Shock!

Question 1

Shock is defined as a state of systemic tissue ________ due to ____________________ and/or _________________________

Answer 1

hypoperfusion

reduced cardiac output

reduced effective circulating blood volume.

Question 2

Types of shock

__________ shock
__________ shock
_______ shock
________ shock
____________ shock

Answer 2

cardiogenic

hypovolaemic

septic

neurogenic

anaphylactic

Question 3

Cardiogenic shock

Acute ______ failure with sudden fall in ________ without actual _________

Answer 3

circulatory

cardiac output

reduction of blood volume.

Question 4

Cardiogenic shock

This results from ___________ failure.

Answer 4

myocardial pump

Question 5

Cardiogenic shock

The causes include
A. Deficient emptying

_________________ is the most obvious cause of pump failure.

_____________ rupture

_________ rupture

acute myocarditis

cardiac _______

Cardiomyopathies

Answer 5

Myocardial infarction

papillary muscle

ventricular

arrhythmias

Question 6

Cardiogenic shock

The causes include
B. Deficient filling

Cardiac _______ [extrinsic ____] from ________

Answer 6

tamponade; compression

haemopericardium

Question 7

Cardiogenic shock

The causes include

C. obstruction to outflow

_______________
Tension __________
Dissecting _____________

Answer 7

Pulmonary embolism

pneumothorax

aortic aneurysm

Question 8

Hypovolaemic shock

This results from ____________ or _______

Causes include

Severe ________,

Fluid loss :severe ____, diarrhoea, vomiting, extensive ____, uncontrolled ________,__________, ______ over _____.

Answer 8

loss of blood or plasma volume

haemorrhage

burns; injury; diabetes mellitus

diabetes insipidus

diuretic over dose

Question 9

Shock associated with systemic inflammation

It is caused by a variety of ______,

Like : _________________

Answer 9

insults

Microbial infections, burns, trauma, and or pancreatitis

Question 10

Shock associated with systemic inflammation

The common pathogenic feature is a massive _________ that produce arterial _______, vascular _____, and venous _______

Answer 10

outpouring of inflammatory mediators

vasodilation

leakage
blood pooling

Question 11

Neurogenic and anaphylactic shock

Less commonly, shock can occur in the setting of an anesthetic accident (accidental high spinal anesthesia) or a _______ injury ( _______ shock), or an ___–mediated hypersensitivity reaction ( _________ shock).

Answer 11

spinal cord; neurogenic

IgE; anaphylactic

Question 12

Neurogenic and anaphylactic shock

In both of these forms of shock, acute _________ leads to ________ and tissue _______

Answer 12

vasodilation

hypotension

hypoperfusion

Question 13

Septic shock

Sepsis is defined as ________________________ due to a dysregulated ______________.

Answer 13

life-threatening organ dysfunction

host response to infection.

Question 14

Sepsis accompanies infection either ____________________, or associated with the _________________________

Answer 14

confined to a local site from which toxins are absorbed

invasion of organisms into the blood stream (septicaemia).

Question 15

Septic shock is defined as a subset of _______ in which particularly profound _____,______, and _______ abnormalities substantially increase mortality.

Answer 15

sepsis

circulatory, cellular, and metabolic

Question 16

Pathogenesis of septic shock

It is associated with systemic ______ and peripheral _______ leading to _______

It is caused by ________ and ______

Answer 16

vasodilation

pooling of blood

tissue hypoperfusion

bacterial and fungal infection .

Question 17

Septic shock is Commonly triggered by _______________ infections followed by _______ organisms and then systemic _______ infections.

Answer 17

gram positive bacterial

gram negative

fungal

Question 18

In septic shock

There is widespread _____________ often leading to a _______ state that can manifest as ____________

Answer 18

endothelial cell activation and injury

hypercoagulable

DIC (Disseminated Intravascular Coagulation)

Question 19

Several microbial constituents can initiate the process of septic shock

T/F

Answer 19

T

Question 20

Septic shock has a ___ to ___% mortality rate depending on centres.

