SHOCK!

Question 1

shock definition

Answer 1

reversible life threatening emergency if recognized/treated early; GLOBAL metabolic (lactic) acidosis and tissue hypoperfusion that can occur with hypotension or NORMAL BP

Question 2

2 initial/compensatory autonomic NS responses to shock

Answer 2

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

Question 3

common S&S of shock

Answer 3

altered mental status, skin cool + mottled or hot + flushed, weak/absent pulse due to vasoconstriction peripherally, systolic BP <110mmHg, tachycardia

Question 4

general shock tx

Answer 4

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

Question 5

types of shock

Answer 5

cardiogenic, obstructive, distributive (septic, anaphylactic, neurogenic), hypovolemia, undifferentiated

Question 6

describe general definition, subclassifications, and tx of hypovolemic shock

Answer 6

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)

Question 7

define septic shock

Answer 7

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

Question 8

clinical signs of septic shock

Answer 8

hyper/hypothermia - warm initially then cool to touch once tissue hypoperfusion occurs, tachycardia, hypotension systolic < 90mmHg, mental status change

Question 9

describe qSOFA scoring

Answer 9

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)

Question 10

briefly describe SOFA scoring

Answer 10

• 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

Question 11

normal serum lactate

Answer 11

0.5 - 1mmol/L

Question 12

Tx of septic shock

Answer 12

2 large bore IVs for fluid resuscitation, +/- vasopressors, O2, Abx broad + additional for specific organisms, likely require lung protective strategies (ARDS common complication)

Question 13

Abx for psuedomonas

Answer 13

gentamicin

Question 14

Abx for MRSA (methicillin resistant staph aureus)

Answer 14

vancomycin

Question 15

Abx for intra-abdominal anaerobic infections

Answer 15

clindamycin

Question 16

anaphylaxis vs. anaphylactoid

Answer 16

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

Question 17

symptoms of anaphylactic shock (first, next, last)

Answer 17

first: pruritus (severe itch), flushing, urticaria (hives/welts)
next: throat fullness, anxiety, chest tightness, SOB, lightheaded
last: altered mental status, resp distress, circ collapse

Question 18

T/F labs can help diagnose anaphylaxis

Answer 18

false; doesnt tell you the cause or whether they are in shock. not used to diagnose.

Question 19

Tx of anaphylactic shock

Answer 19

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

Question 20

describe neurogenic shock

Answer 20

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

Question 21

Tx for neurogenic shock

Answer 21

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

Question 22

causes of cardiogenic shock

Answer 22

acute MI, sepsis, myocarditis, myocardial contusions, aortic or mitral valve stenosis

Question 23

define cardiogenic shock

Answer 23

SBP <90mmHg, CI < 2.2L/min/m2, PCWP > 18mmHg

Question 24

signs of cardiogenic shock

Answer 24

cool, mottled skin, tachypnea, hypotension, altered mental status, NARROWED PULSE PRESSURE (indicates decreased LV stroke volume)

Question 25

Tx for cardiogenic shock

Answer 25

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

Question 26

describe obstructive shock and potential causes

Answer 26

• shock from obstruction of great vessels or heart resulting in ineffective heart pumping
• causes: tension pneumo, cardiac tamponade, PE, aortic stenosis

Question 27

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.

1. Type of Shock?
2. Treatment?

Answer 27

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

Question 28

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.

1. Type of Shock?
2. Treatment?

Answer 28

Obstructive shock
Treatment:
Likely due to tension pneumothorax; do chest tube and needle decompression

Question 29

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.

1. Type of Shock?
2. Treatment?

Answer 29

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

Question 30

A 55 year old male presents with “crushing” substernal chest pain, diaphoresis, hypotension, tachycardia and cool, clammy extremities.

1. Type of Shock?
2. Treatment?

Answer 30

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

Question 31

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

1. Type of Shock?
2. Treatment?

Answer 31

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)

Question 32

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.

1. Type of Shock?
2. Treatment?

Answer 32

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