Shock Flashcards
- Inadequate oxygen delivery to meet metabolic demands
- results in global tissue hypoperfusion and metabolic acidosis
shock
What is the pathophysiology of shock?
this imbalance between tissue oxygen supply and demand leads to
- stimulation of autonomic response (goal is to maintain cerebral and cardiac perfusion)
- abnormal celluar response
- anaerobic metabolism
Causes
- worsening lactic acidosis
- cardiovascular insufficiency
- increase oxygen demand
Results in “End Organ Damage”
- multiorgan dysfunction syndrome (MODS)
- cardiac depression, respiratory distress, renal failure and DIC
Global tissue Hypoxia
What are signs and symptoms of shock?
- mental status changes
- pinpoint pupils
- tachycardia
- other dysrhythmias
- hypotension
- oliguria
- cool, clammy
- lactic acidosis
- fever
- cyanosis
- negative inotrope
- bicarbonate is rarely used for treatment
- treat with improved ventilation and mild hyperventilation
acidosis
what does non-hemorrhagic hypovolemic shock look like?
- vomiting
- diarrhea
- bowel obstruction, pancreatitis
- burns
- neglect, environmental (dehydration)
what does a hemorrhagic hypovolemic shock look like?
- GI bleed
- trauma
- massive hemoptysis
- AAA rupture
- ectopic pregnancy, post-partum bleeding
treatment of hypovolemic shock?
- ABC- stop the bleeding
- establish 2 large bore IVs or a central line
- crystalloids (normal saline or lactate ringers)
- PRBCs +++ EARLY
- control any bleeding
- permissive hypotension
signs of cardiogenic shock?
- cool, mottled skin
- tachypnea
- hypotension
- altered mental status
- narrowed pulse pressure
- rales, murmur
what is the pathophysiology behind cardiogenic shock?
- often after ischemia, loss of LV function
- CO reduction= lactic acidosis, hypoxia
-lose 40% of LV–> clinical shock ensues - stroke volume is reduced
-tachycardia develops as compensation
-ischemia and infarction worsens
what is the initial treatment of cardogenic shock?
- airway stability and improving myocardial pump function
- cardiac monitor, pulse oximetry
- supplemental oxygen, IV access
- intubation will decrease preload and result in hypotension
Treatment of cardiogenic shock?
AMI
- aspirin, heparin, antiplatelet
- if no pulmonary edema- IVF challenge
- if pulmonary edema: Dopamine- will increase HR and thus cardiac work (rarely used); dobutamine- may drop blood pressure; norepi; combination therapy may be more effective
- PCI
RV infarct
- fluids and dobutamine (no NTG)
Acute mitral regurgitaiton or VSD
- pressors (dobutuamine and nitroprusside)
- air trapped in pleural space with 1 way valve, air/pressure builds up
- mediastinum shifted impeding venous return
- chest pain, SOB, decreased breath sounds
- no tests needed
- rx: needle decompression, chest tube
Tension Pneumothorax
Type of obstructive shock
- Blood in pericardial sac prevents venous return to and contraction of heart
- related trauma, pericarditis, MI
- Beck’s triad: hypotension, muffled heart sounds, JVD
- dx: large heart CXR, POCUS
- rx: pericardiocentesis, thoractomy
cardiac tamponade
type of obstructive shock
- Virchow’s triad: hypercoagulable, venous injury, venostasis
- signs: tachypnea, tachycardia, hypoxia
- low risk: D-dimer
- higher risk: CT chest or VQ scan
- rx: Norepi, heparin, consider thrombolytics
- avoid intubation
- catheter directed tx/OR
Pulmonary emobilism
type of obstructive shock
Two or more of the following
* temperature > 38 C or < 36 c
* heart rate > 90
* respiratory > 20resp/min or PACO2 < 32
* WBC>12,000, < 4,000 or > 10% bands
* plus existance of an infection
SIRS
severe sepsis with hypotension unresponsive to fluid resuscitation and perfusion abnormalities
septic shock
treatment of septic shock?
2 large bore IVs
- NS IVF bolus 1-2 L wide open (if no contraindicaions)
supplemental oxygen
empiric antibiotics, based on suspected source, as soon as possible
severe systemic hypersenistivity rxn characterized by multisystem involvment
- IgE mediated
- Mild localized urticaria can progress to full anaphylaxis
- symptoms usually begin within 60 minutes of exposure
- faster the onset of symptoms= more severe reaction
- biphasic phenomenon occurs in up to 20% of pts
- symptoms return 3-4 days after initial reaction has cleared
Anaphylaxis
clinicallly indistinguishable from systemic hypersenistivity rxn
-doesn’t require a sensitizing exposure
-not IgE mediate
Anaphylactoid reaction
first line tx for anaphylactic shock is?
IV epinephrine
treatment of anaphylactic shock?
Epinephrine
- repeat every 5-10 min as needed
- caution with patients taking beta blockers: can cause severe hypertension due to unopposed alpha stimulation
- for CV collapse, 1mg IV of 1:10,000
- if refractory, start IV drip
Corticosteroids
antihistamines
bronchodilators
glucagon
altered physiologic state immediately after a spinal cord injury (SCI), which presents as loss of spinal cord function cuadal to the level of injury with flaccid paralysis
Spinal Shock
- component of the spinal shock syndrome and refers to the hemodynamic instability seen in thse patients with hypotension, bradycardia, and hypothermia
neurogenic shock