Answer 20

20

75

Question 21

Factors that play major roles in Pathophysiology of septic shock

Inflammatory and counter inflammatory responses
– –
Microbial cell constituents engage _________ of _____ immune system to activate pro inflammatory responses

Answer 21

receptors on cells

innate

Question 22

Factors that play major roles in Pathophysiology of septic shock

Inflammatory and counter inflammatory responses
– –
________________________ + _________________
G-protein coupled receptors that detect bacterial peptides

Answer 22

TLRs [Toll-like receptors]+ Pathogen associated molecular patterns[PAMP]

Question 23

Factors that play major roles in Pathophysiology of septic shock

Activated immune cells (monocytes/macrophages) produce

_____ ,_____,———,______, reactive oxygen species and lipid mediators such as _______ and _________

Answer 23

TNF, IL-1, IFN-γ, IL-12, and IL-18

Prostaglandins; platelet activating factor (PAF)

Question 24

Factors that play major roles in Pathophysiology of septic shock

The effects TNF-α and IL-1cytokines are as under:

a) By altering _________________

B) Promoting _______ synthase

Answer 24

endothelial cell adhesiveness

nitric oxide

Question 25

Factors that play major roles in Pathophysiology of septic shock Activation of other inflammatory responses such as under: 1) Activation of ____ cells: _____ is released which increases capillary permeability. 2) The ———— cascade is also activated by microbial components, resulting in the production of anaphylatoxins (______),chemotactic fragments (___), and opsonins (___), all of which contribute to the pro-inflammatory state

Answer 25

mast; Histamine complement C3a, C5a C5a; C3b

Question 26

In septic shock Microbial components can activate coagulation directly through ____ and indirectly through altered ______ function

Answer 26

factor XII; endothelial

Question 27

The hyperinflammatory state initiated by sepsis also activates counter-regulatory ________ mechanisms, which may involve _____________ cells..

Answer 27

immunosuppressive both innate and adaptive immune

Question 28

Factors that play major roles in Pathophysiology of sepsis Endothelial activation and injury The (anti or pro?) -inflammatory state and endothelial cell activation associated with sepsis leads to widespread vascular _______ and tissue _____. One effect of inflammatory cytokines is to ____________________, making vessels ____ and resulting in the accumulation of __________ throughout the body.

Answer 28

Pro; leakage; edema loosen endothelial cell tight junctions leaky; protein-rich edema

Question 29

Factors that play major roles in Pathophysiology of sepsis Endothelial activation and injury Activated endothelium also upregulates production of ——- and other vasoactive inflammatory mediators (e.g., C3a, C5a, and PAF), which may contribute to vascular smooth muscle _______ and systemic ______

Answer 29

nitric oxide (NO) relaxation hypotension

Question 30

Factors that play major roles in Pathophysiology of sepsis Induction of a procoagulant state Proinflammatory cytokines increase _____ production by ——- and possibly ______ cells as well, and decrease the production of endothelial anti-coagulant factors, such as tissue factor pathway inhibitor, thrombomodulin, and protein C Decreases fibrinolysis by increasing ______________ expression. These effects lead to systemic activation of ______ and the deposition of _________ in small vessels throughout the body.

Answer 30

tissue factor monocytes; endothelial plasminogen activator inhibitor- 1 thrombin; fibrin-rich thrombi

Question 31

Sepsis alters the expression of many factors against coagulation T/F

Answer 31

F to favor

Question 32

In sepsis Metabolic abnormalities Septic patients exhibit _____ resistance and ______ TNF, IL-1, stress induced hormones eg glucagon, GH, glucocorticoids and catecholamines all drive __________

Answer 32

insulin hyperglycaemia gluconeogenesis

Question 33

Proinflammatory cytokines suppress ________ and promote _______ in liver and other tissues

Answer 33

insulin release insulin resistance

Question 34

Organ dysfunction in sepsis Systemic ___tension and small vessel _____ will ___ease delivery of oxygen and nutrients to tissues

Answer 34

hypo; thrombosis; decr

Question 35

Organ dysfunction in sepsis Inflammatory cytokines and other mediators may decrease myocardial _______ and _______, increase vascular _____, and cause endothelial ____ that may lead to ____________ All these may cause ________, particularly the _____,______,_______, and ______ culminating in death.

