shock

Question 1

Hypovolemic shock

Answer 1

decreased CO and PCWP (CVP

Question 2

Cardiogenic shock

Answer 2

decreased CI (or CO)(

Question 3

Distributive (vasodilatory-“warm or septic shock”)

Answer 3

increased CI(> 4.0 L/min/m2) with decreased SVR (

Question 4

Clinical shock markers

Answer 4

1. SBP 1.0 mmol/L

Question 5

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 5

hypovolemic

Question 6

A 56 year old alcoholic patient with cirrhosis and ascitespresents with vomiting, dry mucous membranes, clammy skin, oliguria, mental status change and BP of 70/50. Which parameter will be found?
A. Decreased CVP (normal 0-5 mmHg)
B. Increased CI (normal 2.0-4.0 L/min/m2)
C. Increased PCWP (normal 4-12 mmHg)
D. Decreased SVR (normal 800-1500 dyne-sec-cm-5)

Answer 6

Decreased CVP (normal 0-5 mmHg)

Question 7

Treatment for Hypovolemic Shock

Answer 7

Hypovolemic shock: CVP

Question 8

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 8

cardiogenic

CVP > 18 mm Hg and Cardiac Index

Question 9

Treatment of Cardiogenic Shock

1

Answer 9

Upright, O2, Fluid bolus (CVP to 15 -18 mmHg), NIPPV

Question 10

Treatment of Cardiogenic Shock

2

Answer 10

Low BP –dobutamine#(initial 0.5-1 mcg/kg/min with maintenance of 2-20 mcg/kg/min) or milrinone#with intraaorticballoon counterpulsation

Question 11

Treatment of Cardiogenic Shock

3

Answer 11

Normal or high BP –IV nitroglycerin or nitroprusside with IV loop diuretic/furesomide (to relax blood vessels)

Question 12

Treatment of Cardiogenic Shock

4

Answer 12

AF –esmololor cardioversion

Question 13

Treatment of Cardiogenic Shock

5

Answer 13

Post MI –antiplatelets, norepinephrine* or dopamine** if hypotensive –MAP to 65 mm Hg) (dobutamine or milrinone#for those with vasoconstriction and not as severe hypotension, ie. BP 80 mm Hg)

Question 14

Treatment of Cardiogenic Shock

6

Answer 14

IABP, CABG, or PCI

Question 15

when treating cardiogenic shock cvp is usually

Answer 15

15-18 so use ionotropic agents or vasopressers

Question 16

dobutamine is best

Answer 16

ionotropic

Question 17

norepi and dopa are good

Answer 17

vasopressors

Question 18

what meds in cardiogenic shock

Answer 18

norepi dopa and dobutamine

Question 19

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 electircal alteran

Answer 19

pericardial tamponade

Question 20

electircal alteran

Answer 20

every other complex is diffe size it is a marker for pericardia effusion or fluid around the heart

Question 21

Beck’s triad for Cardiac Tamponade

Answer 21

obstructive

• Distended neck veins
• Distant heart sounds (bc fluid around heart
• Distressed BP (Hypotension)

Question 22

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

Answer 22

obstructive

Question 23

Cause of Obstructive Shock

Answer 23

Tension pneumothorax

Pericardial disease

Disease of pulmonary circulation (PE)

Cardiac tumor (myxoma)

Left atrial mural thrombus

Obstructive valvular disease

Question 24

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/mm3with 15% bands. Glucose is 145 mg/dL. This patient most likely has

Answer 24

SIRS

Question 25

SIRS

Answer 25

Dysregulatedinflammation related to autoimmune disorders, pancreatitis, vasculitis, VTE, burns, surgery, etc. Same category as sepsis septic immune response syndrome body is producing cytokines and bacteria are releasing them also

Question 26

SIRS breathing

Answer 26

RR > 20 bpm, or PCO2

Question 27

SIRS triad

Answer 27

pulse above 90 temp above 38 white count greater than 12000 are the other markers

Question 28

Labs in SIRS, sepsis, or distributive shock

Answer 28

CMP ABGs Type and crossmatch Coagulation parameters Lactate Blood cultures

Question 29

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

Answer 29

sepsis

Question 30

What do the organisms release that cause these patients who are in sepsis to go on to shock?

Answer 30

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 Shock/MOF/Death.

Question 31

Initiation of Host Response in shock/sepsis

Answer 31

–Pathogen Associated Molecular Patterns (PAMPs) –Pattern Recognition Receptors

Question 32

Activation of Pattern Recognition Receptors

Answer 32

–MyD88 / NF-kB Signaling •Pro-inflammatory Cytokines •Vascular Adhesion Molecules

Question 33

Pro-Inflammatory Cytokines Involved

Answer 33

Tumor Necrosis Factor (TNF-a) IL-1 IL-6

Question 34

Tumor Necrosis Factor (TNF-a)

Answer 34

•Stimulates the recruitment and activation of neutrophils and monocytes –Leads to the production of IL-1 * Activates vascular endothelial cells to express cellular adhesion molecules * Can induce extrinsic apoptosis

