Hypotension (Exam 4)

Question 1

Technically, At what systolic and diastolic pressures, do we consider a pt to be hypotensive?

Answer 1

Systolic 90mmHG or lower

Diastolic 60mmHG or lower

Question 2

True or false?

Some people’s normal blood pressure runs at 90/60mmHg or lower.

Answer 2

True!
**Clinically, we appreciate that a patient is hypotensive if signs or symptoms of end-organ damage are present or that the patient is symptomatic

Question 3

True or false?

Older, thicker folks tend to have lower BP.

Answer 3

False.

Younger, fitter, thinner folks tend to have lower blood pressure

Question 4

___________ hypotension is an acute drop in blood pressure after a change in body position (laying/sitting to standing) secondary to a delay in the normal compensatory ability of the autonomic nervous system

Answer 4

Orthostatic

Question 5

Orthostatic hypotension may be a “random occurrence” but is often a sign of _________ or medication side effects.

Answer 5

hypovolemia

Question 6

In order for a pt to be diagnosed with orthostatic hypotension, their BP must either: 1.) decrease in systolic blood pressure by __mmHg OR 2.) decrease in diastolic blood pressure by __mmHg, within three minutes of standing, when compared to their BP from sitting or supine position. OR their pulse must rise by more than __ bpm within 3 mins of standing.

Answer 6

20
10
20

Question 7

Shock is a life-threatening condition secondary to ________ _________ __________.

Answer 7

inadequate tissue perfusion

Question 8

___________ shock is caused by Inadequate circulating volume.

Answer 8

Hypovolemic

Question 9

___________ shock is caused by Inadequate cardiac function; heart not pumping properly.

Answer 9

Cardiogenic

Question 10

__________ shock is Associated with physical blockage of the great vessels or the heart itself.

Answer 10

Obstructive

Question 11

Distributive shock is the Abnormal distribution of blood flow that results in inadequate supply of blood to the body’s tissues and organs, due to profound ____________ in a system (ex: sepsis, anaphylaxis)

Answer 11

vasodilation

Question 12

What clinical features might you see in a pt who is in shock?

Answer 12

• Hypotension
• tachycardia
• evidence of end-organ damage
• AMS
• decreased urine output
• cyanosis
• low cardiac output (ECHO)
• other sx’s based on etiology of the shock; fever w/ sepsis, JVD w/cardiogenic, etc

Question 13

If you suspected sepsis in a pt you believe to be in shock, what lab would you order?
What would you expect the result to be if the pt was in septic shock?

Answer 13

Lactate
> 4mmol/L

(*note lactate can be elevated in other conditions than sepsis; like dehydration, ischemia, pseudo, etc. Only depend on this if the pt has signs of infxn.)

Question 14

True or False?

WBC’s will always be elevated in an infection.

Answer 14

False.

WBC’s can be elevated or depleted (low) in an infection.

Question 15

If you ordered a BMP in a potential shock pt, what would you be looking for?

Answer 15

electrolyte deficiencies
renal impairment
acidosis (BUN/Creatinine)

Question 16

What would a CBC tell you about a pt who is potentially in shock for an unknown cause?

Answer 16

H/H–> anemia vs. dehydration

WBC’s–> infection?

Question 17

RUSH Protocol encourages a rapid _________, in pt’s with signs of shock and/or acute hypotension

Answer 17

ultrasound

Question 18

Which type is the most common type of shock?

Answer 18

hypovolemic

Question 19

Hypovolemic shock Typically occurs after a loss of ____% of a persons circulating blood volume.

Answer 19

> 20% (appx 1 liter)

Question 20

A 50 yr old pt presents to the ER after an MVC. Pt's pulse is 120; weak and thready, BP of 80/55mmHg and a temp of 95.7F. Her skin is cool and clammy. Which type of hypovolemic shock  do you suspect?
What lab(s) would you definetly want to order?

Answer 20

HEMORRHAGIC
labs to order:
-CBC (dont order to early, false normal)
-Type & screen or Type & Cross–> EARLY!!

Question 21

What type of blood would you give to a pt that you did not yet have a type and screen or type and cross on??

Answer 21

O -

universal blood type

Question 22

What are the 4 components of “whole blood”?

