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Acute Care I > Shock > Flashcards

Shock Flashcards

1
Q

Regardless of “type” of shock, there is an inability to obtain or utilize what?

A

O2 in sufficient quantities to meet metabolic requirements; from compromised CO &/or BP

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2
Q

Shock causes what demand and supply imbalance?

A

demand > supply

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3
Q

Shock is most often from changes in O2 delivery; as delivery decreases, extraction increases as compensatory mechanism.
What is a normal extraction ratio?
What is the maximal extraction ratio?

A

20%
60%

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4
Q

As O2 delivery decreases, extraction eventually decreases (point of critical O2 delivery) leading to what?

A

Dysoxia (o2 debt), anaerobic metabolism/lactic acidosis leading to
cellular dysfunction leading to
Organ dysfunction leading to
death

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5
Q

What is cytopathic hypoxia?

A

adequate O2 delivery but inability to use O2 d/t mitochondrial dysfunction (sepsis) which is mediated by inflammatory cytokines and NO

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6
Q

O2 delivery equation
DO2 =?
Example question
Hb = 12.3
SaO2 = 98%
CO = 3.5

A

[1.39 x Hb x SaO2] x CO x 10

586.4 ml O2/min

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7
Q

CNS complications of shock?

A

Encephalopathy

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8
Q

Cardiac Complications of shock?

A

Tachycardia
Decreased coronary artery perfusion, possible ischemia
Myocardial depression

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9
Q

Respiratory Complications of shock?

A

Increased MV resulting in hypocapnia & respiratory alkalosis
Increased ventilation/perfusion mismatch
Respiratory failure d/t increased workload, muscle impairment
ARDS

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10
Q

Renal Complications of shock?

A

ARF secondary to ATN from hypoperfusion

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11
Q

GI Complications of shock?

A

Ileus
Erosive gastritis
Pancreatitis
Acalculous cholecystitis
Submucosal hemorrhage
Bacterial translocation d/t ischemia

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12
Q

Liver Complications of shock?

A

“shock liver” is atypical in absence of hepatocellular dz or very severe injury
Mild elevations of LFTs, bili, alk phos more common
Impaired synthetic fxn - decreased albumin, coag factors

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13
Q

Hematologic Complications of shock?

A

DIC
Dilutional thrombocytopenia following resuscitation

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14
Q

Metabolic Complications of shock?

A

Hyperglycemia d/t increased ACTH, glucocorticoids, glucagon
Decreased insulin release results in glycogenolysis, gluconeogenesis

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15
Q

Immunologic Complications of shock?

A

Immune dysfunction d/t mucosal injury
Decreased T& B lymphocytes

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16
Q

Compensatory Mechanisms of Shock
Maintenance of MAP

A

Fluid redistribution to vascular space
Decreased Renal losses
Increased sympathetic activity
Increased adrenal epi
Increased angiotensin

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17
Q

Compensatory Mechanisms of Shock
Maintenance of MAP
Where does Fluid redistribution to vascular space come from?

A

From interstitium
from intracellular space

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18
Q

Compensatory Mechanisms of Shock
Maintenance of MAP
Decreased Renal losses occurs because of?

A

decreased GFR
Increased aldosterone from adrenals
increased vasopressin from pituitary

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19
Q

Compensatory Mechanisms of Shock
Cardiac performance

A

increased contractility d/t
sympathetic stimulation
adrenal stimulation

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20
Q

Compensatory Mechanisms of Shock
Perfusion distribution

A

Extrinsic regulation of arterial tone systemically
Autoregulation of vital organs

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21
Q

Compensatory Mechanisms of Shock
O2 unloading

A

Increased RBC 2,3-diphophoglycerate
decreased tissue PO2
tissue acidosis
pyrexia

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22
Q

2,3-diphosphoglycerate has what effect on Hemoglobin-O2 dissociation curve?

A

Shifts it to the R increasing O2 offloading at the level of tissue

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23
Q

Classifications of Shock
Hypodynamic:

A

Low CO
Narrow pulse pressure

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24
Q

Classifications of Shock
Hypodynamic Types of shock?

