SHOCK! Flashcards
shock definition
reversible life threatening emergency if recognized/treated early; GLOBAL metabolic (lactic) acidosis and tissue hypoperfusion that can occur with hypotension or NORMAL BP
2 initial/compensatory autonomic NS responses to shock
1) sympathetic: NE, epinephrine, dopamine, cortisol release = high HR, vasoconstriction, initial CO increase
2) RAS/renin-angiotensin system = water/sodium conservation + vasoconstriction to increase blood volume and BP initially and shunt blood to essential organs
common S&S of shock
altered mental status, skin cool + mottled or hot + flushed, weak/absent pulse due to vasoconstriction peripherally, systolic BP <110mmHg, tachycardia
general shock tx
consider volume resusc prior to intubation (bc of intubation = vagal/hypotensive response); start with 1L bolus NS or RL; control WOB, achieve end points: urine output >0.5ml/kg/hr, CVP 8-12mmHg, MAP 65-90mmHg
types of shock
cardiogenic, obstructive, distributive (septic, anaphylactic, neurogenic), hypovolemia, undifferentiated
describe general definition, subclassifications, and tx of hypovolemic shock
description: most common, cold + mottled + pale
subclassifications:
-non-hemorrhagic = vomiting, diarrhea, bowel obstruction/pancreatitis, burns, neglect/dehydration
-hemorrhagic = GI bleed, trauma, massive hemoptysis, AAA rupture (pain in lower back + afebrile), ectopic pregnancy/post-partum bleeding
Tx:
-ABC, 2 large bore IV or central line, crystalloid (RL or NS 1L bolus), Packed RBCs, control bleeding, TXA for hemorrhagic type within 3hrs injury, and labs (CXR, blood gas, coagulogram, ultrasound, CT, bronchoscopy)
define septic shock
sepsis + refractory hypotension (after bolus 20-40ml/kg Pt still has MAP < 65mmHg and needs vasopressors AND serum lactate >2mmol/L)
-requires having qSOFA >2 or more, SOFA >2 or more + refractory to fluid resuscitation AND requires vasopressors to maintain MAP
clinical signs of septic shock
hyper/hypothermia - warm initially then cool to touch once tissue hypoperfusion occurs, tachycardia, hypotension systolic < 90mmHg, mental status change
describe qSOFA scoring
RR >22 = 1 point, change in mental status = 1 point, systolic pressure <100mmHg = 1 point
- if > 2 SOFA points = considered risk of sepsis + further testing for organ failure (SOFA at ICU)
- done outside ICU (e.g. ER or floors or wards)
briefly describe SOFA scoring
- done in ICU to determine sepsis (not shock yet)
- respiration = P/F ratio
- coagulation = platelets
- liver = bilirubin
- cardiovascular = MAP and catecholamine (dopamine/dobutamine/epi/NE) dose
- CNS = GCS
- renal = creatinine and urine output
normal serum lactate
0.5 - 1mmol/L
Tx of septic shock
2 large bore IVs for fluid resuscitation, +/- vasopressors, O2, Abx broad + additional for specific organisms, likely require lung protective strategies (ARDS common complication)
Abx for psuedomonas
gentamicin
Abx for MRSA (methicillin resistant staph aureus)
vancomycin
Abx for intra-abdominal anaerobic infections
clindamycin
anaphylaxis vs. anaphylactoid
anaphylaxis = IgE mediated and requires sensitivity to antigen
anaphylactoid = not IgE mediated, results in direct breakdown of mast cell and basophils, does not require sensitivity and can be triggered by substances (e.g. NSAIDs, aspirin)
Note: both referred to as anaphylaxis bc clinically treated the same way
symptoms of anaphylactic shock (first, next, last)
first: pruritus (severe itch), flushing, urticaria (hives/welts)
next: throat fullness, anxiety, chest tightness, SOB, lightheaded
last: altered mental status, resp distress, circ collapse
T/F labs can help diagnose anaphylaxis
false; doesnt tell you the cause or whether they are in shock. not used to diagnose.
