SHOCK Flashcards
What is shock?
When there is a drop in BP, tissues aren’t profused enough, cells shift to anaerobic respiration, and cells eventually die
What is the 1st stage of shock?
Cold shock (body vasoconstricts)
primary cause of death in those within 24hrs of septic shock?
Multi organ failure due to neutrophils circulating to other organs during reprofusion
2 main SS of ALL SHOCK THAT YOU MUST KNOW
1. CHANGE IN MENTAL STATUS
2. HYPOTNESION
3. HR >90 (not on BB)
4. RR > 20
5. Early shock -> Warm extrem with bounding pulses and incr pulse pressure (SBP - DBP)
6. Late shock -> COLD extrem
7. Hyperthermia >101F
8. Hypothermia <96.8F
9. Pulse Ox -> relative hypoxemia
10. Decr urine output
11. SS of underyling ET (infx, anaphylaxis, stroke)
4 types of shock
- Distributive (Vasodilation)
- Hypovolemic (Intravascular volume loss)
- Obstructive (Physical obstruction of blood)
- Cardiogenic (Pump failure)
MC type of shock
Distrubitive shock (vasodilation)
Distributive shock:
Definition and Types
Anything that causes vessel hyperpermeability
* Septic shock (MC)
* Toxic Shock
* Systemic inflammatory response syndrome (SIRS)
* Anaphylactic Shock
* Adrenal Insufficiency
* Neurogenic Shock
What is the MC type of distributive shock?
Septic shock
Can a person be in septic shock if their extremities feel warm?
YES
Early shock -> WARM
Late shock -> COLD
At first, the body starts to peripherally vasodilate in hopes of incr CO, so the extremities are full of blood and are very warm. Late shock is cold due to the system getting worse until it eventually fails
Distributive Shock
MC sites for infx in septic shock
Chest
Abd
UTI??????? Idk
Distributive Shock
MC bac in septic shock infx
G-
G+
MDR Strains
MDR = Multi-drug resistant?
Distributive shock
Is the cognitive impairement from septic shock permanent?
Sometimes
At 1 yr follow up, 70% still have cognitive impairment, 1/3 severly
Which organ is affected the most from Multi Organ Dysfn Syndrome (MODS) due to septic shock
- Lungs are affected the most, increasing alveolar permeability and flooding the lungs -> ARDS
- If kidney perfusion is decreased -> Acute Tubular Necrosis and you will see dramatic increase in Creatinine and oliguria (peeing less and less)
- If decreased perfusion to heart -> MI or arrhythmias, reduce CO
These are alternative causes of ____ shock
- Systemic Inflammatory Response Syndrome
- Toxic Shock Syndrome
- Adrenal Insufficiency
on test
Distributive Shock
Alternative Causes of Distributive Shock
Causes of Systemic Inflammatory Response Syndrome (SIRS)
Infx
Burns
Sx
Trauma
Pancreatitis
Fulminant liver failure
Alternative Causes of Distributive Shock
Causes of Adrenal Insufficiency
Adrenal destruction (AIDS, TB, Tumor)
HPA axis suppresion by steroid >20mg QD
Hypopituitarism
Drug induced (Ketaconazole)
Distributive shock
Toxic shock syndrome is due to which bacteria
Streptococcus pyogenes(Grp AStrep)
or
Staphylococcus aureus
fatigue, HA, confusion, fever, conjunctivitis, ST, vomiting, red skin, watery diarrhea, 3rd-7th day sloughing of epidermis on palms and soles. Within 48 hours of sxs beginning, hypotension, syncope and then shock.
Toxic Shock Syndrome
Distributive Shock
Toxic shock syndrome Trmnt
- remove object
- IVF (10-15L/d)
-
ABX for Grp A Strep & Straph (pick 1):
* Clindamycin
* 1st gen Cephalosporin
* Vancomycin
Distributive Shock
How many L of IV Fluids do you give a pt with toxic shock syndrome each day?
10-15L / day
Distributive Shock
What does Anaphylaxis do to your vasculature?
Massive histamine mast cells and IgE response, results in decreased peripheral vascular resistance -> vasodilation
This is why we want Epi, which Vasoconstricts!
