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3. E Med & Surgery > 2- Hypotension and Shock > Flashcards

2- Hypotension and Shock Flashcards

1
Q

How is shock defined?

A

Inadequate systemic tissue perfusion leads to cellular hypoxia and metabolic malfunction

(demand > supply)

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2
Q

Shock must be promptly recognized and treated because it can result in what?

A

Cell death, end organ damage, multi-system organ failure, death

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3
Q

What parameters determine the etiology of shock?

A

CO and SVR (when decreased = systemic tissue perfusion decreased)

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4
Q

What are possible ways to assess adequate global perfusion? (4)

A

Mental status, UOP (urinary output), serum lactate/ acidosis, peripheral perfusion assessment

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5
Q

Are all pts with hypotension in shock?

A

NO

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6
Q

What stage of shock is defined as warm shock or compensatory shock and will manifest as tachycardia, peripheral vasoconstriction, and decreased BP?

A

Pre-shock

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7
Q

In what stage of shock are compensatory mechanisms overwhelmed and signs and sxs of organ dysfunction appear?

A

Shock

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8
Q

What are the PE manifestations of shock?

A

Tachycardia, dyspnea, metabolic acidosis, oliguria, confusion, cool clammy skin

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9
Q

What occurs in the end-organ dysfunction phase of shock?

A

Irreversible organ damage, coma, death

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10
Q

What are the 5 etiologies of shock?

A

Hypovolemic

Cardiogenic

Obstructive

Neurogenic

Distributive (aka vasodilatory)

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11
Q

What is the most important part of shock management?

A

Efficient resuscitation

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12
Q

What is the use of an arterial line in the management of shock?

A

Continuous BP monitoring, usually radial artery

NOT used for infusion of meds

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13
Q

What are the indications for a central line in the management of shock?

A

Delivery of caustic or critical meds and measurement of CVP (central venous pressure)

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14
Q

What type of central line runs much deeper through the venous system and is more quickly acting on the heart?

A

Peripherally inserted central line catheter (PICC)

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15
Q

How is central venous pressure best utilized in the management of shock?

A

Trending is helpful (not in isolation)

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16
Q

What type of central line sits at the pulmonary artery, is an estimate for CO and pulmonary artery pressure and is useful for cardiogenic shock?

A

Swan-Ganz (PA) catheter

(waveforms used to know anatomical location when inserting)

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17
Q

What are the hemodynamic parameters monitored during shock?

A

Central venous pressure (CVP)

Pulmonary capillary wedge pressure (PCWP)

Cardiac output (CO)

Systemic vascular resistance (SVR)

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18
Q

In terms of monitoring hemodynamics, what are appropriate for determining fluid status and resuscitation in other types of shock?

A

Central lines (including PICC lines)

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19
Q

All types of shock present with what findings?

A

Hypotension, tachypnea, oliguria, mental status changes (confusion, lethargy), metabolic acidosis, later- multi-organ failure, coagulopathy

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20
Q

All types of shock present with tachycardia with the exception of what?

A

Neurogenic shock = decreased HR

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21
Q

All types of shock present with cool clammy skin with the exception of what?

A

Early distributive and neurogenic shock = flushed, warm

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22
Q

What population can compensate for shock for a while because they have increased CO?

A

Pregnant patients

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23
Q

What occurs in hypovolemic shock?

A

Inadequate intravascular volume leads to decreased CO and decreased O2 delivery

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24
Q

Pt who presents with trauma, GI bleed, internal hemorrhage, or post-surgery is at risk for what type of shock?

A

Hypovolemic (blood loss- hemorrhagic)

