shock

Question 1

essentials of shock dx

Answer 1

Hypotension
Tachycardia—often first symptom
Oliguria (dec. urine output)
AMS-very common
Peripheral hypoperfusion and impaired O2 delivery : why tx is set up: to inc. perfusion
*shock is important because regulated tightly by CMS (compensated-need to meet medicare guidelines) prevent ppl from dying of shock

Question 2

Flow chart for the basics of shock

Answer 2

Arterial blood flow can not keep up demand of tissues metabolic needs

• ->resulting in hypoxia to the body as a whole
• ->Resulting in anaerobic metabolism to kick in at peripheral tissues (bad!)
• ->Resulting in lactic acidosis (lab test: lactate) do not want!! (TEST: prognostic indicator of “badness”)

Question 3

shock: AMS Marshall stat

Answer 3

60-70% nursing home pts w. AMS have UTI, may not have fever, but hypothermia: poor px

Question 4

types of shock

Answer 4

Hypovolemic
Cardiogenic
Obstructive
Distributive

Question 5

hypovolemic shock

Answer 5

Decreased intravascular volume-Due to loss of blood, fluid, electrolytes (Clinical setting tells all here usually)
-Blood loss from whatever reason (trauma, ruptured ectopic pregnancy, GI bleed, etc)
-Loss of fluid and electrolytes (N/V/D)
-Body will compensate by vasoconstricting, but after 15% loss of volume, shock sets in : Oliguria, AMS, cool extremities, diaphoresis, pale
Narrow pulse pressure (reduced SV, clinically relevant)
Decreased PCWP, CO, venous return; Elevated TPR (low cardiac output failure)
-Improves with fluids

Question 6

Cardiogenic shock

Answer 6

Results from cardiac failure (MI, CHF)
Heart cannot maintain necessary CO
Defined as evidence of tissue hypoxia due to decreased CO in the presence of adequate intravascular volume.
-due to: MI, cardiomyopathy, valve dysfunction, arrhythmias (unstable VT, SVT (fine in younger pts, not in 70+)

-presentation: Oliguria, mental status changes, diaphoresis, cool extremities, jugular venous pressure is elevated, pulmonary edema might be present with respiratory failure, Low output failure (elev TPR, Low CO, venous return), Elev PCWP, BP improves with fluids

Question 7

How to differ between cardiogenic and hypovolemic shock

test question

Answer 7

Cardiac ECHO (and history, duh!!)

Hypovolemic shock: LV will be small due to poor filling, but maintains contractility
(doing what it should, not enough fluid to pump)

Cardiogenic shock: decrease in LV contractility
(problem with heart)

Question 8

Obstructive shock

Answer 8

Cardiac tamponade
Tension pneumothorax (needle first remember, not chest tube)
Massive PE

Question 9

Distributive shock (septic, SIRS, neurogenic, anaphylaxis) (CMS worries about THIS one)

Answer 9

Also known as vasodilatory shock
Produces a decreases in systemic vascular resistance…resulting tissue hypoperfusion (volume is there, just very vasodilated)

Normal circulatory volume
Low TPR, PCWP
Elevated CO, venous return (high output failure)
Vasodilation (warm dry skin) (not cold, pale, diaphoretic)

Question 10

SIRS

Answer 10

Systemic Inflammatory Response Syndrome
Can occur from an infectious cause, or noninfectious (burns, pancreatitis, trauma, ischemia)
“baby sepsis”

Question 11

SIRS: need to have at least 2 of the following:

Answer 11

• Temp more than 100.4, or less than 96.8
• HR more than 90
• RR more than 20 or hyperventilation with a CO2 on abg less than 32
• WBC more than 12 or less than 4 or greater than 10% bands

Question 12

Septic shock

Answer 12

The new rage!!!!
SIRS + a source (UTI, pneumonia, cellultis, meningitis)
-Most common type of distributive, 20-50% mortality
-Risks are age, DM, immunosupression (AIDs, steroids), recent invasive procedures
-Most common due to gram negatives (E coli, Pseudomonas*, Klebsiella)
Shock in setting of DIC from trauma often is from sepsis

