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EM - Exam 2 > Shock > Flashcards

Shock Flashcards

1
Q

Define shock

A
  • Inadequate tissue perfusion
  • Leads to anaerobic metabolism (lactic acidosis)
  • Eventually, end organ damage/failure
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2
Q

Oxygen delivery is a factor of:

A
  • Lung function
  • Hgb concentration
  • Cardiac output (preload, afterload, contractility, HR)
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3
Q

What are most cases of shock associated with? What are the exceptions?

A
  • Hypotension

- Exceptions: hypertensive emergencies, CO poisoning (may be normo or hypertensive)

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4
Q

PE to evaluate shock

A
  • Airway
  • Breathing (effort, rate, sounds, pulse ox, ABG)
  • Circulation (BP, HR, MAP)
  • Disability/Neuro status (GCS)
  • Exposure (head to toe assessment)
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5
Q

Signs of end organ damage

A
  • Confusion
  • Decreased urine output
  • CP or ischemic EKG changes
  • Diffuse abd pain
  • Generalized muscle pain
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6
Q

Define hypovolemic shock

A

More than 15% loss of intravascular volume causing hypotension that leads to decreased end-organ perfusion

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7
Q

What is the MC cause of shock?

A

Hypovolemia

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8
Q

Etiology of hypovolemic shock

A
  • Fluid loss (vomiting, diarrhea, 3rd degree burns, DKA urine)
  • Hemorrhagic (trauma, GI bleed)
  • 3rd spacing (ascites 2/2 cirrhosis, cancer, pancreatitis)
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9
Q

Treatment of hypovolemic shock

A
  • IVF (until MAP over 65)
  • Transfusion (preferred if cause is hemorrhagic)
  • Vasopressors (initiate if IVF cannot get MAP over 65)
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10
Q

When should vasopressors be avoided in treating hypovolemic shock?

A

If cause is hemorrhagic

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11
Q

Preferred vasopressor in treating hypovolemic shock

A

Norepi

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12
Q

What is the preferred volume expander if hypovolemic shock is caused by hemorrhage?

A

Blood transfusion

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13
Q

Define cardiogenic shock

A

Decreased cardiac output 2/2 abnormal cardiac function in the setting of NORMAL intravascular volume

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14
Q

Etiology of cardiogenic shock

A
  • MI (50% of cases)
  • Arrhythmias (tachy or brady)
  • Mechanical (cardiomyopathy, ventricular septum or wall rupture)
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15
Q

Treatments of cardiogenic shock

A
  • Norepi for hypotension
  • Dobutamine for wet/cold HF
  • Cath lab or CABG for MI
  • Intra-aortic balloon pump (temporizing measure)
  • Atropine and pacemaker for bradycardia
  • Electrical cardioversion for AFib/VFib-tach
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16
Q

Define neurogenic shock

A
  • Hypotension and bradycardia 2/2 sympathetic ganglion chain injury
  • Sometimes considered a component of distributive shock (d/t significant vasodilation)
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17
Q

What type of injury MC causes hypotension and bradycardia (i.e. neurogenic shock)?

A

C-spine injuries

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18
Q

Etiology of neurogenic shock

A
  • Trauma (MC)

- Improper location of regional anesthesia delivery

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19
Q

Key signs of neurogenic shock

A
  • Bradycardia and hypotension in setting of trauma or injection
  • Limbs are warm, rest of body is cold
  • Neuro symptoms (urine retention, paralysis)
20
Q

Treatment of neurogenic shock

A
  • ABCDE and spine immobilization
  • Treat or avoid hypothermia
  • IVF, vasopressors, atropine
  • IV steroids
  • Neurosurgery/ortho consults
21
Q

Define obstructive shock

A
  • Decreased CO despite normal cardiac function

- Can be 2/2 obstructive decrease in preload OR increase in ventricle outflow resistance

22
Q

Etiology of obstructive shock

A
  • Tension PTX
  • Pericardial tamponade
  • Massive PE
  • Aortic stenosis
  • Pulm HTN
  • Atrial myxoma
  • HTN emergency
23
Q