A

Hypovolemia (hemorrhage)
Cardiogenic (acute MI)
Obstructive (PE, tamponade, tension PTX)

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25
Q

Classifications of Shock
Hyperdynamic aka distributive or vasodilatory:

A

Low SVR
Widened Pulse pressure

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26
Q

Classifications of Shock
Hyperdynamic aka distributive or vasodilatory types of shock?

A

Sepsis
Anaphylaxis
Liver failure
Neurogenic

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27
Q

Hypovolemic shock occurs d/t what?

A

Decreased ventricular preload

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28
Q

Hypovolemic shock types?

A

Hemorrhagic
Non-hemorrhagic
Venodilation

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29
Q

Hypovolemic shock
Hemorrhagic occurs from?

A

Trauma
GI Bleed
RP bleed

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30
Q

Hypovolemic shock
Non-hemorrhagic occurs from?

A

dehydration
vomiting/diarrhea
polyurea
thermal injury
anaphylaxis

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31
Q

Hypovolemic shock
Venodilation occurs from?

A

Sepsis
Anaphylaxis
Toxins/drugs

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32
Q

Cardiogenic aka decreased pump function shock types are?

A

Myopathic
Mechanical
Arrhythmias

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33
Q

Cardiogenic aka decreased pump function
Myopathic occurs from?

A

MI (LV or RV)
myocardial contusion
myocarditis
CM
Post-ischemic stunning
Septic myocardial depression
meds (CCB)

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34
Q

Cardiogenic aka decreased pump function
Mechanical occurs from?

A

valvular d/os (stesnosis, regurg)
Hypertrophic CM
VSD

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35
Q

Cardiogenic aka decreased pump function
Arrhythmias occur from?

A

brady/tachycardias

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36
Q

Obstructive - obstruction of flow in CV circuit types are?

A

impaired diastolic filling
Impaired systolic contraction / increased afterload

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37
Q

Obstructive - obstruction of flow in CV circuit
Impaired Diastolic Filling occurs from?

A

Tension PTX
MV w/ PEEP, volume depletion
Constrictive pericarditis
Cardiac tamponade

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38
Q

Obstructive - obstruction of flow in CV circuit
Impaired systolic contraction / increased afterload occurs from?

A

PE
Acute pulm HTN
Aortic dissection

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39
Q

Distributive - loss of peripheral resistance types are?

A

sepsis (most common cause)
Toxic Shock
Anaphylaxis
Neurogenic
Thyroid storm
Toxic (nipride)

40
Q

General Clinical Presentation of shock?

A

Tachycardia
Tachypnea
Cyanosis
Oliguria
Encephalopathy
Mottling
Hypotension (SBP < 90 mmHg)

41
Q

Clinical Presentation (hypovolemic shock)

A

Hypodynamic
Orthostatic hypotension
Dizziness
Tachycardia
A fib (elderly)
Collapsed peripheral veins
Decreased body temp (elderly)
Cold, clammy skin
Tachypnea
Oliguria
Peripheral cyanosis

42
Q

Clinical Presentation (cardiogenic shock)

A

Hypodynamic
Ashen or cyanotic
Cool skin
Mottled extremities
Decreased MS
Rapid, weak pulse
JVD
Crackles
Palpable precordial heave
S3 or S4

43
Q

Clinical Presentation (Obstructive shock - tamponade)

A

Hypodynamic
Dyspnea
JVD
Hypotension
Muffled heart sounds
Pulsus Paradoxus (inspiratory fall in SBP > 10 mmHg d/t decreased LV volume on inspiration)
Cool, clammy skin
Tachycardia

44
Q

Clinical Presentation (Obstructive shock - tension PTX)

A

Hypodynamic
Chest pain
Dyspnea
Tachycardia
Tachypnea
Decreased breath sounds, hyperresonance on affected side
JVD

45
Q

Clinical Presentation (Obstructive shock - PE)

A

Hypodynamic
Tachycardia
Dyspnea
Hypotension
Chest Pain
Hemoptysis

46
Q

Clinical Presentation (distributive shock - sepsis)

A

Hyperdynamic
Fever or hypothermic
Tachycardia
Tachypnea
Hypotension (SBP < 90 mmHg)
Warm or cold extremities

47
Q

Clinical Presentation (distributive shock - neurogenic)

A

Hyperdynamic
Bradycardia
Warm extremities
Bounding pulses

48
Q

Lab Studies to collect with shock state?

