Shock

Question 1

• Life-threatening condition of circulatory failure
• 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 1

Shock

Question 2

4 categories of shock

Answer 2

• Hypovolemic
• Cardiogenic
• Distributive
• Obstructive

Question 3

1) Caused by decreased intravascular volume secondary to blood loss or loss of fluid and electrolytes.
2) Cardiac output = Stroke volume x Heart rate. Decrease blood or fluid volume lead to decrease stroke volume, as a way to compensate the HR
will increase to maintain CO until it no longer can maintain CO and then you go into shock

Answer 3

Hypovolemic shock

Question 4

The following can cause what kind of shock:
a) Trauma
b) Massive hemorrhage
c) GI Bleed
d) Burns
e) Vomiting or Diarrhea
f) Excessive sweating
g) Hyperosmolar states (DKA)

Answer 4

Hypovolemic shock

Question 5

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 shock

Question 6

Labs/studies for hypovolemic shock

Answer 6

1) Chemistry panel (looking for acidosis, kidney failure, electrolyte imbalance)
2) CBC (look at hemoglobin level)
3) LFT’s (looking for signs of liver hypoperfusion (increased AST, ALT))
4) ABG (looking at pH and degree of acidosis)
5) Lactic acid level (as tissues do not get enough oxygen from low perfusion the tissue will go in to anaerobic metabolism which the by product is Lactic acid)
6) EKG: looking for signs of hypoperfusion to the heart (ST depression or elevation)

Question 7

Treatment of hypovolemic shock

Answer 7

1) Goal is to maintain adequate tissue perfusion
2) Fluid replacement
a) If loosing fluids then give LR 1-2 Liter bolus (if giving
unwarmed fluid then this can lead to hypothermia)
b) If loosing blood then need to give blood transfusion (remember that they are losing whole blood so need to give PRBC, FFP, and
Platelets)
c) For every 1 unit PRBC you give your hematocrit should increase 3%

Question 8

Medications for hypovolemic shock

Answer 8

• Norepinephrine 0.02 - mcg/kg/min IV infusion
• Epinephrine 0.014 - 0.5 mcg/kg/min IV infusion
• Dopamine 1-20 mcg/kg/min IV infusion

Question 9

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 9

Cardiogenic shock

Question 10

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 10

Cardiogenic shock

Question 11

Labs/studies for cardiogenic shock

Answer 11

1) Chemistry panel (looking for acidosis, kidney failure, electrolyte imbalance)
2) CBC (look at hemoglobin level)
3) LFT’s (looking for signs of liver hypoperfusion (increased AST, ALT)
4) ABG (looking at pH and degree of acidosis)
5) Lactic acid level (as tissues do not get enough oxygen from low perfusion the tissue will go in to anaerobic metabolism which the by product is Lactic Acid)
6) EKG: looking for signs of AMI, arrhythmia
7) Transthoracic Echocardiogram (TTE): to evaluate heart function, cardiac valves

Question 12

Treatment of cardiogenic shock

Answer 12

1) Initial management focuses on airway stability and improving pump function, until definitive treatment re-establishes adequate cardiac output
2) Follow ACLS if go into cardiac arrest
3) Fluid replacement requires smaller fluid challenges (250 ml)
4) Vasopressors

Question 13

Medications for cardiogenic shock

Answer 13

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 14

What kind of shock Causes a reduction in Systemic vascular resistance

Answer 14

Distributive shock

Question 15

What conditions can cause distributive shock

Answer 15

Sepsis, Anaphylaxis, Neurogenic

Question 16

What is the most common cause of distributive shock

Answer 16

Sepsis

Question 17

Physical Findings
1) Sepsis
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 infection

2) Anaphylaxis
a) Evidence of diffuse urticaria, angioedema, bronchospasm, SOB, fullness of the throat, hoarseness.
b) History of an insect bite, exposure to certain food, etc.

3) Neurogenic
a) Evidence of acute traumatic spinal cord injury and
hypotension without compensatory tachycardia.
b) Unresponsive to fluid resuscitation, Bradycardia
c) Warm, dry skin

Answer 17

Distributive shock

Question 18

Labs/studies for distributive shock

Answer 18

1) CBC
2) Chemistry panel looking for signs of kidney dysfuntion (important marker of mortality and important to know when dosing medications)
3) Any studies required to evaluate for source of infection or spinal trauma

Question 19

Treatment of sepsis distributive shock

Answer 19

a) ABC’s, 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
d) If does not respond to 2 Liters of IVFL then start pressors to keep MAP > 60
(1 Norepinephrine (Levophed) 0.02 – 1 mcg/kg/min IV infusion
(2 Epinephrine 0.014 – 0.5 mcg/kg/min IV infusion

Question 20

Treatment for anaphylaxis distributive shock

Answer 20

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 per dose)
c) IV fluids with LR or NS

Question 21

Medications for anaphylaxis distributive shock

Answer 21

• Benadryl 50 mg IV q6 hours prn
• Zantac 50 mg IV q 6 hours prn or 150mg PO BID
• Solumedrol 125mg IM/IV q 4 hours prn

Question 22

Treatment of neurogenic distributive shock

Answer 22

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 23

1) Shock is mostly due to extra cardiac 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 23

Obstructive shock

Question 24

Physical Findings
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 24

Obstructive shock

Question 25

Labs/EKG/Studies obstructive shock

Answer 25

1) CXR
2) CT Chest looking for PE
3) Echocardiogram to look for pericardial Tamponade, restrictive cardiomyopathy
4) Abdominal pressures performed through a special type of Foley catheter

Question 26

Treatment of obstructive shock

Answer 26

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 250 ml bolus at a time to see response