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Unit 3 Emerg/Surg > L11: Hypotension + Shock > Flashcards

L11: Hypotension + Shock Flashcards

1
Q

First thing to do in a case of hypotension

A

give a small fluid bolus to check responsiveness

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2
Q

____ determines systemic tissue perfusion, and normal values are _____-

A

Mean arterial pressure (MAP)

Normal: 60-80

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3
Q

MAP=

A

CO x SVR

Inversely related per chart at end– if one is increased, the other is decreased to compensate, etc.
This is to keep MAP constant.

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4
Q

Decreased systemic tissue perfusion might be due to either ____ or ____, which ______

A

Decrease CO and/or SVR

Determines the etiology of shock

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5
Q

CO=

A

HR x SV

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6
Q

SVR is influenced by

A

Vessel
length and diameter,
blood viscosity

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7
Q

4 ways you can assess adequate global (brain) perfusion

A

Mental status

Urine Output (exception: renal failure pts)

Serum lactate/acidosis

Peripheral perfusion assessment

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8
Q

The 3 stages of shock

A
  1. Pre-Shock
  2. Shock
  3. End-organ dysfunction
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9
Q

Warm shock/compensated shock

Tachycardia, peripheral vasoconstriction, decreased blood pressure

A

Pre-shock

stage 1

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10
Q

Compensatory mechanisms overwhelmed→ signs/symptoms of organ dysfunction
Tachycardia, dyspnea, metabolic acidosis, oliguria, confusion, cool clammy skin

A

Shock

stage 2

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11
Q

Progressive end organ dysfunction→ irreversible organ damage, coma, death

A

End organ dysfunction

stage 3

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12
Q

Is all hypotension an indicator of shock?

A

No

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13
Q

5 Etiologies of Shock

A 
Distributive=vasodilatory shock
Hypovolemic
Cardiogenic
Neurogenic
Obstructive
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14
Q

Arterial lines may be placed in the ______ (3)

A

Radial artery
Brachial artery
Femoral artery

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15
Q

Arterial lines are used for _______ and _______, but NOT used for ______

A

Used for:
Invasive arterial blood pressure monitoring
Recurrent ABGs

Not used for:
Medications

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16
Q

Indications for a central line

A

delivery of caustic or critical medications and measurement of CVP

Appropriate for determining fluid status (CVP) and resuscitation in non-cardiogenic shock

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17
Q

5 types of central lines

A 
Triple lumen
Double lumen
Dialysis catheters
Swan-Ganz Catheter
PICC Line
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18
Q

PICC line

A

Peripherally Inserted Central Line Catheter

Goes from arm→ heart

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19
Q

Goes through heart and sits in pulmonary artery

Gives RA, RV, Pulmonary artery, or pulmonary artery wedge pressures depending on where it is

A

Swan-Ganz (PA) Catheter

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20
Q

Most appropriate in cardiogenic shock→ improve patient outcomes

A

Swan-Ganz (PA) Catheter

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21
Q

Central venous pressure (CVP)

A

5 – 15 mmHg

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22
Q

Pulmonary capillary wedge pressure

PCWP

A

5-15 mmHg

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23
Q

Cardiac Output (CO): blood flow/min

A

4-8 L/min

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24
Q

Systemic vascular resistance (SVR)

A

1000-1500 dynes/sec/cm5

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25
Q

Clinical Presentation for ALL TYPES of shock

A 
Hypotension 
Tachycardia (except neurogenic)

Tachypnea
Oliguria
Mental status changes (confusion, lethargy)
Metabolic acidosis
**
Cool clammy skin (exception: early distributive and neurogenic shock)

Later: multi-organ failure, coagulopathy

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26
Q

Hypotension is defined as

A

SBP<90, or decreased in SBP of >40 mmHg

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27
Q

Who can compensate in shock for a while due to their increased CO?

A

Pregnant patients

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28
Q

Which kind of shock doesn’t have tachycardia?

A

Exception: neurogenic shock = decreased HR

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29
Q

Which kind of shock doesn’t have cool clammy skin?

A

Exception: early distributive and neurogenic shock have flushed, warm

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30
Q

inadequate intravascular volume→ decreased CO→ decreased oxygen delivery

A

Hypovolemic shock

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31
Q

Etiology of hypovolemic shock (2)

A
  1. Blood loss (hemorrhagic)

2. Fluid loss

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32
Q

Causes of blood loss

A

Trauma
GI bleeding
Internal hemorrhage
Post-surgical

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33
Q

Causes of fluid loss

A

Dehydration
Protracted nausea, vomiting, diarrhea
Burns
Acute pancreatitis

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34
Q

Anytime you’re taking care of a trauma patient, you must ______

A

rule out hemorrhagic shock first

35
Q

Hypovolemic shock pathophysiology

A

Decreased blood volume (decrease preload due to intravascular volume loss) → decreased stroke volume→ decreased CO + BP

