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EMED Unit 3 > Hypotension and Shock > Flashcards

Hypotension and Shock Flashcards

1
Q

Which is scarier - hypotension or hypertension?

A

Hypotension

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2
Q

What is helpful to know when evaluating a patient you think is hypotensive?

A

Their baseline BP

There’s no set value for hypotension like their is for hypertension - everyone is different

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3
Q

If a patient’s BP is low and you don’t know what their baseline is, you should always start by…

A

Giving a small fluid bolus to check fluid responsiveness

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4
Q

Why is hypotension bad?

A

Because it can cause hypoperfusion of organs —> end organ damage

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5
Q

What is shock exactly?

A

When low BP results in a discrepancy between oxygen supply and demand

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6
Q

Shock is a physiological condition of __________ —> decreased ________ —> cellular hypoxia and _________.

A

Inadequate systemic tissue perfusion

Decreased O2 delivery

Cellular hypoxia and metabolic malfunction

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7
Q

Shock can result in sequential _____, ______, _____, and ______.

A

Cell death

End-organ damage

Multi-system organ failure

DEATH

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8
Q

Systemic tissue perfusion is determined by…

A

Mean Arterial Pressure (MAP)

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9
Q

What is the formula for determining MAP?

A

MAP = CO x SVR

Cardiac Output x Systemic Vascular Resistance

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10
Q

SVR is influenced by …

A

Vessel length

Vessel diameter

Blood viscosity

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11
Q

What are some ways to assess for adequate global perfusion?

A

Mental status (brain perfusion)

Urine output (kidney perfusion)

Serum lactate/acidosis

Peripheral perfusion assessment (warm/cold/cap refill)

Remember - not all patients with hypotension are in shock! Depends on level of perfusion

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12
Q

What are the stages of shock?

A

Pre-shock
• Warm or COMPENSATED shock
• Tachycardia, peripheral vasoconstriction, low BP

Shock
• Compensatory mechanisms overwhelmed —> SSx of organ dysfunction
• Tachycardia, dyspnea, metabolic acidosis, oliguria, confusion, cool clammy skin

End-organ dysfunction
• Progressive end organ dysfunction
• Irreversible organ damage, coma, death

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13
Q

What are the five different etiologies of shock?

A

Hypovolemic

Cardiogenic

Obstructive

Neurogenic

Distributive

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14
Q

What types of lines can be utilized in resuscitation of shock patients?

A

Arterial lines
Central lines
Swan-Ganz (pulmonary artery) catheter

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15
Q

What arteries can be used for arterial lines?

A

RADIAL artery
Brachial artery
Femoral artery

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16
Q

How are arterial lines used?

A

Invasive arterial BP monitoring

Recurrent ABGs

NOT used for meds or to infuse anything!

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17
Q

Indications for central lines

A

Delivery of caustic or critical medications and measurements of CVP

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18
Q

What are the different types of central line?

A 
Triple lumen
Double lumen
Dialysis catheters
Swan-Ganz catheter
PICC line
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19
Q

What does PICC stand for?

A

Peripherally Inserted Central Line Catheter

Inserted into Basilic or Cephalic vein in upper arm

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20
Q

Normal value for central venous pressure (CVP)

A

5-15 mmHg

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21
Q

What is central venous pressure (CVP)?

A

Pressure near the right atrium

Correlates to “preload” or overall volume status

Can be obtained with any central line

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22
Q

What type of line is like a central line but provides more info bc it goes through the heart and sits in the pulmonary artery

A

Swan-Ganz Catheter

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23
Q

What type of shock is the Swan-Ganz Catheter especially useful for?

A

Cardiogenic shock

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24
Q

What is the main hemodynamic parameter?

A

Central Venous Pressure (CVP)

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25
Q

Why hemodynamic parameters can only be obtained with a Swan-Ganz catheter?

