Shock

Question 1

In three words, what is shock?

Answer 1

Underperfusion of tissues

Question 2

What is the result of underperfused organ systems

Answer 2

Muscles - lactic acidosis
Renal - oliguria/anuria
CNS dysfunction - altered mentation

Question 3

What are the three things you must assess in your patient to determine if the shock is cardiogenic, hypovomemic, septic, or neurogenic

Answer 3

Cardiac output, systemic vascular resistance, and volume status via JVP or PCWP

Question 4

What are the four common symptoms between all types of shock

Answer 4

Hypotension, oliguria, tachycardia, and altered mental status

Question 5

What is the initial steps when a patient presents with shock

Answer 5

Simultaneously stabilize the patient hemodynamically and determine cause of shock

1. ) Established two large bore venous catheters, central line, arterial line, then bolus 1000ml normal saline and then continuous infusion. If they continue to remain hypotensive, give vasopressors (dopamine/NE)
2. ) Draw blood for tests
3. ) ECG/CXR (in case cardiac) and pulse oximetry

Question 6

What are hints to suggest what kind of shock it is

Answer 6

Fever, infection = septic shock
Trauma, GI bleed, vomiting, diarrhea = hypovolemic shock
Heart problems, for sure JVD = cardiogenic shock
Spinal cord injury/neuro defects = neurogenic shock

Question 7

How can cardiogenic shock be defined by

Answer 7

Decreased cardiac output?

Question 8

What is the general treatment for all kinds of shock

Answer 8

First ABC, and fluids/blood (more advanced stage of shock = greater fluid requirement)

Question 9

What are the general causes of cardiogenic shock

Answer 9

MI (most common), arrhythmia, tamponade and pneumothorax (compression of heart), myocardial and mechanical abnormalities

Question 10

What is different about cardiogenic shock in terms of symptoms compared to the other forms of shock that will help you distinguish

Answer 10

1. ) Engorged neck veins - venous pressure elevated

2. ) Pulmonary Congestion

Question 11

What is the treatment for cardiogenic shock, and what is the effect of continuing to give IV fluids in these patients?

Answer 11

ABC’s and treat underlying cause of the heart problem
Also give vasopressors (dopamine drug of choice, second line NE/phenylephrine if severe) to help hypotension even more
IV FLUIDS HARMFUL if LV pressure elevated, may have to give diuretics
Depends more on vasopressors than IV fluids

Question 12

What is the pathophysiology of hypovolemic shock

Answer 12

Less volume altogether, so less preload and less cardiac output indirectly

Question 13

What determines mortality/morbidity in hypovolemic loss

Answer 13

The rate of loss (slower = better)

Question 14

What happens if you are unable to diagnose a patient with vital signs and clinical picture, what should you use

Answer 14

Central venous line/pulmonary artery catheter - gives info about PCWP, cardiac output, SVR (like cardiogenic shock)

Question 15

What is the treatment for hypovolemic shock

Answer 15

1. ) Airway/Breathing - Mechanical intubation (if severe)
2. ) Circulation - If hemorrhage is cause, may have to give fluids and blood, if no hemorrhage then a crystalloid solution with electrolytes is sufficient

Question 16

What is the definition of septic shock

Answer 16

Hypotension induced by sepsis that persists despite adequate fluid resuscitation

Question 17

Septic shock is a condition where there is a progression to it, and then more progression from it in terms of diagnoses. What are these

Answer 17

Systemic inflammatory response syndrome (SIRS) –> Sepsis –> Septic shock –> MDDS

Question 18

Before septic shock, you have SIRS leading to sepsis and then septic shock. What is the criteria of SIRS and sepsis

Answer 18

SIRS - You need two of four things

1. ) Fever or hypothermia
2. ) Hyperventilation (rate > 20) or PaCO2
3. ) heart rate > 90
4. ) WBC > 12000

Sepsis - SIRS present and blood cultures positive

Question 19

What do you see for SVR and cardiac output in septic shock

Answer 19

SVR - severely decreased (peripheral vasodilation)
Cardiac output - normal/increased

Fever is a hint

Question 20

What is the management for septic shock

Answer 20

Initial - IV antibiotics broad spectrum at maximum doses

After - cut down antibiotics once blood cultures return

Fluid resuscitation and vasopressors

Surgical drainage may be necessary

Question 21

What is the pathophysiology of neurogenic shock

Answer 21

Failure of sympathetic nervous system to maintain adequate vascular tone

Question 22

What is neurogenic shock characterized in terms of numbers

Answer 22

Peripheral vasodilation with decreased SVR (warm skin), brady cardia and hypotension, cardiac output low, SVR low, PCWP low

Question 23

What are the two things you need to do for treatment of neurogenic shock

Answer 23

IV fluids and vasoconstrictors

Question 24

Is cardiac output decreased or increased for all types of shock

Answer 24

Cardiac output decreased for every shock except septic shock

Question 25

Is SVR increased or decreased for every kind of shock

Answer 25

SVR increased for cardiogenic and hypovolemic shock (pale cool skin due to peripheral vasoconstriction), SVR decreased a lot for neurogenic and septic shock (warm skin due to peripheral vasodilation)

This is why fluid resuscitation is not working as well for last two because body has decreased vascular resistance

Question 26

What are the exceptions for all the types of shocks

Answer 26

Cardiogenic shock - JVP or PCWP increased (decreased in all others)

Septic shock - CO increased (decreased in all the others) and mixed venous oxygen saturation increased (decreased in all others)