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2020 CPR II Cardio Exam 1 > Clinical Medicine 5: Altered Physiology and Shock (Arnce) > Flashcards

Clinical Medicine 5: Altered Physiology and Shock (Arnce) Flashcards

1
Q

Shock can be defined as systolic BP < _____ mmHg or a ↓ systolic BP ______ mmHg below baseline.

A

Shock can be defined as systolic BP < 80-90 mmHg or a ↓ systolic BP 40 mmHg below baseline.

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2
Q

Shock can be defined as a MAP

A

<60-65 mmHg

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3
Q

Levels of what are a reflection of tissue hypoxia?

A

Lactate

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4
Q

Which 3 categories of shock present with skin that is cool, clammy, cyanotic, pallor, and mottled (blotchy) distal extremities due to ↓ perfusion/vasoconstriction?

A
  • Hypovolemic
  • Cardiogenic
  • Obstructive
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5
Q

Which type of shock will present with skin/extremities that are warm and pink due to vasodilation?

A

Distributive/dissociative shock (cyanide poisoning)

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6
Q

What is the HR like in shock and is useful why?

A
  • Usually fast; occasionally slow
  • Sensitive indicator of shock
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7
Q

Common renal manifestation of shock?

A

Oliguria

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8
Q

Which serum value associated with shock is related to an increase in mortality as levels get higher?

A

Lactate

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9
Q

What is responsible for the mental status changes associated with shock?

A

↓ cerebral perfusion –> confusion, restlessness, agitation, delirium, stupor, coma

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10
Q

What is the most common cause of hypovolemic shock?

A

Hemorrhagic shock

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11
Q

What are 3 non-hemorrhagic causes of hypovolemic shock?

A
  • GI losses (vomiting, diarrhea)
  • Skin losses (burns, heat strokes)
  • DKA –> renal losses
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12
Q

What are 3 causes of distended neck veins?

A
  • HF
  • PE
  • Tamponade
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13
Q

In shock what is the initial acid-base disturbance and then is followed by what?

A

Respiratory alkalosis —-> metabolic acidosis (think ↑ lactate)

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14
Q

Hypoaldosteronism, adrenal insufficiency, 3rd space loss, bowel obstruction, and systemic inflammation may all cause what type of shock?

A

HYPOvolemic

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15
Q

What is initial management for someone in hypovolemic shock, whether due to hemorrhagic or non-hemorrhagic cause?

A
  • Fluids FAST - monitor BP and tissue perfusion
  • Crystalloids —> NS useful in hypovol. from renal, GI, sweat, burns, hemorrhage
  • Packed RBC for hemorrhage/function is erythrocyte
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16
Q

How does the pulse rate, BP, and pulse pressure change as you move from class I to class IV criteria of hemorrhagic shock?

A
  • Pulse rate will ↑as the HR ↑
  • BP will ↓
  • Pulse pressure will ↓
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17
Q

What is the most common cause of non-cardiogenic shock?

A

Septic or Non-septic (vasodilation)=Distributive shock

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18
Q

What are 4 signs/sx’s of sepsis (distributive shock)?

A
  • Fever (>38 C or <36 C)
  • Tachycardia (>90/min)
  • Tachypnea (>20 breaths/min)
  • ↑ WBC (>12,000) or WBC (<4000)
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19
Q

What is the definition of septic shock?

A

Severe sepsis and dysfunction of organ system w/ hypotension (<90 systolic or >40 mmHg ↓ baseline) despite fluids

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20
Q

How does endothelial injury in distributive shock lead to a ↓ preload?

A

Becomes permeable and leaks fluid into tissue (lung, intestine, capillary leak) releases NO2 = potent vasodilator which ↓ preload

21
Q

What are PE findings of the skin/extremities, HR, BP, and neck veins associated with distributive septic shock?

A
  • Skin/extremities = warm, flushed (vasodilation)
  • HR = fast (10-30% will have myocardial depression)
  • BP = low (<90 systolic BP)
  • Neck veins = flat = ↓ JVP
22
Q

What are some of the common sources/underlying infections throughout each body system which may lead to sepsis (i.e., pulmonary, abdominal, GU, CNS, and skin..)

A
  • Pneumonia, emphysema
  • Peritonitis, cholangitis
  • Pyelonephritis, abscess
  • Meningitis

Cellulitis, necrotizing fascitis

23
Q

If patient with septic shock doesn’t respond to IV fluids what should be given to maintain perfusion pressure; what is the 1st line agent and 2nd line agent?

A

- Norepinephrine = 1st line

  • Dopamine = 2nd line –> can cause tachycardia
24
Q

Other than fluids/pressors what else should be given as treatment for septic shock?

