Shock

Question 1

Define Shock

Answer 1

condition affecting all body systems in which tissue perfusion is inadequate to deliver oxygen and nutrients to support vital organs, cellular function

Question 2

1. Define Hypovolemic shock
2. What are some examples?

Answer 2

1. shock state resulting from decreased intravascular volume due to fluid loss
2. e.g., hemorrhage, severe dehydration

Question 3

1. Define cardiogenic shock
2. What are some examples?

Answer 3

1. shock state resulting from impairment or failure of myocardium (cardiac muscle) leading to inadequate systemic perfusion.
2. e.g., myocardium infarction

Question 4

1. Define septic shock
2. What is an example?

Answer 4

1. Circulatory shock state resulting from systemic inflammatory response causing relative hypovolemia (systemic vasodilation).
2. Sepsis

Vasodilation throughout the body =, vasoconstriction is not occurring

Question 5

1. Define neurogenic shock
2. What is example?

Answer 5

1. shock state resulting from loss of sympathetic tone causing relative hypovolemia (systemic vasodilation)
2. brain or spinal cord injury

Question 6

Define anaphylactic shock

Answer 6

circulatory shock state resulting from severe allergic reaction producing relative hypovolemia (systemic vasodilation)

Question 7

1. Define obstructive shock?
2. What are some examples?

Answer 7

1. Inadequate perfusion as a result of blockage, pressure, or obstruction on the heart or lungs.
2. PE, tension pneumo, cardiac tamponade

Least common shock

Question 8

What is the most common type of shock?
What is the two 2nd most common?

Answer 8

Septic
(2 - Cardiogenic/Hypovolemic)
(3 - Anaphylatic/Neurogenic)

Question 9

What causes the “early signs” of shock to occur?

Answer 9

Decreased tissue perfusion (hypoxia and ischemia) and oxygenation caused by an insult.

Question 10

What early signs may be seen with shock?

Answer 10

1. SNS response (↑ HR, BP, cardiac contractility = ↑ CO)
2. ↑ RR = ↑ oxygen saturation and delivery
3. RAAS activation = Na+/H2O retention = ↑ preload and ↓ UO
4. Adrenal Gland activation ↑ catecholamines and cortisol = ↑ glucose for metabolism

Question 11

How much time does the provider have to recognize the early signs of shock to begin aggressive tx to decrease mortality?

Answer 11

approx. 3 hours

Question 12

Which type of shock would have difficulty affecting the SA node to increase HR?

Answer 12

Neurogenic shock
(unable to trigger SNS compensatory mechanism due to TBI or Spinal Injury)

Question 13

Which type of shock would present w/ bradycardia as an early sign?

Answer 13

Neurogenic shock

Question 14

During the compensatory stage of shock blood is shunted away from the body. Where is this seen and what are the signs?

Answer 14

1. Skin = cool, clammy, pale
2. Kidneys = ↓ UO
3. GI tract = ↓ bowel sounds, abdominal discomfort

Blood is shunted away to heart and brain

Question 15

if a patient is just lying in bed and suddenly HR kicks up for no apparent reason; what might this be an early sign of?

Answer 15

Shock

Question 16

Why would metabolic acidosis occur during shock?

Answer 16

• Hypoxia forces cells to perform anaerobic metabolism
• Anaerobic metabolism byproduct is lactic acid

Question 17

In darker skin patients how can skin be checked for poor perfusion?

Answer 17

conjunctiva (pale)
Ashen-grey tongue

Question 18

What happens during acute DIC?

Disseminated intravascular coagulation

Answer 18

activation of clotting factors until all factors are used up then risk for bleeding occurs.

entire inflammatory system active → activation of coagulation proteins

Question 19

• Normal platelet count
• Worrisome platelet count

Answer 19

• 150 to 400k
• < 100k

Question 20

What happens to PT and aPTT values as clotting time decreases vs. increases.

Answer 20

• ↓ PT/aPTT = clot faster
• ↑ PT/aPTT = clot slower

Inverse relationship b/w PT and clot time

Question 21

What are the 4 possible interventions for DIC?

Disseminated intravascular coagulation

Answer 21

• Possibly heparin for clots (temporarily)
• replace coagulation factors w/ Fresh Frozen Plasma or platelets.
• Fibrinogen (clots)
• Plasmapheresis (severe cases)

Question 22

What is the mortality rate of irreversible stage of shock

Answer 22

75%

Question 23

What is sign a patient has entered irreversible stage of shock?

Answer 23

Presence of altered function of two or more organs in acutely ill patient such that interventions are necessary to support continued organ function

organ failure

Question 24

Metabolic acidosis tx for shock patients

Answer 24

1. Increase RR setting on ventilator or body naturally ↑ RR if not on vent.
2. Sodium bicarbonate (reduce stomach acids)

Question 25

* What is the primary and secondary **fluid** **tx** for shock patients? * What is each used for?

Answer 25

* Crystalloid (NS, LR) **primary** tx increase blood volume * Colloid (**albumin**) **secondary** tx used to pull fluids back into blood vessels.

Question 26

How does blood glucose vary throughout shock?

Answer 26

* Early compensatory stage = **hyper**glycemia * Progressive and Irreversible stage = **hypo**glycemia

Question 27

* What is the procedure for giving fluid to a shock patient experiencing hypovolemia? * What potential risks are associated w/ fluids?

Answer 27

* 250 to 500 ml bolus inital (**risk of pulmonary edema if to much fluid given**) * Check to see if BP increases * If BP does not improve; move onto vasoactive medication.

Question 28

What happens within the kidneys as shock progresses?

Answer 28

1. **RAAS activation** causes water retention and ↓ UO 2. **De-compensation** = Oliguria < 30 ml/hr (0.5 ml/kg/hr) 3. **Refractory** = Anuria < 50 ml/day and **Dialysis***

Question 29

What are the 5 steps of the suriving shock campaign? | begins immediately upon suspection of shock

Answer 29

1. Measure lactate 2. Obtain blood cultures 3. Adminster antibiotics 4. Adminster crystalloid 5. Vasopressor

Question 30

When should you priortize giving fluids in the suriving shock campaign?

Answer 30

SBP < 90 or MAP < 65

Question 31

What is the first line vasoactive medications? | Used when fluid therapy alone does not maintain MAP.

Answer 31

norepinephrine (Levophed) | *2nd line tx = Epinephrine, Vasopressin*

Question 32

* What is the most common inotrope medication for cardiogenic shock? * What risk is it associated with?

Answer 32

* Dopamine * risk arrhythmia and Gangrene with extravasation

Question 33

What are s/sx of clotting that may be occuring?

Answer 33

petechiae, purpura (mini-clots)

Question 34

* What are the three shocks that fall under distributive shock? * What do all distributive shock have in common?

Answer 34

Distributive Shock: 1. Septic 2. Neurogenic 3. Anaphylatic Distributive Shock is associated w/ causing relative hypovolemia. | *Blood stays out in the periphery and does not go back to the heart*