Hemodynamics V Flashcards
What are the causes of shock?
Hemorrhage Trauma Burns MI PE Sepsis
What is the definition of shock?
Clinical manifestation of the inability of the circulatory system to adequately supply tissues with nutrients and remove toxic wastes
What are the sequela of shock?
Hypotension
Impaired tissue perfusion
Cellular hypoxia
What are the four types of cardiogenic shock?
Infarction
Arrhythmia
Tamponade
PE
What are the five type of shock?
Cardiogenic Neurogenic Anaphylactic Septic Hypovolemic
What is neurogenic shock?
Neurogenic dysfunction causes loss of vascular tone and peripheral pooling of blood
What is anaphylactic shock mediated by?
IgE mediated hypersensitivity response
What are the etiological classifications of shock?
Septic Spinal Hypovolemic Hemorrhage Obstructive Cardiogenic Cellular toxins Anaphylactic Endocrine/adrenal crisis
(SSHHOCCKE)
What are the causes of vasodilation seen in shock?
Anaphylaxis
Neurogenic impulses
Sepsis
What happens to muscles during shock? What is the major systemic effect?
Produce lactic acid, producing metabolic acidosis
What happens to the kidneys in shock?
Decreased blood flow = oliguria
What happens to the lungs in severe shock?
ARDS
What are the two major cytokines in shock?
TNFalpha
IL-1
What is the final common pathway in shock?
Cellular injury
What are the five unifying features of shock?
Intracellular Ca overload Intracellular H ion Cellular interstitial edema Catabolic metabolism Inflammation
What are the 6 Rosen’s Empiric criteria of shock? How many are needed to diagnose shock?
Toxic appearance Tachycardia Tachypnea Acidemia Anuria Hypotension
4/6
How long does someone have to be hypotensive for, to be actually considered hypotensive?
> 20 minutes
What are the three stages of shock?
Non Progressive stage
Progressive stage
Irreversible stage
What happens in the non-progressive stage of shock?
Maintain pressure and CO
How does the body attempt to maintain bp and CO in the nonprogressive stage? (3)
Tachycardia
Peripheral vasoconstriction
Renal conservation of fluid
What are the five main things that happen in the “progressive stage” of shock?
Widespread hypoxia Lactic acidosis Arteriolar dilation Confusion Anuria
What causes the widespread cellular injury seen in the irreversible stage of cell injury?
Lysosomal enzyme leakage
Decrease myocardial contraction
Renal failure
What happens in the brain during shock?
Ischemic encephalopathy
What happens in the heart during shock?
Coagulative necrosis
What happens in the kidneys during shock?
Acute tubular necrosis
What happens in the lungs during shock?
Diffuse alveolar damage
What happens in the adrenal glands during shock?
Cortical cell lipid depletion
What happens in the GI tract during shock?
Hemorrhages and necrosis
What happens in the liver during shock?
Fatty change, hemorrhagic necrosis
What happens to the blood vessel sympathetic tone in cardiogenic shock? What two bad outcomes does this lead to?
Increases (vasoconstriction), leading to edema, and renal ischemia
What causes the sympathetic tone in cardiogenic shock?
Decreased myocardial contractility
What happens pathologically in cardiogenic shock?
40% loss of myocardium
What is the cardiac index, and what happens during cardiogenic shock?
CO/surface area
Falls below 2.2
What happens to the arteries and vein volume in cardiogenic shock?
Arteries volume decreased
Veins increased
What happens to the arteries and vein volume in hypovolemic shock?
both decreased
What happens to the arteries and vein volume in obstructive shock?
Severe decreased in arteries and increase in veins
What are the management steps of cardiogenic shock? (3)
Stabilize ABCs
Identify etiology
IVFs
What percent of volume loss is characteristic of each class (I-IV) of hemorrhagic shock?
I = 40 %
At what class of hemorrhagic shock is BP decreased?
Class III
At what class of hemorrhagic shock is PP decreased?
Class II
Why are colloids given in shock?
Less fluid required
Draw fluids from tissues
What are the disadvantages of colloids?
Allergic rxn
Coagulopathies
Which type of bacteria has LPS?
Gram negative
What are the three major cytokines that are released in response to gram negative bacteria?
IL-1
TNFa
IFNgamma
What are the three effects of cytokine production in shock?
Coag
Leukotrienes
Complement activation
What are the three major effects of inflammatory cytokines in low quantities?
C5a, C3a increased
Endothelial cell activation
Leukocyte activation
What are the three systemic effects of inflammatory cytokines in moderate quantities?
Leukocytosis
Acute phase proteins
Fever
What are the three systemic effects of inflammatory cytokines in high quantities?
DIC
ARDS
Low CO
What are bands?
Immature white cells that have gotten out into the circulation
SIRS + documented infx =?
Sepsis
Sepsis + MODS = ?
Severe sepsis
Sepsis + hypotension refractory to volume resuscitation = ?
Septic shock
What are the three chemicals that are used to treat the coagulation cascade in the shock?
Protein C
Protein S
Antithrombin III
What are the two vasoactive mediators given in septic shock?
Vasopressin
NO
What are the inflammatory mediators given in septic shock?
Tissue factor pathway inhibitor
IVIG
What is spinal shock?
Initial loss of spinal cord function following spinal cord injury
Above what spinal level is neurogenic shock seen?
T6
What causes the bradycardia in neurogenic shock?
Unopposed parasympathetic stimulation
What causes the hypotension seen in neurogenic shock?
Loss of sympathetic tone
What type of T cells are activated in anaphylactic shock? What does this cause?
Th2 cells–promotes B cell class switching to IgE
What is the main goal of treating shock?
Prevent organ failure
What happens to intracellular Ca levels in shock?
Increases
What happens to intracellular hydrogen ion in shock?
Increases
What happens to cellular and interstitial fluid in shock?
Increases (edema)
What happens to cellular metabolism during shock?
Shift to catabolic metabolism
What is a base deficit?
Amount of base required to neutralize the pH (normal is > -2)
True or false: hypotension is absolutely necessary to diagnose shock
False–early stages are without hypotension
What type of hypersensitivity is anaphylactic shock?
Type I
What is the HR for Class I-IV of hemorrhagic shock?
I = 140
When does the Pulse pressure decrease in hemorrhagic shock: Class I, II, III, or IV
After I/ at II
When does the BP drop in hemorrhagic shock: (class I, II, III, or IV)?
After class II/at class III
When does the LOC change from anxious to confused to lethargic in hemorrhagic shock? (Class I, II, III, IV)
Class III = confused
Class IV = lethargic
ACtivation of TNFalpha and IL-1 leads to what three inflammatory responses?
- Coag activation
- Prostaglandin/leukotriene release
- Complement activation
What is the MOA of Ranitidine?
Blocks release of histamine from mast cells