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Hematology & Anaphylaxis > Shock > Flashcards

Shock Flashcards

1
Q

What are three reasons for hypoperfusion?

A

Inadequate pump
Inadequate fluid
Inadequate container

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2
Q

What are the five aspects of an inadequate pump that cause hypoperfusion?

A 
Inadequate preload
Inadequate stroke volume
Inadequate cardiac output
Inadequate heart rate
Excessive afterload
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3
Q

What is the aspect of inadequate fluid that causes hypoperfusion?

A

Hypovolemia

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4
Q

What are the two aspects of an inadequate container that cause hypoperfusion?

A

Inadequate systemic vascular resistance

Over dilation

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5
Q

How does shock affect the cellular level?

A

It causes a state of acute nutritional insufficiency for oxygen and other essential substrates, resulting in cellular anoxia, cellular dysfunction and eventually, cell death

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6
Q

What is the 60-40-20 rule?

A

60% of the body weight is water
40% of body weight is intracellular fluids
20% of body weight is extracellular fluid

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7
Q

What is stroke volume?

A

It is the amount of blood released from the heart per beat

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8
Q

What is the formula for cardiac output?

A

Cardiac output = stroke volume x heart rate

CO = SV x HR

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9
Q

What is cardiac output?

A

It is the amount of blood circulated from the heart in a minute

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10
Q

What are three principle factors that affect cardiac output?

A

Preload
Afterload
Myocardial contractility

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11
Q

What is preload?

A

It is the amount of blood delivered to the heart during diastole

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12
Q

What is preload dependent on?

A

Venous return

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13
Q

What happens if there is an increase in preload?

A

There is an increase in stroke volume

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14
Q

What is afterload?

A

It is the pressure at which the ventricle pumps against

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15
Q

With afterload, when is blood ejected?

A

Only after the resistance is overcome

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16
Q

What is afterload dependent on?

A

The degree of peripheral arterial vasoconstriction

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17
Q

What is myocardial contractility? (2)

A

The force generated by the myocardium on contraction

Remember Starling’s Law (the rubber band theory)

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18
Q

What is the formula for blood pressure?

A

Blood pressure = cardiac output x peripheral vascular resistance

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19
Q

What may peripheral vascular resistance be also seen as?

A

Systemic vascular resistance (SVR)

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20
Q

What is blood pressure?

A

THe resistance of blood flow by the force of friction between the blood and walls of the vessels

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21
Q

What is blood flow?

A

Systemic vascular resistance is dependent on the internal diameter of the vessels and viscosity of blood

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22
Q

What two vessels do not significantly change diameter?

A

Aorta

Arteries

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23
Q

How large can the arterioles change their lumen?

A

Factor of 5

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24
Q

What are baroreceptors?

A

They are sensory fibers located in the aortic and carotid tissues

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25
Q

What do the baroreceptors help control?

A

They help control the BP by using two negative feedback mechanisms

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26
Q

What are the two negative feedback mechanisms used by the baroreceptors?

A

Lower BP in response to increased arterial pressure

Increase BP in response to decreased arterial pressure

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27
Q

What are two systemic pressures?

A

Venous

Arterial

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28
Q

What does the venous systemic pressure control?

A

Venous system constriction increases preload and stroke volume

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29
Q

What does the arterial systemic pressure control?

A

Arterial system constriction increases afterload and BP

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30
Q

What are the four components of microcirculation?

A

It is a capillary network

It is responsive to the needs of local tissues

It will adjust to supply/bypass tissues in need/or without need

Utilizes the pre and post capillary sphincters to facilitate these needs

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31
Q

What are ten affects on microcirculation?

A 
Local control by tissues
Nervous control of blood flow
Baroreceptors
Chemoreceptors
CNS ischemia response
Hormonal response
Adrenal-medullary response
Renin-Angiotensin-Aldosterone mechanism
Vasopressin
Reabsorption of tissue fluid
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32
Q

What is the function of oxygen?

A

It bends to hemoglobin and diffuses across the capillary membrane

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33
Q

What is the normal percentage of hemoglobin that is saturated by oxygen?

A

97-100%

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34
Q

What is Fick’s principle?

