Shock

Question 1

Basic definition of shock

Answer 1

Arterial blood flow inadequate to meet tissue needs for O2

Question 2

Tissue perfusion depends on:

Answer 2

CO and SVR

Question 3

CO depends on:

Answer 3

Cardiac output

Preload, contractility, and afterload

Question 4

SVR depends on:

Answer 4

Systemic venous resistance
Depending on viscosity, vessel length and diameter

vL/r^4

Question 5

Hypovolemic shock

Answer 5

Decrease CO and PCWP
CVP < 5mmHg
Increased SVR

Question 6

Causes of hypovolemic shock

Answer 6

Hemorrhage induced
Fluid loss induced
Poor intake

Vomiting, severe edema/ascites, diarrhea, burns

Question 7

Cardiogenic shock

Answer 7

Decreased CO

Increased PCWP and SVR

Question 8

PCWP

Answer 8

Left side of heart pressure

Question 9

Cardiogenic shock causes

Answer 9

Cardiomyopathies
Arrhythmias
Mechanical

Question 10

Extracardiac/Obstruction shock

Answer 10

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

Question 11

Distributive shock

Answer 11

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

Question 12

Distributive shock causes

Answer 12

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

Question 13

Decreased CO

Answer 13

< 2.2

Question 14

Increased CO

Answer 14

> 4.0

Question 15

Decreased SVR

Answer 15

< 800

Question 16

CVOS normal

Answer 16

Central venous oxygen saturation

70%

Question 17

Clinical markers of shock

Answer 17

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

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

Question 18

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?

Answer 18

Hypovolemic shock – no protein keeping fluid out of the tissue

Question 19

Treatment for hypovolemic shock

Answer 19

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

Question 20

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?

Answer 20

Cardiogenic

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

Question 21

Treatment of all cardiogenic shock

Answer 21

Upright, O2, NIPPV

IABP, CABG, or PCI

Question 22

Treatment of cardiogenic shock with low BP

Answer 22

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

Question 23

Treatment of cardiogenic shock with normal or high BP

Answer 23

IV nitroglycerin or nitroprusside with IV loop diuretic (furesomide)

Question 24

Treatment of cardiogenic shock with AF

Answer 24

Esmolol or cardioversion

Question 25

Treatment of cardiogenic shock with post MI

Answer 25

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

Question 26

Norepinephrine

Answer 26

Vasopressor with some inotropic properties

Question 27

Dopamine

Answer 27

Alpha agonist with some inotropic effects but increases PCWP

Question 28

Dobutamine

Answer 28

Inotropic agents that also produce vasodilation

Question 29

When do you not use dobutamine?

Answer 29

Post MI with vasodilation rather than vasoconstriction

Question 30

Electrical alterans

Answer 30

Pericardial tamponade | Heart is swinging back and forth in bag of fluid

Question 31

Beck's triad for cardiac tamponade

Answer 31

Distended neck veins Distant heart sounds Distressed BP (Hypotension)

Question 32

Presentation of cardiac tamponade

Answer 32

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.

Question 33

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

Answer 33

Obstructive Fluid around the heart

Question 34

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:

Answer 34

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

Question 35

What is SIRS?

Answer 35

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

Question 36

Acid base imbalance with SIRS?

Answer 36

Respiratory alkalosis Increase in RR, decrease in CO2

Question 37

Labs used for SIRS, sepsis, or distributive shock

Answer 37

``` CMP ABGs Type and crossmatch Coagulation parameters Lactate Blood cultures ```

Question 38

Positive culture means diagnosis of:

Answer 38

Sepsis

Question 39

PAMPs

Answer 39

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

Question 40

DAMPs

Answer 40

Made by host, act like PAMPs

Question 41

Sepsis/SIRS = Infection + ?

Answer 41

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

Question 42

Inflammatory variables of sepsis

Answer 42

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

Question 43

Hemodynamic variables of sepsis

Answer 43

SBP < 90 mmHg | MAP < 70 mmHg

Question 44

Organ dysfunction variables of sepsis

Answer 44

``` 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) ```

Question 45

Severe sepsis

Answer 45

Variables worsen | Signification dysfunction of 1 organ system (or more)

Question 46

Most common evidence of severe organ dysfunction:

Answer 46

ARDS, ARF and DIC | Serum lactate > 4 mmol/L

Question 47

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

Answer 47

Fluid resuscitation

Question 48

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

Answer 48

SVR < 800 dynes.s/cm-5

Question 49

CVOS and shock

Answer 49

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%

Question 50

9 immediate steps for sepsis treatment

Answer 50

``` 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 ```

Question 51

Early therapy with septic shock

Answer 51

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

Question 52

Vasopressors

Answer 52

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

Question 53

Ionotropic therapy

Answer 53

Dobutamine

Question 54

Steroids and septic shock

Answer 54

Give hydrocortisone is adrenal insufficiency is present