Distributive Shock
Anaphylaxis SHOCK Trmnt
Distributive Shock
Neurogenic Shock
Loss of sympathetic vascular tone from severe injury to the nervous system
* CVA
* TBI
* Spindal cord injury
Distributive Shock WU
- Gluc POC (Goal: 150-180)
- CBC W/Diff
- UA + Cultures
- CMP (e-, BUN/Creatinine)
- Liver enzymes +/- Amylase/Lipase
- PT/INR
- Blood Cultures
- ABG
- Serum lactate (esp if metabolic acidosis or high anion gap)
- ECG
- CXR
When cells are low on O2, they resort to anaerobic resp. This produces lactic acid -> HIGH serum lactate
Distributive Shock Trmnt
- Treat underlying ET ASAP
- Fluid Resuscitation ~ 6hrs
- Transfuse pRBC to a goal of HCT 30, Hgb 10
- Vasopressors: Dobutamine or NorEpi
If HypoTN continues -> 2nd Line Vasopressin (risk of acidosis/MI)
Empiric ABX are only for what type of distributive shock?
Septic Shock
MC recommended empiric ABX for Septic Shock?
Ceftriaxone (3rd gen Cephalosporin)
aka Rocephin
Empiric ABX for Septic Shock involving abd sepsis, aspiration pneumonia, pelvic infx, or necrotizing cellulitis
3rd gen Cephalosporin or Metronidazole
Empiric ABX for Septic Shock due to Meningitis
Ceftriaxone + Vancomycin
What does the body do to compensate for fluid loss?
Pulls water from its extravascular reserves (interstitium & cells) and puts it into the vascularture to maintain BP at expense of body water
Use IVF ______ for acute brain injury
- 0.9% NS?
- Lactated Ringers?
0.9% NS for acute brain injury over LR
It keeps water intravascular, as opposed to intracellular, reducing brain swelling
Use IVF ____ for shock & large volumes
Lactated ringers
Has less Cl- than Saline & is less likely to cause acidosis
Use IVF ____ for volume replacement during major hemorrhage
Albumin (Colloid)
Use IVF ____ for volume replacement during major hemorrhage
Albumin (Colloid)
Hyperchloremic Acidosis is a ______ acidosis
Non-anion gap
if a pt is at risk of severe blood loss, transfuse 1 unit of pRBCs within ___min
packed RBCs = pRBCs
5
If in shock: adults tolerate ____L at max infusion rate, and then reassess
1
Children in shock need ____mL/kg
5-20
Most children with intravascular volume depletion (w/o shock) can tolerate ____mL/hr
500
Children receive half their daily fluid requirements by weight in first _____hours
8
Children should receive fluids up to a MAX OF _____mL DAILY
2400
Urine output of >_______mL/kg/hour = they’re hydrated!
0.5 to 1
in traumatic shock, try to get the SBP > ____
80
80-90 SBP is okay
Pt is severely bleeding and requires >6 units pRBCs. What also needs to be given?
Platelets and FFP should be administered WITH blood products, 1 unit of each for each unit of pRBCs
Blood must be warmed if giving >2 units
Rules
>6 units pRBCs require Platelets and FFP (1:1 unit ratio)
Give together
Warm up the blood if giving >2 units (avoid hypothermia)
What is FFP?
Fresh Frozen Plasma
Stable patients w/o CAD or CVD req blood transfusions if Hgb <____g.
Stop transfusing once Hgb is at least _____g
7 & 8
Pts with CAD, CVD, or Active Bleed req blood transfusions if Hgb <____g.
Stop transfusing once Hgb is at least ___g
10 & 10
These pts are higher risk & therefore, req more blood vol
is HIGH or VERY LOW dose Dopamine a Vasoconstrictor?
HIGH Dose Dopamine
Inotrope (heart beats harder)
Vasoconstricter
Norepinephrine (Levophed)
Chronotrope or Inotrope?
Vasoconstrictor or Vasodilator?
Intrope
Vasoconstrictor
Vasopressin
Vasodilater or vasoconstricter?
Inotrope?
Vasoconstricter
NOT and inotrope or vasodilator
Hypovolemic Shock
A critical decrease in intravascular volume
Diminished venous return (preload)→decreased ventricular filling and reduced stroke volume.→Unless compensated for by increased heart rate, cardiac output decreases.
Common causes of hypovolemic shock?
- Bleeding due to: Trauma, Sx, GI bleed, Ruptured Aortic Aneurysm
- Incr losses of bodily fluids other than blood
- Inadequate fluid intake
Ways you can lose fluid (aside from bleeding out)
Trmnt for hypovolemic shock
- Restore fluid loss (IVF if fluid loss, transfuse if blood or plasma loss
- Correct cause (beeding, etc)
Obstructive shock
Mechanical factors that interfere with filling or emptying of the heart or great vessels
Main causes of Obstructive shock?
Tension Pneumo, Cardiac Tamponade
Pulmonary Embolism
Cardiogenic Shock:
What is it? Causes?
Reduction in CO due to primary heart problem
Cardiogenic Shock Trmnt