Question 13

Neurogenic shock

Answer 13

Caused by traumatic spinal cord injury or by effects of an epidural, or spinal anesthetic
Loss of sympathetic tone and systemic vascular resistance
Hypotension WITHOUT a compensatory tachycardia

A benign other type of neurogenic shock which can result in syncope is “vasovagal syncope”—caused by pain, gastric dilatation, or fright, producing hypotension, bradycardia, and syncope. (may get better with laying down, in contrast to septic shock)

Question 14

shock s/s

Answer 14

• Hypotension: may be masked in early stages by compensatory mechanisms such as tachycardia, increased cardiac contractility, and vasoconstriction
• Cool and mottled extremities
• Splanchnic vasoconstriction can lead to oliguria (lead to renal failure), bowel ischemia, hepatic dysfunction, MSOF, AMS is very very common

Question 15

sepsis lab markers

Answer 15

lactate (draw serial lactates to monitor how well tx is working)
procalcitonin

Question 16

General treatment measures

what type of acid/base imbalance??

Answer 16

ABC’s with prompt intervention

• Respiratory failure not uncommon—due to existing metabolic acidosis (can’t compensate with respiratory hyperventilation, still tachypnic)
• Intubation can reduce O2 demand of respiratory muscles and allow improved oxygen delivery to other hypoperfused tissues.

Monitor urinary output (bad if nothing coming out while giving fluids), possibly foley
IV fluids for hypotension

Question 17

Hemorrhagic shock: Volume tx

Answer 17

IVF to an extent
BLOOD!: need the O2 carrying capacity vs. saline (just fluid volume, but body need O2 carrying capacity!!–>blood)
O neg (universal if no time)
Type and Cross if have time (30-45-60 min)

Question 18

Hypovolemic shock volume tx

Answer 18

.9NS 1 L increments usually

Question 19

Cardiogenic shock volume tx

Answer 19

.9NS 250ml boluses—be careful here not to fluid overload—pressers (inc. BP)

“baby boluses”, not giving Liters here (contractility issue), the heart is failing, will put in CHF–>use pressors

Question 20

Septic shock (i.e. SIRS + source) volume tx

Answer 20

30ml/kg .9NS to start off
WITHOUT exception
100 kg guy: 3L! (tons of fluid, hard to do)
main enemy is hypotension, not necessarily HF

Question 21

Early Goal Directed Therapy for septic shock

test question

Answer 21

.9NS to achieve CVP (central venous pressure) 8-12 mm Hg
Vasopressors to achieve MAP 65 mm Hg or greater
PRBCs (packed RBCs) to achieve Hgb of 10 or greater
Results in lower mortality and morbidity

Question 22

When fluids don’t work to maintain blood pressure ??

Answer 22

PRESSORS!
Need central line to give (not IV, localized inc. in pressure–>necrosis (story: lost leg)
Dobutamine, Norepinephrine (Levophed), vasopressin, dopamine

DO NOT place central line in artery: how to tell in vv vs. aa: ABG should be a lot different (higher O2) than values measured in vein (problem if same!! implies you are in artery)

Question 23

Corticosteriods used in shock when due to ??

Answer 23

adrenal insufficiency

Otherwise, not shown to be beneficial

Question 24

abx for ??

Answer 24

Septic shock
SIRS

Vancomycin for MRSA in oldies

Question 25

Narrow pulse pressure (reduced stroke volume)
Decreased PCWP
decreased CO
decreased venous return Elevated TPR

Answer 25

hypovolemic shock

low output failure

Question 26

Normal circulatory volume
Low TPR
low PCWP
Elevated CO
elevated venous return

Answer 26

distributive shock (sepsis, SIRS, neurogenic, anaphylaxis)
high output failure

Question 27

Low output failure 
elevated TPR
Low CO
low venous return
Elev PCWP

Answer 27

cardiogenic shock

low output failure