A

Pulmonary capillary wedge pressure (PCWP) - normally 5-15 mmHg

Cardiac Output (CO): blood flow/min (normal 4-8 L/min)

Systemic vascular resistance (SVR) - Normal 1000-1500 dynes/sec/cm5

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26
Q

When should you monitor hemodynamic parameters?

A

When cause of shock is unclear

Swan-Ganz most appropriate in cardiogenic shock

Central lines (including PICC) appropriate for determining fluid status and resuscitation in other types of shock

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27
Q

Clinical presentation for ALL types of shock…

A

Hypotension (SBP <90 or decrease of >40)

Tachycardia (Exception = neurogenic shock)

Tachypnea***

Oliguria***

Mental status changes (confusion, lethargy)***

Metabolic acidosis***

Cool, clammy skin (exception = early distributive and neurogenic shock = warm, flushed)

Later: multi-organ failure, coagulopathy

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28
Q

Which type of shock is the only one with Bradycardia instead of tachycardia?

A

Neurogenic shock

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29
Q

Warm skin early, cool skin later

A

Distributive and neurogenic shock

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30
Q

Why are pregnant patients able to compensate for shock for a longer time?

A

They have increased cardiac output

31
Q

What are the two main etiologies for Hypovolemic shock?

A 
Blood loss (hemorrhagic)
• Trauma
• GI bleed
• Internal hemorrhage
• Post surgical

Fluid loss
• Dehydration (incl protracted N/V/D)
• Burns
•Acute pancreatitis

32
Q

Pathophysiology of hypovolemic shock

A

⬇️ blood volume (⬇️ preload due to intravascular volume loss) leads to ⬇️ SV

⬇️ SV —> ⬇️ CO and ⬇️ BP

⬇️ BP along with ⬇️ volume leads to impaired oxygen carrying capacity and inadequate tissue perfusion

⬆️SVR to compensate for ⬇️ CO

Body switches from aerobic to anaerobic metabolism

⬇️ BP detected by baroreceptors —> reflexive vasoconstriction —> preferential shunting/redistribution of blood

33
Q

Hemodynamic parameters in hypovolemic shock

A

CVP ⬇️ <5

CO ⬇️ <4

SVR ⬆️ >1500 (COMPENSATORY MECHANISM)

34
Q

Clinical presentation of hypovolemic shock is dependent upon…

A

Amount of loss (small losses generally tolerated vs large)

Rate of loss (slow losses allow for more compensation)

35
Q

Clinical presentation of hypovolemic shock

A

Hematemesis, hematochezia, melena

N/V/D

Abdominal pain

Evidence of trauma

Post-operative

36
Q

Physical exam findings for hypovolemic shock

A

(THINK ABOUT IT - A VERY DEHYDRATED PATIENT)

Dry oral mucosa

VS: Hypotension, tachycardia, tachypnea, dec JVP, dec CVP, dec urine output

Extremities: cool, clammy, decreased skin turgor

Mental status: confused

37
Q

Why is it important to order lactate with your labs when working up a patient with hypovolemic shock?

A

Lactate increases during anaerobic metabolism derangement affecting O2 utilization and decreased hepatic clearance

ORDER EARLY - need to trend - if going DOWN, resuscitation efforts are working

Normal lactate is less than 2

38
Q

What diagnostic studies are you gonna get for your patient that’s in hypovolemic shock?

A 
CBC (hemorrhagic or not?)
CMP
PT/INR
LACTATE*********
ABG
CXR/Chest CT
Abdominal x-ray/CT
39
Q

How do you manage hypovolemic shock?

A

Treat the underlying problem

REPLACE THE VOLUME!
• Crystalloids (ie NS)
• Colloid (albumin)
• Blood (PRBCs, FFP, Platelets)

Monitor clinical response
• Urine output
• Peripheral perfusion
• Mentation

40
Q

Do you give vasopressors to patients in hypovolemic shock?

