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4Q EM Surg test 2 > Shock > Flashcards

Shock Flashcards

1-understand different types of shock 2-understand similarities & differences in various type of shock 3-ID at least 3 sympathetic reflex compensatory mechanisms in shock 4-ID percent blood loss for the three phases of hemorrhagic shock 5-understand how to ID & tx shock 6-understand the specific features of septic shock

1
Q

The definition of shock

A

inadequate tissue perfusion

supply<VO2)

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2
Q

What is the eventual result of shock (2)

A

anaerobic metabolism->acidosis

decreased cardiac output & acidosis->HYPOtension

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3
Q

Delivery of oxygen is a direct function of what?

A 
cardiac output (CO) and the arterial oxygen content (CaO2)
DO2=COxCaO2
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4
Q

Which 3 things are direct determinants of blood pressure?

A

Cardiac output
preload
peripheral vascular resistance

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5
Q

Ohm’s law

A

BP=flow(Q)x Resistance (R)

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6
Q

Clinical features of shock

A

Tachycardia
Tachypnea
+/- hypotension
Signs of poor end-perfusion (altered mental status, oliguria, lactic acidosis, cool, mottled extremities, thread pulses)

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7
Q

signs of poor end perfusion (4)

A
  • altered mental status
  • oliguria
  • lactic acidosis
  • cool, mottled extremities, thread pulses
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8
Q

How can you increase supply? (DO2)

A 
maximize CO 
-preload
-afterload
-increase contractility -appropriate HR
Maximize CaO2 [arterial oxygen content] 
-Hct
-supplemental O2
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9
Q

Causes of cardiogenic shock (3)

A

decreased function
arrhythmia
obstruction

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10
Q

Causes of hypovolemic shock (6)

A 
Hemorrhage (GI bleed, trauma, ruptured aneurysm, post-operative)
Over-diuresis
Diarrhea
Dehydration
Diabetic ketoacidosis
Burns
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11
Q

Causes of septic shock (4)

A
  • positive blood cultures of any organism in 40-70%
  • widespread endothelial injury
  • decreased peripheral vascular resistance cause hypotension
  • other findings: tachycardia, fever, leukocytosis, abnormal clotting parameters, acidosis, renal dysfunction
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12
Q

Other causes of shock

A 
anaphylactic
neurologic-spinal cord injury
pulmonary embolus
Addisonian crisis
myxedema
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13
Q

Which form of shock has a LOW A-VO2 difference?

A

Septic shock

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14
Q

Hypovolemic shock definition

A

reduction in intravascular volume/preload leading to DECREASED CO & insufficient O2 delivery to cells (mitochondria)
-loss of circulating blood volume (plasma)

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15
Q

Normal blood volume (adult, kid)

A

70Kg adult=5.5 liters (approx. 15 units)

10kg toddler=900ml

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16
Q

possible etiologies of non-hemorrhagic hypovolemic shock (5)

A 
Excessive GI losses (vomiting, diarrhea)
Dehydration
Evaporative (burns)
Third-Space Losses
Neurologic/Renal-diabetes insipidus/melitus
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17
Q

possible etiologies of hemorrhagic hypovolemic shock (4)

A
  1. Internal bleeding (GI tract, soft tissues, retroperitoneum-can be hard to detect)
  2. external bleeding (trauma)
  3. operative
  4. iatrogenic (open c-line, aline)
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18
Q

What word should not be used in shock?

A

STABLE is for horses, if patients are bleeding, they are NEVER stable

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19
Q

What is the body’s response to hypovolemic shock?

A

Compensated shock->baroreceptor mediated vasoconstriction
-increased Epi, vasopressin, angiotensin
results in:
-tachycardia
-tachypnea
-NARROWED PULSE PRESSURE (under 15-20 is very concerning
-slightly lowered urine output

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20
Q

compensated hemorrhagic shock:
how much blood loss
what happens to BP?

A

0-20% blood loss

BP is maintained via ↑ vascular tone & ↑blood flow to vital organs

↑ contractility maintains SV +slight↑ in HR maintains near normal CO

vasoconstriction maintains near normal BP

21
Q

5 compensations in non-progressive (compensated) shock

A
  1. baroreceptor reflexes
  2. renin release
  3. ADH release
  4. Epi & Norepi Release
  5. Compensatory Mechanisms effective
22
Q

In hypovolemic shock, the body will make whatever adjustments it can to maintain ______________.

Who wins? who loses?

A

Adequate Cardiac Output
more important organs remain normal, less critical organs are stressed by ischemia

WINNERS: brain, heart, kidneys, liver
LOSERS: skin, GI tract, skeletal muscle

23
Q

Progressive (un-compensated) shock

A
  • intravascular volume deficient exceeds heart capacity to maintain CO->INADEQUATE PRELOAD->HR ↑
  • sympathetic & neurohormonal response no longer able to maintain enough vasoconstriction to maintain systemic perfusion pressure (P=CO*PVR)
  • ACIDOSIS, CHANGE IN MENTAL STATUS, POOR URINE OUTPUT EVIDENT
24
Q

What is evident in progressive (Un-compensated) shock (3)

A

acidosis
change in mental status
poor urine output

25
Q

problem with cuff pressures in obesity

A

cuff pressures may falsely over-estimate pressure, difficulty with palpable pulses, difficult airway

26
Q

Relative Hypovolemic Shock (3)

A
  • Tension Pneumothorax
  • Spinal Shock
  • Early Septic Shock
27
Q

Cardiogenic shock: simple def

A

pump failure possibly due to CAD, myocardial loss or arrhythmia

28
Q

progression of Cardiogenic shock

A

acute hypotension->low CO->
inadequate LV outflow-> poor end organ perfusion!
(same signs/sxs you see in other shock, just a different cause)

