Shock

Question 1

What are the 4 types of shock

Answer 1

Hypovolemic shock
Cardiogenic shock
Distributive shock
Obstructive shock

Question 2

What is pre-shock

Answer 2

Stage of shock characterized by rapid compensation of diminished tissue perfusion by various homeostatic mechanisms

Question 3

What are general signs of all types of shock

Answer 3

low blood pressure, decreased urine output, and altered mental status

Question 4

what are the early signs of shock

Answer 4

hypotension, tachycardia, dyspnea, mental confusion, restlessness, diaphoresis and cool, clammy skin

Question 5

What are late signs of shock

Answer 5

Dropping or unobtainable blood pressure, a rapid, thready pulse, dusky discoloration of skin, skin is cool or cold to the touch, irregular, gasping respirations and decreased level of consciousness with eventual unresponsiveness

Question 6

What are causes of hypovolemic shock

Answer 6

• Loss of blood: examples include trauma with either external or internal bleeding - may be referred to as hemorrhagic shock.
• External loss of fluids: examples include vomiting, diarrhea, burns and severe exfoliative dermatitis (i.e. SJS and TSS).
• Internal loss of fluids (“third spacing”): examples include ascites and pancreatitis

Question 7

What are the ssx of hypovolemic shock

Answer 7

A rapid, weak, thready pulse due to decreased blood flow combined with tachycardia.
Rapid and shallow breathing due to sympathetic nervous system stimulation and acidosis.
Hypothermia due to decreased perfusion and evaporation of sweat.
Thirst and dry mouth, due to fluid depletion.
Cold and mottled skin (livedo reticularis), especially extremities, due to insufficient perfusion of the skin

Question 8

Who is at risk for hypovolemic shock

Answer 8

Those with: Disorders involving vascular integrity
Disorders of platelet number and/or function
Disorders of coagulation factors
Medications

Question 9

How long does the effect of ibuprofen on platelets last

Answer 9

48-72 hours

Question 10

How long should aspirin be discontinued before surgery

Answer 10

7 days at least, 10 is better, 14 is best

Question 11

What labs should be checked if someone is on Warfarin

Answer 11

INR (standardized PT)

Question 12

What is checked if some one is on heparin

Answer 12

PTT. normally you are switched of heparin

Question 13

What is the action of warfarin (coumadin)

Answer 13

Poisons the liver pathway, so antidote with vitamin K

Question 14

What is the antidote for hepatin

Answer 14

protamine sulfate

Question 15

What common drug can cause bleeding in those on warfarin

Answer 15

antibiotics, as the number of vitamin K producing gut bacteria can be significantly reduced

Question 16

What is a shock index

Answer 16

patient’s heart rate divided by the pt’s systolic blood pressure

Question 17

Why is the shock index used

Answer 17

SI has been shown to be a stronger predictor of the impact of blood loss than either the heart rate and blood pressure alone.
The shock index has been used to better risk stratify patients for increasing transfusion requirements and for mortality

Question 18

What is a normal shock index

Answer 18

Normal SI = 0.5 - 0.7

Question 19

What is a class 1 hemorrhage

Answer 19

Involves 1-15% of person’s blood volume. typically no change in vitals and fluid resuscitation is not normally necessary

Question 20

What is a class 2 hemorrhage

Answer 20

15-30% blood volume loss. A patient is often tachycardic with a narrowing of the difference between the systolic and diastolic blood pressures. 
In class II hemorrhage, the body attempts to compensate for decreasing circulatory blood volume with peripheral vasoconstriction; the skin may look pale and be cool to the touch

Question 21

What is the minimum treatment for class 2 hemorrhage

Answer 21

Volume resuscitation with crystalloids such as hypertonic saline solution or lactated Ringer’s solution is generally required

Question 22

What is livedo reticularis

Answer 22

Livedo reticularis is a common skin finding consisting of a mottled reticulated vascular pattern that appears as a lace-like purplish discoloration of the skin. The discoloration is caused by swelling of the venules owing to obstruction of capillaries by small blood clots.

Question 23

What is class 3 hemorrhage

Answer 23

30-40% blood volume loss. Blood pressure drops, heart rate increases, peripheral hypoperfusion increases and mental status worsens with altering level of consciousness

Question 24

What is class 4 hemorrhage

Answer 24

> 40% blood volume loss. The limit of the body’s compensation is reached and aggressive resuscitation is required in order to prevent death

Question 25

How do you estimate BP

Answer 25

If a radial pulse is palp. - B/P is ≈ 80 syst.
If a brachial pulse is palp. - B/P ≈ 70 syst.
If a femoral pulse is palp. - B/P ≈ 60 syst.
If a carotid pulse is palp. - B/P ≈ 50 syst

Question 26

What should be done if there is hemorrhagic shock due to trauma

Answer 26

Establish a patent and protected airway while protecting the cervical spine
Maximize oxygenation
Gain intravenous access and initiate fluid resuscitation
Control hemorrhage
Monitor level of consciousness and reassess V/S at least every 3 - 5 minutes

Question 27

What is a big no-no if someone has hemorrhagic shock

Answer 27

No food or drink!! (they probably have to go to surgery and there is a risk of vomiting)

Question 28

What causes cardiogenic shock

Answer 28

A shock that results from an inadequate circulation of blood due to primary failure of the ventricles of the heart, resulting in insufficient perfusion of tissue to meet the demands for oxygen and nutrients.

Question 29

What are ssx of cardiogenic shock

Answer 29

Drop in blood pressure
Distended jugular veins due to increased jugular venous pressure
Weak or absent pulse
Arrhythmias, often tachycardias
Pulsus paradoxus in case of tamponade
Congestive heart failure

Question 30

What is the treatment for cardiogenic shock

Answer 30

Depending on the type of cardiogenic shock, treatment involves infusion of intravenous fluids, or in shock refractory to fluids, inotropic medications, anti-arrhythmic agents may be administered.
If cardiogenic shock is due to a MI, attempts to open the heart’s arteries may help.
Intra-aortic balloon pump

Question 31

What is distributive shock

Answer 31

Output of heart is normal but vasoconstriction prevents perfusion

Question 32

What subclasses of distributive shock

Answer 32

Septic shock
Anaphylactic shock
Neurogenic shock
Vasodilator drugs
Endocrine related shock (addisonian crisis)

Question 33

What is obstructive shock

Answer 33

form of shock associated with physical obstruction of the great vessels or the heart itself.

Question 34

What are common causes of obstruct shock

Answer 34

Pulmonary embolism, emboli to the cardiac vessels, severe aortic stenosis and cardiac tamponade forms of obstructive shock