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BCPS Exam > Critical Care: Treatment of Shock > Flashcards

Critical Care: Treatment of Shock Flashcards

1
Q

List four hemodynamic subsets of shock

A
  1. Distributive or vasodilatory
  2. Hypovolemic
  3. Obstructive
  4. Cardiogenic
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2
Q

What three hemodynamic parameters are used in the diagnosis of shock

A
  1. Cardiac index (CI)
  2. Central Venous Pressure/Pulmonary Capillary Wedge Pressure
  3. Systemic Vascular Resistance
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3
Q

What are the diagnostic hemodynamic paramters for distributive or vasodilatory shock

A
  1. High CI (early) and low CI (late)
  2. Low CVP/PCWP (early) and normal to high CVP/PCWP (late)
  3. Low SVR (early and late)
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4
Q

Describe distributive or vasodilatory shock using hemodynamic parameters

A
  1. Patients with distributive shock are typically hyperdynamic (high CI, due to increased HR) with
  2. vasodilation (low SVR) and increased vascular permeability (“leaky capillaries”),
  3. causing intravascular fluid shift into the interstitial spaces (thus, low PCWP.)
  4. The vasodilation and vascular permeability are attributable to cytokines and inflammatory mediators.
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5
Q

Describe hypovolemic shock using hemodynamic parameters

A
  1. As illustrated with Starling curves, as intravascular volume is reduced, preload is reduced, causing decreased CI.
  2. The reduced intravascular volume is indicated by a low PCWP.
  3. There is a reflex increase in SVR to maintain tissue perfusion.
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6
Q

What are the diagnostic hemodynamic parameters for hypovolemic shock?

A
  1. Low CI
  2. Low CVP/PCWP
  3. High SVR
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7
Q

What are the diagnostic hemodynamic parameters of obstructive shock?

A
  1. Low CI
  2. Low/High PCWP, i.e. LV preload.
  3. High SVR
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8
Q

Why can CVP be high or low in obstructive shock ?

A
  1. Obstructive shock is a diagnosis of two disparate etiologies (i.e. pulmonary embolism and tamponade.)
  2. Pulmonary embolism, tumors, acute worsening of pulmonary HTN, etc. cause right ventricular failure. This leads to decreased LV preload. (low PCWP)
  3. In tamponade, there is an increased PCWP due to right atrial pressure from the tamponade compressing the atrium.
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9
Q

What are the diagnostic hemodynamic parameters in cardiogenic shock?

A
  1. Low CI
  2. High CVP/PCWP
  3. High SVR
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10
Q

Describe cardiogenic shock in terms of hemodynamic parameters

A
  1. Patients with cardiogenic shock have acute heart failure (low CI)
  2. The insufficient forward blood flow causes venous congestion (high PCWP) and an underfilled arterial blood volume.
  3. The subsequent reduced tissue perfusion causes a reflex vasoconstriction (high SVR.) and reduced renal excretion of sodium and water. Although it can improve blood flow to vital organs, can worsen heart function by increasing afterload.
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11
Q

Treatment of hypovolemic shock focuses on what two aspects?

A
  1. Restoring pressure

2. Restoring oxygen-carrying capacity

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12
Q

What are two interventions in hypovolemic shock to restore pressure?

A
  1. Volume resuscitation

2. Vasopressors

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13
Q

When are blood products indicated in patients with hypovolemic shock in the general ICU?

A

Hgb less than 7 g/dL

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14
Q

When might higher Hgb targets be permissible in patients with hypovolemic shock?

A

If they are indicated for other reasons, e.g. for patients with symptomatic cardiovascular disease needing a target greater than 10 g/dL

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15
Q

When should blood products be given to patients with hypovolemic shock that are actively bleeding?

A

Actively bleeding patients should have blood products administered regardless of hemoglobin concentration in conjunction with interventions to stop the source of bleeding

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16
Q

When should vasopressors be given to patients with hypovolemic shock?

A

Patients may need vasopressors if hypotension is not rapidly reversed with fluid resuscitation

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17
Q

Two reasons why do you not give vasopressors to patients with intravascular volume depletion

A
  1. The efficacy of vasopressors is reduced in patients who have not received adequate intravascular volume resuscitation
  2. Adverse events associated with vasopressors (e.g. arrhythmias, ischemia) are greater in patients who have not received adequate fluid resuscitation.
18
Q

In obstructive shock, how can you temporarily improve symptoms without reversing the shock state?

