#6 Shock

Question 1

Equation for Shock Index and conditions where may be skewed:

Answer 1

SI= HR/Systolic BP (0.5-0.7)
elevated in…
- LV dysfx
- volume loss

Question 2

DX for shock

Answer 2

clinical dx

- rq systematic eval

Question 3

PE for Shock may include (14)

Answer 3

1-Temperature-hyper/hypothermia, via both endogenous and exogenous sources
2- HR- MC, elevated (paradoxical bradycardia)
3- Systolic/Diastolic BP- initially rises, then falls
4- Pulse pressure: increases early in shock, then declines before SBP
5- Pulsus pardoxus: decrease in SBP with inspiration
6- MAP: relationship between CO and SVR
7- SI
8- CNS: AMS, focal findings…–
-Chronic HTN: SXS with NML BP
9- Skin– Pallor pale, dusky, cyanosis, sweating, altered temperature, decreased cap refill
10- CV- JVD/flattening, tachycardia, arrhythmia
11- Pulm- tachypnea, increased MV, increased dead space, bronchospasm, hypocapnea, ARDS
12- GI- Ileus, GI bleeding, pancreatitis, kidney stone, AMI
13- Renal- reduced GFR, oliguria
14-Metabolic- respiratory alkalosis is the first acid base abnormality
-acidosis follows
-hyperglycemia
-hyperkalemia

Question 4

What conditions may you see paradoxical bradycardia? (4)

Answer 4

BB
Cardiac DZ
hemorrhage
hypoglycemia

Question 5

Pulse pressure depends on (2) and calculation

Answer 5

=SBP-DBP
aortic rigidity
SV

Question 6

Describe pulsus parodoxus and conditions it is seen (3)

Answer 6

• Rise/Fall in intrathoracic pressure affects CO
• severe cardiac decomp
• asthma
• tamponade

Question 7

Describe SIRS DX

Answer 7

rq 2 of the following to DX:
1-WBC:
<4K
>10% immature bands
>12K
2- RR>20
3- Temp: 
<36 C (96.8 F)
>38 (100.4 F)
4- HR>90 BPM

Question 8

early abx tx agents in septic shock (3)

Answer 8

Zosyn, 4.5g q6 hr
Vancomycin, 15 mg/kg q12 hr
——(often 1g)
Levaquin, 750 mg, q24 hr

Question 9

Vasopressor MAP Goal Range and MC

Answer 9

MAP 60-90 mmHg

MC 65

Question 10

What study supports higher MAP goals in fluid resusscitation for shock and what are those goals?

Answer 10

SEPSISPAM
MAP of 70-75 mmHg
(ESP WITH HX HTN)
— may cause A.fib

Question 11

Vasopressors to know: (4)

Answer 11

Dopamine, Dobutamine: 5-20 mcg/kg/min** PER KG
Norepinephrine, Epi: 5-20 mcg/min
Phenylephrine ~ 50-150 mcg/min
Vasopressin 0.04 U/min

Question 12

Goal directed approach Values: (4)

Answer 12

UOP: >0.5 mL/kg/H
CVP: 8-12 mmHg
MAP: 65-90 mmHg
ScV02: >70%

Question 13

Hypovolemic shock robust features of concern: 3

Answer 13

comorbid conditions
duration
source

Question 14

_____ in the ED is associated w/poor outcomes

Answer 14

HoTN

Question 15

Poor outcomes in prognosis associated with: (4)

Answer 15

1-Shock severity
2-Pre-existing vital organ dysfx
3-Lack of reversibility of dz
4- Persistently elevated lactate in trauma, septic and cardiac arrest patients

Question 16

TX for extravasation seen in vasopressor agents:

Answer 16

Local PHENTOLAMINE and the cessation of the agent- 2/2 to tissue necrosis risk

Question 17

Only vasopressor which is generally safe to use in peripheral IV

Answer 17

Dobutamine

Question 18

Dobutamine paradoxical effect on HR

Answer 18

in doses greater than 20 mcg/kg/min

Question 19

Regarded as the preferred agent in cardiogenic shock

Answer 19

Dobutamine

Question 20

Epinephrine Uses: (4)

Answer 20

• Anaphylactic shock
• Bronchodilator in acute asthma attack
• Cardiac arrest
• refractory, sxs bradycardia

Question 21

Epinephrine MOA

Answer 21

Non-selective Alpha/Beta stimulator

Question 22

Epinephrine may contribute to arrhythmias secondary to this MOA

Answer 22

increase Myocardial oxygen consumption, exacerbating Ventricular Arrhythmias if cardiac ischemia and established cardiac irritability

Question 23

Norepinephrine (Levophed) MOA and how it differs from epi

Answer 23

Stimulates the Alpha/Beta receptors, increasing Arterial and Venous Tone

• Ionotropic/Chronotropic activity
• Differs from Epi, in that is has no effect on Beta 2

Question 24

Norepinephrine (Levophed) MC use:

Answer 24

hemodynamic imbalances persist following fluid management

Question 25

First line agent in septic shock

Answer 25

Norepinephrine (Levophed)

Question 26

Paradoxical PNS response associated with Norepinephrine:

Answer 26

Can have a paradoxical parasympathetic stimulation, inducing a bradycardic response

Question 27

Phenylephrine (Neo-Synephrine) MOA and SXS

Answer 27

Though structurally similar to Epi, it actually predominantly acts on Alpha Receptor

• –NEAR exclusion of beta cell stimulation (though not absolute)- ie. Considerable vasoconstriction
• –Rise in BP w/subsequent decline in HR

Question 28

Phenylephrine (Neo-Synephrine) Use and Caution:

Answer 28

• HoTn and shock (though not severe HoTn, 2/2 to decrease in SV and reflex bradycardia)
• -caution w/ brady pts