29
Q

Causes of Cardiogenic Shock (9)

A
  1. Acute exacerbation of cardiomyopathy
  2. Acute MI
  3. Acute myocarditis
  4. Acute Ventricular Septal or Left Ventricular Rupture
  5. Acute Aortic Insufficiency-Aortic Dissection
  6. Cardiac Tamponade 2* pericardial effusion
  7. Arryhythmia
  8. Meds: Anti-HTN, AV blockin meds
  9. Acute Mitral Regurg (papillary m. rupture, ruptured chordae)
30
Q

Clinical manifestations of cardiogenic shock (9)

A 
hypotension BP<90/60 or 80/60
tachypnea
tachycardia
pallor, mottled skin
restlessness
confusion, altered mental status
weak pulses
cold, clammy extremities
oliguria
31
Q

Tx of cardiogenic shock

A 
tx underlying cause
inotropes &/or vasopressors
fluids if appropriate
intraaortic balloon counterpulsation
revascularize if acute MI:
-fibrinolyrics  (tPA, streptokinase)
-angioplasty
-CABG
32
Q

Septic shock: definition/description

A

exaggerated endogenous inflammatory response to invasive infection leading to:
-circulatory collapse
-multiple organ failure
-death
mortality over 35% (sepsis w/hypotension)

33
Q

Cardiac output in fluid resuscitated septic shock is

A

increased

initially they are hypovolemic, but once you put fluid in them, they are in a high output state

34
Q

Systemic Inflammatory Response Syndrome (SIRS) definition

A

response to a variety of severe clinical insults, manifested by 2 OR MORE of the following:

  1. temp>38*C or90bpm
  2. RR>20 or PaCO212,000/mm3, 10% immature (band) forms “left shift”
35
Q

Infection Definition

A

inflammatory response to microorganisms or invasion of normally sterile tissues

36
Q

Sepsis definition

A

systemic response to infection-i.e. confirmed or suspected infection PLUS > or = 2 SIRS criteria

37
Q

Severe Sepsis Def

A

-sepsis a/w organ dysfxn, hypoperfusion or hypotension

hypoperfusion abnormalities may include but are not limited to: lactic acidosis, oliguria, acute alteration in mental status

38
Q

Septic Shock: ACCP/SCCM def

A

sepsis-induced hypotension DESPITE ADEQUATE FLUID RESUSCITATION along w/ perfusion abn (incl. lactic acidosis, oliguria, or acute alteration of mental status)

patients receiving inotropic or vasopressor agents may not be hypotensive at the time perfusion abnormalities are measured

39
Q

G+ vs. G- sepsis presentation

A

G+ may have less hypotension than with G- sepsis

40
Q

What is ARDS

A

adult respiratory distress syndrome
-inflammatory response where you get leaky capillaries in lungs, lungs become stiff (can occur in sepsis/septic shock, blood transfusion), hard to ventilate, very poor oxygenization

41
Q

MSOF- multisystem organ failure

A

Hepatic: transaminitis,↑bilirubin
Renal: ATN, uremia, oliguria progressing to anuria
Pulmonary: ARDS, infections
Cardiac: myocardial depression, arrhythmias
Neuro: altered mental status, confusion, delirium, coma
Others: immune, hematopoietic, coagulation

42
Q

Warm (hyperdynamic) shock clinical manifestation

A

hypotensive, tachycardia, tachypnea

  • BOUNDING PULSE
  • WARM, WELL PERFUSED EXTREMITIES
  • SKIN FLUSHED, MOIST
43
Q

Cold (hypodynamic) shock

A

hypotensive, tachycardia, tachypnea

  • NARROW, THREADY PULSE
  • COLD, POORLY PERFUSED EXTREMITIES
  • SKIN PALE, DRY
44
Q

Septic Shock hemodynamics

A

CVP doesn’t accurately estimate ventricular filling in the critically ill

  • when PWP (pulmonary wedge pressure) is appropriately elevated to 12-15 mmHg w/fluid resuscitation, 90% of pts w/septic shock exhibit hyperdynamic circulatory state
  • hyperdynamic state persist to death
45
Q

hypodynamic septic shock=

A

inadequately fluid resuscitated septic shock (until PWP shows filling pressures btwn 12-15mm Hg)
[if you adequately resuscitate (6-8L saline), they have a better chance]

46
Q

Metabolic derangement in sepsis

A

↑ lactate, ↑ MVO3

  • micro-anatomic shunts (non-nutritive capillaries)
  • functional shunts (impaired micro-circulatory vasomotor contro)
  • citric acid (Kreb’s) cycle defect w/anaerobic glycolysis
  • aerobic glycolysis w/lactate production
47
Q

Tx of septic shock

A
  • FluidResuscitation(CVP8‐12,PCWP12‐15)
  • IVAntibioticsbroadspreaduntilsourceidentified
  • Decreasemetabolicdemands
  • Supportbloodpressure,vasoconstrictorsafterfluids
  • VentilatorySupport‐ventilator,sedation
  • CardiacSupport‐inotropesinsomecases,monitor cardiacoutputandmaximizeit
  • NutritionalSupport
  • WatchoutforDIC
48
Q

Classes of hypovolemic shock: blood loss, systolic BP, pulse pressure, pulse, mental status

A

Class I: 40% blood loss (>2000cc), dec to absent SBP, dec. PP, very tachycardic, lethargic

4Q EM Surg test 2 (4 decks)

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