Answer 22

• Plasma
• Platelets
• RBC’s
• WBC’s

Question 23

On a trauma pt, who is in hemorrhagic shock, what blood product would you order ?
(not blood “type”, but think whole blood vs, platelets, etc)

Answer 23

PRBC’s

Packed red blood cells

Question 24

A dialysis pt presents to the ER due to excessive thirst, dry mouth, and extreme weakness for the last 12 hrs. You notice he has a weak, rapid pulse and that his BP is hypotensive. He was last dialyzed yesterday. What condition do you suspect?

Answer 24

Non-hemorrhagic hypovolemic shock

Question 25

What would you expect to see on a pts lab results, who has non-hemorrhagic hypovolemic shock?
(I.e. High/low H/H?, high/low BUN?, electrolytes?)

Answer 25

• ELEVATED H/H - 2/2 hemoconcentration
• ELEVATED BUN
• NA usu. elevated
• addt’l electrolyte derangements possible

Question 26

True or false?

When considering IV fluid resuscitation for a hypolemic pt, you should choose LR over NS if available.

Answer 26

TRUE

Question 27

______ ________ occurs when fluid moves from the intravascular space (blood vessels) into the interstitial space; the nonfunctional area between cells.

Answer 27

“Third Spacing”

Question 28

What are 3 common conditions caused by Third spacing?

Answer 28

Ascites
edema
pancreatitis

Question 29

What are 2 common causes of cardiogenic shock?

Answer 29

massive MI

heart failure

Question 30

_____________ are a class of medications that increase BP by increasing “squeeze” or vasoconstrictors. These might be considered in a pt in cardiogenic shock.

Answer 30

Vasopressors

ex: Dobutamine for left heart failure or Dopamine for MI

Question 31

This type of shock could be caused by cardiac tamponade, PE, or tension PTX.

Answer 31

Obstructive

Occurs when an extra-cardiac obstruction impedes cardiac filling or emptying

Question 32

There are __ categories of distributive shock. What are they?

Answer 32

4

• SIRS (Systemic inflammatory response -syndrome)
• Anaphylaxis
• Neurogenic shock
• rewarming in hypothermia

Question 33

SIRS CRITERIA -need to memorize!!! (slide 23)
What are the 4 criteria?
How many does a pt need to meet SIRS criteria?

Answer 33

1. Fever >100.4 or <96.8
2. HR > 90 bpm
3. RR >20 breaths per min
4. Abnormal WBC count

Pt needs 2 or more to meet criteria.

Question 34

Know the 3 criteria for septic shock. (slide 23)

Answer 34

Criteria 1- suspected or known infection
Criteria 2- Meets 2+ SIRS criteria
Criteria 3- Evidence of organ dysfunction
–>SBP<90, lactate>2, resp distress, Cr>2, Bili>2, INR>1.5, Platelets<100,000

Question 35

If you suspect distributive shock due to SIRS/Sepsis, you should initiate what systemic abx? What other tx must you initiate immediately??

Answer 35

Vancomycin + imipenem (Zosyn)
FLUIDS FLUIDS FLUIDS (30mL/kg bolus, then maintenance) (LR>NS)
–may consider vasopressor if still hypotensive after fluids

Question 36

This type of distributive shock is caused by a widespread release of inflammatory mediators (histamine, leukotrienes, prostaglandins) leading to massive peripheral vasodilation.

Answer 36

Anaphylaxis

Question 37

How would you treat a pt with anaphylaxis?

Answer 37

• Antihistamines (Benadryl, Cimetidine)
• Corticosteriods (Solu-Medrol)
• Beta2 Agonists (Albuterol)
• Epinephrine (for unstable and/or sig resp distress)

Question 38

This type of distributive shock occurs when an acute spinal cord injury occurs above the level of T6 causing autonomic system dysfunction

Answer 38

Neurogenic

Question 39

When treating a pt in hypovolemic shock with fluid resuscitation, you want their urine output to be ___ cc’s per hour, which indicates success!

Answer 39

30

Question 40

When doing fluid resuscitation on a pt, what condition could they develop? what s/sx’s would you want to watch out for?

Answer 40

Pulmonary edema

Watch for hypoxia, or if pt complains of SOB