Decreased BP and volume→ impaired oxygen carrying capacity and inadequate tissue perfusion→ increased SVR to compensate for decreased CO

Switch from aerobic to anaerobic metabolism
Compensatory response→ decreased BP detected by
baroreceptors→ activation of the
sympathetic nervous system→ vasoconstriction→ blood is preferentially shunted and redistributed

36
Q

Hemodynamic parameters in hypovolemic shock

A 
HR: high
CVP: low
PCWP: low
CO: low
SVR: high
37
Q

Cardiogenic shock symptoms

A

Chest pain, Dyspnea

Palpitations, Fatigue

38
Q

Cardiogenic shock signs

A

Tachycardia, tachypnea, hypotension

Extremities: cool, clammy

39
Q

Cardiogenic shock cardiac exam

A

JVP

Heart sounds: muffled, new murmur, tachycardia

40
Q

Main treatment for hypovolemic shock

A

Replace volume and/or blood products

41
Q

Hemodynamic parameters for cardiogenic shock (including obstructive)

A 
HR: high
CVP: high
PCWP: high
CO: low
SVR: high
42
Q

Hemodynamic parameters for EARLY septic shock (and other vasodilatory causes: adrenal insufficiency, anaphylaxis, liver disease, medication)

A 
HR: high
CVP: low
PCWP: +/-
CO: high or normal
SVR: low
43
Q

Hemodynamic parameters for LATE septic shock

A 
HR: high
CVP: low
PCWP: +/p
CO:  low
SVR: high
44
Q

Hemodynamic parameters for neurogenic shock

A

Everything is normal or low

SVR: low

45
Q

Main treatment for cardiogenic shock (including obstructive)

A

Fix underlying cause
Relieve obstruction (if needed)
Caution with fluids
+/- inotropes

46
Q

Main treatment for early septic shock (and other vasodilatory causes: adrenal insufficiency, anaphylaxis, liver disease, medication)

A

Give fluids
Treat infection
Vasopressors

47
Q

Main treatment for late septic shock

A

Treat infection

Vasopressors

48
Q

Main treatment for neurogenic shock

A

Neurosurgery

49
Q

Early vs Late septic shock

Early=warm shock
(Late=cold shock)

A

Both:
HR: high
CVP: low
PCWP: +/-

CO:
Early: high or normal
Late: low

SVR:
Early: low
Late: high

50
Q

Hypovolemic shock presentation depends on

A
  1. Amount of loss
  2. Rate of loss
    (slow can be compensated)
51
Q

Main laboratory indicator of hypovolemic shock

A 
***Lactate*** 
increases (>4) during
anaerobic metabolism,
derangements affecting O2 utilization and decreased hepatic clearance→  increased
mortality
52
Q

Vasopressors should be used to treat hypovolemic shock IF:

A

If situation is dire SBP<70, use while restoring volume

but this is a volume problem, so fixing that is #1

53
Q

Hypovolemic shock symptoms

A

Hematemesis, hematochezia, melena
N/V/D
Abdominal pain
Evidence of trauma, Post-operative

54
Q

Hypovolemic shock signs on exam

A 
Physical signs
Dry oral mucosa
Hypotension, tachycardia, tachypnea,
Decreased JVP, CVP
*Decreased Urine Output* 
 Extremities: cool, clammy, decreased skin turgor
Confused
55
Q

Don’t ignore ______ because it’s often the earliest indicator of hypovolemic shock

A

Decreased urine output

56
Q

decreased CO secondary to heart failure

A

Cardiogenic shock

57
Q

IF found, deviated trachea or crackles consistent with diffuse pulmonary edema would indicate ________

A

Cardiogenic origin of shock

58
Q

Cardiogenic shock pathophysiolgoy

A
  1. Pump failure→ decreased BP and decreased CO→ activation of the sympathetic nervous system
  2. Hypotension and deceased CO→ decreased renal perfusion→ sodium and fluid retention
  3. Secondary response: increased filling pressures
    (CVP/PCWP) → volume overload in the lungs
  4. Increased SVR to compensate for decreased CO
59
Q

Possible etiologies of cardiogenic shock

A

Ischemia:
MI, cardiomyopathy

Valvular heart disease:
Ruptured papillary muscle or chordae tendineae, critical
AS, ventricular septum rupture

Arrhythmias:
Vfib, Vtach, complete heart block, Afib, Aflutter

OBSTRUCTIVE:
(extracardiac) (subclassification)
Massive PE, cardiac tamponade, tension pneumothorax

