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CV II Exam 3 > Shock > Flashcards

Shock Flashcards

1
Q

Basic definition of shock

A

Arterial blood flow inadequate to meet tissue needs for O2

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2
Q

Tissue perfusion depends on:

A

CO and SVR

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3
Q

CO depends on:

A

Cardiac output

Preload, contractility, and afterload

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4
Q

SVR depends on:

A

Systemic venous resistance
Depending on viscosity, vessel length and diameter

vL/r^4

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5
Q

Hypovolemic shock

A

Decrease CO and PCWP
CVP < 5mmHg
Increased SVR

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6
Q

Causes of hypovolemic shock

A

Hemorrhage induced
Fluid loss induced
Poor intake

Vomiting, severe edema/ascites, diarrhea, burns

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7
Q

Cardiogenic shock

A

Decreased CO

Increased PCWP and SVR

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8
Q

PCWP

A

Left side of heart pressure

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9
Q

Cardiogenic shock causes

A

Cardiomyopathies
Arrhythmias
Mechanical

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10
Q

Extracardiac/Obstruction shock

A

Subset of cardiogenic
*Tension pneumothorax, PE, cardiac tamponade

Pericardial disease
Disease of pulmonary circulation (PE)
Cardiac tumor (myxoma)
Left atrial mural thrombus
Obstructive valvular disease
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11
Q

Distributive shock

A 
Warm or vasodilatory shock
Increased CO
Decreased SVR
Decreased/normal PCWP
Decreased CVP
Normal or high CVOS
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12
Q

Distributive shock causes

A

Sepsis, toxic shock syndrome, anaphylaxis, toxin reactions (heavy metal, insect bites, etc.), spinal cord injury (neurogenic), myxedema, adrenal crisis, excessive burns

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13
Q

Decreased CO

A

< 2.2

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14
Q

Increased CO

A

> 4.0

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15
Q

Decreased SVR

A

< 800

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16
Q

CVOS normal

A

Central venous oxygen saturation

70%

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17
Q

Clinical markers of shock

A

SBP < 90 mm Hg (or mean BP < 60-65 mm Hg)

Cutaneous - mottled extremities (Livedo reticularis)
Renal - 1.0 mmol/L

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18
Q

A 56 year old alcoholic patient with cirrhosis and ascites presents with vomiting, dry mucous membranes, clammy skin, oliguria, mental status change and BP of 70/50. This patient has which type of shock?

A

Hypovolemic shock – no protein keeping fluid out of the tissue

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19
Q

Treatment for hypovolemic shock

A

0.9% saline: 1-2 liters wide open –> continue based on BP, skin, urine and mentation.

PRBCs

Goal to achieve CVP of 8-12 mmHg

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20
Q

A 52 y/o female diabetic presents with dyspnea and BP of 65/50. History is positive for an old MI. The patient is on a loop diuretic, an aldosterone antagonist, an ACE inhibitor, and a beta blocker. Heart rate is 140. The skin is cool and clammy and the patient is restless. There are bilateral basilar crackles and the neck veins are distended. This patient most likely has which type of shock?

A

Cardiogenic

CO is low
CI low
Preload is high
Afterload is high
PCWP is high
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21
Q

Treatment of all cardiogenic shock

A

Upright, O2, NIPPV

IABP, CABG, or PCI

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22
Q

Treatment of cardiogenic shock with low BP

A

Dobutamine (initial 0.5-1 mcg/kg/min with maintainamce of 2-20 mcg/kg/min) or milrinone with intraaortic balloon counterpulsation

23
Q

Treatment of cardiogenic shock with normal or high BP

A

IV nitroglycerin or nitroprusside with IV loop diuretic (furesomide)

24
Q

Treatment of cardiogenic shock with AF

A

Esmolol or cardioversion

25
Q

Treatment of cardiogenic shock with post MI

A

Antiplatelets, norepinephrine or dopamine if hypotensive (dobutamine or milrinone for those with vasoconstriction and not as severe hypotension)

26
Q

Norepinephrine

A

Vasopressor with some inotropic properties

27
Q

Dopamine

A

Alpha agonist with some inotropic effects but increases PCWP

28
Q

Dobutamine

A

Inotropic agents that also produce vasodilation

29
Q

When do you not use dobutamine?

