Shock

Question 1

What type of shock has decreased intravascular volume

Answer 1

Hypovolemic shock (hemorrhagic or severe dehydration)

Question 2

What type of shock has widespread vasodilation and increased capillary permeability?

Answer 2

Distributive shock (Spinal, Anaphylactic, Septic shock)

Question 3

Paremeter to evaluate tissue perfusion

Answer 3

MAP (less than 60mmhg tissue perfusion becomes compromised)

Urine output

Question 4

Explain the stages of shock

Answer 4

1) Initial stage - no visible changes, but changes are occurring at the cellular level
2) Compensatory - measurable increase in HR, vasoconstriction to increase CO (goal is to restore tissue perfusion)
3) Progressive - compensatory mechanism begins to fail
4) Refractory - irreversible shock, total body failure.

Question 5

S/S of DIC

Answer 5

Petechiae, ecchymosis, bleeding form membrane and puncture sites.
Prolonged or elevated PT, aPtt, INR, fibrin split products,
D-Dimer

Question 6

What is the ABG in the early stage of shock and late stage of shock and why?

Answer 6

Early stage: Respiratory alkalosis bc of hyperventilation (blow off CO2)
Late stage: Respiratory/Metabolic Acidosis bc the patient RR decreases bc the pt is getting tired.

Question 7

Normal Lactate levels

Answer 7

0.9-1.7mmol/L

Question 8

Which lab values would you look for in shock

Answer 8

Increased lactate (acidosis)
Decreased H&H if hemorrhaging
Increased Potassium with dehydration and acidosis
Increased C-reactive protein bc of inflammatory state.

Question 9

Assessment finding in the Compensatory, Progressive and Irreversible stages of shock?

Answer 9

Compensatory stage: Normal BP, RR>22, HR>100, cold and clammy skin, decreased UO, confused, Resp alkalosis.

Progressive Stage: Systolic BP150, mottled/patechiae, decreased UO, Lethargy, Metabolic acidosis

Irreversible stage: Requires mechanical ventilation and pharm support, erratic or asystole, jaundice, anuria (dialysis), unconscious, profound acidosis.

Question 10

SIRS criterias

Answer 10

Two or more of the following:
Hyperthermia >38C (100.4) or Hypothermia 90bpm
RR > 20 bpm or PaCO2 12000 or Decreased WBC

Question 11

Sepsis Continuum (Sepsis - Severe Sepsis - Septic Shock - MODS)

Answer 11

Sepsis - suspected or present source of sepsis (activation of SIRS may or may not be present)

Severe Sepsis - Organ dysfunction, hypotension or hypo-perfusion; Lactic Acidosis; SBP 40mmHg of normal

Septic Shock - Severe sepsis with hypotension, despite adequate fluid resuscitation.

MODS - Altered fx of two or more organs (monitor labs)

Question 12

Goal of septic shock

Answer 12

Resolve infection and maintain adequate CO
CVP >8-12 mmHg (on vent 12-15mmHg)
Map >65 mmHg (or SBP > 90mmHg)
ScvO2 > 70%

Question 13

Assessment finding in the warm phase

Answer 13

Skin is warm and flushed 
Increase CO (d/t low SVR)
Decreased SVR (vasodilation)

Question 14

Assessment finding in the cold phase

Answer 14

S/S of the irreversible phase
Decreased CO d/t decreased venous return (preload) and decreased contractility (decrease ventricular filling = decreased stretch = decreased contractility)
Increased SVR (vasoconstriction)

Question 15

Severe Sepsis 3hr Resuscitation Bundle

Answer 15

Measure lactate level
Draw cultures prior to administrating broad spectrum antibiotic
Adminster 30ml/kg of crystalloid for hypertension or lactate > 4

Question 16

6 hr septic shock bundle

Answer 16

Vasopressor (for hypotension that doesn't respond to fluid resuscitation to maintain MAP > 65mmHg)
Measure CVP (keep >8-12mmHg), ScvO2 > 70%
Remeasure Lactate if initial lactate was elevated.

Question 17

Within 24hrs of shock

Answer 17

Hydrocortison (may be depleted) - given to pt with persistent hypotension (SBP