A

Avoid if possible - constricts vessels harder to get blood places

It’s a VOLUME problem - focus on replacing the volume rather than constricting

If SBP <70, can use vasopressors short term while restoring volume

41
Q

Name that type of shock:

Decreased CO secondary to pump failure

A

Cardiogenic shock

42
Q

What are the different etiologies of cardiogenic shock?

A

Ischemia (MI, cardiomyopathy)

Valvular heart disease (ruptured papillary muscles/chordae tendineae, critical AS, ventricular septum rupture)

Arrhythmias (Vfib, Vtach, complete heart block, Afib, Aflutter, etc)

Obstructive (extracardiac)

43
Q

What type of shock is caused by massive PE, cardiac tamponade, or tension pneumothorax?

A

Obstructive (extracardiac)

Problem is outside of the heart but is causing pressure or obstruction on the heart

44
Q

What is the main difference between the pathophysiology of cardiogenic vs hypovolemic shock?

A

Cardiogenic is pump failure —> decreased BP/CO

Vs

Decreased volume —> decreased BP/CO

45
Q

Hemodynamic parameters for Cardiogenic Shock

A

CVP: ⬆️ >5 ** (think preload)

PCWP: ⬆️ >5

CO: ⬇️ <4

SVR: ⬆️ >1500 ** (afterload)

46
Q

Clinical presentation of cardiogenic shock?

A

Chest pain
Dyspnea
Palpitations
Fatigue

47
Q

Physical exam findings for cardiogenic shock

A

(LIKE A HEART FAILURE PATIENT)

VS: tachycardia, tachypnea, hypotension

Extremities: Cool, clammy

Cardiac exam: Increased JVP, muffled heart sounds, new murmur, tachycardia

Pulmonary exam: Possibly deviated trachea, lung sounds dependent on pathology (maybe crackles if diffuse pulmonary edema)

48
Q

What diagnostic studies you gonna get for your patient in cardiogenic shock?

A 
CBC, CMP
Cardiac enzymes
ABG
EKG
CXR
Echo
CT chest
49
Q

How do you manage a patient in cardiogenic shock?

A

Treat underlying problem (cath lab if MI, ACLS if vtach/vfib, decompression the tension pneumo, pericardiocentesis if tamponade)

Cardiology consult

BE CAUTIOUS WITH FLUIDS

Inotropes (enhance myocardial contractility) - Dobutamine**

Others:
• Diuresis
• Anti-arrhythmias
• Heart failure meds

50
Q

Last ditch efforts you might have to go to for cardiogenic shock if all the other shit you tried don’t work

A

Assist devices (LVAD, RVAD, total artificial heart)

ECMO - perfume heart outside the body)

Heart transplant

51
Q

Which type of shock is the only once that you might have to be cautious with giving fluids?

A

Cardiogenic shock

52
Q

Which type of shock is characterized by decreased SVR?

A

Distributive (Vasodilatory) shock

53
Q

What are the etiologies of Distributive Shock?

A

SALAD

Sepsis
Adrenal insufficiency
Liver disease 
Anaphylaxis
Drugs/meds

Can also be neurogenic in origin

54
Q

Septic shock is primarily a problem of …

A

Oxygen demand

Inadequate tissue perfusion and cellular hypoxia result from increased oxygen demand from tissues to combat systemic infection and septic endotoxins

55
Q

Etiology of septic shock

A

Any kind of infection - UTI, PNA, bacteremia, etc

56
Q

Early septic shock is associated with…

A

Hyperdynamic response

Fairly well compensated but difficult to maintain

Circulating endotoxins aggravate cellular hypoxia and exert toxic effects on the soft tissues and organs —> signs of organ impairment

57
Q

What happens in late septic shock?

