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Pathopharm Final > 10: Burns & Shock (Part 3) > Flashcards

10: Burns & Shock (Part 3) Flashcards

1
Q

Shock
definition

A

condition of acute & progressive circulatory dysfunction that results in inadequate delivery of oxygen and nutrients to the tissues

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2
Q

Shock is commonly the result of
(4)

A
  • hemorrhage
  • severe dehydration
  • progressive heart failure
  • sepsis
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3
Q

Shock is present if…

A

signs of poor systemic perfusion are evident regardless of BP

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4
Q

T/F
Your patient has signs of inadequate perfusion, but his BP is normal. You can rule out shock.

A

False
Shock is present when signs of poor systemic perfusion, regardless of blood pressure, are evident

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5
Q

What is decompensated shock?

A

Systolic hypotension is associated within adequate tissue perfusion

*now called hypotensive shock

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6
Q

What is distributive shock in kids?

A

Results from the inappropriate distribution of blood flow, increased capillary permeability, and myocardial dysfunction (septic or anaphylactic shock) or central nervous system injury (neurogenic or spinal shock)

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7
Q

What is obstructive shock in kids?

A
  • Mechanical obstruction to blood flow into and through the heart and great vessels, resulting in low cardiac output
  • May be from cardiac tamponade, pulmonary embolus, obstructive congenital heart lesions such as critical aortic stenosis
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8
Q

What are the clinical manifestation of shock in kids?

A
  • Extremely irritable
  • Lethargy (d/t less oxygen)
  • Decreased response to painful stimulus (usually indicates severe cardiorespiratory or neuro compromise)
  • Extremely tachypnic
  • Hyperpnea (^ depth)
  • Retractions & grunting
  • Mottling, pallor, or flushed, red skin
  • Prolonged cap refill
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9
Q

Simultaneous failure of at least two organs resulting from a single cause

A

Multiple organ dysfunction syndrome (MODS)

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10
Q

Secondary MODS

A

Typically occurs later.
May be associated with more sequential development of organ dysfunction.

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11
Q

Primary MODS

A

Is directly attributable to the insult.
Typically occurs 3 to 7 days after an insult.

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12
Q

Risk factors for MODS

A

Severe or prolonged shock, sepsis, trauma
Cardiopulmonary arrest, congenital heart disease, and liver and bone marrow transplantation
Children with chronic diseases: Increased risk for MODS and increased mortality

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13
Q

clinical manifestation of shock in kids

A

Extremely irritable
- Lethargy (d/t less oxygen)
- Decreased response to painful stimulus (usually indicates severe cardiorespiratory or neuro compromise)
- Extremely tachypnic
- Hyperpnea (^ depth)
- Retractions & grunting
- Mottling, pallor, or flushed, red skin
- Prolonged cap refill

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14
Q

What causes mottling in kids? When Is it concerning?

A

Alterations in blood flow, concerning if not due to being in cold environment (those who have undergone hypothermic surgery or a procedure in a cold room)

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15
Q

what causes Pallor

A

Poor perfusion

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16
Q

what causes Flushed, bright red skin

A

Sepsis

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17
Q

How reliable is cap refill?

A

Subjective interpretation; therefore not reliable

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18
Q

Compromise in systemic perfusion: ____ capillary refill time (>2 seconds)

A

Prolonged

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19
Q

How reliable are vital signs in children?

A

Not always indicative or appropriate in the child who is seriously ill or injured

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20
Q

When would tachycardia be interpreted as a possible cause rather than a symptom of shock?

A

If extremely rapid or present with decreased myocardial function

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21
Q

What is considered tachycardia in kids?

A
  • Ventricular rate exceeding 200 to 220 beats/minute in an infant or 160 to 180 in a child
  • Ventricular diastolic filling time and coronary artery perfusion time are significantly reduced, and stroke volume falls
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22
Q

most common cause of bradycardia in kids

A

hypoxia

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23
Q

What is the most common terminal cardiac rhythm observed in children?

A

Bradycardia, often indicates impending cardiovascular collapse

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24
Q

T/F: Systolic blood pressure is one of the best indicators of shock in kids.

A

False, shock may be present, despite a systolic blood pressure within the normal range for the age of the child

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25
Q

If systolic hypotension develops, or the mean arterial pressure falls, what does this indicate?

A

Hypotensive shock, urgent treatment is needed

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26
Q

What is a normal central venous pressure?

A

0 to 5 (mmHg)

27
Q

What is a normal pulmonary artery wedge pressure?

A

Heart failure or cardiogenic shock

28
Q

What urine output would indicate shock in infants, children, & adolescents?

A
  • Less than 2 ml/kg/hr in infants
  • Less than 1 ml/kg/hr in children
  • Less than 0.5 ml/kg/hr in adolescents
29
Q

What other lab values are indicative of shock?

A
  • Elevated liver enzymes if hepatic perfusion is reduced
  • Metabolic acidosis and serum lactate above 4
  • Altered glucose levels
30
Q

What is considered hypoglycemia in kids? When do we see it?

A
  • Less than 60
  • Seen in infants who are seriously ill or injured
  • Possible cardiovascular or neurologic deterioration
31
Q

What is considered hyperglycemia in kids?

A
  • Greater than 150
  • Due to insulin-resistant state from catecholamines and hydrocortisone secretion
32
Q

When do we see hyperglycemia in kids

A
  • Often observed in the first 12 to 18 hours, then falling to normal
33
Q

What is persistent hyperglycemia in kids?