A

Post MI with vasodilation rather than vasoconstriction

30
Q

Electrical alterans

A

Pericardial tamponade

Heart is swinging back and forth in bag of fluid

31
Q

Beck’s triad for cardiac tamponade

A

Distended neck veins
Distant heart sounds
Distressed BP (Hypotension)

32
Q

Presentation of cardiac tamponade

A

A 46 y/o female with lung cancer presents with dyspnea and cough. Heart sounds are distant and lungs are clear. Neck veins are distended (heart can’t pump blood out). BP is 60/40.

33
Q

TEE shows an echo free space anterior and posterior to the left ventricular wall. This represents which type of shock?

A

Obstructive

Fluid around the heart

34
Q

A 25 y/o HIV patient presents with cough, fever of 39C and heart rate of 98 beat/min. Respiratory rate is 26 breaths/min with WBC of 9,000 cells/mm3 with 15% bands. Glucose is 145 mg/dL. This patient most likely has:

A

SIRS

Fever, increase HR, increase RR, increase WBC with bandemia
Elevated glucose

35
Q

What is SIRS?

A

Dysregulated inflammation related to autoimmune disorders, pancreatitis, vasculitis, VTE, burns, surgery, etc.

**bacterial infection (but can be any insult to the body)

Can progress to sepsis and shock

36
Q

Acid base imbalance with SIRS?

A

Respiratory alkalosis

Increase in RR, decrease in CO2

37
Q

Labs used for SIRS, sepsis, or distributive shock

A 
CMP
ABGs
Type and crossmatch
Coagulation parameters
Lactate
Blood cultures
38
Q

Positive culture means diagnosis of:

A

Sepsis

39
Q

PAMPs

A

Activate Pattern Recognition Receptors -> release cytokines and chemokines ->SIRS/Sepsis

40
Q

DAMPs

A

Made by host, act like PAMPs

41
Q

Sepsis/SIRS = Infection + ?

A

TPR changes –T > 38.3C or < 36C; HR > 90 bpm; RR > 20bpm
Glucose > 140 mg/dL
Altered mentation
Edema of > 20mL/kg over 24 hours

42
Q

Inflammatory variables of sepsis

A

WBC > 12,000 with bandemia > 10%
WBC < 4,000
Increased CRP and procalcitonin (increased CD 64)

43
Q

Hemodynamic variables of sepsis

A

SBP < 90 mmHg

MAP < 70 mmHg

44
Q

Organ dysfunction variables of sepsis

A 
PaO2/FiO2 < 300
Urine output  0.5 mg/dL
INR > 1.5 or PTT > 60 seconds
Ileus
Platelets < 100,000 microl-1
Bilirubin > 4 mg/dL
Hyperprolactinemia > 1 mmol/L (tissue hypoxia)                 
Decreased capillary refill (tissue hypoxia)
45
Q

Severe sepsis

A

Variables worsen

Signification dysfunction of 1 organ system (or more)

46
Q

Most common evidence of severe organ dysfunction:

A

ARDS, ARF and DIC

Serum lactate > 4 mmol/L

47
Q

Patient is considered to have developed septic shock when unable to maintain a mean arterial pressure > 60 mmHg after:

A

Fluid resuscitation

48
Q

Distributive shock, including septic shock, anaphylaxis, or adrenal insufficiency is characterized by:

A

SVR < 800 dynes.s/cm-5

49
Q

CVOS and shock

A

Redistribution of oxygen delivery or inability of tissues to extract O2 can actually lead to a high central oxygen saturation of greater than 70%, with increased serum lactate

Later CVOS may drop and require fluid, RBCs, and vasopressors to maintain it above 70%

50
Q

9 immediate steps for sepsis treatment

A 
Serum lactate
Two sets of blood cultures
Two 18 gauge lines
Start antibiotics
Give 2 liters NS
CBC and BMP
O2 sat > 90%
Start norepinephrine if shock is present.
Transfer for lactate > 4 mmol/L, Systolic BP < 90 mm Hg, or MAP < 60 after 2 liters of NS
51
Q

Early therapy with septic shock

A

Maintain CVP at 8-12 with fluids
Maintain MAP at >65 mmHg and CI at 2-4 L/min2 with vasopressors
Maintain CVOS with PRBC and ionotropic therapy
Reduce lactate

52
Q

Vasopressors

A

NE - most shock
Epi - anaphylactic
Phenylephrine - warm shock
Vasopressin potentiates

53
Q

Ionotropic therapy

A

Dobutamine

54
Q

Steroids and septic shock

A

Give hydrocortisone is adrenal insufficiency is present

CV II Exam 3 (13 decks)

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