Lecture 11: Altered Physiology and Shock Flashcards
Shock can be defined as systolic BP < _____ mmHg or a ↓ systolic BP ______ mmHg below baseline.
Shock can be defined as systolic BP < 80-90 mmHg or a ↓ systolic BP 40 mmHg below baseline.
Shock can be defined as a MAP
<60-65 mmHg
Levels of what are a reflection of tissue hypoxia?
Lactate
Which 3 categories of shock present with skin that is cool, clammy, cyanotic, pallor, and mottled (blotchy) distal extremities due to ↓ perfusion/vasoconstriction?
- Hypovolemic
- Cardiogenic
- Obstructive
Which type of shock will present with skin/extremities that are warm and pink due to vasodilation?
Distributive/dissociative shock (cyanide poisoning)
What is the HR like in shock and is useful why?
- Usually fast; occasionally slow
- Sensitive indicator of shock
Common renal manifestation of shock?
Oliguria
Which serum value associated with shock is related to an increase in mortality as levels get higher?
Lactate
What is responsible for the mental status changes associated with shock?
↓ cerebral perfusion –> confusion, restlessness, agitation, delirium, stupor, coma
What is the most common cause of hypovolemic shock?
Hemorrhagic shock
What are 3 non-hemorrhagic causes of hypovolemic shock?
- GI losses (vomiting, diarrhea)
- Skin losses (burns, heat strokes)
- DKA –> renal losses
What are 3 causes of distended neck veins?
- HF
- PE
- Tamponade
In shock what is the initial acid-base disturbance and then is followed by what?
Respiratory alkalosis —-> metabolic acidosis (think ↑ lactate)
Hypoaldosteronism, adrenal insufficiency, 3rd space loss, bowel obstruction, and systemic inflammation may all cause what type of shock?
HYPOvolemic
What is initial management for someone in hypovolemic shock, whether due to hemorrhagic or non-hemorrhagic cause?
- Fluids FAST - monitor BP and tissue perfusion
- Crystalloids —> NS useful in hypovol. from renal, GI, sweat, burns, hemorrhage
- Packed RBC for hemorrhage/function is erythrocyte
How does the pulse rate, BP, and pulse pressure change as you move from class I to class IV criteria of hemorrhagic shock?
- Pulse rate will ↑as the HR ↑
- BP will ↓
- Pulse pressure will ↓
What is the most common cause of non-cardiogenic shock?
Septic or Non-septic (vasodilation)=Distributive shock
What are 4 signs/sx’s of sepsis (distributive shock)?
- Fever (>38 C or <36 C)
- Tachycardia (>90/min)
- Tachypnea (>20 breaths/min)
- ↑ WBC (>12,000) or WBC (<4000)
What is the definition of septic shock?
Severe sepsis and dysfunction of organ system w/ hypotension (<90 systolic or >40 mmHg ↓ baseline) despite fluids
How does endothelial injury in distributive shock lead to a ↓ preload?
Becomes permeable and leaks fluid into tissue (lung, intestine, capillary leak) releases NO2 = potent vasodilator which ↓ preload
What are PE findings of the skin/extremities, HR, BP, and neck veins associated with distributive septic shock?
- Skin/extremities = warm, flushed (vasodilation)
- HR = fast (10-30% will have myocardial depression)
- BP = low (<90 systolic BP)
- Neck veins = flat = ↓ JVP
What are some of the common sources/underlying infections throughout each body system which may lead to sepsis (i.e., pulmonary, abdominal, GU, CNS, and skin..)
- Pneumonia, emphysema
- Peritonitis, cholangitis
- Pyelonephritis, abscess
- Meningitis
Cellulitis, necrotizing fascitis
If patient with septic shock doesn’t respond to IV fluids what should be given to maintain perfusion pressure; what is the 1st line agent and 2nd line agent?
- Norepinephrine = 1st line
- Dopamine = 2nd line –> can cause tachycardia
Other than fluids/pressors what else should be given as treatment for septic shock?
- Antibiotics –> vancomycin + piperacillin/tazobactam + aminoglycoside
- ± low dose steroids
