Shock

Question 0

Diagnosis of shock

• hypotension
• urine output
• metabolic
• tissue effect

Answer 0

• BP: sBP < 90 or 30% below base line
• urine output < .5 cc/kg/hr
• lactic acidemia
• organ dysfunction

Question 1

Three stages of shock

Answer 1

1. Non-progressive: compensatory changes (increased CO to maintain MAP) keeps it sub clinical
2. Progressive: increased BP/CO can’t compensate -> shift to anaerobic metabolism
   > metabolic products (adenosine, NO et al) result in vasodilation
3. Irreversible stage: hyperpolarization of vascular smooth muscle vasodilation that cannot be reversed -> vascular collapse

Question 2

Symptoms: pallor, diaphoresis, cyanosis, mottling

Answer 2

• tissue hypo perfusion
• increased HR, SVR and contractility
  > can result in ischemia -> arrythmias

Question 3

Most common cause of death in shock

Answer 3

• hypoxemia: respiratory failure

Question 4

Most common type of shock and etiology

Answer 4

• hypovolemic shock (HR up, contract up, preload way down, afterload up)
• whole blood loss
• protein free fluid loss (dehydration)

Question 5

Hypovolemic

Answer 5

• increased HR
• Increased contractility
• increase in afterload
• large decease in preload
• decrease in PAWP

Question 6

Hypovolemic Shock treatment

Answer 6

• reverse hypoperfusion as quickly as possible
• fluid resusc - rapid peripheral IV infusion of isotonic crystalloids
• short catheter large bore (radius directly and length inverse to fluid speed)

Question 7

Worst kinds of shock

Answer 7

• cardiogenic shock (~7% of cases of shock)
• up to 40% loss of cardiac tissue (more is non-survivable)
• usually a result of cardiac ischemia or dysrhythmias

Question 8

JVD, S3/S4, inspiratory rales

Answer 8

Cardiogenic shock

• may have increased or decreased HR
• increased preload
• increased afterload
• sig decreased contractility

Question 9

Treatment of cardiogenic shock

Answer 9

- correct cardiac dysfunction: 
     > MI - reperfusion
     > contractility - inotropy 
     > high preload - furosemide 
     > vasodilation 
- improve CO
- optimize 02 supply

Question 10

Distributive shock

Answer 10

• septic, anaphylactic, spinal, drug/toxins

Question 11

Septic shock

Answer 11

• 75% hospital acquired (50% GNR)
• mostly result is pneumonia
• infection in blood sets off inflammatory cascade -> vasodilation -> decreased afterload (massive), preload and contractility

Question 12

Clinical presentation of sepsis warm type/cold type

Answer 12

• warm: most common

> hypotension, fever, warm, pink, confusion

Question 13

Treatment of sepsis (primary, secondary)

Answer 13

• trt infxn
• two agents, broad spectrum treat early
• surgery
• improve perfusion, fluid resusc, + inotropy, pressors

Question 14

Obstructive shock, egs clinical presentation

Answer 14

• tamponade, tension pneumo, PE, aortic dissection

- marked JVD