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Acute PNP > Initial Shock > Flashcards

Initial Shock Flashcards

1
Q

Acute failure of the cardiovascular system to adequately deliver substrate or remove metabolic waste from tissues that results in anaerobic metabolism and acidosis

A

Shock

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2
Q

neurohumoral mechanisms maintain BP and tissue perfusion and during which shock can be reversed with appropriate therapy

A

Compensated stage of shock

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3
Q

when compensatory mechanisms fail and pathophysiologic derangements worsen

A

Progressive stage of shock

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4
Q

Without aggressive support, severe organ and tissue injury occurs leading to multiple organ failure and death

A

Refractory stage of shock

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5
Q

Hemorrhagic and non-hemorrhagic cause of fluid depletion

A

Hypovolemic shock

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6
Q

Common causes of hypovolemic shock?

A

Volume losses from vomiting and diarrhea secondary to GI infections

Hemorrhage (trauma, postsurgical, HI)

Plasma losses (burns, hypoproteinemia, pancreatitis)

Extra GI water losses (glucosuria diuresis, heat stroke)

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7
Q

When cardiac compensatory mechanism fail; may occur in children with preexisting myocardial disease or injury

A

Cardiogenic Shock

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8
Q

What are common causes of cardiogenic shock?

A

Viral myocarditis, anomalous left coronary artery arising from pulmonary artery (ALCAPA), incessant arrhythmias, drug ingestions (cocaine), metabolic derangements (hypoglycemia), and postop complications

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9
Q

What are the characteristics signs of cardiogenic shock?

A

Congestive heart failure (pulmonary rales, gallop cardiac rhythm), hepatomegaly, jugular venous distention, pitting peripheral edema, cardiomegaly on x-ray

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10
Q

What are the lab findings for cardiogenic shock?

A

Increased creatinine kinase, troponin, or brain natriuretic protein (BNP) levels

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11
Q

Due to obstruction of blood flow from certain types of congenital heart lesions or increased afterload of right or left ventricle

A

Obstructive shock

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12
Q

What are the common causes of obstructive shock?

A

Cardiac tamponade, pulmonary embolism, tension pneumothorax

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13
Q

There is an increase in acute WHAT in obstructive shock?

A

Acute increase in SVR due to sudden decrease in cardiac output and functional hypovolemia

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14
Q

Associated with peripheral vasodilation, pooling of venous blood, and decreased venous return to the heart

A

Distributive shock

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15
Q

What are the common causes of distributive shock?

A

Septic, neurogenic, anaphylactic shock, drug ingestions (such as atypical antipsychotics)

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16
Q

What shock is distributive shock usually associated with?

A

Hypovolemic shock

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17
Q

What is systemic inflammatory response syndrome?

A

Sepsis

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18
Q

Result of inadequate oxygen-releasing capacity

A

Dissociative shock

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19
Q

What are the common causes of dissociative shock?

A

Profound anemia, carbon monoxide poisoning, and methemoglobinemia

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20
Q

Special cause of distributive shock due to sudden disruption of sympathetic nerve stimulation to the vascular smooth vessel?

A

Neurogenic shock

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21
Q

What are the common causes of neurogenic shock?

A

Severe traumatic brain or cervical spine injury

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22
Q

How do you calculate cardiac output?

A

Stroke volume (volume ejected by L ventricle) x HR (ejection cycles/minute)

23
Q

How do children normally present with shock?

A

Tachycardia and abnormal perfusion with normal BP

24
Q

What are the clinical signs of successful resuscitation from shock?

A

Decrease in HR and RR; increase in BP; improve urine output to 0.5 mg/kg/hr; normalization of mental status, decreased capillary refill time, and warmth of distal extremities

25
Q

What Central Venous Pressure (CVP) signals satisfactory initial fluid therapy?

A

> 8 to 12 mmHG

26
Q

What does cutaneous near-infrared spectroscopy (NIRS) measure?

A

Venous-weighted oxyhemoglobin striation in underlying tissue bed and displays number that varies with local oxygen delivery and extraction

27
Q

What counts as fluid refractory shock?

A

Persistence of insufficient tissue perfusion despite at least 60 mg/kg of fluid resuscitation and epinephrine/norepinephrine >1 ug/kg/min

28
Q

What is the management of fluid refractory shock?

A

Treatment with:
Reverse etiologies
Vasoactive drug therapy
Reduce metabolic demand through mechanical ventilation [sedation and endotracheal intubation]
Stress-dose corticosteroid therapy [50-100 mg/m2/day]
ECMO support [successful for treating hemorrhagic shock]

29
Q

What is early goal-directed therapy?

A

Prompt fluid resuscitation, targeted vasoactive therapy, early empiric antimicrobial therapy, and continuous monitoring of hemodynamic status

30
Q

What vasoactive drugs do you use for “warm” shock?

A

Vasoconstrictor agents [Noradrenaline]

31
Q

What vasoactive drugs do you use for “cold” shock?

A

Inotropic agents are most helpful [dobutamine, adrenaline, milrinone]

32
Q

What are the signs of vasodilated shock?

A

Bounding pulses, warm extremities, normal capillary refill time

“Warm” shock

33
Q

What are the signs of vasoconstricted shock?

A

Weak pulses, cool extremities, prolonged CRT

34
Q

What is the most common cause of shock in the developed world?

A

Sepsis

35
Q

What is the most common cause of shock worldwide?

A

Hypovolemic

36
Q

What antibiotic choice for healthy patients with no central line?

A

Ceftriaxone

Vancomycin

37
Q

What antibiotic choice for patients with immunocompromise, immunosuppressive meds, recent hospitalization, chronic medical condition with the central line?

A

Cefepime

Vancomycin

38
Q

What antibiotic choice for oncology patients?

A

Cefepime
Vancomycin
Gentamicin

39
Q

What antibiotic choice for intra-abdominal sources is suspected?

A

Piperacillin/tazobactam

Vancomycin

40
Q

How do you decrease lactate levels?

A

Fluid resuscitation

Decrease energy need

41
Q

What does ScvO2 measure?

A

The amount of oxygen in the blood returning to the heart

42
Q

What should ScvO2 be?

A

Greater than 65-75%

43
Q

What questions should you ask if ScvO2 is out of range?

A

Are you providing enough oxygen?
Is there enough hemoglobin?
Is cardiac output enough?

44
Q

Where does the line terminate for Central Venous Line?

A

SVC in the right atrium

45
Q

What does central venous pressure measure?

A

Volume status in the vessels (intravascular volume)

46
Q

What is the CVP goal in shock in non-intubated/intubated patients?

A

8-12 cm H2O in non-intubated patients

12-15 cm H20 in intubated patients

47
Q

What does near-infrared spectroscopy (NIRS) measure?

A

Pulse oximetry for brain or kidney

Measures end-organ perfusion (measures difference between oxygen delivery and oxygen leaving the organ)

48
Q

What is the normal NIRS value?

A

65-75

49
Q

What does a NIRS value of 100 mean?

A

The organ is not using an oxygen at all

50
Q

If there is a decreasing NIRS, what do you do?

A

Fluid resuscitation
Vasoactive drugs
Increase oxygenation

51
Q

What do you do with low CVP?

A

Provide fluid

52
Q

What do you do with low BP?

A

Provide fluid and vasopressors

53
Q

What do you do with low ScvO2?

A

Evaluate for energy expenditure and oxygen delivery

54
Q

What do you do with low NIRS or high lactate?

A

Evaluate for energy expenditure

-Fever, tachycardia, sedation, paralysis

Acute PNP (8 decks)

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