A

It recognizes the five conditions required for effective movement of oxygen within the body

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35
Q

What are the five conditions of Fick’s principle?

A 
Adequate FiO2
Appropriate O2, diffusion from blood to the capillaries
Adequate number of RBC's
Proper tissue perfusion
Effective tissue offloading
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36
Q

What are the four Weil-Shubin classifications of shock?

A

Distributive
Hypovolemic
Cardiogenic
Obstructive

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37
Q

What is psychogenic shock? (2)

A

It is relative hypovolemia due to severe vasodilation

It is caused by sudden and temporary sympathetic nervous system failure

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38
Q

What is neurogenic shock? (5)

A

AKA Spinal shock
Massive relative hypovolemia due to severe vasodilation
Damage caused to the nervous system inhibiting its involuntary/voluntary control of homeostasis
Sudden loss of sympathetic tone to the smooth muscles of the vessels below the point of injury
Without constant stimulation widespread relaxation of these muscles causes a decrease in PVR and a drop in BP

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39
Q

What is respiratory shock? (6)

A 
Airway obstruction
Hypoventilation
Toxic inhalation
Severe pulmonary edema
Exacerbation COPD
Multi-lobe bilateral pneumonia
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40
Q

What is hypovolemic shock? (3)

A

Inadequate perfusion of tissues caused by a volume deficiency other than blood
AKA third space loss
Severe dehydration: diarrhea/vomiting, peritonitis, heat exhaustion, severe burns

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41
Q

What is hemorrhagic shock? (2)

A

Internal/external hemorrhage resulting in hypovolemia and a systemic reduction in tissue perfusion

Mortality rate dependent on etiology, early recognition, and aggressive intervention

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42
Q

What is cardiogenic shock? (3)

A

Failure of the pump to supply O2 rich blood to the tissues

Potentially a combination shock, depending on the etiology: Massive AMI, Valvular insufficiency, Lethal dysrhythmia, Cardiac arrest

Has a 60-90% mortality rate

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43
Q

What is metabolic shock?

A

It is shock that is a result of a change in the chemistry of the endocrine system in the body

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44
Q

What are some causes of metabolic shock? (7)

A 
Insulin shock
Diabetic ketoacidosis
Adrenal gland failure
Thyroid failure
Pituitary gland failure
Renal failure
Toxic ingestion
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45
Q

What is septic shock? (3)

A

Massive infection and toxin production resulting in the inability of the cell to exchange O2/CO2 resulting in cellular death

Relative hypovolemia due to pool of blood in extremities

1 month morality rate 35-45%

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46
Q

What is the progression of shock? (4)

A

Follows a sequence of stages related to changes in capillary perfusion and cellular necrosis

Various shock states may interrelate clinically to produce a mixed picture

Hypovolemic shock may lead to acidosis and result in cardiogenic shock

Septic shock may lead to hypovolemia as a result of microbal toxins, cytokines, and capillary permeability

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47
Q

What are the four stages of shock?

A

Initial stage of shock

Compensatory stage

Progressive stage

Refractory stage

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48
Q

What happens in the initial stage of shock? (3)

A

Cellular changes occur in response to shock

Anaerobic metabolism due to the lack of oxygen

Clinical signs not detectable

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49
Q

What happens in the compensatory stage of shock? (3)

A

Neural compensation: baroreceptors in aortic and carotid sinus are stimulated by a drop in MAP, sympathetic nervous system stimulated via vasomotor and cardiac centers of the medulla, catecholamine response causes arteriole constriction, venous reservoir constriction, inotropic and chronotropic effect on the heart

Hormonal compensation causes the RAAS system to start

Chemical compensation, increased respiratory rate to clear CO2

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50
Q

What happens in the progressive stage of shock? (2)

A

Compensatory mechanisms not effective

Severe hypoperfusion causes MODS

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51
Q

What happens in the refractory stage of shock? (2)

A

It is the irreversible stage

Cell and organ destruction are severe enough that death is inevitable

52
Q

What are the brain specific effects of shock? (4)

A

The brain is essential

Adrenergic stimulation to maintain cerebral blood flow

Irritability and agitation (early stage)

Unresponsive (late)

53
Q

What is the heart specific effects of shock? (2)

A

The heart is essential

The protective flow, except in cardiogenic shock

54
Q

What is the skeletal, muscle and integumentary specific effects of shock? (1)

A

Vasoconstriction limits flow to non-essential areas

55
Q

What are the kidney specific effects of shock?

