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CVM > Shock > Flashcards

Shock Flashcards

1
Q

What is the definition of shock?

A

Tissue hyoperfusion and cellular hypoxia

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2
Q

What are the six different factors that lead to shock?

A

decreased O2 delivery, or utilization, increased O2 consumption. Hypotension below 80-90 mm Hg
Decreased systolic BP 40 mm Hg below baseline
MAP (mean arterial pressure) <60-65 mm Hg

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3
Q

What is the pathophysiology behind shock? (up to vasodilatory shock)

A

Failure to deliver and utilize O2
Increased O2 consumption (tissue demand)
Anaerobic glycolysis leads to lactate
Non-compensatory response- pathologic results

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4
Q

What is the pathophysiology of shock starting at vasodilatory shock has occurred?

A

Vasodilatory Shock- unregulated NOS, interstitial fluid, cellular edema, impaired O2 diffusion
Increased lactate-> acidosis accompanies shock
Lactate levels reflect tissue hypoxia
If D O2 fails to meet O2 demand, develop O2 debt. Cellular inflammation and injury; irreversible/ decompensated shock

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5
Q

What are the broad categories that are included in the S/S of shock?

A 
Extremities/skin
Neck veins
Heart Rate
BP
Respirations
Renal
Heart
Metabolic
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6
Q

What are the S/S of shock in the extremities/skin

A

Cool, clammy, cyanotic, pallor mottled distally, decreased perfusion/vasoconstriction, dry mucous membranes, decreased skin turgor- seen in hypovolemic, cardiogenic, obstructive shock; warm and pink extremities- associated with vasodilation of distributive/dissociative shock (cyanide position

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7
Q

What are the neck S/S of shock?

A

Neck veins: Distended (HF, PE, tamponade); flat (hypovolemic)

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8
Q

What are the hear rate s/s of Shock?

A

Fast (sensitive indicator of shock); occasionally slow

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9
Q

What are the BP S/S of shock?

A

Systolic usually low; diastolic usually low

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10
Q

What are the respiration S/S of shock?

A

Tachypnea, bronchospasm, respiratory failure

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11
Q

What are the renal symptoms of shock?

A

Receive 20% of CO oliguria; associated with vomiting, diarrhea, hemorrhage

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12
Q

What is the criteria of oliguria

A

<400-450 cc/24 hr; < 5 cc/kg/hr

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13
Q

What are the heart symptoms of shock?

A

Decreased coronary perfusion, ischemica; increased LVDP; mental status changes- decreased cerebral perfusion, confused restless, agitated, deliria, stupor, coma

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14
Q

What are the metabolic symptoms of shock?

A 
Respiratory alk (decreased pCO2, breathing), followed by met acidosis; increased glycerin, decreased glycemia, increased K, increased anion gap (non-measurable anions) (Na-(Cl+HCO3))
Frequently increased lactate/think shock; higher lactate= higher mortality
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15
Q

What are the 3 categories of hypovolemic shock?

A

Hemorrhagic
Non-hemorrhagic
DKA

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16
Q

What is the hemorrhagic version of shock?

A

GI bleeding (varices, ulcer, diverticuli), pelvic bleeding (post-partum hemorrhage, vaginal hemorrhage (laceration), hemorrhagic pancreatitis, AVM

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17
Q

What is the non-hemorrhagic cause of shock?

A

GI losses (V/D), skin losses (burns, heat strokes)

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18
Q

Discuss DKA form of shock?

A

Renal losses (salt washing, osmotic diuresis) hypoaldosternoism, adrenal insufficiency, third space loss (pancreatitis, bowel obstruction (sequestration of fluids) systemic inflammation

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19
Q

What is the most common cause of hypovolemic shock?

A

Hemorrhagic

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20
Q

What is a critical component to the presentation of hypovolemic shock?

A

Date of volume loss; helps determine acute vs slow

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21
Q

What are treatment issues with volume?

