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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
Q

Pt who presents with dehydration (protracted nausea, vomiting, diarrhea), burns, or acute pancreatitis is at risk for what type of shock?

A

Hypovolemic

26
Q

What will the following parameters show for hypovolemic shock?

HR, CVP, PCWP, CO, SVR

A

↑ HR , ↓ CVP, ↓ PCWP, ↓ CO, ↑ SVR

27
Q

What will the following parameters show for cardiogenic shock (including obstructive)?

HR, CVP, PCWP, CO, SVR

A

↑ HR , ↑ CVP, ↑ PCWP, ↓ CO, ↑ SVR

28
Q

What will the following parameters show for early septic shock?

HR, CVP, PCWP, CO, SVR

A

↑ HR , ↓ CVP, +/- PCWP, ↑ (or N) CO, ↓ SVR

29
Q

What will the following parameters show for late septic shock?

HR, CVP, PCWP, CO, SVR

A

↑ HR , ↓ CVP, +/- PCWP, ↓ CO, ↑ SVR

30
Q

What will the following parameters show for neurogenic shock?

HR, CVP, PCWP, CO, SVR

A

N/ ↓ HR , N/ ↓ CVP, N/ ↓ PCWP, N/ ↓ CO, ↓ SVR

31
Q

In which type of shock is blood preferentially shunted and redistributed?

A

Hypovolemic shock

32
Q

Clinical presentation of hypovolemic shock is dependent on what?

A

Amount and rate of loss

33
Q

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?

A

Hypovolemic

34
Q

What PE finding should never be ignored as it is often the first sign that something bad is happening?

A

Decreased UOP

35
Q

What lab value may be elevated in all types of shock, is used for trending purposes, and is a/w increased mortality?

A

Lactate

36
Q

Diagnostic studies ordered for suspected hypovolemic shock is dependent on what?

A

Underlying cause

37
Q

What is the tx for hypovolemic shock?

A

Treat underlying

Repalce volume (crystalloid, colloid, blood)

Monitor clinical response

38
Q

While the main focus of treatment for hypovolemic shock is volume replacement, if SBP < 70, what additional treatment may be added temporarily?

A

Vasopressors

39
Q

In cardiogenic shock, decreased CO is secondary to what?

A

Pump failure

40
Q

What are the most common etiologies of cardiogenic shock?

A

Obstructive (extracardiac), ischemia, valvular heart disease, arrhythmias

41
Q

Although dependent on etiology, CP, dyspnea, palpitations, and fatigue might indicate what type of shock?

A

Cardiogenic

42
Q

What is the best diagnostic test used for cardiogenic shock?

A

Echocardiogram

43
Q

What is the general management for cardiogenic shock? (5)

A

Inotropes (Dobutamine, Milrinone)

Treat underlying

Cardio consult

Fluids (but caution because already fluid overloaded)

Last line: assost devives, ECMO, heart transplant

44
Q

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?

A

Cardiogenic

45
Q

What main parameter will be decreased with distributive (vasodilatory shock)?

A

SVR (vasodilatory process)

46
Q

What are the common etiologies for distributive (vasodilatory) shock? (5)

A

SALAD
Sepsis

Adrenal insufficiency

Liver disease

Anaphylaxis

Drugs/ meds

47
Q

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?

A

Septic

48
Q

What is the etiology for septic shock?

A

Any kind of infection

49
Q

How do you differentiate between early and late septic shock?

A
  • 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
Q

Profound vasodilation a/w septic shock is the result of what?

A

Pro-inflammatory cells outnumber anti-inflammatory cells

51
Q

Pt presents with fever, decreased BP, increased HR/ RR, tachypnea, warm extremities, and confused. What type of shock might you be concerned for?

A

Early septic shock

52
Q

Pt presents with fever, decreased BP, increased HR/ RR, tachypnea, cool extremities, and confused. What type of shock might you be concerned for?

A

Late septic shock

53
Q

What PE manifestation is often the initial physiologic response to septic shock and should therefore never be ignored?

A

Tachypnea

54
Q

What type of shock should be suspected in elderly or IMC if unexplained hypotension, mental status changes, or signs of organ system dysfunction?

A

Septic shock

55
Q

What is the management for septic shock?

A

Vasopressors- norepinephrine = 1st line

Early goal-directed therapy

ID/ tx underlying (panculture before abx)

Fluid replacement

56
Q

Mortality rate of 35-60% from septic shock can be seen within how long of onset?

A

1 month

57
Q

What type of shock is defined as a loss of sympathetic tone, leading to vasodilation and hypotension and displays bradycardia?

A

Neurogenic shock

58
Q

What are the 2 most common etiologies a/w neurogenic shock?

A

Spinal cord injury, closed head trauma

59
Q

In what type of shock does unopposed parasympathetic action lead to hypotension with decreased SVR?

A

Neurogenic

60
Q

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?

A

Neurogenic shock

(also presentation highly dependent on location of injury)

61
Q

What dx studies should be ordered for neurogenic shock?

A

Head CT, spinal CT/ MRI, X-rays (c-spine)

62
Q

What is the management for neurogenic shock?

A

Neurosurgery consult

Address co-existing + fluids to correct hypovolemia

3. E Med & Surgery (19 decks)

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