Shock Flashcards
In three words, what is shock?
Underperfusion of tissues
What is the result of underperfused organ systems
Muscles - lactic acidosis
Renal - oliguria/anuria
CNS dysfunction - altered mentation
What are the three things you must assess in your patient to determine if the shock is cardiogenic, hypovomemic, septic, or neurogenic
Cardiac output, systemic vascular resistance, and volume status via JVP or PCWP
What are the four common symptoms between all types of shock
Hypotension, oliguria, tachycardia, and altered mental status
What is the initial steps when a patient presents with shock
Simultaneously stabilize the patient hemodynamically and determine cause of shock
- ) 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)
- ) Draw blood for tests
- ) ECG/CXR (in case cardiac) and pulse oximetry
What are hints to suggest what kind of shock it is
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
How can cardiogenic shock be defined by
Decreased cardiac output?
What is the general treatment for all kinds of shock
First ABC, and fluids/blood (more advanced stage of shock = greater fluid requirement)
What are the general causes of cardiogenic shock
MI (most common), arrhythmia, tamponade and pneumothorax (compression of heart), myocardial and mechanical abnormalities
What is different about cardiogenic shock in terms of symptoms compared to the other forms of shock that will help you distinguish
- ) Engorged neck veins - venous pressure elevated
2. ) Pulmonary Congestion
What is the treatment for cardiogenic shock, and what is the effect of continuing to give IV fluids in these patients?
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
What is the pathophysiology of hypovolemic shock
Less volume altogether, so less preload and less cardiac output indirectly
What determines mortality/morbidity in hypovolemic loss
The rate of loss (slower = better)
What happens if you are unable to diagnose a patient with vital signs and clinical picture, what should you use
Central venous line/pulmonary artery catheter - gives info about PCWP, cardiac output, SVR (like cardiogenic shock)
What is the treatment for hypovolemic shock
- ) Airway/Breathing - Mechanical intubation (if severe)
- ) Circulation - If hemorrhage is cause, may have to give fluids and blood, if no hemorrhage then a crystalloid solution with electrolytes is sufficient
What is the definition of septic shock
Hypotension induced by sepsis that persists despite adequate fluid resuscitation
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
Systemic inflammatory response syndrome (SIRS) –> Sepsis –> Septic shock –> MDDS
Before septic shock, you have SIRS leading to sepsis and then septic shock. What is the criteria of SIRS and sepsis
SIRS - You need two of four things
- ) Fever or hypothermia
- ) Hyperventilation (rate > 20) or PaCO2
- ) heart rate > 90
- ) WBC > 12000
Sepsis - SIRS present and blood cultures positive
What do you see for SVR and cardiac output in septic shock
SVR - severely decreased (peripheral vasodilation)
Cardiac output - normal/increased
Fever is a hint
What is the management for septic shock
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
What is the pathophysiology of neurogenic shock
Failure of sympathetic nervous system to maintain adequate vascular tone
What is neurogenic shock characterized in terms of numbers
Peripheral vasodilation with decreased SVR (warm skin), brady cardia and hypotension, cardiac output low, SVR low, PCWP low
What are the two things you need to do for treatment of neurogenic shock
IV fluids and vasoconstrictors
Is cardiac output decreased or increased for all types of shock
Cardiac output decreased for every shock except septic shock
Is SVR increased or decreased for every kind of shock
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
What are the exceptions for all the types of shocks
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)
