritis

 D

Acute papillary damage

Q. 8

Renal failure in patients with septic shock occurs primarily from:

 A

Acute tubular mecrosis

 B

Acute cortical necrosis

 C

Acute clomerulonephritis

 D

Acute papillary damage

Ans. A

Explanation:

Answer is A (Acute Tubular necrosis)

Most common cause of renal failure in patients with septic shock is Acute tubular necrosis

Most renal failure is due to acute tubular necrosis induced by hypotension or capillary injury although some patients also have glomerulonephritis, renal cortical necrosis or interstitial nephritis-Harrison’s 17th/1699


Q. 9

Warm periphery is noticed in which type of shock:

September 2012

 A

Cardiogenic shock

 B

Septic shock

 C

Hemorrhagic shock

 D

Traumatic shock

Q. 9

Warm periphery is noticed in which type of shock:

September 2012

 A

Cardiogenic shock

 B

Septic shock

 C

Hemorrhagic shock

 D

Traumatic shock

Ans. B

Explanation:

Ans. B i.e. Septic shock

Distributive shock

  • Peripheral vasodilatation and subsequent maldistribution of blood flow.
  • This leads to a relative hypovolaemia.
  • Common examples of this type being septic, anaphylactic and neurogenic shock.

Septic shock

  • It includes vasodilatation, high cardiac output, and loss of intravascular volume due to ‘leaky capillaries’.
  • The patient may start with a low cardiac output due to the leaky capillaries with loss of fluid and because the vasodilated arterial tree requires a larger blood volume to fill it (relative hypovolaemia).
  • With appropriate fluid volume replacement the heart will pump against lower resistance and therefore there will often be an increase in cardiac output in order to compensate for the reduction in SVR.
  • The patient may remain hypotensive but will have warm peripheries and a bounding pulse.
  • The bounding pulse is a reflection of the wide pulse pressure which is due to a low diastolic pressure.
  • Due to toxins and acidosis, sepsis may have a negative inotropic affect on the heart as well as causing vasodilatation and the patient can therefore have a low cardiac output and a low SVR.

Q. 10

All are true of septic shock, except:

MP 11; Bihar 12; KCET 13

 A

Tachycardia

 B

Warm skin

 C

Decreased cardiac output

 D

Caused by gram-positive bacteria

Q. 10

All are true of septic shock, except:

MP 11; Bihar 12; KCET 13

 A

Tachycardia

 B

Warm skin

 C

Decreased cardiac output

 D

Caused by gram-positive bacteria

Ans. D

Explanation:

Ans. Caused by gram-positive bacteria


Q. 11

Septic shock is due to 

 A

Protein

 B

Lipopolysaccharide

 C

Teichoic acid

 D

Peptidoglycan

Q. 11

Septic shock is due to 

 A

Protein

 B

Lipopolysaccharide

 C

Teichoic acid

 D

Peptidoglycan

Ans. B

Explanation:

Ans. is ‘b’ i.e., Lipopolysaccharide

  • Septic shock is due to endotoxin of gram negative bacteria. Therefore it is also called as endotoxic shock. 
  • Endotoxin is lipopolysaccharide.

Q. 12

This 29-year-old obese diabetic man presented in a state of septic shock, requiring resuscitation in the Intensive Care Unit.On examination,following picture was seen.What can be the most possible diagnosis?

 A

Scrotal abscess

 B

Testicular torsion

 C

Acute epididymo-orchitis

 D

Fournier gangrene

Q. 12

This 29-year-old obese diabetic man presented in a state of septic shock, requiring resuscitation in the Intensive Care Unit.On examination,following picture was seen.What can be the most possible diagnosis?

 A

Scrotal abscess

 B

Testicular torsion

 C

Acute epididymo-orchitis

 D

Fournier gangrene

Ans. D

Explanation:

Ans:D.)Fournier gangrene.

Fournier gangrene

  • It is defined as a polymicrobial necrotizing fasciitis of the perineal, perianal, or genital areas.
  • It is usually caused by a mixed infection of both aerobic and anaerobic bacteria.
  • They present with systemic toxicity and pain over the perineum. Cellulits is seen in the patient but they may present with crepitance and extensive necrosis under relative normal skin.
  •  Synergistic flora of the anorectal and urogenital area (streptococcus, clostridia, and non-hemolytic streptococcus).
  • Immuno-compromised patients (e.g. diabetics, alcoholics and malnourished patients).
  •  They are associated with high morbidity and mortality. Aggressive surgical debridement and broad spectrum antibiotics is necessary.


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