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Emergency Medicine > shock > Flashcards

shock Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

what is shock

A

Impaired O2 delivery/utilization

Increased O2 consumption

asymmetry in supply and demand

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2
Q

why do we care about shock

A

hypo-perfusion

When it becomes irreversible (cells start to die) > multi-organ failure and death

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3
Q

what decreases supply

A

Pump failure

Decreased total blood volume

Poor vascular tone (vessels can’t be leaky)

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4
Q

What can increase demand?

A

Exercise
Infection
Meds/toxins
Hypermetabolic states (hyperthyroidism, pregnancy, anemia)

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5
Q

poor vascular tone

A

leaky blood vessels

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6
Q

kidney failure looks like

A

increase in Cr

fluid retention
(urine output is decreased)

might need a catheter

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7
Q

loss of perfusion to the brain looks like

A 
altered mental state
agitation
loc 
confusion
intracerebral bleeding
coma
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8
Q

loss of perfusion to the lungs can result in

A

acute respiratory distress

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9
Q

drugs that cause shock

A

prescription medications

toxins

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10
Q

BP

A

CO times SVR (systemic vascular resistance)

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11
Q

co

A

SV (amt of blood you are pushing out)

times HR

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12
Q

anaphylaxis and toxins have a direct effect on

A

SVR (systemic vascular reserve)

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13
Q

What happens when we don’t have O2

A

We go through the process of fermentation. We get a build up of lactate

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14
Q

what happens when you get a lactic acid build up?

A

You get lactate build up bc it disrupts the electrolyte balances in the cell. We see influx of Ca++ and it triggers a process called apoptosis.

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15
Q

respiratory complications of

A

tachypnea
SOB
can go into ARDS
(lungs fill with fluid and lungs are crying bc they are not getting enough oxygen),

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16
Q

The normal blood lactate concentration in unstressed patients is

A

0.5-1 mmol/L.

something around 2

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17
Q

Early sign shock

A

MAP decreased 10 mmHG

effective compensation

O2 is still getting to vital organs and

increased heart rate

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18
Q

what are compensatory signs

A

MAP down 10-15 mm Hg
increased RENIN and ADH

–>vasoconstriction

decreased PP
increased HR
decreased pH 
restless
apprehensive
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19
Q

progressive signs (intermediate)

A

decreased MAP 20 mm Hg

tissue organ hypoxia
decreased UO
decreased pH
weak rapid pulse

sensory changes

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20
Q

refractory signs irreversible

A

excessive cell organ damage

multisystem failure and decreased pH

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21
Q

this is where you start to see cellular damage. Kidneys start to fail

A

Progressive signs of shock

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22
Q

Coagulation of shock

A

PT/INR will be elevated, DIC is present (purpura, INR will be through the roof)

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23
Q

effect on kidneys

A

decreased urine output, get creatinine

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24
Q

cardiac markers of shock

A

tachycardia, chest pain, EKG disturbances

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25
Q

Liver effects

A

hypotensive, LFTs (AST/ALT in the 1000s –> this is shock liver), bilirubin and albumin can be high

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26
Q

your vascular tone is failing (leaky blood vessels)

A

i. Distributive shock

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27
Q

Distributive shock what is happening

A

Something is telling them to dilate and it causes leakage of nutrients into the interstitium. So even though your blood volume is good, your blood vessels are leaky so they are not getting the nutrients

SUPPLY

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28
Q

hypovolemic

A

not enough gas in your tank. Pump is working and vascular tone is good but don’t have enough volume

SUPPLY

29
Q

Cardiogenic shock

A

DEMAND

pump failure can’t get the blood where it needs to be

NO FLUIDS

fluid in lungs–> need to intubate–> sedation drops pressure–> coding

30
Q

obstructive shock

A

SUPPLY

everything is working but there is something blocking and you’re not getting O2

31
Q

peritoneal signs of hypovolemic shock

A

rigid abdomen

blood is irritating

32
Q

hemorrhagic hypovolemic shock can look like

A
  • Trauma
  • GI Bleed
  • AAA rupture
  • Ruptured ectopic pregnancy (call the OB)
  • Post-partum hemorrhage
33
Q

hypovolemic tx can look like

A

pressor
fluids
blood

34
Q

Non-hemorrhagic causes of hypovolemic (4)

A
  • GI loss (vomiting/diarrhea)
  • Inadequate intake
  • Environmental/neglect
  • Burns
35
Q

if you loose 700 mL of blood or 15% BV you are what class of shock

A

class I

normally HR increased

36
Q

class 3 of shock

A 
1500-2000
loss of 30-40% BV
HR >120 
RR 30-40
decreased systolic blood pressure
urine output decreased
 5-15 mL
37
Q

class 2 of shock

A 
750-1500
15-30%
>100
20-30 rr
NORMAL bp

20-30mL UO

38
Q

class IV of shock

A 
>2000 mL 
>40%
>140
>35 RR
greatly decreased systolic BP
UO minimal
39
Q

in hypovolemic shock you want to start IV with a

A

crystalloid

maybe colloid for cardiac and pulmonary complications

40
Q

TX of hypovolemic shock

A
  1. ABCs
  2. Good IV access
  3. VOLUME – start with crystalloid
  4. Blood if bleeding (massive transfusion protocol)
  5. Pressors - Norepinephrine
  6. Definitive management (stop bleeding, OR/endoscopy if needed, treat underlying condition)
41
Q