A
  • Greater than 180
  • Linked with poor survival in children who are critically ill
34
Q

Hypoglycemia, hyperglycemia, and glucose instability are linked with _______.

A

Multiple organ death syndrome

35
Q

most common type of shock in children

A

Hypovolemic

36
Q

most common cause of hypovolemic shock

A

Dehydration and trauma

Other cause is from relative hypovolemia from burns or sepsis or “third spacing”

37
Q

Dehydration, hypovolemia, and low cardiac output stimulate adrenergic and renal compensatory mechanisms in adults. What does this cause?

A
  • Tachycardia and redistribution of blood from the skin, gut, and kidney to the brain and heart
  • Stimulation of the RAAS causing renal sodium and water retention
  • Secretion of antidiuretic hormone causing water retention by the kidneys
38
Q

How are neonatal kidneys different than adults?

A
  • They are incapable of excreting concentrated urine
  • So, compensatory mechanisms are relatively ineffective during the 1st weeks of life
39
Q

What are clinical manifestations of hypovolemic shock in kids?

A

Tachycardia, peripheral vasoconstriction, and altered level of consciousness; cool extremities, oliguria

39
Q

What is the treatment for hypovolemic shock?

A

Volume resuscitation

39
Q

What causes neurogenic shock?

A

Loss of vasomotor tone after severe injury to the spinal cord

40
Q

What are clinical manifestations of neurogenic shock?

A
  • Warm skin
  • Hypotension with a low diastolic blood pressure
  • Poor systemic perfusion

**No tachycardia present

40
Q

What is the most common cause of cardiogenic shock?

A

After cardiovascular surgery or with inflammatory heart diseases

41
Q

What are clinical manifestations of cardiogenic shock?

A
  • Cool extremities & delayed capillary refill, despite a warm, ambient temperature
  • Mottled skin
42
Q

What is the treatment for cardiogenic shock?

A
  • Fluid titration to optimize preload
  • Vasoactive drugs to improve myocardial function
  • Vasodilators or vasoconstrictors to support systemic perfusion
43
Q

What causes septic shock?

A

The formation or activation of cytokines and other mediators from infection

Results in vasodilation, increased capillary permeability, maldistribution of blood flow, and cardiovascular dysfunction

44
Q

What population in kids accounts for over 20% of children with sepsis?

A

Low birth-weight neonates

45
Q

Most common sites of infection
(3)

A

Primary bloodstream: 25%
Respiratory tract: 37%
Underlying disease: Approximately 50%

46
Q

Formation or activation of cytokines & other mediators from infection causes

A

Vasodilation, increased capillary permeability, maldistribution of blood flow, & cardiovascular dysfunction

47
Q

Prevention of septic shock

A

Proper handwashing by health care providers before & after contact with kids
Appropriate sterile and aseptic technique during catheter insertion & tubing changes
Use of protocols to reduce central venous catheter infections & ventilator-associated pneumonias

48
Q

Genetics and its influence on septic shock

A

Alter the outcomes of infections, sepsis, and septic shock

49
Q

pathogenesis behind septic shock

A

There is an imbalance between pro-inflammatory and anti-inflammatory mediators

  • Pro-inflammatory mediators = TNF, nitric oxide, and platelet-activating factor, can become destructive
  • Endotoxin makes endothelium into a secretory organ (= changes from a normal pro-fibrinolytic and anti-coagulant state to an anti-fibrinolytic and pro-coagulant state, & contributes to maldistribution of blood flow)
50
Q

What lab is a reliable predictor of pediatric sepsis mortality?

A

Interleukin 8 (IL-8) levels

51
Q

What are clinical manifestations of warm septic shock?

A
  • Peripheral vasodilation
  • Warm skin with flash cap refill
  • Bounding pulses and wide pulse pressure
52
Q

What are clinical manifestations of cold septic shock?

A
  • Peripheral vasoconstriction
  • Cold skin with prolonged cap refill
  • Decreased peripheral pulses
53
Q

What population is warm septic shock more common?

A

Adults

54
Q

What population is cold septic shock more common?

A

Kids

55
Q

When is systemic inflammatory response syndrome present in septic shock?

A

When a child demonstrates two or more of the following changes:

  • Temperature higher than 38.5°/101.3° or lower than 36°/96.8°
  • Tachypnea or bradycardia (in infants)
  • Respiratory rate requiring mechanical ventilation
  • WBC count: Leukocytes, leukopenia, or an increase in the percentage of immature or band forms of WBCs
56
Q

How is severe sepsis differentiated from septic shock?

A
  • Severe sepsis is SIRS with a suspected infection
  • Septic shock is the development of cardiovascular dysfunction
57
Q

In treating septic shock, aggressive administration of fluids, antibiotics and titration of inotropes, vasopressors, and vasodilators should be accomplished within what time frame?

A

Within the first hour of medical contact

58
Q

What clinical manifestations may present differently in newborns?

A

They often develop hypothermia rather than fever & they may develop bradycardia instead of tachycardia

59
Q

In septic shock treatment, fluid and vasoactive therapy should support high cardiac output and oxygen delivery, maintaining the central venous oxygen saturation (ScvO2) level at approximately ______.

A

70%

60
Q
A

Pathopharm Final (8 decks)

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