A

Tx depends on the circulating integrity (shock)- over zealous or too rapid correction
(rate of replacement composition of replacement)

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22
Q

If someone is in shock how fast should you administer fluids and what two things do you have to monitor afterwards?

A

Rx fluids fast. Monitor BP and tissue perfusion

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23
Q

Discuss crystalloids, what is the main cation, when are they useful for fluid replacement?

A

Na (main cation), used in hypovolemia from renal, GI, sweat, burns, hemorrhage

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24
Q

What is D5-W equivalent to?

A

free water

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25
Q

When should packed RBC be administered?

A

for hemorrhage

26
Q

How do we classify hemorrhagic shock?

A

Class I through IV

27
Q

Discuss the criteria for class I hemorrhagic shock (including blood loss, % volume, PP, BP, Pulse pressure, RR, Urine output, mental status, fluid replacement)

A 
Blood loss (ml) up to 750 ml
% volume up to 15
Pulse rate (per min) <100
Blood pressure Normal
Pulse pressure Normal or increased
RR- 14-20
Urine output (ml/hr) >30
Mental Status Slightly anxious
Fluid replacement- Crystalloid
28
Q

Discuss the criteria for class II hemorrhagic shock (including blood loss, % volume, PP, BP, Pulse pressure, RR, Urine output, mental status, fluid replacement)

A 
Blood loss (ml) 750-1500
% volume 15-30
pulse rate (per minute) >100
Blood pressure Normal
Pulse pressure Decreased 
Respiratory rate 20-30 per min
Urine output 20-30 ml/hr
Mental status mildly anxious
Fluid replacement crystalloid
29
Q

Discuss the criteria for class III hemorrhagic shock (including blood loss, % volume, PP, BP, Pulse pressure, RR, Urine output, mental status, fluid replacement)

A 
Blood loss (ml) 1500-2000
% volume 30-40
Pulse rate (per minute) >120
Blood pressure decreased
Pulse pressure Decreased
RR 30-40
Urine output 5-15 ml/hr
Mental Status anxious, confused
Fluid replacement crystalloid and blood
30
Q

Discuss the criteria for class IV hemorrhagic shock (including blood loss, % volume, PP, BP, Pulse pressure, RR, Urine output, mental status, fluid replacement)

A 
Blood loss (ml) >2000 ml 
% vol >40
Pulse rate (/min) >140
Blood pressure decreased
Pulse pressure Decreased
RR >35
Urine output (ml/hr) negligible
Mental Status- confused, lethargic
Fluid replacement crystalloid and blood
31
Q

What if someone’s blood pressure doesn’t improve after giving fluid (for a hypovolemic shock)?

A

Continue with fluids and add a vasopressor

32
Q

Describe the two forms of distributive shock?

A

Septic or non-septic (vasodilation)

33
Q

How common is distributive shock?

A

Most common form of noncardiogenic shock

34
Q

What is the mortality rate of distributive shock?

A

29-46%

35
Q

What is sepsis criteria?

A

Fever, Tachy, increased RR, increased WBC (you need two or the four plus a suspected source of infection)

36
Q

What are some common sources of infection?

A

Pulmonary (pneumonia, emphysema), abdominal (peritonitis, cholangitis), GU (pyelonephritis, abscess), CNS (meningitis), Skin (cellulitis, necrotizing fasciitis)

37
Q

What are the criteria for septic shock?

A

If there is severe sepsis you have a decreased BP (<90 systolic or >40 mmHg and decreased baseline)

38
Q

Describe the septic shock pathophysiology up to (and including) the action of microorganisms

A

Tissue hypoxia activates inflammation
Endothelial injury- release NO2 potent vasodilator
Mediators of sepsis-endotoxin
Cytokines (IL-6, TNFa)
Nitric oxide
Microorganisms activate innate, adaptive, endothelial immune responses and coagulation

39
Q

Describe the septic shock pathophysiology after the action of microorganisms

A

Endothelial injury- becomes permeable to leak fluids into tissue (lung, intestine, capillary leak) release NO2, potent vasodilator decreased preload
Distributive- abnormal distribution of systemic blood flow
In addition to vasodilation/microvascular vasoconstrictive tissue hypoxia increased lactate

40
Q

What are some S/S of septic shock?

