A.3-7 Flashcards
shock definition?
Acute hymodynamic disorder, independant of cause, leading to insufficient O2 supply and tissue hypoxia
which part of our circulation is the main thing in shock?
microcirculation due to shunting and skipping this part causing hypoxia
phases of shock?
compensated: initially, reversible
decompensated: critical pH7.2. irreversible
pahtophysiology of compensated phase?
-centralized circulation
-catecholamines outflow
what do we need to examine during the compensated phase of shock?
organ perfusion:
- brain: consciousness, orientation
- skin: CRT, extremity temp
- bowel: paralyisis, sounds
- kidney: diuresis/hr (nromal:0.5-1.5ml/kg/h)
pahtophysiology of decompensated phase?
-cetralized circulation become affected
-catecholamines are ineffective
what are the hypodynamic shocks?
what do they all have in common)
cardiogenic (increased preload)
hypovolemic
obstructive
all: cold and clammy
decreased CO, preload
Increased SVR (afterload)
what are the hyperdynamic shocks?
what do they have in common?
The three distributiv shocks (septic, anaphylactic, neurogenic)
All: flushed, warm
increased CO, later decreases due to CMP
decreased SVR (afterload), PCWP (preload)
what is Neurogenic shock?
loss of normal SYMP innervation after damage to CNS by a spinal cord injury
what happens in Neurogenic shock?
loss of the ability of normal vasoconstriction
blood shunts from a–>v in shortest way instead of capillary
tissue is still hypoperfused !!
symptoms of shock?
skin: alpha1 rec. –> vasoconstriction –> pale clammy
brain: cerebral hypoperfusion –> confusion
kidney: alpha1 rec. –> vasoconstriction –> oliguria
heart: beta1 rec. –> tachycardia
lungs: increase in O2 supply requirement + acidosis compensation –> tachypnoe
low BP: depletion of compensation
bowel: splanchnic vasoconstriction –> absence of bowel sounds
how do you diagnose shock?
physical examination
hemodynamic monitoring
invasive BP monitoring
invasive MAP monitoring
CVP monitoring
CO monitoring
ABG
ECG
RUSH protocol
non-invasive hemodynamic monitoring in shock?
non-invasive BP
ECG
pulse oximetry
echo
esophageal doppler
ultrasonic CO monitoring
invasive hemodynamic monitoring in shock?
invasive BP monitoring
CVP measurement
PiCCO
Swan-Ganz catheter
indications of invasive BP monitoring?
unstable hemodynamics
vasoactive therapy required
perioperative monitoring of high risk surgery
advantages of invasive BP monitoring?
continuous and accurate
shock therapy main goals?
restoration of homeostasis before compensation
elimination of local acidotic mediators from hypoperfused regions
maintenance of O2 level and tissue perfusion
shock therapy initial management?
O2 supplimentation: face mask
obtaining 2 large IV catheters: 14G and 16G
or central line
admission to ICU
Etiology of cardiogenic shock?
- decrease in pump function
- valvular disorder
- intracardiac shunt
- arrythmia
how do you treat cardiogenic shock?
supportive
drugs
circulatory support
supportive therapy in cardiogenic shock?
oxygenation
IV access
fluid resuscitation
Drug used in Cardiogenic shock?
Dobutamine
Levosimendan
milirinone
mechanical circulatory support in cardiogenic shock?
VAD: ventricular assist device
ECMO: Veno-Venous, Arterio-Venous
Anaphylactic shock definition?
Generalized immunological condition of sudden onset, which develops after the exposure to a foreign subtsance
symptoms of typical anaphylactic shock?
(the triad)
angioedema
bronchoconstriction
hypotension
other important clinical features of anaphylactic shock?
skin and mucosa:
-erythma
-urticaria
-pruritus
resp.:
-chest tightness
-dyspnoe
-stridor, wheezing
-hypoxia, cyanosis
G.I.:
-nausea and vomiting
-diarrhea and pain
cardiovascular:
-hypotension
-tachycardia
-weak peripheral pulses
signs of End-organ failure in anaphylactic shock?
brain: syncope
kidney: oliguria, anuria
skin: motteling, low temp, CRT >2s
therapy of anaphylactic shock?
allergen removal
drugs
resp. support
fluids
Drugs of choice in anaphylactic shock?
1st line: Epinephrine/Adrenalin
(0.5 mg IM or 0.1 IV)
Antihistamines: H1-rec. antag
steroids (resp)
beta2 agonists (resp)
muscarinic antag. (resp)
resp support in anaphylactic shock?
- high flow O2
- early intubation in stridor after epineph.
Hemmorrhagic shock signs and symps?
- cold peripheries
- decrease: CO, SVR, BP
- tachycardia
- altered mental status
ABG:
-low Hgb
-high lactate
-metabolic acidosis
Hemorrhagic shock diagnostics?
ABCDE
and physical examination
ABG
coagulation studies, bleeding time and elastography
Hemorrhagic shock therapy?
- stop bleeding
- aggressive fluid resusci. (isotonic ringer 2L)
-blood transfusion:
packed RBC
FFP: if coagulopathy
-PLT transfusion
what to give if refractory to NE of in severe pulmonary hypertension?
Argipressin
Hemodynamic parameters you look at in shock?
CVP
CO
PCWP
SVR
HR
SVO2
Why is temperature important in bleeding?
Temperature affects coagulation
Hypothermia decreases coagulation!!!!
what the deal with distributive shock?
there is a loss of vasoconstriction and blood is going “everywhere” and not to the tissue really needing it
Obstructive shock definition?
obstruction of blood flow into or out of the heart due to impaired diastolic filling or excessive afterload
Obstructive shock etiology?
- pulmonary embolism
- temponade
- tension PTX
symptoms of obstuctive shock?
cold peripheries
hypotension
tachycardia
tachypnoe
oliguria
subcutanous emphysema
chest/abd. pain
obstructive shock diagnosis?
ABCDE
ABG
RUSH
Pulmonary angiography/scintigraphy
obstructive shock treatment?
PE
- Anticoagulation: Heparin
- thrombolysis: Alteplase
- Trend.el.burg procedure: surgical thrombectomy
obstructive shock treatment?
Temponade
Pericardiocentesis
surgery: seldinger technique
obstructive shock treatment?
TPTX
needle thoracostomy
