Shock Flashcards
What is problem of cardiogenic shock?
Heart can’t pump
Usually from acute MI
S/Sx of Cardiogenic shock?
Looks a lot like acute HF
Tachypnea with crackles
Hypotension with peripheral hypoperfusion (like cool clammy skin, cyanotic, weak pulses, delayed cap refill)
Tachycardia
Narrow Pulse pressure
Decreased urine output
Anxiety, confusion, agitation
What is difference between absolute and relative hypovolemic shock?
Absolute=loss of fluids from blood, GI, diuresis
Relative=3rd spacing like in sepsis, burns, ascites, bowel obstruction, trauma
S/sx of hypovolemic shock
Tachycardia/Tachypnea
Absent bowel sounds/decreased urine output
Decreased cerebral perfusion=agitation, anxiety, confusion
Decreased peripheral perfusion=cool, clammy skin, weak pulses and slow cap refill
Diagnostic findings in hypovolemia shock
Electrolyte changes
Decreased: HCT, HGB
Increased: Lactic acid, Urine specific gravity
Diagnostic findings in cardiogenic shock
Increased: BNP, Glucose, BUN, Cardiac markers
EKG
ECHO
Chest XR
What is neurogenic shock?
How quickly will this start after spinal cord injury?
CNS and Body can’t communicate
From spinal cord injury or CNS depression
Will start within 30 min of injury and last up to 6 weeks
S/sx of neurogenic shock?
Hypotension
Bradycardia
Can’t control temp/low perfusion
Incontinence
Flaccidity
Difference between spinal shock and neurogenic shock?
Spinal shock=temporary, only affects nervous system while neurogenic shock affects the CV system
Do have similar s/sx.
Can occur at same time
What is abdominal compartment syndrome? What type of shock is it associated with?
Abdominal pressure increased and prevents blood return to heart
Obstructive shock
What is obstructive shock?
S/sx?
Something is physically blocking the blood flow
Tachycardia/tachypnea
Hypotension with low peripheral perfusion signs
Low to absent bowel sounds/decreased urine output
Decreased cerebral perfusion
S/sx of anaphylactic shock
Tachycardia/chest pain
Edema/stridor/wheezing/SOB
Flushing/pruritus/urticaria/angioedema
Decreased cerebral perfusion
Abdominal pain/cramping/diarrhea/
nausea/vomiting
What is characteristic sign of septic shock?
What is one sign of septic shock that separates it from other types of shock?
Persistent hypotension despite volume replacement
Temperature elevated with warm flushed skin in early stages, cool and mottled skin is late sign
Diagnostic findings in septic shock?
Increased: glucose, lactate, procalcitonin, urine specific gravity, WBCs
Decreased: Platelets, Urine Na+
Postive blood cultures
Classic sign of shock?
Drop in BP
What “non vital” organs have decreased perfusion during body’s compensatory stage of shock?
Blood is shunted to heart and brain and away from:
Lungs (increased physiologic dead space»V/Q mismatch»tachypnea)
Kidneys (activates RAAS to increase BP)
GI (absent/hypoactive bowel sounds)
Skin (cool and clammy)
Changes that happen in progressive stage of shock?
Increase in cap permeability»diffuse profound edema (called anasarca)
Dropping MAP
Reduced LOC (from decreased perfusion to brain)
Alveoli continue edema
GI»loss of mucous barrier»ulcers
Bacteria leaks from GI to invade organs
Liver begins to fail»increased liver enzymes»jaundice
AKI»Met acidosis
Risk for DIC
If this is not reversible, pt goes into refractory stage»organ failure.
Labs that will be abnormally high in shock?
Abnormally low?
BUN, creatinine high
Lactic Acid high
Liver enzymes high
PCT (this is procalcitonin) high in bacterial infection
WBC high in infection
Sodium (in early stage from increased ADH)
Potassium (from cell death or AKI, early or late)
Glucose (early)
Low:
Potassium (early from increased aldosterone, renal excretion)
Glucose (late)
Diagnostic markers of sepsis?
Temp or hypothermia
HR>90
Hyperglycemia >140
SBP <100
Edema
Tachypnea
Mottling
High Lactic acid
Leukocytosis or leukopenia
High CRP
High procalcitonin (PCT)
High INR or PTT
High Creatinine
High Bilirubin
Oliguria
Hypoxemia
Low platelet count
What is passive leg raise challenge?
Checking to see if pt needs more fluids
If raise legs up 45 degrees, wait 2 min, measure CO or SV for improvement. If they improve, you know pt needs increased fluids.
What is cornerstone therapy for septic, hypovolemic and anaphylactic shock?
Fluid resuscitation
Isotonic fluids?
Uses?
NS and LR
Increase volume of intravascular space
Initial treatment in most types of shock
Caution in LR?
In liver failure, they can’t break it down. Will increase lactate levels
Hypertonic fluids?
Uses?
Caution?
NaCl 1.8, 3, 5%
Also D10W, D20W (but these aren’t used in shock)
Shifts fluid into intravascular space out of cells
Sometimes used in hypovolemic shock for initial volume expansion.
Highly irritating to veins. Central line preferred. Can also cause hypernatremia.
Hypotonic fluids?
Uses?
NS .45%
D5W (at first isotonic, then when sugar metabolizes it becomes hypotonic)
Uses: shifts fluid into cells, sometimes uses in dehydration
Before vasopressors are considered, what must have been done first?
Fluid resuscitation
If hypotension persists after adequate hydration, then vasopressors.
Common meds used to treat shock?
Positive inotropic meds:
Dobutamine
Dopamine
Beta adrenergic agonists:
Epi (in low dose)
Norepi
Vasodilators:
Nitro
Sodium nitroprusside
Alpha adrenergic agonists:
These cause peripheral vasoconstriction.
Epi (in high dose)
Phenylephrine
Vasopressin (ADH, to raise BP)
Angiotensin 2 (to raise BP)
What is the 3:1 rule in fluid resuscitation?
What is a fluid challenge?
What is added to increase BP after fluid replacement is no longer working?
3 ml of isotonic for every 1 ml of blood loss
Fluid challenge is 30 ml/kg repeated until we see hemodynamic stability.
Vasopressors: 1st=Levophed, 2nd=Vasopressin
What effect do vasopressors have on stroke volume?
They decrease it (because of the increased after load)…to offset this we give positive inotropic meds
Goal of Abx start time in sepsis?
<1 hour
Remember to get cultures first
Treatment for neurogenic shock?
Careful with fluids because their hypotension is not from fluid loss.
Vasopressor phenylephrine (this is Sudafed given as IV to raise BP)
Atropine for bradycardia
What is SIRS?
Systemic inflammatory response syndrome
Systemic inflammation from a variety of reasons like:
Sepsis
Ischemia
Infarction
Injury
Leads to MODS
What is MODS?
Multiple organ dysfunction syndrome
Failure of 2 or more organs
Results from SIRS