Treatment of obstructive shock

A
  • Needle decompression for PTX/tamponade
  • Thrombolytics/thrombectomy for massive PE
  • NO inhalation for pulm HTN
  • Valve replacement for AS
  • Operative resection for atrial myxoma
  • IV anti-HTNs for HTN emergency
24
Q

Define hypertensive urgency

A

Asymptomatic severe HTN (SBP over 220 or DBP over 125)

25
Q

Define hypertensive emergency

A

Severe HTN with signs of end organ damage (encephalopathy, nephropathy, aortic dissection, pulm edema, MI, etc)

26
Q

Define malignant/accelerated HTN

A

Severe HTN involving retinopathy (papilledema)

27
Q

Etiology of HTN urgency/emergency

A
  • Noncompliance or med withdrawal (clonidine)
  • RAS or chronic renal dz progression
  • Thyroid storm
  • Pheochromocytoma
  • Cocaine
  • Pregnancy
  • CNS (head injury, ICB, CVA)
  • Intra/postop
28
Q

Treatment goal of HTN urgency

A

Mild BP reduction initially with a focus on long term control

29
Q

Treatments of HTN urgency and what to monitor for each

A
  • Captopril (30 min onset)
  • Labetalol (monitor for bradycardia)
  • Clonidine (potential for rebound HTN)
  • Nifedipine (unpredictable response)
30
Q

Treatment goal of HTN emergency (and exceptions to this)

A

BP reduction of 25% within 1 hour and then to 160/100 within 6 hours
*Exceptions: CVA (maintain SBP 160-165) and ICB (target SBP under 130 or 20% below pt’s baseline)

31
Q

Treatments of HTN emergency

A
  • Nicardipine IV (caution in CAD)
  • Labetalol IV
  • Nitro infusion
  • Hydralazine IV (mostly for pregnancy related)
  • Furosemide
32
Q

Define distributive shock

A

Hypotension 2/2 decreased vascular resistance despite NORMAL circulatory volume

33
Q

Etiology of distributive shock

A
  • Sepsis
  • Anaphylaxis
  • Intoxication
  • Acute adrenal insufficiency
  • Neurogenic shock
34
Q

How can pregnancy cause shock?

A
  • Increases BV and CO due to increased HR and SV
  • Decreases systemic resistance
  • Net result: 5-10 mmHg decrease in MAP (either WNL or early signs of shock)
35
Q

When is shock in pregnancy MC?

A

3rd trimester - when the pathophysiologic factors are most prominent

36
Q

Explain hypotension in pregnancy

A
  • Pregnancy causes increased BV and CO with decreased systemic resistance
  • These changes could be normal OR early signs of shock
37
Q

Etiology of shock in early pregnancy

A

Ruptured ectopic pregnancy

38
Q

Etiology of shock in late pregnancy

A
  • PE
  • Amniotic fluid emboli
  • Uterine rupture
  • Postpartum hemorrhage
  • Postpartum cardiomyopathy
  • Septic shock
39
Q

Reasons why intubation of a critically ill person can cause shock

A
  • Vasodilation from induction meds
  • Increased vagal tone from hypopharyngeal stimulation
  • Decreased RV preload from positive pressure ventilation
40
Q

Describe central venous catheter

A

Lengthy catheter passed through a vein to end up in thoracic portion of vena cava or RA of heart

41
Q

Insertion locations of CVC

A
  1. Internal jugular vein
  2. Subclavian vein
  3. Femoral vein
42
Q

Potential complications a/w CVC placement

A
  • Hematoma
  • PTX, hemothorax
  • Air embolism
  • Misguided or kinked catheter
  • Wire migration
  • Infection
43
Q

Indications for CVC

A
  1. Provide vasopressors or other centrally administered meds
  2. Measure CVP
  3. Measure central venous O2 saturation (ScvO2)
  4. Inadequate peripheral venous access
44
Q

What does CVP under 5 mmHg suggest?

A

Hypovolemia

45
Q

What does CVP over 18 mmHg suggest?

A

Tamponade
Overload
Pulm HTN

46
Q

Which site(s) are preferable for measuring ScvO2?

A

Internal jugular or subclavian

47
Q

What does ScvO2 under 70% indicate?

A

Oxygen delivery is inadequate to meet oxygen uptake in the tissues

EM - Exam 2 (7 decks)

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