71 y/o M, hx of HTN, DM, prior stents with CP/SOB/dizziness/weakness for the last 5 hours

VS: 96.2 104 72/50 27 91% 4L NC

what type of shock would you suspect

i. Ill appearing, dyspneic
ii. Tachycardic
iii. Crackles in both lungs
iv. 2+ pitting edema to knees bilaterally

A

cardiogenic shock picture

need an ECG
bedside echo

42
Q

causes of cardiogenic shock (5)

A 
MI or infarction
valvular disease
cardiomyopathy
myocarditis
toxins
43
Q

Tx of cardiogenic shock

A

i. ABCs (C also for Call Cardiology!!)
ii. Oxygenation/Intubation
iii. IV access
iv. Careful fluid resuscitation
v. Inotropes/Vasopressors (Dobutamine/Norepinephrine)
vi. Definitive management (cath lab for stent/balloon pump vs. OR for CABG/valve replacement)

44
Q

a. A 23 y/o healthy M presents with weakness, chills, nausea and abdominal pain for 3 days

b. VS: 103.2 117 71/45 22 100% on RA
c. Exam
i. Ill appearing, +rigors
ii. Dry MM
iii. Abdomen uncomfortable to palpation, particularly in the lower quadrants, +rebound/guarding

i. WBC 29
ii. Creatinine 2.9
iii. Lactic acid 4
iv. UA: no signs of infection

A

distributive shock

45
Q

WBC normal

A

4.5-11

46
Q

normal creatinine

A

.8-1.4

47
Q

reasons for distributive shock

A

septic shock
anaphylactic shock
neurogenic shock

48
Q

what is the reason for septic shock

A

Overwhelming systemic infection

49
Q

common causes of Anaphylactic shock

A

a. Food
b. Medication
c. Contrast
d. Insects

50
Q

reasons for neurogenic shock

A

spinal cord injury is an example

51
Q

in general how should we treat distributive shock

A
  • ABCs
  • IV access
  • Fluids
  • Vasopressors (Norepinephrine)
52
Q

septic shock tx

A
  • Look for source!
  • Antibiotics (broad)
  • Source control (surgery if needed)
53
Q

anaphylactic shock tx

A
  • Epinephrine (0.3mg IM)
  • Steroids
  • H1/H2 blockers
  • Decontamination
54
Q

neurogenic shock tx

A
  • C collar/stabilize spine
  • Atropine/pressors
  • Steroids controversial
  • NSG intervention
55
Q

what would obstructive shock look like on a ecg

on CXR

on echo

A

low voltage

CXR shows – cardiomegaly

ECHO shows — large pericardial effusion w/ cardiac tamponade

56
Q

causes of obstructive shock

A
  1. Cardiac tamponade
  2. Tension pneumothorax
  3. Pulmonary embolism
  4. Severe aortic stenosis
57
Q

how does Cardiac tamponade create shock

TX

A

Tamponade = can’t fill the heart

Obstruction = pericardial effusion

• Pericardiocentesis

58
Q

how does tension pneumothorax cause shock

A

can’t fill the heart

Obstruction = air in chest; with mediastinal shift and tracheal deviation

• Chest tube

59
Q

Pulmonary embolism as a cause of shock

A

can’t fill the heart
a. Obstruction = large clot in PA

• Thrombolytics/anticoagulation

60
Q

Severe aortic stenosis

A

can’t pump out into aorta
a. Obstruction = stenotic aortic valve

• Valve replacement

61
Q

what does a pt in shock look like ?

A

i. Ill appearing
ii. Abnormal vitals (hypotension, tachycardia)
iii. Weak pulses
iv. Mental status changes
v. Cool/clammy extremities

62
Q

what does assessment look like in a pt with shock

A

i. BP (?Art line/central line for CVP)
ii. Lactate clearance
iii. Hemoglobin (>10)
iv. Urine output (>0.5 ml/kg/hr)

63
Q

SNS neurotransmitters

A

noraderenaline and adrenaline

64
Q

B1 receptor

A

both increases heart rate and contractility and speed

65
Q

B2

A

stimulation leads to vasodilation

66
Q

A1

A

stimulation causes vasoconstriction

67
Q

catecholamine release that in response to a drope in CO

A

epinephrine

norepinephrine

68
Q

septic shock

A

LPS toxins cause

nitric oxide release from cell damage

compliment cascade triggered causing mor vasodilation

TNF causes more release of inflammatory chemicals

damagining the endothelial cells and making them leaky

procoagulant-TF also released leads to clotting and bloackages and further decreased profusion

69
Q

how does distributive shock look different

A

MVO2 shock can be normal

Emergency Medicine (28 decks)

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