A

Extremities/skin- warm, flushed (vasodilator)
Heart rate- fast; 10-30% have myocardial depression
BP- low (<90 systolic BP)
Neck veins- flat
Mental status changes
Renal
Clinically- hypovolemic, vasodilation, impaired tissue O2 use (dissociative shock)

41
Q

What are the distributive hemodynamics with septic shock (vasodilatory)

A

Decreased BP, decreased JVP/decreased CVP, decreased SVR
Increased HR, Increased CO, PAOP decreased
Extremities warm
Lungs dry
Tissue perfusion (mixed venous (SVO2 oxyhemoglobin sat) >65%

42
Q

How do we dx anaphylactic shock?

A

Clinically

43
Q

What are the sx of anaphylactic shock?

A

Cutaneous (urticaria, oral-facial angioedema, hives, flushing, pruritus)
Respiratory (dyspnea, cough, wheezing, stridor)
Abdominal (cramping, pain)
Vascular (decreased BP, chest pain, arrhythmias)

44
Q

What is a life-threatening/danger signal in anaphylactic shock?

A

Rapid progression of sx

45
Q

What is respiratory distress (in the context of anaphylactic shock)?

A

stridor, persistent cough, wheezing, hypotension

46
Q

What is the pathophysiology of septic shock?

A

Type I IGE mediated (immediate) hypersensitivity; mast cells release cytokines, histamine, tryptase
Vasodilation, vascular permeability, visceral smooth muscle contraction, tissue inflammation

47
Q

What are some tx for anaphylatic shock

A

Oxygen, Ivs for saline bolus
Epinephrine
If bronchospasm- albuterol
Methylprednisolone

48
Q

How does the distributive hemodynamic profile of anaphylactic shock compare to that of septic shock?

A 
It is the same
PAOP N(early) or decreased (late)
Decreased or increased CO
Decreased SVR
Tissue perfusion >65%
49
Q

What is the definition of cardiogenic shock

A

Decreased systemic O2 delivery; deterioration of cardiac dysfunction due to myocardial, valvular, structural, toxic or infectious

50
Q

What does inadequate cardiac pumping lead to (cardiogenic shock)?

A 
Decreased BP (<90 or > 30 mm Hg below baseline)
Decreased CO, decreased UO
51
Q

What would you expect of other lab values including
Cl, PCWP, EF, SVR
Tissue perfusion during cardiogenic shock?

A 
Cl < 22
Increased PCWP
Decreased EF
SVR
Decreased Tissue perfusion <65%
52
Q

What are the 3 broad categories of cardiogenic shock

A

Cardiomyopathic, arrhythmogenic

Mechanical

53
Q

What falls into the category of Cardiomyopathic cardiogenic shock

A

MI, myocarditis, cardiomyopathy, exacerbation of severe HF

54
Q

What falls into the category of arrhythmogenic cardiogenic shock

A

Tach (A fib, flutter, re entrant tach, brady (complete heart block, Mobitz (2nd degree

55
Q

What falls into mechanical?

A

Severe AI or MR; acute valvular rupture (papillary or chordae teninea rupture, abscess) Critical AS, VSD, rupture vent wall aneurysm, atrial myxoma

56
Q

What are some Clinical signs of cardiogenic shock?

A

Decreased blood pressure, decreased urinary output, AMS
Cool, mottled extremities
Distended neck veins
Pul edema

57
Q

What is the most common etiology of Cardiogenic shock

A

LV failure secondary to AMI, acute MR, VSD, RV infarction, ventricular wall rupture (tamponade)

58
Q

What is the pathophysiology of cardiogenic shock?

A

Failure to pump
SV and CL
Increased SVR
Increased cyotkines

59
Q

What is the mortality rate of CS

A

~40-50%

60
Q

How long does it take for a CS to develop s/p STEMI

A

7-10 hours

CVM (10 decks)

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