Tx of anaphylactic shock
ABCs: epinephrine to decrease swelling + increase BP and treat edema, intubation may be required
IV, monitors for ECG and sats
Second line corticosteroids (prednisone), H1 blockers (suppress histamine - Benadryl), H2 blockers (competitively bind to H2 receptor site - Zantac, Pepcid), bronchodilators
describe neurogenic shock
temporary/reversible 1-3 weeks, occurs in 20% cervical spine injuries/after acute SCI above T6, disrupted sympathetic flow resulting in hypotension and BRADYCARDIA, WARM, DRY skin
Tx for neurogenic shock
ABCs with C-spine precautions, fluid resuscitation MAP > 90mmHg maintained, search for other causes of hypotension, atropine or pacemaker for bradycardia, Methyprednisolone (Medrol) = CS for blood SCIs
causes of cardiogenic shock
acute MI, sepsis, myocarditis, myocardial contusions, aortic or mitral valve stenosis
define cardiogenic shock
SBP <90mmHg, CI < 2.2L/min/m2, PCWP > 18mmHg
signs of cardiogenic shock
cool, mottled skin, tachypnea, hypotension, altered mental status, NARROWED PULSE PRESSURE (indicates decreased LV stroke volume)
Tx for cardiogenic shock
airway (may require intubation but may result in hypotension so need IV access for fluids + drugs), inotropes for myocardial pump, if Acute MI do MONA + PCI or thrombolytics
describe obstructive shock and potential causes
- shock from obstruction of great vessels or heart resulting in ineffective heart pumping
- causes: tension pneumo, cardiac tamponade, PE, aortic stenosis
A 47 year old male presents to the ER after a motor vehicle incident complaining of decreased sensation below his waist and is now hypotensive, bradycardic and has warm extremities.
- Type of Shock?
- Treatment?
Neurogenic shock
Treatment =
-ABCs with C-spine precautions
-Fluid resuscitation - keep MAP > 90mmHg
-Search for other causes of hypotension (bleeding?)
-Bradycardia – atropine or pacemaker
-Methylprednisolone (Medrol) - corticosteroid used for blood spinal cord injuries
A 22 year old male presents to the ER after a skiing into a tree. He is complaining of chest pain and difficulty breathing. On physical examination, you note the patient to be tachycardic, hypotensive, cyanotic and has decreased breath sounds on the left side of his chest.
- Type of Shock?
- Treatment?
Obstructive shock
Treatment:
Likely due to tension pneumothorax; do chest tube and needle decompression
A 34 year old female presents to the ER after dining at a restaurant. Shortly after eating the first few bites of her meal, she became anxious, diaphoretic, began wheezing, noted pruritic rash, nausea and a sensation of her “throat closing off”. She is currently hypotensive, tachycardic and ill appearing.
- Type of Shock?
- Treatment?
Anaphylactic shock
Treatment:
-ABCs: Try to treat edema and respiratory compromise, May require intubation
-IV, monitors: ECG, saturations
-Epinephrine: Causes vasoconstriction → decreases swelling + increases BP
-Second line – Corticosteriods (prednisone), H1 and H2 blockers - H1 blockers suppress histamine mediated effect/Benadryl; H2 competitive antagonist at H2 receptor site- Zantac, Pepcid
-Bronchodilators: Salbutamol, Ventolin
A 55 year old male presents with “crushing” substernal chest pain, diaphoresis, hypotension, tachycardia and cool, clammy extremities.
- Type of Shock?
- Treatment?
Cardiogenic shock
Treatment:
Might be MI - improve myocardial pump with inotropic drugs, ABC on airway and IV, oxygenate, provide MONA or PCI depending on what heart issue is occuring/dysrrhythmia
An 85 year old female resident of a nursing home presents in the ER with altered mental status. She is febrile (40.0 C), hypotensive with a widened pulse pressure, tachycardic, with warm extremities. RR=28, SBP = 70
- Type of Shock?
- Treatment?
Sepsis (would need to do the SOFA in the ICU to know)
Treatment:
2 large bore IVs (1-2 L N/S) – may need vasopressor if no response to fluid resuscitation
Oxygen
Antibiotics, based on suspected source ASAP (within 1 hour)
60 year old male with a history of hypertension and diabetes mellitus presents in the ER with abrupt onset of diffuse abdominal pain with pain radiating to his lower back. The patient is hypotensive, tachycardic, afebrile, with cool but dry skin.
- Type of Shock?
- Treatment?
Hypovolemic from bowel obstruction? → could be considered and if they had bleeding on top of it. The hypotension is the cause of concern. They would need to do FAST and see what is happening in the belly.
- AAA → main cause of this type of picture; abrupt, intense abdominal pain that starts with back and then go hypotensive
- pancreatitis is not the right answer bc would be with fever, sweaty