Answer 35

contractility and Cardiac Output permeability; injury Adult Respiratory Distress Syndrome multiple organ failure kidneys, liver, lungs, and heart,

Question 36

Septic shock pathogenesis The collective actions of bacterial constituents and chemical mediators result in the following: 1)___ and increased synthesis of ________ 2)Systemic vaso_______ (___tension) 3)Diminished myocardial ______ 4) Activation of the coagulation system culminating in ___________ 5)Widespread endothelial injury and activation, causing systemic _____ and ______________ damage (_____) or ______

Answer 36

fever; acute phase proteins dilatation; hypo contractility (DIC) disseminated intravascular coagulopathy leucocyte adhesion; pulmonary alveolar capillary ; ARDS; shock lung

Question 37

Toxic shock syndrome is similar to septic shock T/F

Answer 37

T

Question 38

Toxic shock syndrome It is caused by _____ produced by ______ The syndrome is associated with the use of __________ during ______ because It aids the ________________________________

Answer 38

exotoxins; staph aureus. absorbent tampons; menstruation growth of staph aureus organism in menstrual blood.

Question 39

Neurogenic shock Occurs as a result of ________ and ___________ ________ and ———— are common causes.

Answer 39

loss of vascular tone peripheral pooling of blood Spinal cord injury and anaesthesia

Question 40

Anaphylactic shock This is initiated by generalised ___________________ reaction.

Answer 40

IgE mediated hypersensitivity

Question 41

Anaphylactic shock Mechanism- acute widespread systemic peripheral vaso_____ and increased vascular _______ resulting in tissue ________ and _______

Answer 41

dilatation permeability hypoperfusion and hypoxia.

Question 42

Pathogenesis of anaphylactic shock Two basic features Reduced ___________________ Reduced _______________ with resultant ______

Answer 42

effective circulating blood volume supply of oxygen to cells and tissues; anoxia

Question 43

Stages of shock __________________ phase ___________ stage _______________ stage

Answer 43

Initial non progressive Progressive Irreversible/intractable

Question 44

Initial non progressive stage In the early stage of shock an attempt is made to maintain an adequate _____ and ______ blood supply by __________ so that the vital organs (brain, heart) are ________________

Answer 44

cerebral and coronary redistribution of blood adequately perfused and oxygenated

Question 45

Initial non progressive stage Neurohumoral mechanisms that help maintain C.O and blood pressure: ________ reflexes, chemoreceptors, stimulation of _______ with release of ______, activation of _________ system, ____ release, generalised sympathetic stimulation. These mechanisms will have a net effect of ______, peripheral _______, and _______

Answer 45

baroreceptor; adrenal medulla catecholamines; renin angiotensin ADH tachycardia; vasoconstriction; renal conservation of fluid.

Question 46

Progressive shock Widespread tissue ______ ________ glycolysis with ______ _______ of pH, makes the ______ response ineffective- arteriolar _____ and _______ in the microcirculation. ___ease in CO, _____ injury to the endothelium which may progress to _______,_______ and decreased _____

Answer 46

hypoxia Anaerobic; lactic acidosis Lowering; vasomotor; dilatation pooling of blood Decr; anoxic DIC Organ failure, confusion; urinary output.

Question 47

Irreversible / intractable stage Widespread cell injury with _________ Decreased myocardial ______ Renal _____ as a result of ________ Ischaemia of the bowel may allow __________________ causing ____ shock.

Answer 47

lysosomal enzyme leakage. contractility shutdown; acute tubular necrosis the entry of intestinal bacterial flora into the blood; septic

Question 48

Morphology of shock Basic pathologic changes include ________, tissue _____ and _______ in capillaries, venules and small veins.

Answer 48

haemorrhages necrosis fibrin thrombi

Question 49

Morphology of shock Heart: subendocardial _______ and _____ __________ necrosis.

