Shock

Question 1

Shock is a life-threatening condition of ______

Answer 1

circulatory failure

Question 2

_________ defined as circulatory insufficiency that creates an imbalance between tissue oxygen supply and demand resulting in global tissue hypoperfusion. This leads to hypoxia, acidosis, and eventual end organ damage and failure.

Answer 2

Shock…

Question 3

Shock is divided into 4 distinct categories:

Answer 3

-Hypovolemic
-Cardiogenic
-Distributive
-Obstructive

Question 4

What type of shock?
Caused by decreased intravascular volume secondary to blood loss or loss of fluid and electrolytes.

Answer 4

Hypovolemic

Question 5

S/s of what type of shock?
1) Tachycardia, but can decompensate and become bradycardic when there is not enough CO to supply blood to the heart
2) Hypotension (Systolic BP < 90 mmHg)
3) Mental status changes (due to decreased blood flow to the brain)
4) Oliguria (due to decreased blood flow to the kidneys)
5) Cool extremities (due to peripheral vasoconstriction in order to shunt
blood back to the heart)
6) Weak pulse (due to low cardiac output)
7) Low JVP

Answer 5

Hypovolemic

Question 6

These etiologies can cause what type of shock?
a) Trauma
b) Massive hemorrhage
c) GI Bleed
d) Burns
e) Vomiting or Diarrhea
f) Excessive sweating
g) Hyperosmolar states (DKA)

Answer 6

Hypovolemic

Question 7

Hypovolemic Shock Tx

Answer 7

1) Goal is to maintain adequate tissue perfusion
2) Fluid replacement
–Fluid loss = 1-2 LR
–Blood loss = blood transfusion
3) Meds
–Vasopressors (Epi, Nor-epi)

Question 8

For every 1 unit PRBC you give your hematocrit should increase by how much?

Answer 8

3%

Question 9

What is the goal when tx hypovolemic shock

Answer 9

Maintain adequate tissue perfusion

Question 10

Definition of what type of shock?
1) Pump failure secondary to AMI, Cardiac contusion, Arrhythmia, Valvular incompetence or stenosis
2) The problem is that the muscle is either not getting enough blood supply to maintain CO, that the CO is not all going forward, or that the heart cannot work hard enough to maintain the CO

Answer 10

Cardiogenic

Question 11

Physical findings of what type of shock?
1) Hypotension (SBP < 90 mmHg)
2) Mental status changes
3) Oliguria
4) Cool extremities
5) Elevated JVP
6) JVD
7) Tachypnea
8) Pulmonary edema
9) Irregular pulse if arrhythmia

Answer 11

Cardiogenic

Question 12

Tx Cardiogenic shock

Answer 12

1) Initial management focuses on airway stability and improving pump function, until definitive treatment re-establishes adequate CO
2) Follow ACLS if go into cardiac arrest
3) Fluid replacement requires smaller fluid challenges (250 ml)
4) Vasopressors
-a) Epinephrine 0.014 - 0.5 mcg/kg/min IV infusion
-b) Dopamine 1-20 mcg/kg/min IV infusion
-c) Dobutamine 2-20 mcg/kg/min IV infusion

Question 13

What kind of shock Causes a reduction in Systemic vascular resistance

Answer 13

Distributive

Question 14

What are the different etiologies of Distributive shock

Answer 14

a) Sepsis
b) Anaphylaxis
c) Neurogenic

Question 15

What type of distributive shock?
(1 Caused by spinal cord injury resulting in loss of sympathetic stimulation and reduction in systemic vascular resistance.
(2 Reflex vagal parasympathetic stimulation from pain, gastric dilation may stimulate

Answer 15

neurogenic shock.

Question 16

What type of distributive shock?
(1 Caused by massive release of histamine and other vasoactive substances cause systemic vasodilation, potential airway compromise due to airway edema and bronchospasm
(2 Severe systemic hypersensitivity reaction

Answer 16

Anaphylaxis

Question 17

What type of distributive shock?
(1 Overwhelming infection with a massive release of bacterial endotoxins causing inability to maintain perfusion

Answer 17

Sepsis

Question 18

What is the most common cause of distributive shock?

Answer 18

Sepsis

Question 19

Sepsis is most commonly caused by gram neg or gram pos bacteria?

Answer 19

gram negative bacteremia

Question 20

Physical Findings of what type of distributive shock?
a) Evidence of diffuse urticaria, angioedema, bronchospasm, SOB, fullness of the throat, hoarseness.
b) History of an insect bite, exposure to certain food, etc

Answer 20

Anaphylaxis

Question 20

Physical Findings of what type of distributive shock?
a) Evidence of infection (fever, tachycardia) in the setting of persistent hypoperfusion despite volume resuscitation.
b) Check CBC (will reveal elevated WBC)
c) History should help point you to the source of the infection

Answer 20

Sepsis

Question 21

Physical Findings of what type of distributive shock?
a) Evidence of acute traumatic spinal cord injury and hypotension without compensatory tachycardia.
b) Unresponsive to fluid resuscitation, Bradycardia
c) Warm, dry skin

Answer 21

Neurogenic

Question 22

Sepsis Treatment

Answer 22

a) ABCs, O2 if saturation < 92%, IV, Monitor
b) Primary treatment is to treat underlying infection with early initiation of broad spectrum antibiotics
–(1 Ertapenem 1 gram IV Daily
c) Fluid resuscitation, start with 1 L LR

Question 23

IF does not respond to 2 Liters of IVFL what do you do?

Answer 23

start pressors to keep MAP > 60
(1 Norepinephrine (Levophed)
(2 Epinephrine

Question 24

Anaphylaxis Tx

Answer 24

a) ABCs (secure airway), O2 to keep saturation > 92%, IV, Monitor
b) Epinephrine (Epipen): 0.1- 0.5 mg SC/IM repeat q 10- 15 minutes (Epipen delivers 0.3 mg dose IM)
c) IV Fluids with LR or NS
d) Ancillary Treatments
-Benadryl 50mg IV q6 hours prn
-Solumedrol 125mg IM/IV q 4 hours prn
-Zantac 50mg IV q 6 hours prn or 150mg PO BID

Question 25

How often are Epi doses repeated for anaphylaxis?

Answer 25

10-15 min

Question 26

Neurogenic tx

Answer 26

a) ABCDE (trauma primary survey to include neurological examination)
b) Maintain cervical spine protection
c) Rapid infusion of LR or NS 1 Liter bolus should treat most hypotensive episodes
d) Secondary survey

Question 27

What type of shock?
1. mostly due to extracardiac causes of cardiac pump failure and often associated with poor right ventricle output
2) Caused by: Massive PE, Tension pneumothorax, Pericardial
Tamponade, Restrictive cardiomyopathy, or abdominal compartment
syndrome

Answer 27

Obstructive

Question 28

Physical Findings of what type of shock?
1) Depends on the etiology:
2) Massive PE: shock, JVD, elevated JVP, LE pitting edema
3) Tension PTX: deviated trachea, absent breath sounds on one side
4) Pericardial Tamponade: distal or muffled heart tones, JVD, elevated
JVP

Answer 28

Obstructive

Question 29

Obstructive tx

Answer 29

1) ABCs, IV, O2 to keep saturation > 92%, Monitor
2) Thrombolytics or endovascular thrombus retrieval for PE
3) Needle decompression or chest tube for PTX
4) Pericardiocentesis to drain pericardial fluid
5) IV fluids LR or NS 250ml bolus at a time to see response