Cardiology #9 (Shock)

Question 1

The physical responses to shock are mediated by 6 things. Name them.

Answer 1

Antidiuretic hormone (ADH)
Renin
Catecholamines
Glucagon
Growth Hormone
Cortisol

Question 2

What exactly is shock?

Answer 2

Inadequate organ perfusion and tissue oxygenation to meet the body’s needs. Based on either low cardiac output or high systemic vascular resistance

Question 3

The first type of shock, hypovolemic shock is _____ and occurs due to _____

Answer 3

Loss of blood or fluid volume due to hemorrhage or fluid loss

Question 4

Common causes of hypovolemic shock

Answer 4

• Hemorrhagic: GI bleed, AAA rupture, massive hemoptysis, ectopic pregnancy
• Non-blood fluid loss: Vomiting, bowel obstruction, pancreatitis, severe burns, DKA

Question 5

What is the pathophysiology of hypovolemic shock?

Answer 5

Loss of blood fluid volume –> increases HR –> vasoconstriction, hypotension, low cardiac output

-The body’s response is peripheral vasoconstriction, increase cardiac activity, Na/water retention, and increase cortisol

Question 6

Symptoms of hypovolemic shock

Answer 6

Tachycardia
Hypotension
Oliguria or Anuria
Pale cool dry skin
Slow capillary refill > 2 seconds
Decreased skin turgor
Dry mucous membranes
AMS

EVERYTHING IS DRY AND SLOW

Question 7

What are the hallmark symptoms that diagnose a patient with hypovolemic shock?

Answer 7

Vasoconstriction (increased SVR)
Hypotension
Decreased cardiac output and pulmonary capillary pressure

Question 8

Treatment of hypovolemic shock

Answer 8

ABCDEs, insert 2 large bore IV lines or central line
Volume resuscitation: crystalloid (Normal Saline or Lactated Ringers) 3-4 liters
Monitor urine output to assess further need for fluid
Packed RBC blood transfusion if severe hemorrhage
Prevention of hypothermia

Question 9

What are the ABCDE’s of shock management

Answer 9

A: Airway (intubation)
B: Breathing (mechanical ventilation and sedation)
C: Circulation (Normal Saline, Lactated Ringer’s)
D: Delivery of Oxygen (monitor lactate levels)
E: Endpoint of Resuscitation (urine output 0.5ml/kg/hr, CVP 8-12 mmHg, MAP 65-90 mmHg)

Question 10

Cardiogenic shock often produces what symptom that hypovolemic shock does not?

Answer 10

Increased respiratory effort/distress

Question 11

Etiology of cardiogenic shock

Answer 11

Cardiac disease: MI, myocarditis, cardiomyopathy, congenital heart disease, arrhythmias

Question 12

What is one unique thing about the treatment for cardiogenic shock?

Answer 12

Isotonic fluids are given in small amounts. The only type of shock in which LARGE amounts of fluid are not given.

Question 13

What are the other treatment recommendations for cardiogenic shock?

Answer 13

• Inotropic support: drugs to increase cardiac output such as Dobutamine, Epinephrine, Amrinone
• Treat the underlying cause: If MI, early angioplasty or thrombolytics

Question 14

What is obstructive shock?

Answer 14

Obstruction of blood flow due to physical obstruction of heart of great vessels

Question 15

What are 4 HUGE etiologies of obstructive shock?

Answer 15

• Massive pulmonary embolism: obstructed pulmonary artery blood flow.
• Pericardial Tamponade: blood in pericardial space prevents venous return to heart
• Tension pneumothorax: positive air pressure causes external pressure on heart
• Aortic dissection

Question 16

What is distributive shock?

Answer 16

Excess vasodilation and altered distribution of blood flow with shunting of blood flow from vital organs (heart, kidney) to non-vital tissues (skin, skeletal muscle)

Question 17

What are the three factors of distributive shock?

Answer 17

• Decreased CO
• Decreased Systemic vascular resistance
• Decreased pulmonary capillary wedge pressure

Question 18

MC type of distributive shock?

Answer 18

Septic Shock

Question 19

Pathophysiology of septic shock

Answer 19

-infective organisms active the immune system –> host produces systemic inflammatory response –> cytokines cause peripheral vasodilation –> lowers SVR, and increases capillary permeability which induces shock and end organ thrombosis

Question 20

Symptoms of septic shock

Answer 20

• Hypotension with wide pulse pressure (bounding peripheral arterial pulses)
• Only major type of shock with increased cardiac output (fast capillary refill time, warm, flushed extremities)
• Fever or hypothermia (<96.8)
• Pulse > 90
• RR > 20
• WBC > 12,000 or < 4,000

Question 21

Management of septic shock

Answer 21

• Broad spectrum IV ABX: Zosyn + Ceftriaxone or Imipenem
• IV Fluid Resuscitation: isotonic crystalloids (Normal saline, Lactated Ringer’s)
• Vasopressors: if no response to 2-3 L of fluids.

Question 22

1st line treatment for anaphylactic shock

Answer 22

Epinephrine (0.3mg IM)
Airway management
Antihistamines
IVF
Observe patients for 4-6 hours

Question 23

Why should you observe patients for 4-6 hours after anaphylactic shock?

Answer 23

Up to 20% of patients have a biphasic phenomenon (return of symptoms 3-4 hours after the initial reaction)

Question 24

What is neurogenic shock?

Answer 24

due to acute spinal cord injury

Question 25

Symptoms of neurogenic shock

Answer 25

• Wide pulse pressure
• Bradycardia
• Hypotension
• Warm, dry skin
• Loss of sympathetic tone

Question 26

Endocrine shock (such as Addisonian crisis) has a first line management of

Answer 26

Hydrocortisone 100mg IV