Answer 49

haemorrhages and necrosis contraction band

Question 50

Morphology of shock kidneys: renal ______ following sustained systemic _______ is responsible for the changes Grossly, the kidneys are (soft or hard?) and _____. Sectioned surface shows _______________ Microscopically:__________ leading to _______,________ and _______

Answer 50

ischaemia; hypotension Soft; swollen; blurred architectural markings Acute tubular necrosis (ATN) oliguria, anuria and electrolyte imbalance.

Question 51

Morphology of shock The lungs: 1)(Light or Heavy?) and (dry or wet?). 2)____________________ damage (_____)

Answer 51

Heavy; wet Pulmonary alveolar capillary ARDS

Question 52

Adult Respiratory Distress Syndrome shows ———, interstitial and alveolar _____, interstitial lymphocytic infiltrate, alveolar hyaline membranes, thickening and fibrosis of _______, fibrin and platelet thrombi in the pulmonary microvasculature

Answer 52

congestion oedema; alveolar septa

Question 53

The lungs are often affected in pure hypovolemic shock T/F With reason

Answer 53

F The lungs are seldom affected in pure hypovolemic shock because of it’s dual vascular supply.

Question 54

Morphology of shock GIT: Patchy mucosal haemorrhages and necroses (_____________), acute _______ of the stomach or duodenum may occur and are known as _______. Grossly: lesions are ____ and widely distributed throughout. The lesions are _______. The bowel mucosa is _______ and _______ Microscopically there is ___________ of the mucosa and sometimes submucosa

Answer 54

haemorrhagic enteropathy stress ulcers Curlings ulcer. multifocal; superficial ulcers oedematous and haemorrhagic. haemorrhagic necrosis

Question 55

Morphology of shock Liver: ______ and central _______. _________ appearance is seen.

Answer 55

Fatty change haemorrhagic necrosis Faint nutmeg

Question 56

Morphology of shock Hypoxic encephalopathy: Sustained blood pressure of below __mmHg leads to serious brain tissue ______ damage with loss of _______, coma and _____ state Grossly: The area supplied by the most (distal or proximal?) branches of the cerebral arteries (border zone between the anterior and middle cerebral arteries) suffers from severe ________ Changes are more noticeable in prolonged cerebral ischaemia.

Answer 56

50 ; ischaemic cortical functions; vegetative state Distal ; ischaemic necrosis.

Question 57

Neurons particularly _______ are more prone to ischaemia. The cytoplasm of the affected neuron is intensely ______ and the nucleus is ____ and ____

Answer 57

Purkinje cells eosinophilic small and pyknotic.

Question 58

Morphology of shock Adrenals- __________ depletion

Answer 58

cortical cell lipid

Question 59

Clinical manifestation of shock ___tension Decreased/increased SVR(Systemic vascular resistance also known as TPR) depending on _______ (Weak or strong?) (slow or rapid?) pulse (Cool or warm?) _______ ______ skin

Answer 59

Hypo the stage of shock Weak rapid Cool, clammy cyanotic

Question 60

Clinical manifestations of shock in septic shock the skin is _____ and ______ because of ________

Answer 60

warm and flushed peripheral vasodilatation.

Question 61

Clinical manifestations of shock Phase of ____uria due to ____, later phase of ______ due to _________________ of _______.

Answer 61

oliguria; ATN diuresis regeneration of tubular epithelium

Question 62

Clinical manifestations of shock ______________ in early oliguric phase while marked __________ occurs in diuretic phase

Answer 62

Haemoconcentration electrolyte imbalance

Question 63

Management of septic shock Treat _____ with ___________ Set up ______ Fluid Resuscitation/monitor BP Administer _____ Nutritional Support Vaso______ ______ drugs _______ therapy for _______

Answer 63

infection; broad spectrum antibiotics IV line; oxygen constrictors Inotropic Insulin; hyperglycaemia

Question 64

Septic shock can be corrected with infusing fluids T/F

Answer 64

F

Question 65

Septic shock The most common Gram +ve bacteria include: ______,________,_______

Answer 65

S. aureus, enterococci, S. pneumonia.