A

Decreased GFR

56
Q

What are the lung specific effects of shock? (2)

A

Tachypnea

Increased pulmonary muscle oxygen consumption

57
Q

What are the liver specific effects of shock? (3)

A

Glucose release as stimulated by catecholamines

May result in hyperglycemia due to lack of cell usage

Loss of clotting factors may cause DIC

58
Q

What are the mesenteric specific effects of shock? (2)

A

Decreased blood flow to the gut and causes nausea and vomiting

Necrosis by digestive enzymes cause damage to the protective mucosal barrier. Bacteria and toxins are released into the bloodstream

59
Q

What are the pancreas specific effects of shock? (2)

A

Release of amylase and lipase into the circulation

Myocardial depressant factor (MDF) released decreasing myocardial contractility

60
Q

What are the four classifications of hemorrhage?

A

Class I (vasoconstriction)

Class II (Capillary and venule opening)

Class III (Disseminated intravascular coagulation)

Class IV (Multiorgan dysfunction syndrome)

61
Q

What is class I (vasoconstriction) hemorrhage? (3)

A

It is approx 15% blood loss (500-750 mls)

The healthy body can easily accommodate for the loss

No effect on BP, pulse pressure or renal output

62
Q

What is the compensation for class I (vasoconstriciton) hemorrhage? (6)

A 
Catecholamine release
RR (normal ranges)
HR (mild tachycardia to maintain CO due to reduced SV)
BP (possible orthostatic hypotension)
Cap refill (normal)
CNS (mild anxiety)
63
Q

What is class II (capillary and venule opening) hemorrhage? (3)

A

15-25% blood loss (750-1250 mls)

First line compensatory mechanisms can no longer maintain BP

Secondary mechanisms now employed

64
Q

What are signs of early decompensation of class II (capillary and venule opening) hemorrhage? (6)

A 
RR (Tachypnea)
HR (Tachycardia)
BP (Hypotension may be prevalent/decreased pulse pressures)
CR (delayed)
CNS (anxiety)
Pale, cool, clammy skin
65
Q

What is capillary washout? (3)

A

Accumulated cellular waste products cause post-capillary sphincter to relax

Waste products, cellular contents and coagulated cells dumped into venous circulation. Profound metabolic acidosis and the release of microscopic emboli

The body quickly moves towards death

66
Q

What is class III (Disseminated intravascular coagulation) hemorrhage? (2)

A

25-35% blood loss (1250-1750 mls)

Compensatory mechanisms unable to cope

67
Q

What are signs of late decompensation in class III (disseminated intravascular coagulation)? (6)

A

Without intervention, patient survival is unlikely
RR (Tachypnea)
HR (Tachycardia)
BP (Moderate/severe hypotension/narrowing pulse pressures)
CR (delayed)
CNS (anxiety/confusion)

68
Q

What is disseminating intravascular coagulopathy (DIC)? (2)

A

Phospholipids released due to injured/lysed cells

Prolonged low CO also triggers phospholipids release due to endothelium injury

69
Q

What is the result of disseminating intravascular coagulopathy (DIC)? (4)

A

Systemic coagulation
Diffuse fibrin formation (results in multiple microscopic emboli)
Exhaustion of clotting factors
Fibrinolytic system activate due to coagulation activation

70
Q

What is class IV (multiorgan dysfunction syndrome) hemorrhage? (2)

A

> 35% blood loss (>1750 mls)

Irreversible shock

71
Q

What are signs of class IV (multiorgan dysfunction syndrome) hemorrhage irreversible shock? (7)

A 
Survival is unlikely
RR (Tachypnea)
HR (Thready, rapid pulse)
BP (Severe hypotension)
CR (delayed)
CNS (unresponsive)
Decreased to absent urine output
72
Q

What are some physiological responses, variations and determining factors in response to shock? (8)

A 
Age and relative health
Older adults
Children
General physical condition
Preexisting disease
Ability to active compensatory mechanisms
Medications
Specific organ system affected
73
Q

What are three keys to shock assessment? (3)

A

Early recognition is the key to patient survival

Look for subtle signs both initially and ongoing

Frequent ongoing assessments and trending

74
Q

What are the five points of shock management?

