Shock

Question 1

Definition of shock

Answer 1

insufficient perfusion and oxygen delivery to tissues leading to cellular hypoxia and end-organ failure

Question 2

Beck’s triage

Answer 2

for tamponade
1) hypotension
2) muffled heart sounds
3) elevated JVP

Question 3

Kussmaul sign (Def’n and sign of__)

Answer 3

Def’n: JVP fails to diminish or paradoxically rises with inspiration

(should normally suck blood out of jugular veins and into right heart)

Sign of RV dysfunction, impaired filling and increased RA pressure.
-Classically associated w constrictive pericarditis
-massive PE
-restrictive cardiomyopathy
-tricuspid stenosis
-severe TR

Question 4

2 ECG findings associated w tamponade

Answer 4

1- low-voltage QRS
2- electrical alternans

Question 5

List 4 US findings of PE

Answer 5

Findings that indicate the RV is struggling to push forward. Normally RV is 60% size of LV.

-any increase in ratio of size of RV to LV
-hypokinesis of RV
-paradoxic movement of intraventricular septum toward LV (“D” sign)
-tricuspid regurg

Question 6

Diagnosis of abdominal compartment syndrome

Answer 6

intra-abdominal pressure (currently intravesicular pressure is gld std) >20 mmHg associated with new organ dysfunction

Question 7

List landmarks/steps in pericardiocentesis

Answer 7

1-elevate head of bed for fluid to accumulate inferiorly
2-insert needle between xyphoid process and left costal margin, advancing at 30-45d
3-once under the costal margin, decrease angle to 15-30d and advance needle towards left shoulder

when possible perform w U/S guidance and choose shortest route to largest pocket of fluid

Question 8

What is PCC? What does it contain?

Answer 8

Prothrombin complex concentrate

-mixture of purified vit K-dependent clotting factors designed for usein pts taking vitK antagonists with sig bleeding or VKA-associated major bleeding
-beneficial effects has been noted in non-VKA induced coagulopathy

Question 9

Landmark for chest tube

Answer 9

5th intercostal space, mid-axillary line, super to rib

safety triangle:
-pectoralis major
-5th intercostal space
-lat dorsi

Question 10

IM and IV doses of epinephrine for anaphylaxis

Answer 10

1) Epi (1:1000/1 mg/mL) 0.5 mg IM q5min x2
-large adult 0.5
-small adult/child >30 kg 0.3
-child <30 kg 0.15
Pediatrics: 0.01 mg/kg (0.01 mL/kg)

2) Epi infusion - 0.01 mcg/kg/min (max 10 mcg/min)
3) Epi (1:10,000/0.1 mg/mL) 0.01 mg/kg

Generally, IM x2 q5 min then infusion

Question 11

List 5 medical conditions commonly associated with RV HTN/Failure

Answer 11

1. Primary Pulm HTN
2. COPD
3. Methamphetamine abuse
4. Massive PE
5. CHF
6. Sepsis
7. ARDS
8. Obesity hypoventilation syndrome

Question 12

List the 3 major causes of RV failure, with 2 examples for each

Answer 12

1. Pressure overload -afterload
   (PE, primary pulm HTN, lung dz, morbid obesity)
2. Volume overload -preload
   (excessive iatrogenic fluid administration, insufficient diuresis [e.g., AKI, med non-compliance])
3. Depressed contractility
   (RV MI, myocarditis, sepsis)

Question 13

Bonus Q:
How does RV overdistension cause RV failure

Answer 13

1. impairs contractility
2. reduces LV preload/CO
3. leads to high wall pressures causes decreased coronary perfusion
4. tricuspid regurg –> further distension

Question 14

List 4 main causes of RV pressure overload with 2 examples for each

Answer 14

1. Primary Pulm HTN
   (connective tissue dz, methamphetamines, portal HTN, HIV, schistosomiasis)
2. Secondary to Left heart disease
   (aortic stenosis/regurg, mitral regurg/stenosis)
3. Chronic lung dz
   (COPD, ILD, OSA, obesity hypoventilation syndrome)
4. VTE (acute or chronic)
5. Intrathoracic tumor
6. toxic multinodular goiter