Shock

Question 1

Leading cause of cardiovascular failure in SICU?

Answer 1

Septic shock

Question 2

What is shock?

Answer 2

Inadequate oxygen delivery and utilization

Question 3

In septic shock refractory to levophed and vasopressin, what’s the cause usually and what are some alternatives we can use?

Answer 3

Usually do to vasoplegia—> uncontrolled vasodilation due to increase nitric oxide production

Methylene blue can be given to decrease release of NO by inhibiting nitric oxide synthase—> helps restore vascular tone

1 to 2 mg/kg IV bolus

Question 4

When assessing IVC variability during respiration for fluid responsiveness, what are we looking at?

Answer 4

Increase in IVC diameter >15 % during inspiration is considered predictive of fluid responsiveness

Question 5

Reliable beside test to predict fluid responsiveness in mechanically ventilated pts?

Answer 5

End-expiratory occlusion test

Stoping ventilator for 15-30 seconds during end expiration and monitoring pts hemodynamics

Increase in CO of at least 5% predicts fluid responsiveness

Question 6

MC source of shock?

Answer 6

Hypovolemia

Question 7

In hypovolemic shock everything is decreased except;

Answer 7

SVR

Question 8

Causes of obstructive shock;

Answer 8

PE
Aortic dissection/tamponade
Tension pts
Diaphragmatic herniation into chest

Question 9

Classic findings of cardiac tamponade;

Answer 9

JVD
muffled heart sounds
Hypotension

Pulsus paradoxus can also be seen; inspirations reduction of SBP >10 mmHg

Question 10

Neurogenic shock:

Answer 10

Result of spinal cord injury with sudden loss of sympathetic tone

Parasympathetic tone is preserved; see bradycardia and hypotension

Question 11

What level do we usually see neurogenic shock where we loss sympathetic tone?

Answer 11

At or above T6

Question 12

Spinal shock vs neurogenic shock:”

Answer 12

Neurogenic shock; loss of sympathetic tone due to spinal cord injury, with parasympathetic active preserved causing hypotension and bradycardia

Spinal shock; loss of all sensation below the level of injury, and is not circulatory in nature

Both can coexist in a patient

Question 13

What is shock?

Answer 13

Inadequate organ perfusion to meet end organ metabolic needs

Question 14

Classic symptoms of fat embolism syndrome?

Answer 14

Petechial rash
Hypotension
Neurological symptoms
Thrombocytopenia

Usually occurs 24-72 hrs after trauma

Tx; no definitive treatment, supportive care provided

Question 15

Type A vs Type B lactic acidosis>

Answer 15

Type A lactic acidosis; related to hypoperfusion 2/2 hypovolemia, sepsis, cardiac failure etc

Type B lactic acidosis; no evidence of systemic hypoperfusion and may be related to impaired cellular metabolism

Question 16

What is sepsis?

Answer 16

Life threatening organ dysfunction 2/2 dysregulated host response to infection

Question 17

What is septic shock?

Answer 17

Requiring a vasopressor to maintain MAP >65 and serum lactate >2

Assc with 40% mortality

Question 18

If we have a patient with candidemia, what needs to be done?

Answer 18

Fundoscopic exam

Question 19

Abx of choice for candida galbratah?

Answer 19

Micafungin

Question 20

Major cause of vasodilation in sepsis?

Answer 20

ATP sensitive K channels in smooth muscle

Increased permeability to K leads to hyperpolarization of the cell membrane, preventing muscle contraction, leading to vasodilation

Question 21

ATHOS-3 trial?

Answer 21

In pts with vasodilatory shock on high dose pressors adding angiotensin II increased MAP by 45% when compared to a placebo