A

Airway and breathing

Hemorrhage control

Fluid resuscitation

Temperature control

Pharmacological intervention

75
Q

What should we assume the shock is until we prove otherwise?

A

Hypovolemic shock

76
Q

How do we differentiate cardiogenic shock from hypovolemic shock? (4)

A

Chief complaint: Chest pain, dyspnea, tachycardia

Heart rate

Signs of congestive heart failure

Dysrhythmias

77
Q

How do we differentiate distributive shock from hypovolemic shock? (3)

A

Mechanism suggesting vasodilation: spinal cord injury, drug overdose, sepsis, anaphylaxis

Warm, flushed skin

Lack of tachycardic response (not a reliable finding)

78
Q

How do we differentiate obstructive shock from hypovolemic shock? (4)

A

Signs and symptoms of:

Cardiac tamponade

Tension pneumothorax

Pulmonary embolism

79
Q

What are key vital signs for the detailed physical examination of shock? (4)

A

Pulse
Blood pressure
Orthostatic vital signs
Evaluate patients ECG

80
Q

What are four key points to resuscitation of shock patients?

A

Restore adequate tissue oxygenation by:

Ensuring adequate oxygenation

Maintaining effective volume-to-container size ratio

Rapid transport to appropriate medical facility

81
Q

How do we ensure red blood cell oxygenation in shock patients? (3)

A

Patent airway

Support ventilation with high FiO2, positive pressure ventilation PRN

Correct airway abnormalities that interfere with adequate ventilation

82
Q

How do we accomplish the ratio of volume to container size? (3)

A

Decrease the size of the container, especially in shock states not associated with hemorrhage

Vasoactive medications in some distributive shock (sepsis and cardiogenic)

Volume replacement as needed

83
Q

What are eight key principles in managing shock?

A 
Open airway
High-concentration oxygen
Assist ventilation as needed
Control external bleeding if present
IV fluid replacement PRN
Maintain body temperature
Monitor ECG and oxygen saturation
Reassess vital signs
84
Q

What are the key treatment guidelines for hypovolemic shock? (3)

A

Fluid volume replacement

Large volume fluid replacement if: systolic BP 90mmHg

85
Q

What are the key treatment guidelines of cardiogenic shock? (5)

A

Improve pumping action of the heart and manage the dysrhythmias
Fluid replacement
Drug therapy if needed
Cardiogenic shock due to myocardial ischemia or infarction requires: reperfusion strategies or possible circulatory support
Manage tension pneumothorax and cardiac tamponade

86
Q

What are the key treatment guidelines for neurogenic shock? (4)

A

Treatment is similar to hypovolemia

Avoid circulatory overload

Monitor lung sounds for pulmonary congestion

Vasopressors may be indicated

87
Q

What are the key treatment guidelines of septic shock? (6)

A

Management of hypovolemia if present
Correction of metabolic acid-base imbalance
Fluid resuscitation
Respiratory support
Vasopressors to improve cardiac output
Thorough history to the find the source of sepsis

88
Q

What are the key treatment guidelines for severe hemorrhagic shock? (5)

A 
Rapid recognition
Initiation of treatment
Prevention of additional injury
Rapid transport to appropriate hospital
Advanced notification to receiving facility
89
Q

What is shock? (3)

A

It is a state of inadequate perfusion relative to the demands of the tissues

It is the transitional stage between homeostasis and death

Underlying killer of all trauma patients

90
Q

What is a hemorrhage?

A

An abnormal internal or external discharge of blood

91
Q

What is homeostasis?

A

The natural tendency of the body to maintain a steady and normal internal environment

92
Q

What are the three types of hemorrhage?

A

Capillary
Venous
Arterial

93
Q

What is clotting?

A

The body’s three step response to stop the loss of blood

94
Q

What are the three phases of the clotting process?

A

Vascular phase
Platelet phase
Coagulation

95
Q

What is the vascular phase of clotting?

A

It is the first step in the clotting process in which smooth blood vessel muscle contracts, reducing the vessel lumen and the flow of blood through it

96
Q

What is the platelet phase of clotting?

