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Emergency Medicine > Shock > Flashcards

Shock Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Shock def

A

a state of cellular and tissue hypoxia either from low O2 delivery or increased production

this leads to: tissue hypo perfusion and met acidosis, which leads to impaired cellular metabolism

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2
Q

what does impaired cellular metabolism lead to

A

lactic acid build up which leads to tissue acidosis and organ dysfunction

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3
Q

3 main causes of shock

A

heart problems (MI, valve dz etc)

low blood volume (burn, dehydration, diabetes insipidus)

overwhelming infection (usually bacteria and resulting toxins)

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4
Q

early signs of shock

A

MAP drops by 10 mmHg from baseline
HR increases

at this point compensation to get o2 to vital organs works

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5
Q

compensatory phase shock

A 
MAP drop by 10-15 
increase in renin and ADH 
vasoconstriction 
drop in pulse pressures 
drop in pH 
restless 
apprehensive
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6
Q

peds and elderly that are acting just not right..

A

need attention fast

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7
Q

progressive phase of shock is when..

A 
MAP dropped by 20 
tissue/organ hypoxia  
oliguria 
weak rapid pulse 
drop in pH 
sensory changes
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8
Q

refractory shock signs

A

MODS, very acidic, excessive cell or organ damage

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9
Q

when pH drops what happens to potassium levels?

A

K+ is pushed out of the cells so get temporary hyperkalemia

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10
Q

what will you see with pH if pt in shock?

A

metabolic acidosis with a high anion gap

elevated lactate

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11
Q

what happens after the ATP pump of hypoxic cells stops working?

A

Cellular edema - hydrolysis and cell death

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12
Q

4 kinds of shock

A

distributive
cardiogenic
hypovolemic
obstructive or extracardiac obstructive

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13
Q

distributive shock def

A

Poor distribution of blood: loss of vasomotor control that leads to arteriolar or venular dilatation

after fluid resuscitation you have increased CO yet low SVR

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14
Q

ex of what can trigger distributive shock

A 
anaphylactic rxn 
Sepsis (most common)  
addisonian crisis 
neurogenic shock 
SIRS/TSS
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15
Q

cardiogenic shock

A

hearts inability to supply enough blood

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16
Q

what can cause cardiogenic shock

A

arrhythmia, AMI, valve failure, cardiomyopathy, PE, pericarditis

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17
Q

hypovolemic

A

lack of blood / fluid

hemorrhagic most common

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18
Q

def obstructive shock

A

due to obstruction to flow in cardiovascular circuit and either impairment of diastolic filling or excessive afterload

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19
Q

possible causes of obstructive shock

A

tension ptx, tamponade, PE

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20
Q

how is cardiac tamponade related to obstructive shock

A

blood is filling up the pericardial sack (due to many reasons, neoplastic dz, aortic dissection, trauma etc)

this compresses the heart and impairs diastolic filling
= obstructs flow in CV circuit which leads to obstructive shock!

not enough blood gets pumped out

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21
Q

what does PROVED MNemonic stand for?

A 
Pump - cardiogenic shock 
Rhythm - arrhythmic shock 
Obstructive 
Volume - hypovolemic shock 
Endocrine - adrenal insufficiency 
Distributive Shock
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22
Q

what does rapid mnemonic mean

A 
resuscitation 
analgesia 
patient needs 
interventions 
disposition
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23
Q

what is nikolskys sign

A

when skin sloughs off

hypovolemic shock

24
Q

TX of hypovolemic shcok

A

IV 3-6 L
PRBC
control any bleeding

25
Q

what type of shock includes the depletion of fat, protein and glucose stores?

A

distributive shock

26
Q

DX criteria for septic shock

A 
sepsis + refractory hypotension 
after bolus 20-40 ml/kg pt still has one of following: 
- SBP under 90 
- MAP under 65 
- Decrease of 40 mmHg from baseline
27
Q

TX septic shock

A

NS IVF bolus 1-2 L wide open (if no CI)
supplemental o2
empiric abx

28
Q

what empiric abx used for septic shock?

A

IV 3.375 g zoysn (pipercillin with tazobactam)

AND

IV 1g ceftriaxone OR 1g Imipenem IV

29
Q

what if pt has septic shock and is asplenic? what abx?

A

ceftriaxone to cover N. meningitides and H. influenza

30
Q

what if pt neutropenic with septic shock?

A

cefepime or Imipenem

31
Q

septic shock with intra abdominal or head/neck anaerobic infxn give

A

clindamycin or metronidazole

32
Q

MRSA with septic shock

A

vancomycin

33
Q

septic shock from pseudomonas infection

A

gentamicin or cefepime

34
Q

what if there is no response in a distributive / septic shock pt after 2-3 L IVF?

A

start vasopressor (dopamine, NE)
titrate effectively
goal MAP over 60
consider adrenal insufficiency: hydrocortisone 100mg IV

35
Q

what is leading cause of death in MI?

A

cardiogenic shock

36
Q

AMI without pulmonary edema can treat with

A

IVF fluid challenge

37
Q

AMI with pulmonary edema treat with

A

dopamine to increase HR
dobutamine ..but may drop BP
combo good idea!

38
Q

RV infarctions tx with

A

fluids and dobutamine NO NTG

NTG will mess up preload

39
Q

acute mitral regurgitation or VSD

A

dobutamine and nitroprusside

40
Q

what is an anaphylactoid rxn

A

clinically cannot tell apart from anaphylaxis but it is not IGE mediated and does not require sensitizing exposure

41
Q

most common causes anaphylaxis

A

abx, food, insects

42
Q

what is epi dose for anaphylaxis

A

0.3 mg of epi IM q5-10 min prn
if CV collapse then.. 1 mg IV
if refractory start epi drip

43
Q

what is corticosteroids for anaphylaxis

A

methylprednisolone 125 mg IV or Prednisone 60 mg PO

44
Q

what antihistamine for anaphylaxis

A

H1 use diphenhydramine 25-50 mg IV

H2 ranitidine 50 mg IV

45
Q

what bronchodilator for anaphylaxis

A

albuterol nebulizer
atrovent neculizer
Magnesium sulfate 2 g IV over 20 min

46
Q

glucagon is for…

A

anaphylactic pts who are on a bb and have refractory hypotension
give 1 mg hypotension until it resolves

47
Q

what if pt has allergic rash but no anaphylaxis

A

H1: diphenhydramine or hydroxyzine
H2: rantidine, famotidine, cimetidine

Prednisone 1 mg/ kg max 50 mg daily for 5 days..unless dexamethasone administered

watch rash until sx improve

48
Q

anaphylaxis tx in general

A

epi q5-10 min prn

watch 4-6 hrs

49
Q

neurogenic shock occurs__-

A

after a spinal cord injury

SNS outflow is disrupted which leaves unopposed vagal tone = hypotension and bradycardia

50
Q

how long does neurogenic shock typically last?

A

lasts 1-3 weeks

51
Q

any injury above ___ can disrupt all of SNS

A

T1

higher the injury the worse the paralysis

52
Q

neurogenic shock vs spinal shock

A

spinal shock is temporary loss of spinal reflex activity below spinal cord injury

53
Q

cardiac tamponade tx

A

pericardiocentesis

54
Q

Virchow triad

A

hypercoagulable, venous injury, venous stasis

55
Q

if someon is high risk for PE what test order?

A

CT chest or VQ scan

56
Q

if someone low risk PE what order?

A

d dmer

57
Q

aortic stenosis tx

A

valve surgery

if give NTG BP will drop ..bad!

Emergency Medicine (19 decks)

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