#6 Shock Flashcards
Equation for Shock Index and conditions where may be skewed:
SI= HR/Systolic BP (0.5-0.7)
elevated in…
- LV dysfx
- volume loss
DX for shock
clinical dx
- rq systematic eval
PE for Shock may include (14)
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
What conditions may you see paradoxical bradycardia? (4)
BB
Cardiac DZ
hemorrhage
hypoglycemia
Pulse pressure depends on (2) and calculation
=SBP-DBP
aortic rigidity
SV
Describe pulsus parodoxus and conditions it is seen (3)
- Rise/Fall in intrathoracic pressure affects CO
- severe cardiac decomp
- asthma
- tamponade
Describe SIRS DX
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
early abx tx agents in septic shock (3)
Zosyn, 4.5g q6 hr
Vancomycin, 15 mg/kg q12 hr
——(often 1g)
Levaquin, 750 mg, q24 hr
Vasopressor MAP Goal Range and MC
MAP 60-90 mmHg
MC 65
What study supports higher MAP goals in fluid resusscitation for shock and what are those goals?
SEPSISPAM
MAP of 70-75 mmHg
(ESP WITH HX HTN)
— may cause A.fib
Vasopressors to know: (4)
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
Goal directed approach Values: (4)
UOP: >0.5 mL/kg/H
CVP: 8-12 mmHg
MAP: 65-90 mmHg
ScV02: >70%
Hypovolemic shock robust features of concern: 3
comorbid conditions
duration
source
_____ in the ED is associated w/poor outcomes
HoTN
Poor outcomes in prognosis associated with: (4)
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
TX for extravasation seen in vasopressor agents:
Local PHENTOLAMINE and the cessation of the agent- 2/2 to tissue necrosis risk
Only vasopressor which is generally safe to use in peripheral IV
Dobutamine
Dobutamine paradoxical effect on HR
in doses greater than 20 mcg/kg/min
Regarded as the preferred agent in cardiogenic shock
Dobutamine
Epinephrine Uses: (4)
- Anaphylactic shock
- Bronchodilator in acute asthma attack
- Cardiac arrest
- refractory, sxs bradycardia
Epinephrine MOA
Non-selective Alpha/Beta stimulator
Epinephrine may contribute to arrhythmias secondary to this MOA
increase Myocardial oxygen consumption, exacerbating Ventricular Arrhythmias if cardiac ischemia and established cardiac irritability
Norepinephrine (Levophed) MOA and how it differs from epi
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
Norepinephrine (Levophed) MC use:
hemodynamic imbalances persist following fluid management
First line agent in septic shock
Norepinephrine (Levophed)
Paradoxical PNS response associated with Norepinephrine:
Can have a paradoxical parasympathetic stimulation, inducing a bradycardic response
Phenylephrine (Neo-Synephrine) MOA and SXS
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
Phenylephrine (Neo-Synephrine) Use and Caution:
- HoTn and shock (though not severe HoTn, 2/2 to decrease in SV and reflex bradycardia)
- -caution w/ brady pts
