Shock Flashcards
1
Q
position to place child in if they are hypotensive and breathign isn’t compromised
A
Trendelenburg (supine, head 30 degrees below feet)
2
Q
position to place child in if they are hypotensive and breathign isn’t compromised
A
Trendelenburg (supine, head 30 degrees below feet)
3
Q
fluid resuscitation for shock
A
isotonic crystalloid in 20 mL/kg bolus over 5-20 minutes
4
Q
fluid resuscitation for cardiogenic shock
A
5-10 ml/kg over 10-20 inutes
5
Q
what does acidosis do to serum potassium concentration
A
increases
6
Q
what can caused decreased ionized calcium concentration
A
sepsis, transfusion of blood products
7
Q
most children with cardiogenic shock benefit form a _______ to decrease SVR and increase CO and tissue perfusion
A
vasodilator (provided BP is adequate)
8
Q
what are the 3 inotropes? They increase cardiac contractility, HR, and variable on SVR
A
dopamine, epinephrine, dobutamine
9
Q
this class of drugs decreases SVR, improves coronary artery blood flow and improves contractility
A
phosphodiesterase inhibitors (milrinone, inamrinone)
10
Q
2 vasodilators that decreases SVR and venosu tone
A
nitroglycerin, nitroprusside
11
Q
4 drugs that are vasopressors (increase SVR and myocardial contractility)
A
epinephrine
norepi
dopamine
vasopressin (doesn’t increase myocardiac contractility)
12
Q
what are 2 isotonic crystalloid solutions
A
normal saline (NS) or lactated Ringer’s (LR)
13
Q
where are isotonic crystalloids distributed
A
throughout the extracellular space (may need a large volume to restore intravascular volume fo rchildren)
14
Q
what are colloid solutions
A
5% albumin, fresh frozen plasma, synthestic plasma expander (hetastarch), dextran40 and dextran 60
15
Q
are colloid or isotonic crystalloid solutions better volume expanders
A
colloid solutions
16
Q
disadvantages of colloids
A
less available, take time to prepare, blood derived can cause sensitivity reactions
17
Q
when should blood products be considered
A
perfusion inadequate despite 2-3 boluses of 20mL/kg of isotonic crystalloid. then administer 10 mL/kg PRBCs ASAP
18
Q
order of preference for blood products
A
crossmatched
type specific
type ) neg
19
Q
this is present in stored blood and inadquate clearance of it can cause ionized hypocalcemia
A
citrate
20
Q
if a patient becomes hypotensive during a rapid blood transfusion what shoudl be administered?
A
calcium
21
Q
hypoglycemia in neonates
A
22
Q
hypoglycemia in infants, children, adolescents
A
23
Q
tx of hypoglycemia if you can’t administer glucose orally
A
IV glucose at 0.5-1 g/kg (IV dextrose as D25 (2-4mL/kg) of D10W (5-10 mL/kg)
24
Q
type of dehydration where patients presents with poor skin turgor, marked oliguira, tachycardia, quiet tachypnea, sunken fontanel
A
moderate (10% in infants, 5-6% in adolescent)
25
type of dehydration with marked tachycardia, weak pulses, narrow pulse pressure, HPOTN
severe 15% in infants, 7-9% in adolescents
26
what is the 3mL to 1 mL rules
in hemorrhagic shock give about 3 mL of crystalloid for every 1 mL of blood lost
27
mild blood loss is less than what percentage?
30%
28
difference between moderate and severe blood loss
severe blood loss involved hypotension and no urine output
29
moderate blood loss percentage
30-45%
30
severe blood loss percentage
>45%
31
what can help minimize adverse effects with blood administration
use a blood warminign device
32
are vasoactive agents routinely used for the management of hypovolemic shock
no
33
is sodium bicarb recommended for the treatment of metabolic acidosis secondary to hypovomeic shock
NO
34
when is bicarb indicated?
