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Emergency medicine > Shock > Flashcards

Shock Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Definition of Shock:

A
  • state of cellular and tissue hypoxia
  • due to reduced oxygen delivery
  • or increased consumption
  • resulting in tissue hypoperfusion and metabolic acidosis
  • initially reversible
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2
Q

another definition of shock:

A
  • inadequate tissue perfusion resulting in impaired cellular metabolism
  • cells deprived of oxygen and nutrients resulting in anaerobic metabolism
  • lactic acid causes tissue acidosis and organ dysfunction
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3
Q

shock is caused by 3 major problems:

A
  1. Problems with the heart
  2. Circulating blood is low
  3. Overwhelming infection
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4
Q

early signs of shock:

A
  • MAP decrease of 10 BP from baseline
  • effective compensation
  • O2 to vital organs
  • increased HR
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5
Q

compensatory signs:

A
  • MAP decreased 10-15 BP from baseline
  • increased renin
  • increased ADH
  • Vasoconstriction
  • decreased pulse pressure
  • increased HR
  • decreased pH
  • restless
  • Apprehensive
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6
Q

progressive signs:

A
  • MAP decreased 20 BP from baseline
  • tissue hypoxia
  • decreased urine
  • weak rapid pulse
  • sensory neural changes
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7
Q

refractory signs:

A
  • excessive cell
  • organ damage
  • multi system organ failure
  • decreased pH
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8
Q

MAP=

A

(SABP+2DABP)/3

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9
Q

Bodys reaction to shock:

A
  1. Arteriolar Vasoconstriction
    - shunting blood from skin, muscle, kidneys, and spleen
  2. Increase in HR and contractility
    - increase cardiac output
  3. Constriction of venous vessels
    - increasing venous return
  4. release of vasoactive hormones
  5. Release of ADH to conserve intravascular volume
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10
Q

What happens during global tissue hypoxia?

A
  • endothelial inflammation and disruption
  • lactic acidosis
  • cardiovascular insufficiency
  • increased metabolic demands
  • vicious cycle!
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11
Q

MODS= multi organ dysfunction syndrome:

A
  • cardiac depression
  • respiratory distress
  • renal failure
  • DIC
  • End organ failure
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12
Q

4 types of shock:

A
  • distributive (septic most common)
  • cardiogenic
  • hypovolemic
  • obstructive
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13
Q

most types of shock are caused by the disruption of:

A
  1. pump
  2. pipes
  3. volume
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14
Q

hypovolemic shock:

A
  • lack of blood or fluid

- hemorrhagic most common

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15
Q

obstructive shock:

A

-some type of obstruction

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16
Q

distributive shock:

A
  • inadequate distribution of blood
  • neuro/vasogenic
  • anaphylactic
  • spetic
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17
Q

cardiogenic shock:

A

-hearts inability to supply adequate blood supply

18
Q

clinical manifestations of shock:

A
  • hypotension
  • tachycardia
  • oliguria
  • mental status changes
  • cool, clammy, cyanotic skin, mottled skin
  • metabolic acidosis- high anion gap with elevated lactate
19
Q

initial stabilization:

A
  • ABCs
  • stop underlying condition
  • assess perfusion:
  • hypotension (shock can occur without this)
  • cool skin, tacky, obtundation, restless, anuria
  • 2 large bore IVs, IO, or central line placement
20
Q

Goals of TX:

A 
ABCDE
Airway
control work of Breathing
optimize Circulation
assure adequate oxygen Delivery
achieve End points of resuscitation
21
Q

68 yo M with hx of HTN and DM presents to the ED c/o severe N/V. Wife says he isn’t “acting right.” Hasn’t been able to tolerate PO for 2 days.
The pt is hypotensive, tachycardic, afebrile, with cool but dry skin, poor turgor.

A

Hypovolemic Shock

22
Q

non-hemorrhagic hypovolemic shock:

A 
Vomiting  (DKA)
Diarrhea
Bowel obstruction, pancreatitis
Burns 
Neglect, environmental (dehydration)
23
Q

hemorrhagic hypovolemic shock:

A 
GI bleed
Trauma
Massive hemoptysis
AAA rupture
Ectopic pregnancy, postpartum bleeding
24
Q

An 81 yo with altered mental status. She is febrile to 39.4, hypotensive, coughing, hypoxic to 88%, tachycardic to 133.

