Shock

Question 1

shock

Answer 1

= arterial blood flow inadequate to meet tissue needs for O2

• tissue perfusion depends on CO and SVR
• CO depends on preload, contractility, and afterload
• SVR depends on viscosity, vessel length and diameter (SVR=vL/r4)

Question 2

hypovolemic shock

Answer 2

decreased CO and PCWP (CVP < 5 mmHg) with increased SVR.

1. . Hemorrhage induced
2. Fluid loss induced
3. Poor intake

: blood vessels are empty, will have deceased CO, decreased central venous pressure because there isn’t volume, have decreased pulmonary capillary wedge pressure b/c there is no volume, have increased systemic vascular resistance (b/c blood vessels are clamped, trying to maintain CO)

Question 3

cardiogenic shock

Answer 3

decreased CO (< 2.2 l/min/m2) with increased PCWP and SVR.

1. Cardiomyopathies
2. Arrhythmias
3. Mechanical
   4.Extracardiac/Obstruction
   (tension pneumothorax, PE, cardiac tamponade)

: heart isn’t putting out blood, the CO will be decreased (aka cardiac index is low, this is CO divided by weight), preload and afterload are both increased b/c they are just sitting there, and not being pumped out. the increased PCWP and SVR.

Question 4

obstructive shock

Answer 4

could be considered a type of cardiogenic - due to decreased blood flow

ex. tension pneumo, PE, cardiac temopnade

Question 5

pulmonary capillary wedge pressure

Answer 5

is measured in left side of heart- it is in the left atria

Question 6

central venous pressure

Answer 6

measured in right side of heart

Question 7

distributive shock

Answer 7

“vasodilatory - warm shock”

• increased CO (> 4.0 L/min/m2)
• decreased SVR (< 800 dynes.S/cm-5) and decreased PCWP (can be normal)
• seen in sepsis, toxic shock syndrome, anaphylaxis, toxin reactions (heavy metal, insect bites, etc.), spinal cord injury (neurogenic), myxedema, or adrenal crisis.
• May also have normal (70%) to high central venous O2 saturation (CVOS) due to redistribution of flow.

has to do with blood distribution: all the blood is going to skin, no blood going to the vital organs – it is a distribution problem – it is all going to skin b/c afterload is reduced, vessels are all dilated and the skin and muscles is where all the blood goes. CO increases b/c there is no afterload – as it pumps it just blows it out t

Question 8

what are clinical markers of shock?

Answer 8

1. SBP < 90 mm Hg (or mean BP < 60-65 mm Hg)
2. three “windows” of body:
   - cutaneous - see mottled/blotchy extremities
   - renal: 1.0 mmol/L

Question 9

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 9

this patients fluid is all in abdomen, this patient is dehydrated = hypovolemic shock due to protein leaving blood (liver not making albumin) – all fluid is out in tissue

• Will see decreased CVP (central venous pressure)

Question 10

normal CVP?

Answer 10

0-5 mm Hg

Question 11

normal CO?

Answer 11

2-4 L/min/m2

Question 12

normal PCWP?

Answer 12

8-12 mmHg

Question 13

normal SVR?

Answer 13

800-1500 dyne-sec-cm-5

Question 14

tx of hypovolemic shock?

Answer 14

CVP<5 mm Hg

1. 0.9% saline – 1-2 liters wide open – continue based on BP, skin, urine and mentation
2. PRBCs (packed red blood cells)
   Goal to obtain CVP 8-12 mmHg

Question 15

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 15

cardiogenic shock

CO is low, PCWP is high, afterload is high because the problem is the heart

Question 16

tx or cardiogenic shock? first step…..

Answer 16

Upright, O2, NIPPV

Question 17

tx or cardiogenic shock? for low BP?

Answer 17

Dobutamine (or milrinone w/ intraaortic balloon couterpulsation)

dobutamine: is mostly inotropic, If its cardiogenic shock not due to MI Then use dobutamine

Question 18

tx or cardiogenic shock? for normal/high BP

Answer 18

IV nitroglycerine/nitroprusside with IV loop diuretic (furesomide)

Question 19

tx or cardiogenic shock? for A fib….

Answer 19

esmolol

Question 20

tx or cardiogenic shock? Post MI…

Answer 20

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

• always use NE if its related with MI
• NE and dopamine are vasopressors

Question 21

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. BP is 60/40. EKG shows QRS complexes that alternate in size….

Answer 21

patient has pericardial tamponade

small complex is called electrical alterans – the heart is swinging back and forth, its swinging out toward EKG and swings back because its in a bag of water – can’t get enough blood into heart to have effective blood pressure, this explains low blood pressure, the distended neck vv. is due to high preload, there is distension

Question 22

Beck’s Triad for cardiac tamponade?