A

WBC count
Hb
Plt count
ABG
BUN/Cr
ECG
Lactate
Central Venous O2 saturation

49
Q

Why collect WBC count in shock state?

A

often elevated early
may be decreased in sepsis & late shock

50
Q

Why collect Hb in shock state?

A

May be elevated in non-hemorrhagic, hypovolemic shock, septic shock d/t extravasation

51
Q

Why collect plt count in shock state?

A

may be elevated early
decreased w/ sepsis, hemorrhage

52
Q

Why collect ABG in shock state?

A

anion gap acidosis w/ elevated lactate

53
Q

Why collect BUN/Cr in shock state?

A

BUN may be elevated if GI blood loss, hypovolemia
Elevated creatinine w/ ongoing decreased tissue perfusion

54
Q

Why collect EKG in shock state?

A

To evaluate for cardiac ischemia in cardiogenic shock or secondary to other shock
R heart strain/R axis deviation, RBBB in PE

55
Q

Why collect Lactate in shock state?

A

Relatively late marker of decreased tissue perfusion/oxygenation
Cleared by liver; may be elevated in liver failure
Serial levels can be used as markers of adequacy of resuscitation

56
Q

What imaging should be collected for shock state?

A

CXR
CT scan if suspect hemorrhage, PE, Sepsis
US (RUSH exam)
VQ scan if suspect PE

57
Q

Why get a CXR in shock state?

A

Infiltrates in septic shock
Pulmonary Edema in cardiogenic shock
PTX
Cardiac tamponade (obstructive shock)

58
Q

HD monitoring in shock state can include?

A

Arterial catheter
CVP
PAC
Esophageal doppler

59
Q

Why monitor CVP in shock state?

A

May be useful in otherwise healthy patients
may differentiate b/t different forms of shock (low in hypovolemia, high in cardiogenic shock)

60
Q

SvO2 is low w/ decreased O2 delivery w/ what conditions?

A

decreased Hb
Decreased CO
Decreased saturation

61
Q

SvO2 is low w/ increased O2 extraction occurs from?

A

fever
shivering
seizures

62
Q

SvO2 is elevated w/ maldistribution of blood flow from?

A

sepsis

63
Q

Hemodynamic Profiles
Hypovolemic Shock

A

Decreased CO
Increased SVR
Decreased PWP
Decreased CVP
Decreased SvO2

64
Q

Hemodynamic Profiles
Cardiogenic from Mi, MR, RV infarction

A

Decreased CO
Increased SVR
Increased PWP
Increased CVP
Decreased SvO2

65
Q

Hemodynamic Profiles
Obstructive (cardiac tamponade)

A

Decreased CO
Increased SVR
Increased PWP
Increased CVP
Decreased SvO2

66
Q

Hemodynamic Profiles
Obstructive (massive PE)

A

Decreased CO
Increased SVR
NL or low PWP
Increased CVP
Decreased SvO2

67
Q

Hemodynamic Profiles
Distributive (sepsis, anaphylaxis)

A

NL or elevated CO
Decreased SVR
NL or low PWP
NL or low CVP
Elevated SvO2

68
Q

Management of Shock
Depends on what?
but goal is the same which is?

A

underlying pathology
prompt restoration of perfusion to vital organs & tissues before cellular injury ensues

69
Q

Management of Shock
Goal of volume?

A

Increase stroke volume/SVO

70
Q

Management of Shock
General management goals

A

BP support (>60-65 mmHg)
CI > 2.1 L/min/m squared (cardiogenic & obstructive)
Lactate Level < 2.2 mmol/L
ScvO2 > 70% (sepsis)
Fluid resuscitation < 6hrs (sepsis)
Antibiotics < 1hr (sepsis)

71
Q

Stroke Volume Optimization
Indications

A

age
HF
Low UOP
Bleeding
Monitoring fluid boluses/vasopressors
Cardiac conditions
risk of hypoperfusion

72
Q

Stroke Volume Optimization
Methods

A

Noninvasive doppler imaging
Esophageal doppler imaging
Bioimpedence
Endotracheally applied bioimpedence
Pulse coutour
Exhaled CO2
PAC

