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  <head>
    <title>010-01 Foundations</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Shock, perfusion failure, fluids and vasoactive therapy">
      <outline text="What shock is">
        <outline text="Acute circulatory failure of tissue perfusion"/>
        <outline text="Pressure may be low, normal or maintained"/>
        <outline text="Self-reinforcing injury">
          <outline text="Inflammation and endothelial injury"/>
          <outline text="Coagulation and myocardial dysfunction"/>
          <outline text="Microvascular shunting and organ failure"/>
        </outline>
      </outline>
      <outline text="Oxygen delivery and extraction">
        <outline text="Delivery equals output times arterial content"/>
        <outline text="Output equals rate times stroke volume"/>
        <outline text="Normal saturation can hide poor delivery"/>
        <outline text="Consumption equals delivery times extraction"/>
        <outline text="Beyond a critical point, supply-dependent"/>
        <outline text="Lactate is a trend marker, not a meter">
          <outline text="Adrenergic drive, clearance, mitochondria, drugs"/>
        </outline>
        <outline text="Mean pressure is not effective perfusion"/>
      </outline>
      <outline text="Shock categories">
        <outline text="Hypovolaemic: reduced venous return"/>
        <outline text="Cardiogenic: pump failure, high filling pressures"/>
        <outline text="Distributive: vasodilation and maldistribution">
          <outline text="Sepsis: dilation, leak, depression, microvascular failure"/>
          <outline text="Anaphylaxis: leakage, bronchospasm, airway oedema"/>
          <outline text="Neurogenic: bradycardia with warm skin"/>
        </outline>
        <outline text="Obstructive: filling or outflow blocked">
          <outline text="Embolism, tamponade, tension pneumothorax, hyperinflation"/>
        </outline>
        <outline text="Mixed shock is expected"/>
      </outline>
      <outline text="Obstructed filling and tamponade">
        <outline text="Shared septum in one pericardial enclosure"/>
        <outline text="Filling one ventricle competes with the other"/>
        <outline text="Inspiratory septal shift cuts left filling"/>
        <outline text="Pulsus paradoxus follows the stroke-volume fall"/>
        <outline text="External restriction, not contractile failure"/>
        <outline text="Rate and compliance, not effusion volume"/>
        <outline text="Pulsus paradoxus also in airway obstruction"/>
      </outline>
      <outline text="Recognition and monitoring">
        <outline text="Mental state, mottled skin, delayed refill"/>
        <outline text="Rising lactate, acidosis, narrow pulse pressure"/>
        <outline text="Warm shock can have bounding pulses early"/>
        <outline text="One normal pressure excludes nothing"/>
        <outline text="Bedside ultrasound needs skill and context"/>
        <outline text="Repeated reassessment beats invasive numbers"/>
      </outline>
      <outline text="Fluids">
        <outline text="Fluid is a drug with a stop criterion"/>
        <outline text="A bolus tests stressed volume against output"/>
        <outline text="Crystalloid spreads through extracellular fluid"/>
        <outline text="Balanced solutions limit chloride load"/>
        <outline text="Albumin is selective, starches cause harm"/>
        <outline text="Excess fluid: oedema, congestion, delayed healing"/>
        <outline text="Dynamic tests over static filling pressure"/>
        <outline text="Haemorrhage needs blood and bleeding control"/>
      </outline>
      <outline text="Vasoactive and inotropic therapy">
        <outline text="Norepinephrine first in septic vasodilatory shock"/>
        <outline text="Vasopressin supplements catecholamines"/>
        <outline text="Epinephrine for anaphylaxis and cardiac arrest"/>
        <outline text="Excess vasoconstriction costs regional flow"/>
        <outline text="Inotropes when output stays low despite filling"/>
        <outline text="Dobutamine risks tachyarrhythmia and hypotension"/>
        <outline text="Choose from the haemodynamic problem"/>
        <outline text="Reliable access and extravasation surveillance"/>
      </outline>
      <outline text="Mechanism-specific treatment">
        <outline text="Sepsis: antimicrobials, cultures, source control"/>
        <outline text="Anaphylaxis: intramuscular epinephrine first"/>
        <outline text="Cardiogenic: revascularisation, rhythm, mechanical support"/>
        <outline text="Tamponade drained, pneumothorax decompressed"/>
        <outline text="Resuscitation is a repeating cycle"/>
        <outline text="Pressure without perfusion is incomplete success"/>
        <outline text="De-resuscitation once shock resolves"/>
      </outline>
      <outline text="Cellular and organ consequences">
        <outline text="Flow diverted from skin, gut and kidney"/>
        <outline text="Mucosal injury and acute kidney injury"/>
        <outline text="Endothelial activation and leukocyte adhesion"/>
        <outline text="Thrombosis and bleeding at the same time"/>
        <outline text="Permeability oedema and respiratory distress syndrome"/>
        <outline text="Myocardial depression from ischaemia and catecholamines"/>
      </outline>
      <outline text="Special contexts and safety traps">
        <outline text="Pregnancy hides haemorrhage before hypotension"/>
        <outline text="Supine caval compression, left lateral displacement"/>
        <outline text="Older adults: less tachycardia, less fluid tolerance"/>
        <outline text="Burn formulae are starting estimates only"/>
        <outline text="Adrenal insufficiency resists vasopressors"/>
        <outline text="Sedation and positive pressure cut venous return"/>
        <outline text="Imaging must not delay time-critical treatment"/>
      </outline>
    </outline>
  </body>
</opml>