60
Q

MI tx

A

O2, cath lab

61
Q

Vtach/Vfib tx

A

ACLS

62
Q

Tension pneumothorax tx

A

Decompression

63
Q

Cardiac tamponade tx

A

Pericardiocentesis

64
Q

First line inotrope for cardiogenic shock

A

Dobutamine +/- vasopressors

65
Q

Distributive (Vasodilatory) Shock→ Decreased SVR

Etiologies:

A 
Etiologies:
*Sepsis*
Adrenal insufficiency
Liver disease
*Anaphylaxis*
Drugs/medications
*Neurogenic*
66
Q

Be cautious giving fluids in cardiogenic shock because _____

A

Hypotension and deceased CO→ decreased renal perfusion→ sodium and fluid retention

67
Q

Tissues in septic shock have increased O2 demand due to

A

combating systemic infection

and septic endotoxins

68
Q

Get _____ labs for septic shock

A

Lactate
Cultures before abx:
blood x2, urine, sputum

69
Q

When should you suspect septic shock

A

Suspect septic shock in the elderly or immunocompromised for unexplained hypotension, mental status changes, or signs of organ system dysfunction.

70
Q

Pathophysiology of EARLY septic shock

A

Meet increased demand for oxygen by cells→ vasodilation→ decreased SVR→ hypotension→ detected by baroreceptors→ increased HR, contractility and CO.

Hyperdynamic response→ 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→ stampede:
pro-inflammatory cells outnumber anti-inflammatory cells.
“Malignant intravascular inflammation” → profound vasodilation

71
Q

Pathophysiology of LATE septic shock

A

Capillary leakage and loss of vascular tone→
relative hypovolemia and hypotension→ further stimulate the sympathetic nervous system→ increased HR and SVR
Vasoconstriction→ compromised tissue perfusion aggravating cellular hypoxia→ to organ system malfunction:
Poor perfusion of the extremities
Poor perfusion of internal organs

72
Q

Physical signs of septic shock

A

Fever, decreased BP, increased HR and RR

Extremities: warm (early), cool (late)
Confused (especially elderly)

73
Q

NEVER ignore _____→ often the initial physiological response in septic shock

A

Tachypnea

74
Q

First line vasopressor in septic shock

A

Norepinephrine

75
Q

Acute, potentially life-threatening,
multisystem syndrome caused by the sudden release of mast cell mediators into the systemic circulation.
IgE mediated reactions
to foods, drugs, insect stings, or any agent capable of inciting a sudden, systemic
degranulation of mast cells

A

Anaphylaxis

76
Q

Anaphylaxis presentation

A

Skin/mucosal involvement: hives, rash, itching/flushing, periorbital edema, lip edema, conjunctival swelling

Respiratory: nasal discharge/congestion, change in voice quality, sensation of “throat swelling”, stridor, shortness of breath, wheezing, cough

GI: N/V, diarrhea, crampy abdominal pain

CV: syncope, dizziness, tachycardia, hypotension

Death→ asphyxiation due to upper or lower airway
obstruction or from cardiovascular collapse/shock.

77
Q

Main management of anaphylaxis

A

Start with the “ABCs!”
Oxygen, airway management

IM Epinephrine 1:1000 (1 mg/ml prep): 0.01mg/kg IM q 5-15 min PRN

78
Q

Adjunct therapies for anaphylaxis

A

IV meds
H1 blocker (diphenhydramine)
H2 blocker (ranitidine)
+/- steroids (methylprednisolone)

79
Q

Loss of sympathetic tone,

leading to vasodilation, Bradycardia + hypotension

A

Neurogenic shock

80
Q

Causes of neurogenic shock

A

Spinal cord injury
Disruption between brain and spinal cord
Closed head trauma
Injury to brain stem

81
Q

Make sure to get ______ if you suspect neurogenic shock

A

X- rays→ Cervical spine (C7-T1 to clear the c-spine)
Head CT
R/o structural lesions, evidence of shift or
herniation
Spinal CT/MRI

82
Q

Neurogenic shock pathophysiology

A
  1. Sympathetics leave brain stem and travel down through
    cervical spinal cord when they exit out the thoracolumbar
    regions
  2. Sympathetic nervous system is responsible for release of
    epinephrine and norepinephrine, which cause increased HR,
    myocardial contractility and peripheral vasoconstriction.
  3. Disruption of sympathetic nervous system→ unopposed parasympathetic action
  4. Hypotension with decreased SVR and normal to low HR
83
Q

Neurogenic shock presentation

A

VS: HR normal/low, low BP

Neuro exam:
Mental status: +/- altered LOC

Motor exam: para-/quadriplegic

Sensory exam: depends on level affected

DTRs: absent/hyperreflexia

Extremities: warm (vasodilation)

Rectal exam: decreased sphincter tone

Unit 3 Emerg/Surg (5 decks)

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