Critical Care: Shock

Question 1

Neurogenic Shock S/S and treatments/Interventions

Answer 1

S/S- Hypotension, Bradycardia, Hypothermia, Warm/Dry skin

Nursing interventions- Admin O2, DVT prophylaxis, spinal immobilization (backboard + C-Collar),
Atropine to increase HR, Vasopressors (Epi to increase BP)
Warm blankets/bear huggers for shivers, insert foley, remove tight clothes, 1L NS or LR OK to keep line open

Question 2

Anaphylactic Shock S/S and interventions/Tx

Answer 2

S/S- Wheezing, SOB, angioedema, hives, dizziness, chest pain, hypotension, bronchospasm, urticaria, pruritus
Causes: Bee sting, shellfish, peanuts
Nursing Interventions- Admin O2
Admin EPI IM until S/S resolve
Admin Benadryl/Diphenhydramine IV
Admi Solumedrol/Methylprednisone IV
Admin H2 Blockers (Cimetidine + Famotidine)
Increase SvO2 = improvement
1L of NS or LR OK to keep line open

Question 3

Sepsis S/S

Answer 3

S/S- Edema, Delayed Cap refill, Tachycardia (over 90bpm), hypotension (90/xx), ALOC, Lactic acid above 2, decreased urine output, cool/clammy skin, increased or decreased WBC

Question 4

Obstructive Shock S/S

Answer 4

S/S- JVD, no obvious s/s of other types of shock, decreased BP during inhale, muffled heart sounds, possible trache deviation, ALOC, decreased perfusion assessment, washing machine sound, dyspnea/chest pain

NO FLUIDS

Question 5

Cardiogenic shock interventions + Treatments

Answer 5

Interventions- Admin O2, + Inotropic (Milrinone/Primacor), Digoxin, Dobutamine, Dopamine, Nitro, Epi

Place pt on 12 lead, contact provider for balloon pump (time with EKG), possible transport to Cath lab
If CVP too high = admin diuretic

NO BETA BLOCKERS

Question 6

Which shock types are distributive in nature? [massive vasodilation]

Answer 6

Septic Shock, Neurogenic Shock, Anaphylactic Shock (SNA)

Question 7

MODS- Respiratory S/S and TX

Answer 7

S/S- Increased RR, Crackles, ABG = respiratory alkalosis, V/Q mismatch, decreased O2 stats

Tx- Admin O2, prepare for intubation

Question 8

MODS- Cardiovascular S/S and Tx

Answer 8

S/S- Decreased SVR/CVP/BP/MAP
Increased HR
HF

Tx- IV fluids, vasopressors (Levo/Norepi/Epi/Vasopressin/ADH)

Question 9

MODS- Neuro S/S

Answer 9

ALOC

Question 10

MODS- Renal S/S and Tx

Answer 10

S/S- Decreased urine output (lesss than 30mL/Hr), increased BUN/Creatinine (>1.3)

Tx- Dialysis/CRRT

Question 11

MODS- Liver S/S and Tx

Answer 11

S/S- Increased LFT/Ammonia/aPTT/Lactic Acid/ BG
Decreased Albumin
Jaundice

Tx- Admin lactulose to combat ammonia

Question 12

MODS- Hematologic S/S and Tx

Answer 12

S/S- Increased D-Dimer, FSP
Decreased PH

Question 13

MODS- GI S/S and Tx

Answer 13

S/S- Decreased or absent BS, GI bleed

Tx- H2 blockers (Cimetidine, Famotidine)

Question 14

Septic Shock

Answer 14

Poor perfusion + low MAP despite fluid resuscitation (requires vasopressors)

Question 15

What is the sepsis bundle?

Answer 15

1. Trend lactate
2. Administer ABX
3. BG control
4. x2 Bacterial cultures
5. CVP monitoring
6. IV fluids [LR] (30mL/kg bolus)

Question 16

What is the SIRS criteria?

Answer 16

Increased or decreased WBC
HR above 90
Increased or decreased temp
RR above 20

Question 17

In Septic shock, where would vasopressors be administered?

Answer 17

A central line

Question 18

In Septic shock, if the CVP is good and the patient is at the max on all vasopressors, what would be the next course of action?

Answer 18

Talk to family about end of life care

Question 19

What lactic acid level is indicative of sepsis?

Answer 19

Above 2 (2-4)

Question 20

During shock, what happens in regards to PAWP, RAP and PAMP?

Answer 20

PAWP- decreases due to massive vasodilation
RAP-decrease due to massive vasodilation (normal = 2-8)
PAMP- decreases due to massive vasodilation

PAMP = Pulmonary Arterial Mean Pressure
PAWP= Pulmonary Arterial Wedge Pressure
RAP= Right Atrial Pressure