A
  • Antibiotics –> vancomycin + piperacillin/tazobactam + aminoglycoside
  • ± low dose steroids
25
Q

What are some of the allergens which can lead to anaphylactic shock?

A
  • Drugs (antibiotics, chemo, hormones, NSAIDs)
  • Insect bites
  • Foods
  • Latex
  • Contrast agents
26
Q

What occurs to SVR in distributive shock (i.e., anaphylactic and septic shock) vs. hypovolemic shock vs. cardiogenic shock?

A
  • Distributive (septic and anaphylactic) = ↓ SVR (vasodilation)
  • Hypovolemic = ↑ SVR (due to vasoconstriction)
  • Cardiogenic = ↑ SVR (compensating for ↓BP and ↓CO)
27
Q

Cardiogenic shock is due to a decrease in systemic oxygen delivery caused by what?

A

Deterioration of cardiac function due to myocardial, valvular, structural, toxic or infectious causes = PUMP FAILURE

28
Q

What is the BP, CO, and urine output like in cardiogenic shock?

A
  • ↓ BP (<90 or >30 mmHg below baseline)
  • ↓ CO –> ↓ urine output
29
Q

What are the 3 classifications of cardiogenic shock?

A
  • Cardiomyopathic
  • Arrhythmogenic
  • Mechanical
30
Q

What are the clinical signs of cardiogenic shock (BP, UO, skin, neck veins, and lungs.)

A
  • ↓ BP and ↓UO
  • Cool, mottled extremities
  • Distended neck veins (↑ CVP >12 mmHg)
  • Pulmonary edema
31
Q

What is the most common cause of cardiogenic shock?

A

LV failure due to AMI

32
Q

RV infarction assoc. w/ inferior MI leading to cardiogenic shock should be treated how?

A

IV fluids = preload sensitive (do not give nitrates)

33
Q

What are some complications arising after an MI which can lead to Cardiogenic Shock?

A
  • Acute mitral regurgitation
  • VSD
  • RV infarction
  • Ventricular free wall rupture —> tamponade
34
Q

Which drugs are given for cardiogenic shock?

A
  • Norepinephrine = preferred = alpha-1, beta-1, beta-2 agonist
  • Dopmaine
  • Inotropes = dobutamine and milrinone
35
Q

Which drug can be given in cardiogenic shock to decrease the pulmonary edema?

A

Furosemide (loop diuretic - Lasix)

36
Q

What are some of the causes of extracardiac obstructive shock?

A
  • Obstructed RV output = massive PE air embolus
  • Impaired diastolic filling = SVC syndrome
  • Cardiac tamponade
  • Constrictive pericarditis
  • Severe HTN
37
Q

Any patient with pleuritic chest pain and dyspnea should make you think of what cause?

A

Pulmonary embolism

38
Q

Any patient with chronic dyspnea and ↑ P2 (pulmonic valve sound) should make you think of what cause?

A

Pulmonary HTN

39
Q

Common cause of chest pain, SOB, tracheal deviation (away from affected side), ↓ unilateral breath sounds?

A

Tension Pneumothorax

40
Q

Distended neck veins, muffled heart sounds, pulsus paradoxus dilated IVC are features of what?

A

Cardiac Tamponade

41
Q

Emergent tx for tension pneumothorax?

A
  • 14-16 gauge IV catheter in 2nd, 3rd ICS, MCL followed by thoracostomy

OR

  • Emergent tube thoracostomy in 5th ICS, MCL
42
Q

When using echocardiogram to diagnose pericardial tamponade what highly sensitive sign are you look for and what other common findings?

A

RA collapse (sensitive); RV collapse; IVC dilation

43
Q

Tx for Pericardial Tamponade?

A

Echo/ultrasound to guide pericardialcentesis

44
Q

What occurs to HR, JVD, extremities, lungs, and SVR in extracardiac obstructive shock?

A
  • ↑HR
  • ↑JVP (w/o volume overload)
  • Extremities = cool
  • Lungs = dry
  • SVR = ↑
45
Q

Which imaging is preferred for pulmonary embolism (extracardiac obstructive shock)?

A

Computer Tomography Pulmonary Angiography (CTPA)

46
Q

When would a V/Q scan be preferred over CTPA for diagnosing PE?

A
  • Pt is allergic to contrast agents used in CTPA
  • Renal insufficiency
  • Women <40 y/o to ↓ radiation
  • Pregnancy
47
Q

Which degradation product of fibrin is an indirect index of clotting and has high sensitivty, but low specificity, for PE?

A

D-dimer

48
Q

What are ECG and Echocardiogram findings associated with PE/extracardiac obstructive shock?

A
  • ECG = S1 Q3 T3 + sinus tachycardia (most common sign)
  • Echo = RV dilation w/ tricuspid regurgitation

2020 CPR II Cardio Exam 1 (31 decks)

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