Chapter 3 Shock

Question 1

Define Shock

Answer 1

abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation

Question 2

What is the most common type of shock in an injured trauma pt?

Answer 2

hemorrhagic

Question 3

Define Cardiac output

Answer 3

Vol of blood pumped by the heart per minute

Question 4

Define stroke vol

Answer 4

Amount of blood that leaves the heart w/ each cardiac contraction

Question 5

What is stroke vol determined by?

Answer 5

Preload
Myocardial contractility
Afterload

Question 6

Define preload

Answer 6

Volume of venous blood returned to the L and R side of the heart.

Question 7

Define afterload

Answer 7

Also known as PVR

Amount of resistance to forward flow of blood leaving the heart

Question 8

CO = ____ X _____

Answer 8

CO = Heart rate (BPM) X Stroke Vol (mL/beat)

Question 9

Early physiologic response to blood loss is _____

Answer 9

Compensatory

Question 10

What are the three main compensatory reactions to blood loss?

Answer 10

Vasoconstriction-Preserves blood flow to heart, kidney and brain
Catecholamine release- Increases PVR
Heart Rate Increase - to preserve C.O

Question 11

What are the first signs of shock due to volume loss

Answer 11

Tachycardia

Cutaneous vasoconstriction

Question 12

When does a decrease in systolic pressure occur?

Answer 12

Not until 30% vol loss occurs (SO THIS IS NOT A GOOD INDICATOR)

Question 13

Define Tachycardia in an adult

Answer 13

HR > 100 BPM

Question 14

Define Tachycardia in a pre-school age child

Answer 14

HR >140BPM

Question 15

Define tachycardia in an infant

Answer 15

HR > 160 BPM

Question 16

Define Tachycardia in a school age child-Puberty

Answer 16

HR >120 BPM

Question 17

When looking for source of Hemorrhagic shock the term “The floor plus 4 more” refers to what?

Answer 17

Blood loss from
Chest
Abdomen
Pelvis
Retroperitoneum
External bleeding

Question 18

What sources of Non-hemorrhagic shock should be considered as well?

Answer 18

Cardiogenic shock
Cardiac Tamponade
Tension PTX
Neurogenic shock
Septic Shock

Question 19

When should cardiogenic shock be considered possible?

Answer 19

Blunt cardiac injury when mech of injury is rapid deceleration
Also can be secondary to MI

Question 20

What labs/tests should be done to detect and monitor possible cardiogenic shock?

Answer 20

ECG continuous monitor

Cardiac enzymes

Question 21

When should Cardiac Tamponade as a cause of shock be considered?

Answer 21

Blunt/penetrating chest trauma 
Tachycardia
Muffled heart sounds
dilated engorged Neck veins
Hypotension without response to fluid resusc.

Question 22

What labs/tests should be done to detect and monitor possible cardiac tamponade in the case of shock?

Answer 22

ECG is not quick or that helpful although can detect

FAST US will identify pericardial fluid

Question 23

What symptoms of Tension PTX differ from Cardiac tamponade

Answer 23

All of the symptoms of cardiac tamponade are present in T PTX except for muffled heart sounds, Breath sounds (which are absent in tPTX), and Hyperresonance (echoes in tPTX)

Question 24

If patient has an isolated intracranial injury but appears to be in neurogenic shock what must be done?

Answer 24

Look for other cause!

Isolated intracranial injury does not cause neurogenic shock unless the brainstem is involved.

Question 25

Classic presentation of neurogenic shock

Answer 25

Hypotension without tachycardia or cutaneous vasoconstriction

Question 26

When should septic shock be considered in trauma pt?

Answer 26

Delayed presentation to ED.

Question 27

Class I hemorrhage definition | and exam parameters

Answer 27

< 15% blood loss | All measurable parameters remain stable

Question 28

Class II hemorrhage definition | and exam parameters

Answer 28

``` 15-30% blood loss HR can remain same or increase Tachypnea Pulse pressure drops All other parameters remain stable ```

Question 29

Class III hemorrhage definition | and exam parameters

Answer 29

31-40% blood loss Marked tachycardia and tachypnea Significant mental status change Measurable systolic pressure drop

Question 30

Class IV hemorrhage definition and exam parameters

Answer 30

>40% blood loss Tachycardia marked systolic drop Narrow pulse pressure or no traceable diastolic bp

Question 31

Treat all shock as if it is _____ until proven otherwise

Answer 31

hemorrhagic

Question 32

Steps to physical exam of shock pt

Answer 32

A and B- Establish airway and proper ventilation- provide supp O2, maintain O2 sat 95% C- STOP THE BLEEDING, obtain IV access D-Determine lvl of consciousness and assess cerebral perfusion E-Expose to determine addl bleeding and keep warm!

Question 33

Why is Gastric Decompression necessary in shock

Answer 33

To prevent aspiration

Question 34

Why is urinary Cath helpful in shock?

Answer 34

To assess hematuria and measure urinary output

Question 35

When is urinary cath contraindicated?

Answer 35

urethral injury

Question 36

What is the proper protocol for initial fluid tx?

Answer 36

Initial warmed fluid bolus of isotonic fluid Usual bolus is 1L in adults and 20mL/kg in children < 40kg. bolus amount includes pre-hospital amount

Question 37

Three different patient response schemes

Answer 37

Rapid response Transient response Minimal or No response

Question 38

Rapid response to hemorrhage indicates which class of hemorrhage?

Answer 38

Class 1 <15% loss

Question 39

What intervention should be given to pt with rapid response?

Answer 39

no further fluid management required after initial resusc.

Question 40

Define transient response

Answer 40

Pt responds to initial bolus but return to unstable status once maintenance fluid is started

Question 41

Transient response indicates what class of loss in shock?

Answer 41

Class II - III between 15-40% | indicates pt is still bleeding somewhere

Question 42

What intervention should occur to pt that is a transient responder?

Answer 42

Blood product and blood should be started, Re-eval for operative or angiographic control consider activating MTP

Question 43

What intervention should occur in pt w/ no response to fluid/blood resusc.

Answer 43

Immediate operative or angioembolization Consider other types of shock (tamponade or PTX) Initiate MTP

Question 44

Define MTP

Answer 44

>10u pRBCs w/ the first 24h of admission or | >4u in 1 hour