if metabolic acidosis is caused by significant bicarb losses from renal or GI losses (non-anion gap metagolic acidosis)
35
3 types of distributive shocks
septic, anaphylactic , neurogenic
36
first hour treatment for septic shock
Oxygen, vascular access
push repeated 20mL/kg boluses of isotonic crystalloid
correct hypoglycemia/ hypocalcemia
first dose abx STAT
consider stat vasopressor or stress dose hydrocortisone
37
if patient in septic shock doesn't respond to fluids and is normotensive what drug should you start
dopamine
38
if patient is in warm septic shock (hypotensive vasodilated) what drug should you begin
norepi
39
if septic shock patient is in cold shock (hypotensive, vasoconstricted) what drug should you start
epineophrine
40
what is ScvO2
central venous oxygen saturation
41
ScvO2 goal
>70%>
42
in septic shock if SCVO2 is >70%, and patietn ahs normal bp but poor perfusion what should you do
transfuse to Hgb>10
optomize arterial oxygen satruation, fluid boluses
consider milrinone or nitroprusse or dobutamine
43
if patient's SCVO2 is
transfuse to >10g/dL
fluid boluses
consider epi or dobutamine + norepi
44
why is norepi preferred for warm shock
potent alpha vasoconstricting effects which raise DBP by increasing SVR. increases cardiac contractility w/ little chagne in HR
45
in norepi refractory shock what may be helpful
vasopressin infusion
46
what does vasopressin do
antagonizes the mechanism of sepsis-mediated vasodilation to help stabilze BP. No effect on cardiac contractility
47
why is dopamine preferred for normotensive shock (impaired perfusion but adequate BP)
low doses- improves splanchnic and renal blood flow
intermediate dose- improve cardiac contractility
high doses- increases SVR
48
you should use _____ vasoconstrcitor if the child has normal to high vascular resistance
epinephrine
49
________ provides both inotropic and vasodilating effects, but often causes significant tachycardia and can reduct SVR and cause hypotension
dobutamine
50
________ provides both inotropic and vasodilating effects, but offten causes significant tachycardia and can reduct SVR and cause hypotension
dobutamine
51
fluid resuscitation for shock
isotonic crystalloid in 20 mL/kg bolus over 5-20 minutes
52
fluid resuscitation for cardiogenic shock
5-10 ml/kg over 10-20 inutes
53
what does acidosis do to serum potassium concentration
increases
54
what can caused decreased ionized calcium concentration
sepsis, transfusion of blood products
55
most children with cardiogenic shock benefit form a _______ to decrease SVR and increase CO and tissue perfusion
vasodilator (provided BP is adequate)
56
what are the 3 inotropes? They increase cardiac contractility, HR, and variable on SVR
dopamine, epinephrine, dobutamine
57
this class of drugs decreases SVR, improves coronary artery blood flow and improves contractility
phosphodiesterase inhibitors (milrinone, inamrinone)
58
2 vasodilators that decreases SVR and venosu tone
nitroglycerin, nitroprusside
59
4 drugs that are vasopressors (increase SVR and myocardial contractility)
epinephrine
norepi
dopamine
vasopressin (doesn't increase myocardiac contractility)
60
what are 2 isotonic crystalloid solutions
normal saline (NS) or lactated Ringer's (LR)
61
where are isotonic crystalloids distributed
throughout the extracellular space (may need a large volume to restore intravascular volume fo rchildren)
62
what are colloid solutions
5% albumin, fresh frozen plasma, synthestic plasma expander (hetastarch), dextran40 and dextran 60
63
are colloid or isotonic crystalloid solutions better volume expanders
colloid solutions
64
disadvantages of colloids
less available, take time to prepare, blood derived can cause sensitivity reactions
65
when should blood products be considered
perfusion inadequate despite 2-3 boluses of 20mL/kg of isotonic crystalloid. then administer 10 mL/kg PRBCs ASAP
66
order of preference for blood products
crossmatched
type specific
type ) neg
67
this is present in stored blood and inadquate clearance of it can cause ionized hypocalcemia
citrate
68
if a patient becomes hypotensive during a rapid blood transfusion what shoudl be administered?
calcium
69
hypoglycemia in neonates
70
hypoglycemia in infants, children, adolescents
71
tx of hypoglycemia if you can't administer glucose orally
IV glucose at 0.5-1 g/kg (IV dextrose as D25 (2-4mL/kg) of D10W (5-10 mL/kg)
72
type of dehydration where patients presents with poor skin turgor, marked oliguira, tachycardia, quiet tachypnea, sunken fontanel
moderate (10% in infants, 5-6% in adolescent)
73
type of dehydration with marked tachycardia, weak pulses, narrow pulse pressure, HPOTN
severe 15% in infants, 7-9% in adolescents
74
what is the 3mL to 1 mL rules
in hemorrhagic shock give about 3 mL of crystalloid for every 1 mL of blood lost
75
mild blood loss is less than what percentage?