Answer 22

Distended neck veins
Distant heart sounds
Distressed BP (Hypotension)

Question 23

cardiac tamponade

Answer 23

acute type of pericardial effusion in which fluid accumulates in percardium causing restriction of heart contraction - may be due to trauma, pericarditis, myocardial rupture, uremia, hypothyroidism.

Question 24

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

Answer 24

obstructive shock - there is a bag of water surrounding the heart - see Beck’s triad

Question 25

causes of obstructive shock?

Answer 25

``` Tension pneumothorax Pericardial disease Disease of pulmonary circulation (PE) Cardiac tumor (myxoma) Left atrial mural thrombus Obstructive valvular disease ```

Question 26

A 25 y/o HIV patient presents with cough, fever of 390C 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 26

patient has SIRS

Question 27

SIRS

Answer 27

systemic inflammatory repsonse syndrome - due to cytokine storm --> leads to sepsis --> leads to shock Classification: - body temp greater than 100.4 or less than 96.8 - heart rate greater than 90 bpm - tachypnea (high resp. rate) gretaaer than 20 bpm - leukocytes less than 4,000 or greater than 12,000; or presence of 10% immature neutrophils (band forms), bandemia or left shift

Question 28

what is usual acid base imbalance during SIRS?

Answer 28

if have increased RR, then see respiratory alkalosis

Question 29

What labs to order with SIRS pt?

Answer 29

``` CBC CMP- chemical profile ABGs Type and crossmatch Coagulation parameters Lactate Blood cultures ```

Question 30

A gram stain sputum is obtained on the above patient and shows clusters of a gram positive cocci. One may now diagnose:

Answer 30

sepsis

Question 31

PAMPs vs DAMPs

Answer 31

result in sepsis: due to Pathogen-Associated Molecular Patterns (PAMPs), ie. glycolipids, glycoproteins, lipoproteins, peptidoglycans, lipopolysaccharides, mannoproteins, DNA, RNA, etc. which activate Pattern Recognition Receptors to release cytokines and chemokines and thus produce SIRS/Sepsis. DAMPs = damage-associated molecular patterns, released due to pancreatitis, burns, auto accidents etc.

Question 32

cytokines related to septic shock/

Answer 32

IL1, IL6, IL8, TNFalpha, IFGNgamma

Question 33

What is sepsis?

Answer 33

infection +.... 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 34

inflamm/ hemodynamic variables indicative of sepsis?

Answer 34

inflammatory variables: * **WBC > 12,000 with bandemia > 10% * ** WBC < 4,000 - increased CRP and procalcitonin Hemodynamic variables: worsen with worsening sepsis! SBP* < 90 mmHg; MAP < 70 mmHg

Question 35

organ dysfunction variables seen in sepsis?

Answer 35

PaO2/FiO2 < 300 ( 0.5 *mg/dL (> 2 mg/dL) INR > 1.5 or PTT > 60 seconds Ileus – intestines are going Platelets < 100,000 microl-1 – HGB is going Bilirubin > 4 mg/dL – liver dysfunction Hyperprolactinemia > 1 mmol/L (tissue hypoxia) Decreased capillary refill (tissue hypoxia) * these worsen with development of severe sepsis

Question 36

how many factors needed to ddx severe sepsis?

Answer 36

1 (or more) organ dysfunction

Question 37

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

Answer 37

fluid resuscitation

Question 38

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

Answer 38

SVR < 800 dynes.s/cm-5. In septic 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%, in the presence of increased serum lactate. Ultimately, however, the CVOS may drop and require fluid, RBCs, and vasopressors to maintain it above 70%.

Question 39

early sepsis protocol

Answer 39

to be done within 2 hours of pt. with infection: ``` 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 40

Therapy of septic shok?

Answer 40

1. maintenance of CVP at 8-12 mm: give 5 L fluid initially 2. need to maintain MAP at >65 mm Hg, and CI at 2-4 l/min: give vasopressors - use NE - Phenylephrine for warm shock - Epi for anaphylactic shock 3. maintain central venous O2 sat >70% by giving PRBC and dobutamine 4. hope to reduce lactate levels by 20% in first 2 hours

Question 41

maintain MAP at what?

Answer 41

need to maintain MAP at >65 mm Hg, and CI at 2-4 l/min: give vasopressors - use NE - Phenylephrine for warm shock - Epi for anaphylactic shock

Question 42

maintain CVP?

Answer 42

. Need to maintain CVP at 8-12 mm Hg. Fluids 5 liters in initial 6 hrs.

Question 43

how do you maintain central venous O2 saturation with sepsis?

Answer 43

to maintain central venous O2 saturation at > 70%. For < 70% give PRBC* to obtain hemacrit of 30%. If still < 70%, then dobutamine as ionotropic therapy

Question 44

why give steroids with septick shock?

Answer 44

Cortisol response of 9 ug/dL or less after 250 mcg of ACTH = relative adrenal insufficiency – use hydrocortisone 50 mg q 6 hrs.