A

It is the second step in the clotting process in which platelets adhere to blood vessel walls and to each other

97
Q

What is the coagulation phase of clotting?

A

It is the third step in the clotting process, which involves the formation of a protein called fibrin that forms a network around a wound to stop bleeding, ward off infection, and lay a foundation for healing and repair of the wound.

98
Q

What is to aggregate?

A

To cluster or come together

99
Q

What is fibrin?

A

Protein fibres that trap red blood cells as part of the clotting process

100
Q

What are four factors that hinder the clotting process?

A

Movement of the wound site
Aggressive fluid therapy
Low body temperature
Medications, such as aspirin, heparin, or warfarin

101
Q

What is to apply direct pressure to a wound?

A

It is a method of hemorrhage control that relies on the application of pressure to the actual site of bleeding

102
Q

What is a tourniquet?

A

It is a constrictor used on an extremity to apply circumferential pressure on all arteries to control the bleeding

103
Q

What is lactic acid?

A

Compound produced from pyretic acid during anaerobic glycolysis

104
Q

What does it mean to be anaerobic?

A

The ability to live without oxygen

105
Q

What is fascia?

A

A fibrous membrane that covers, supports, and separates muscles and may also unite the skin with underlying tissue

106
Q

What is a hematoma?

A

A collection of blood beneath the skin or trapped within a body compartment

107
Q

What is epistaxis?

A

It is bleeding from the nose resulting from injury, disease or environmental factors, a nosebleed

108
Q

What is an esophageal varice?

A

They are enlarged and tortuous esophageal veins

109
Q

What is melena?

A

Black, tar-like fees due to gastrointestinal bleeding

110
Q

What is anemia?

A

A reduction in the hemoglobin content in the blood to a point below that required to meet the oxygen requirements of the body

111
Q

What are pulse pressures?

A

The difference between the systolic and diastolic blood pressure

112
Q

What are catecholamines?

A

A hormone, such as epinephrine or norepinephrine, that strongly affects the nervous and cardiovascular systems, metabolic rate, temperature, and smooth muscle

113
Q

What are four early signs or symptoms of internal hemorrhage?

A

Pain, tenderness, swelling or discolouration of suspected injury site

Bleeding from mouth, rectum, vagina or other orficie

Vomiting of bright red blood
Tender, rigid and/or distended abdomen

114
Q

What are twelve late signs or symptoms of internal hemorrhage?

A 
Anxiety, restlessness, combativeness, or altered LOC
Weakness, faintness or dizziness
Vomiting of blood the color of dark coffee grounds
Thirst
Melena
Shallow, rapid breathing
Rapid, weak pulse
Pale, cool, clammy skin
Cap refill greater than 2 seconds
Dropping blood pressure
Dilated pupils sluggish in responding to light
Nausea/vomiting
115
Q

What is hematochezia?

A

The passage of stools containing red blood

116
Q

What is orthostatic hypotension?

A

A decrease in blood pressure that occurs when a person moves from a supine to a sitting or upright position

117
Q

What is metabolism?

A

The total changes that take place in an organism during physiological processes

118
Q

What is ischemia?

A

A blockage in the delivery of oxygenated blood to the cells

119
Q

What is hydrostatic pressure?

A

The pressure of liquids in equilibrium; the pressure exerted by or within liquids

120
Q

What is a rouleaux?

A

A group of red blood cells that are stuck together

121
Q

What is washout?

A

The release of accumulated lactic acid, carbon dioxide (carbonic acid), potassium, and rouleaux into the venous circulation

122
Q

What is compensated shock?

A

Hemodynamic insult to the body in which the body responds effectively. Signs and symptoms are limited, and the human system functions normally

123
Q

What is decompensated shock?

A

The continuing hemodynamic insult to the body in which the compensatory mechanisms breakdown. The signs and symptoms become very pronounced, and the patient moves rapidly toward death

124
Q

What is irreversible shock?

A

The final stage of shock in which organs and cells are so damaged that recovery is impossible

125
Q

What is overdrive respiration?

A

Positive pressure ventilation supplied to a breathing patient

Hematology & Anaphylaxis (8 decks)

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