30%
76
difference between moderate and severe blood loss
severe blood loss involved hypotension and no urine output
77
moderate blood loss percentage
30-45%
78
severe blood loss percentage
>45%
79
what can help minimize adverse effects with blood administration
use a blood warminign device
80
are vasoactive agents routinely used for the management of hypovolemic shock
no
81
is sodium bicarb recommended for the treatment of metabolic acidosis secondary to hypovomeic shock
NO
82
when is bicarb indicated?
if metabolic acidosis is caused by significant bicarb losses from renal or GI losses (non-anion gap metagolic acidosis)
83
3 types of distributive shocks
septic, anaphylactic , neurogenic
84
first hour treatment for septic shock
Oxygen, vascular access
push repeated 20mL/kg boluses of isotonic crystalloid
correct hypoglycemia/ hypocalcemia
first dose abx STAT
consider stat vasopressor or stress dose hydrocortisone
85
if patient in septic shock doesn't respond to fluids and is normotensive what drug should you start
dopamine
86
if patient is in warm septic shock (hypotensive vasodilated) what drug should you begin
norepi
87
if septic shock patient is in cold shock (hypotensive, vasoconstricted) what drug should you start
epineophrine
88
what is ScvO2
central venous oxygen saturation
89
ScvO2 goal
>70%>
90
in septic shock if SCVO2 is >70%, and patietn ahs normal bp but poor perfusion what should you do
transfuse to Hgb>10
optomize arterial oxygen satruation, fluid boluses
consider milrinone or nitroprusse or dobutamine
91
if patient's SCVO2 is
transfuse to >10g/dL
fluid boluses
consider epi or dobutamine + norepi
92
why is norepi preferred for warm shock
potent alpha vasoconstricting effects which raise DBP by increasing SVR. increases cardiac contractility w/ little chagne in HR
93
in norepi refractory shock what may be helpful
vasopressin infusion
94
what does vasopressin do
antagonizes the mechanism of sepsis-mediated vasodilation to help stabilze BP. No effect on cardiac contractility
95
why is dopamine preferred for normotensive shock (impaired perfusion but adequate BP)
low doses- improves splanchnic and renal blood flow
intermediate dose- improve cardiac contractility
high doses- increases SVR
96
you should use _____ vasoconstrcitor if the child has normal to high vascular resistance
epinephrine
97
you should use ____ vasoconstrictor if the child has low vascular resistance
norepi
98
________ provides both inotropic and vasodilating effects, but often causes significant tachycardia and can reduct SVR and cause hypotension
dobutamine
99
a child in septic shock who is fluid refractory and dopamine dependents or norepi dependent may have what?
adrenal insufficiency
100
if you suspect adrenal insufficiency what should be done?
hydrocortisone 2 mg/ kg IV bolus (max is 100 mg)
101
an increase in cortisol
adrenal insufficiency
102
most important treatment for anaphylactic shock
IM epi (1:1000), second dose may be needed 10-15 minutes after
103
Treatment of anaphylactic shock
epi
aminister isotonic crytalloid fluid bolsues
albuterol PRN for bronchospasm
antihistamines (H1- diphenhydramine and H2- ranitidine)
corticosteroid (methylprednisolone)
104
patient presents with HPOTN, bradycardia, and sometimes hypothermia
neurogenic shock
105
BP in neurogenic shock
low DBP with a wide pulse pressure a fro loss of vascular tone
106
Tx for neurogenic shock
child flat or head down
administer trial of fluid (for refractory norepi epi as indicated)
cooling and warming as needed
107
do many children with cardiogenic shock require additional fluid therapy
no, as they have high preload (some may need fluid though )
108
most effective way to increase stroke volume with cardiogenic shock
reduce afterload (SVR) rather than give an inotropic agent
109
what type catheter evaluates left ventricular preload
pulmonary artery catheter
110
this allow monitoring of central venous O2 saturation and measurement of central venous pressure
central venous access
111
useful labs with cardiogenic shock
```
ABG
hemoglobin
lactate
cardiac enzymes
thyroid function tests
```
112
tx for cardiogenic shock in normotensive child
diuretics and vasodilators
113
4 types of obstructive shock
cardiac tamponade, tension pneumo, ductal depdendent congenital heart lesions, massive PE
114
immediate treatment needed for ductal dependent lesions
continuous infusion of prostaglandin E1 (PGE1) to restore ductal patency