A
  1. Fluids
  2. Vasopressors
  3. can be used to temporarily improve end organ perfusion, but may not improve outcomes
19
Q

How to reverse shock state in patients with obstructive shock?

A

Treatment of the actual obstruction

20
Q

Obstructive shock: how to treat pulmonary embolism?

A
  1. Thrombectomy

2. Administration of systemic or catheter-directed thrombolytics

21
Q

In what patients are thrombolytics used for treatment of pulmonary embolism?

A

Patients at high risk of death (due to risk of hemorrhage)

22
Q

Obstructive shock: how to treat pulmonary embolism?

A

Drainage or removal of fluid in the pericardial sac is the only definitive treatment

23
Q

What is the most common cause of vasodilatory shock?

A

Septic shock

24
Q

List 7 causes of distributive or vasodilatory shock

A
  1. Septic shock
  2. Anaphylaxis
  3. vasoplegia
  4. intoxication
  5. pancreatitis
  6. neurogenic
  7. endorine
25
Q

Define sepsis

A

Life-threatening organ dysfunction caused by a dysregulated host response to infection

26
Q

Define septic shock

A

Septic shock is a subset of sepsis in which profound circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone

27
Q

Criteria for sepsis is split into two categories, which are

A
  1. Outside the ICU

2. Inside the ICU

28
Q

What is the definition of sepsis outside the ICU?

A
  1. Infection PLUS

2. Two or more qSOFA points

29
Q

What is the definition of sepsis inside the ICU?

A
  1. Infection PLUS

2. An acute change in total SOFA score greater than or equal to 2 points consequent to the infection

30
Q

What are the three items on the qSOFA?

A
  1. Altered mental status (GCS score less than 15)
  2. Increased respiratory rate (22 breaths/min or more)
  3. SBP less than or equal to 100 mm Hg
31
Q

What is the criteria for septic shock?

A
  1. Sepsis PLUS
  2. Need for vasopressors to maintain MAP greater than or equal to 65 mm Hg
  3. and lactate greater than 2 mmol/L.
32
Q

What is the hallmark treatment of septic shock?

A

Rapid antibiotic administration ideally within the first 1 hour of hypotension

33
Q

What is the surviving sepsis campaign (SSC)?

A

An initiative to reduce mortality from sepsis and septic shock

34
Q

What is the SSC bundle (in general)

A

A group of selected elements of care taken from evidence-based practice guidelines that when implemented as a group have a greater effect on outcomes than any individual element.

35
Q

List six components of the SSC 1-hour bundle

A
  1. Measure lactate
  2. Obtain blood cultures
  3. Crystalloids
  4. Reassess volume status and perfusion
  5. Administer appropriate antibiotics
  6. Vasopressors
36
Q

How much crystalloid should be administered to a patient with sepsis?

A

30 ml/kg rapidly infused (e.g. over an hour)

37
Q

What colloid is not recommended for fluid resuscitation because of an increased risk of acute kidney injury?

A

Hydroxyethyl starches (e.g. hetastarch)

38
Q

Administration of large volumes of chloride-rich solutions leads to metabolic ______ and acute kidney injury

A
  1. Metabolic acidosis

2. Acute kidney injury

39
Q

List two “balance crystalloids” which may protect the kidneys from injury compared to NS

A
  1. lactated Ringer

2. Plasmalyte

40
Q

When to reassess volume status and tissue perfusion in sepsis?

A
  1. Persistent arterial hypotension despite volume resuscitation OR
  2. Initial lactate 4 mmol/L or more
41
Q

What five items should be included on a repeated focused examination of volume status and tissue perfusion?

A
  1. vital signs
  2. cardiopulmonary examination
  3. capillary refill
  4. pulse
  5. skin findings
42
Q

In the SSC bundle, what _ of the following should be performed to measure volume status and tissue perfusion

A
  1. Two
  2. CVP measurement
  3. Scvo2 measurement
  4. Bedside cardiovascular ultrasound
  5. Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge

BCPS Exam (34 decks)

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