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25
Pt who presents with dehydration (protracted nausea, vomiting, diarrhea), burns, or acute pancreatitis is at risk for what type of shock?
Hypovolemic
26
What will the following parameters show for hypovolemic shock? HR, CVP, PCWP, CO, SVR
↑ HR , ↓ CVP, ↓ PCWP, ↓ CO, ↑ SVR
27
What will the following parameters show for cardiogenic shock (including obstructive)? HR, CVP, PCWP, CO, SVR
↑ HR , ↑ CVP, ↑ PCWP, ↓ CO, ↑ SVR
28
What will the following parameters show for early septic shock? HR, CVP, PCWP, CO, SVR
↑ HR , ↓ CVP, +/- PCWP, ↑ (or N) CO, ↓ SVR
29
What will the following parameters show for late septic shock? HR, CVP, PCWP, CO, SVR
↑ HR , ↓ CVP, +/- PCWP, ↓ CO, ↑ SVR
30
What will the following parameters show for neurogenic shock? HR, CVP, PCWP, CO, SVR
N/ ↓ HR , N/ ↓ CVP, N/ ↓ PCWP, N/ ↓ CO, ↓ SVR
31
In which type of shock is blood preferentially shunted and redistributed?
Hypovolemic shock
32
Clinical presentation of hypovolemic shock is dependent on what?
Amount and rate of loss
33
Pt presenting with dry oral mucosa, hypotension, tachycardia, tachypnea, decreased JVP/ CVP and urine output, cool, clammy skin with decreased skin turgor, AMS is concerning for what type of shock?
Hypovolemic
34
What PE finding should never be ignored as it is often the first sign that something bad is happening?
Decreased UOP
35
What lab value may be elevated in all types of shock, is used for trending purposes, and is a/w increased mortality?
Lactate
36
Diagnostic studies ordered for suspected hypovolemic shock is dependent on what?
Underlying cause
37
What is the tx for hypovolemic shock?
Treat underlying Repalce volume (crystalloid, colloid, blood) Monitor clinical response
38
While the main focus of treatment for hypovolemic shock is volume replacement, if SBP \< 70, what additional treatment may be added temporarily?
Vasopressors
39
In cardiogenic shock, decreased CO is secondary to what?
Pump failure
40
What are the most common etiologies of cardiogenic shock?
**Obstructive (extracardiac)**, ischemia, valvular heart disease, arrhythmias
41
Although dependent on etiology, CP, dyspnea, palpitations, and fatigue might indicate what type of shock?
Cardiogenic
42
What is the best diagnostic test used for cardiogenic shock?
Echocardiogram
43
What is the general management for cardiogenic shock? (5)
**Inotropes (Dobutamine, Milrinone)** Treat underlying Cardio consult Fluids (but **caution** because already fluid overloaded) Last line: assost devives, ECMO, heart transplant
44
PE shows tachycardia, tachypnea, hypotension, cool and clammy extremities, **increased JVP**, abn heart sounds (muffled, new murmur), +/- **deviated trachea**. What type of shock might you be concerned for?
Cardiogenic
45
What main parameter will be decreased with distributive (vasodilatory shock)?
SVR (vasodilatory process)
46
What are the common etiologies for distributive (vasodilatory) shock? (5)
SALAD Sepsis Adrenal insufficiency Liver disease Anaphylaxis Drugs/ meds
47
What type of shock results from inadequate tissue perfusion and cellular hypoxia resulting from increased oxygen demand from tissues to combat systemic infection and endotoxins?
Septic
48
What is the etiology for septic shock?
Any kind of infection
49
How do you differentiate between early and late septic shock?
* Early- endotoxins aggravate tissues, start to signs of organ impairment but fairly well compensated * Late- vasoconstriction aggravates cellular hypoxia leading to organ system malfunction (poor perfusion of extremities + internal organs)
50
Profound vasodilation a/w septic shock is the result of what?
Pro-inflammatory cells outnumber anti-inflammatory cells
51
Pt presents with fever, decreased BP, increased HR/ RR, tachypnea, **warm** extremities, and confused. What type of shock might you be concerned for?
Early septic shock
52
Pt presents with fever, decreased BP, increased HR/ RR, tachypnea, **cool** extremities, and confused. What type of shock might you be concerned for?
Late septic shock
53
What PE manifestation is often the initial physiologic response to septic shock and should therefore never be ignored?
Tachypnea
54
What type of shock should be suspected in elderly or IMC if unexplained hypotension, mental status changes, or signs of organ system dysfunction?
Septic shock
55
What is the management for septic shock?
Vasopressors- **norepinephrine = 1st line** Early goal-directed therapy ID/ tx underlying (panculture before abx) Fluid replacement
56
Mortality rate of 35-60% from septic shock can be seen within how long of onset?
1 month
57
What type of shock is defined as a loss of sympathetic tone, leading to vasodilation and hypotension and displays bradycardia?
Neurogenic shock
58
What are the 2 most common etiologies a/w neurogenic shock?
Spinal cord injury, closed head trauma
59
In what type of shock does unopposed parasympathetic action lead to hypotension with decreased SVR?
Neurogenic
60
PE shows decreased BP, para/ quagriplegic, absent or hyperreflexive DTRs, warm extremities, and decreased sphincter tone on rectal exam. What type of shock are you concerned for?
Neurogenic shock (also presentation highly dependent on location of injury)
61
What dx studies should be ordered for neurogenic shock?
Head CT, spinal CT/ MRI, X-rays (c-spine)
62
What is the management for neurogenic shock?
Neurosurgery consult Address co-existing + fluids to correct hypovolemia

3. E Med & Surgery (19 decks)

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