A

Disruptive

Prob 2/2 Sepsis

25
Q

clinical signs of septic shock:

A 
Hyperthermia or hypothermia
Tachycardia
Wide pulse pressure
Low blood pressure (SBP<90)
Mental status changes
Beware of compensated shock!
Blood pressure may be “normal”
26
Q

A 55 yo M with hx of HTN, DM presents with “crushing” substernal CP, diaphoresis, hypotension, tachycardia and cool, clammy extremities.

A

cardiogenic

27
Q

cardiogenic shock

A

heart fails to pump

-decreased contractility causes decreased cardiac output and impaired perfusion

28
Q

Leading cause of death in MI:

A

cardiogenic shock

29
Q

causes of cardiogenic shock:

A
  • AMI
  • Sepsis
  • Myocarditis
  • myocardial contusion
  • aortic or mitral stenosis, HCM
  • Acute aortic insufficiency
30
Q

24 yo mowing the lawn and stung by something. Became anxious, diaphoretic, began wheezing, noted diffuse pruritic rash, nausea, and a sensation of her “throat closing off”. She is currently hypotensive, tachycardic and ill-appearing.

A

Disruptive

2/2 Anaphylaxis

31
Q

Distributive shock:

A

Excessive dilation of blood vessels or decreased vascular resistance
Fluids pool in dependent areas of the body and is not returned to the arterial circulation
Complicated by increased capillary permeability causing plasma into interstitial compartment

32
Q

symptoms of anaphylactic shock:

A

First- Pruritus, flushing, urticaria appear

Next- Throat fullness, anxiety, chest tightness, shortness of breath and lightheadedness

Finally- Altered mental status, respiratory distress and circulatory collapse

33
Q

anaphylactic shock tx:

A 
ABC’s
Angioedema and respiratory compromise require immediate intubation
IV, cardiac monitor, pulse oximetry
IVFs, oxygen
Epinephrine
Second line
Corticosteriods
H1 and H2 blockers
34
Q

Epi is most important step:

A 
0.3 mg IM of 1:1000 (epi-pen) 
Repeat every 5-10 min as needed
Caution with patients taking beta blockers- can cause severe hypertension due to unopposed alpha stimulation
For CV collapse, 1 mg IV of 1:10,000
If refractory, start IV drip
35
Q

how long do you observe its who’ve received epi?

A

All patients who receive epinephrine should be observed for 4-6 hours
If symptom-free, discharge home
If on beta blockers or h/o severe reaction in past, consider admission

36
Q

A 41 yo M presents to the ER after an MVC complaining of decreased sensation below his waist and is now hypotensive, bradycardic, with warm extremities

A

Disruptive

Neurogenic

37
Q

Neurogenic shock:

A

Occurs after acute spinal cord injury
Sympathetic outflow is disrupted leaving unopposed vagal tone
Results in hypotension and bradycardia
Spinal shock- temporary loss of spinal reflex activity below a total or near total spinal cord injury (not the same as neurogenic shock, the terms are not interchangeable)

38
Q

Neurogenic shock tx:

A 
A,B,Cs
Remember C-spine precautions
Fluid resuscitation
Keep MAP at 85-90 mm Hg for first 7 days
Thought to minimize secondary cord injury
If crystalloid is insufficient, use vasopressors
Search for other causes of hypotension
For bradycardia
Atropine
Pacemaker
39
Q

Methylprednisolone tx:

A

Used only for blunt spinal cord injury
High dose therapy for 23 hours
Must be started within 8 hours
Controversial- Risk for infection, GI bleed

40
Q

A 24 yo M presents to the ED after an MVC c/o chest pain and difficulty breathing. On PE, you note the pt to be tachycardic, hypotensive, hypoxic, and with decreased breath sounds on left

A

obstructive

41
Q

causes of obstructive shock:

A

Tension PTX, pericardial tamponade, PE, aortic dissection, abdominal distention

Emergency medicine (10 decks)

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