850-IP8-Shock

Question 1

SHOCK

Answer 1

1. Systemic hypoperfusion caused by a reduction in cardiac output or blood volume
2. Hypotension –> inadequate tissue perfusion –> cellular injury and dysfunction –> multiple organ failure
3. 3 main types: Hypovolemic, Cardiogenic, Distributive

Question 2

HYPOVOLEMIC SHOCK:

Answer 2

1. Decreased cardiac output due to inadequate blood or plasma volume - Common causes: hemorrhage, burns, trauma
2. Presentation:
   - Thirst, nausea, anxiousness, weakness, light-headedness, dizziness, decreased urine output
   - Severe volume loss may result in tachycardia, elevated RR, hypotension, mental status changes/unconsciousness

Question 3

HYPOVOLEMIC SHOCK TREATMENT:

Answer 3

• Non-pharmacologic: control of inciting event, surgery, fractures stabilization, control of blood loss, etc.
• Pharmacologic: Fluids (crystalloids vs. colloids), blood products (packed red blood cells, FFP, platelets)

Question 4

Hypovolemic shock

Crystalloids fluids

Answer 4

• Normal Saline (NS)
• Lactated Ringers (LR)
• 5% Dextrose in Water (D5W)
• Hypertonic (3%) Saline

Question 5

Hypovolemic shock

Colloids fluids

Answer 5

• Albumin
• Hydroxyethyl starch
• Dextrans

Question 6

Hypovolemic shock

Blood Products fluids

Answer 6

• Packed red blood cells (pRBC)
• Fresh frozen plasma (FFP)
• Platelets

Question 7

Hypovolemic shock

Crystalloids considerations for use

Answer 7

1. Preferred initial fluid
2. Consider D5W for dehydration w/minor s/s of volume depletion
3. Consider hypertonic saline (in addition to NS/LR) for head trauma; caution due to osmolarity, risk of cellular crenation and damage

Question 8

Hypovolemic shock

Colloids considerations for use

Answer 8

1. Potential longer intravascular retention time vs. crystalloids
2. No evidence of reduced mortality compared with crystalloids; benefits may exist with certain subsets of patients
3. Hydroxyethyl starch: FDA warning for increased mortality, severe renal injury and risk of bleeding – do not use in critically ill patients
4. Dextrans: increased risk of anaphylaxis, may aggravate bleeding, and cause renal dysfunction

Question 9

Hypovolemic shock

Blood Products considerations for use

Answer 9

1. pRBC: increase the oxygen carrying capacity in the blood
2. FFP: replacement of clotting factors
3. Platelets: administer for thrombocytopenia

Question 10

CARDIOGENIC SHOCK:

Answer 10

1. End-organ hypoperfusion due to cardiac failure (i.e. dysfunctional pump)
   - Common causes: myocardial ischemia, arrhythmia, outflow obstruction, mechanical abnormalities
   - Occurs in 5-8% of STEMI patients and 2.5% in NSTEMI
2. Presentation:
   - AMS, pulmonary edema, hypotension, weak pulses, cool extremities, decreased urine output
3. Diagnostic criteria:
   - Sustained hypotension (SBP<90) and a reduced CI (<2.2 l/min/m2) in the presence of elevated PCWP>18

Question 11

CARDIOGENIC SHOCK Treatment:

General Treatment

Answer 11

1. Fluid resuscitation unless frank pulmonary edema is present (conservative 250-500 ml bolus) o Considerdiuresis(furosemide)forpulmonaryedema
2. Correction of rhythm abnormalities or electrolyte (magnesium/potassium) disturbances
3. Avoid beta-blockers and calcium channel blockers due to negative inotropic effects
4. Individualized vasopressors therapy; use of dopamine may be associated with excess hazard

Question 12

CARDIOGENIC SHOCK Treatment:

For STEMI patients

Answer 12

1. Emergent revascularization with either PCI or CABG if due to pump failure after STEMI
2. Fibrinolytic therapy for patients who are unstable for PCI or CABG
3. Intra-aortic balloon pump counterpulsation unstable patients after pharmacologic therapy (Class IIa)
4. Alternative LV assist devices for circulatory support may be considered in refractory cardiogenic
   shock

Question 13

DISTRIBUTIVE SHOCK

Answer 13

1. Excessive vasodilation resulting in impaired distribution of blood flow
2. Common types:
   - Septic
   - Neurogenic
   - Anaphylactic

Question 14

Septic:

Answer 14

Excessive inflammation due to infectious source

Question 15

Neurogenic:

Answer 15

Not associated with blood loss, but rather a disruption of autonomic regulation in the spinal
cord resulting in decreased SVR and pooling of blood in the periphery

Question 16

Anaphylactic:

Answer 16

Marked arterial vasodilation

Question 17

SIRS:

Answer 17

-Causes of are multifactorial including ischemia, infection, pancreatitis, trauma, and burns

• SIRS Criteria (presence of 2 of the following):
  1. Temperature >38.3°C or <36°C
  2. HR > 90 bpm
  3. RR>20ormechanicalventilation
  4. WBC>12,000 OR <4,000 OR >10% immature forms

Question 18

Sepsis:

Answer 18

SIRS due to infection

Question 19

Severe sepsis:

Answer 19

1. Sepsis with sepsis induced organ dysfunction or tissue hypoperfusion
   - Evaluated by decreased urine output, elevated creatinine, coagulopathy, acute lung injury, etc.

Question 20

Septic shock:

Answer 20

Sepsis hypotension = hypotension persisting after initial fluid challenge or lactate ≥ 4 mmol/L