Shock Flashcards by Rose Clousing

Shock def

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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what does impaired cellular metabolism lead to

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

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3 main causes of shock

heart problems (MI, valve dz etc)

low blood volume (burn, dehydration, diabetes insipidus)

overwhelming infection (usually bacteria and resulting toxins)

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early signs of shock

MAP drops by 10 mmHg from baseline
HR increases

at this point compensation to get o2 to vital organs works

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compensatory phase shock

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

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peds and elderly that are acting just not right..

need attention fast

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progressive phase of shock is when..

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

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refractory shock signs

MODS, very acidic, excessive cell or organ damage

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when pH drops what happens to potassium levels?

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

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what will you see with pH if pt in shock?

metabolic acidosis with a high anion gap

elevated lactate

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

Cellular edema - hydrolysis and cell death

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4 kinds of shock

distributive
cardiogenic
hypovolemic
obstructive or extracardiac obstructive

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distributive shock def

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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ex of what can trigger distributive shock

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

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cardiogenic shock

hearts inability to supply enough blood

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what can cause cardiogenic shock

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

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hypovolemic

lack of blood / fluid

hemorrhagic most common

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def obstructive shock

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

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possible causes of obstructive shock

tension ptx, tamponade, PE

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how is cardiac tamponade related to obstructive shock

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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what does PROVED MNemonic stand for?

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

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what does rapid mnemonic mean

resuscitation 
analgesia 
patient needs 
interventions 
disposition

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what is nikolskys sign

when skin sloughs off

hypovolemic shock

TX of hypovolemic shcok

IV 3-6 L
PRBC
control any bleeding

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

distributive shock

DX criteria for septic shock

``` 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 ```

TX septic shock

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

what empiric abx used for septic shock?

IV 3.375 g zoysn (pipercillin with tazobactam) AND IV 1g ceftriaxone OR 1g Imipenem IV

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

ceftriaxone to cover N. meningitides and H. influenza

what if pt neutropenic with septic shock?

cefepime or Imipenem

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

clindamycin or metronidazole

MRSA with septic shock

vancomycin

septic shock from pseudomonas infection

gentamicin or cefepime

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

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

what is leading cause of death in MI?

cardiogenic shock

AMI without pulmonary edema can treat with

IVF fluid challenge

AMI with pulmonary edema treat with

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

RV infarctions tx with

fluids and dobutamine NO NTG NTG will mess up preload

acute mitral regurgitation or VSD

dobutamine and nitroprusside

what is an anaphylactoid rxn

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

most common causes anaphylaxis

abx, food, insects

what is epi dose for anaphylaxis

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

what is corticosteroids for anaphylaxis

methylprednisolone 125 mg IV or Prednisone 60 mg PO

what antihistamine for anaphylaxis

H1 use diphenhydramine 25-50 mg IV | H2 ranitidine 50 mg IV

what bronchodilator for anaphylaxis

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

glucagon is for...

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

what if pt has allergic rash but no anaphylaxis

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

anaphylaxis tx in general

epi q5-10 min prn | watch 4-6 hrs

neurogenic shock occurs__-

after a spinal cord injury | SNS outflow is disrupted which leaves unopposed vagal tone = hypotension and bradycardia

how long does neurogenic shock typically last?

lasts 1-3 weeks

any injury above ___ can disrupt all of SNS

T1 | higher the injury the worse the paralysis

neurogenic shock vs spinal shock

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

cardiac tamponade tx

pericardiocentesis

Virchow triad

hypercoagulable, venous injury, venous stasis

if someon is high risk for PE what test order?

CT chest or VQ scan

if someone low risk PE what order?

d dmer

aortic stenosis tx

valve surgery if give NTG BP will drop ..bad!