73
Q

HD parameters Reference range
CO

A

4-8 L/min

74
Q

HD parameters Reference range
Stroke Volume

A

50-100 ml

75
Q

HD parameters Reference range
Stroke Index

A

25-45

76
Q

HD parameters Reference range
Flow time corrected (FTc)

A

330-360 ms

77
Q

HD parameters Reference range
Peak velocity

A

30-120 cm/s

78
Q

HD parameters Reference range
Stroke distance

A

10-20

79
Q

HD parameters Reference range
CI

A

2.8-4.2

80
Q

HD parameters Reference range
SVR

A

900-1600 dyne sec cm

81
Q

HD parameters Reference range
ScvO2

A

65-80

82
Q

HD parameters Reference range
CVP

A

2-8 mmHg

83
Q

HD parameters Reference range
Stroke volume variation

A

< 10-15%

84
Q

SVO
With Low SV or FTc do what?

A

Give 200 ml colloid or 500 ml crystalloid

85
Q

SVO
If after giving 200 ml colloid or 500 ml crystalloid the SV increased < 10% do what?
If SV increases > 10% do what?

A

stop giving fluids

Give additional volume

86
Q

Hypovolemic shock
Goals?

A

Rapid restoration of circulating volume, tx underlying cause

87
Q

Hypovolemic Shock
Support needed?
Access required?
Resuscitation is done w/?

A

Airway/breathing
2 large bore IVs
Isotonic (LR or NS), blood products if hemorrhage

88
Q

Hypovolemic Shock
Lab studies to obtain?

A

CBC
T&C
Electrolytes
renal fxn
ABG
Lactate
Coagulation
ScvO2

89
Q

Cardiogenic Shock
Treat underlying cause
Support what?
Fluid resuscitation?
Pressors for what?
Inotropic agents for what?
IABP to reduce what? & Optimize what?

A

Thrombolytics, revascularization
airway/breathing
Predetermined boluses per Starling curve unless frank pulmonary edema present
hypotension despite fluid resuscitation
inadequate perfusion & adequate intravascular volume
afterload; diastolic perfusion pressures

90
Q

Dopamine
Dose
MOA
Notes?

A

5-15mcg/kg/min
Increased HR, Contractility, CI (beta adrenergic), BP (alpha)
May cause tachycardia/exacerbate ischemia

91
Q

Norepinephrine
Dose
MOA
Notes?

A

0.01-3 mcg/kg/min
Increased BP & SVR (alpha), increased splanchnic perfusion (beta), Increased HR
none

92
Q

Phenylephrine
Dose
MOA
Notes?

A

40-180 mcg/kg/min
Increased BP & SVR (alpha), decreased HR
May be useful if tachycardia; caution if reduced cardiac function

93
Q

Epinephrine
Dose
MOA
Notes?

A

0.1-0.8 mcg/kg/min
Increased BP, CI, SV, HR (alpha & beta)
For those refractor to fluid resuscitation or other vasopressors, decreased splanchnic perfusion

94
Q

Dobutamine
Dose
MOA
Notes?

A

2-20 mcg/kg/min
Increased contractility & CO (beta)
May exacerbate hypotension and precipitate arrhythmias

95
Q

Milrinone
Dose
MOA
Notes?

A

0.375 - 0.75 mcg/kg/min

96
Q

Obstructive Shock
Support what?
Tx underlying pathology such as?
Fluid resuscitation?
Meds to use?

A

airway breathing
needle thoracentisis, chest tube (PTX), pericardiocentesis (tamponade), anticoagulation (PE)
Yes
Inotropes

97
Q

Distributive shock
Support what?
Tx what?
Fluid resuscitation goal?
Vasopressors to use?
Surviving ____ campaign
Epinephrine dose for anaphylaxis?

A

airway/breathing
underlying cause
CVP 8-12, MAP >/= 65, UOP >/= 0.5 ml/kg/h, mixed venous O2 sat > 65%
Levo, Epi, Vaso
Sepsis
0.3-0.5 ml 1:1000 solution SC or IM q 15 min prn

Acute Care I (30 decks)

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