Question 35

IL-6

Answer 35

Similar to and redundant of TNF

Question 36

IL-1

Answer 36

Similar to and redundant of TNF

Question 37

Sepsis/SIRS Infection plus: General variables any two you have sirs

Answer 37

TPR changes –T > 38.3C (101 F) or 90 bpm; RR > 20 bpm or PCO2> 32mmHg Glucose > 140 mg/dL Altered mentation Edema of > 20mL/kg over 24 hours

Question 38

Sepsis* Inflammatory variables

Answer 38

WBC > 12,000 with bandemia> 10%; WBC

Question 39

Sepsis Hemodynamic variables

Answer 39

SBP*

Question 40

Sepsis Organ Dysfunction variables

Answer 40

PaO2/FiO2 0.5 mg/dL(> 2 mg/dL) INR > 1.5 or PTT > 60 seconds Ileus Platelets 4 mg/dL Hyperprolactinemia> 1 mmol/L (tissue hypoxia) Decreased capillary refill (tissue hypoxia) Increased serum lactate

Question 41

Severe sepsis may be diagnosed in the above patient with evidence of significant dysfunction in how many organs?

Answer 41

1

Question 42

Most common evidence of severe organ dysfunction are

Answer 42

ARDS, ARF, and DIC; or serum lactate > 4 mmol/L.

Question 43

End-Organ Damage in sepsis

Answer 43

``` –Microcirculatory damage / disorder •Central Nervous System •Lungs •GI •Liver •Kidney ```

Question 44

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

Answer 44

fluid resuscitation

Question 45

give fluids with

Answer 45

septic shock

Question 46

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

Answer 46

SVR

Question 47

In septic shock a redistribution of oxygen delivery or inability of tissues to extract O2 can actually lead to

Answer 47

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 48

with septic shock look for

Answer 48

warm skin

Question 49

Early Sepsis Protocol Nine steps to be done within 2 hours for patients with infection, SIRS, and dysfunction of one organ.

Answer 49

give fluids first 1. Serum lactate 2. Two sets of blood cultures 3. Two 18 gauge lines 4. Start antibiotics 5. Give 2 liters NS 6. CBC and BMP 7. O2 sat > 90% 8. Start norepinephrine if shock is present. 9. Transfer for lactate > 4 mmol/L, Systolic BP

Question 50

Septic shock -EGDT Early Goal Directed Therapy. Problem is O2 utilization (ScvO2)

Answer 50

1. Fluids 2. Vasopressors 3. Need to maintain central venous O2saturation at > 70%. 4. Hope to reduce lactate by 20% in first 2 hours.

Question 51

Fluids for septic shock

Answer 51

need to maintain CVP at 8-12 mm Hg. Give 30mL/kg of crystalloid (1-2 liters over 30-60 minutes). May need 4-6 liters total.

Question 52

Vasopressors for shock

Answer 52

Need to maintain MAP at > 65 mm Hg and cardiac index at 2-4 liters/min2. Use Norepinephrine*5-20 mcg/min (mainly alpha agonist/vasopressor; as is phenylephrine which is pure alpha and therefore good in extreme tachycardia). If norepinephrine fails, go to epinephrine(mainly beta agonist/inotropic effect). May also consider Vasopressin 0.03 units/min (potentiates norepinephrine).

Question 53

heart shock use

Answer 53

dobutamine

Question 54

septic shock use

Answer 54

norepinephrine

Question 55

Need to maintain central venous O2saturation at > 70%.

Answer 55

For

Question 56

Hope to reduce lactate by 20% in first 2 hours.

Answer 56

(Increased glycolysis, inhibition of pyruvate dehydrogenase, and impaired liver function, all increase lactate levels)

Question 57

Generally do not transfuse for

Answer 57

Hb> 7 gm or hematocrit> 21%

Question 58

Septic Shock | Maintain glucose

Question 59

Usual Careversus EGDT

Answer 59

The treatment of septic shock should be based on Usual Care in deference to Early Goal Directed Therapy (EGDT). In other words, provider directed usual care is as good as EGDT, if based on rapid recognition,* early antibiotics, and aggressive fluid resuscitation. This rather than necessarily placing central line for CVP and CvO2

Question 60

56% of sepsis-related deaths

Answer 60

were in people with normal BP and normal or intermediate | serum lactate levels (

Question 61

A patient presents with septic shock. In addition to early recognition and immediate fluid resuscitation:

Answer 61

1. Obtain cultures and remove vascular devices. 2. Begin vancomycin (may use daptomycin, linezolid, or ceftaroline) and cefotaxime(may use cefotetan, cefepime, cefoperazone, ceftazidime, pipericillin-tazobactam, ticarcillin-clavulanate, meropenem, or imipenem). Must cover MRSA, Pseudomonas, and Gm negatives with ESBLactivity

Question 62

Renoprotective effect for acetaminophen in severely septic patients

Answer 62

No long-term benefit of adrenaline in cardiac arrest outside the hospital –contracts vessels in gut, liver, and kidneys. On the other hand, faster administration of epinephrine(one to three minutes) in people who arrest in the hospital with a non-shockablerhythm (asystole or PEA) have increased survival.