A

Start to see CAPILLARY LEAKAGE and LOSS OF VASCULAR TONE —> relative hypovolemia and hypotension

Vasoconstriction further compromises tissue perfusion —> aggravating cellular hypoxia —> organ system malfunction

58
Q

Physical exam findings for septic shock

A

VS: Fever, low BP, tachycardia, tachypnea

Extremities: WARM then COOL

Mental status: confused (esp elderly)

59
Q

Suspect septic shock in the elderly or immunocompromised if…

A

Unexplained hypotension
Mental status changes
Signs of organ system dysfunction

60
Q

Hemodynamic parameters for septic shock

A

Early (warm) shock:
• CVP ⬇️
• CO ⬆️
• SVR ⬇️

Late (cold) shock:
• CVP +/- (usually low)
• CO ⬇️ (heart poops out)
• SVR ⬆️

61
Q

What diagnostic studies do you want for septic shock?

A 
CBC, CMP
LACTATE*****
Cultures (blood x2, urine, sputum)
ABG
CXR (r/o PNA)
Other imaging as indicated
62
Q

How do you manage septic shock?

A

Early, GOAL-DIRECTED therapy

ID and treat underlying problem, infection

FLUID RESUSCITATION*****

Norepinephrine as a vasopressor*****

Ventilator support if indicated

63
Q

Anaphylaxis is another type of ______ shock

A

Vasodilatory

64
Q

Anaphylaxis is an acute, potentially life-threatening multisystem syndrome caused by the sudden release of ______________ into the circulatory system

A

Mast cell mediators

Most often results from IgE mediated reactions to foods, drugs, insect stings, or any agent capable of inciting a sudden, systemic degranulation of mast cells

65
Q

SSx of anaphylaxis

A

Skin/mucosa: Hives, rash, itching/flushing, periorbital edema, lip edema, conjunctival swelling

Respiratory: nasal discharge/congestion, change in voice, sensation of throat swelling, stridor, SOB, wheezing, cough

GI: N/V/D, cramps abdominal pain

CV: syncope, dizziness, tachycardia, hypotension

66
Q

Death from anaphylaxis usually results from…

A

Asphyxiation due to upper or lower airway obstruction or from CV collapse/shock

67
Q

First line treatment for anaphylaxis

A

IM Epinephrine 1:1000 (1mg/ml prep)

Give 0.01 mg/kg IM (can repeat q5-15 min)

Can consider IV epi infusion if necessary

Treat hypotension with fluid bolus

68
Q

Adjunct therapies for anaphylaxis

A

After you give the Epi…

H1 antihistamines (Benadryl 25-50 mg IV)
\+/- H2 antihistamine (ranitidine 50 mg IV)

+/- steroids (1 mg/kg/day methylprednisolone)

69
Q

Neurogenic shock is characterized by…

A

Loss of sympathetic tone, leading to vasodilation and hypotension

BRADYCARDIA and hypotension

70
Q

Etiology of neurogenic shock

A

Spinal cord injury

Closed head trauma (brain stem brain stem)

Basically, the sympathetic NS gets cut off —> unopposed parasympathetic stimulation

71
Q

Physical exam findings for neurogenic shock

A

VS: HR normal or low, low BP

Neuro exam: 
• +/- altered LOC
• Motor exam = para/quadriplegic
• Sensory exam depends on level affected
•DTRs: absent/hyperreflexia
• Extremities: warm (due to vasodilation)

Rectal exam: reduced sphincter tone

72
Q

Hemodynamic parameters for neurogenic shock

A

CVP: normal or reduced (<5)

CO: normal or reduced (<4)

SVR: reduced (<1500)

73
Q

Diagnostic studies you would order for neurogenic shock

A

CBC, CMP

Xrays - cervical spine (need to see C7-T1 to clear C-spine)

Head CT to r/o structural lesions, evidence of shift or herniation

Spinal CT/MRI

74
Q

How do you manage neurogenic shock?

A

Address co-existing problems

Fluids to correct relative hypovolemia

Neurosurgery consult STAT!

EMED Unit 3 (5 decks)

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