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Clin Med II > shock > Flashcards

shock Flashcards

1
Q

how much blood does the normal heart pump at rest?`

A
  • 5 L/min
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2
Q

absolute hypotension

A
  • SBP < 90
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3
Q

relative hypotension

A
  • drop in SBP > 40

- remember that normotension in geriatrics may indicate hypotension

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4
Q

orthostatic hypotension

A
  • drop in SBP > 20 with standing

- drop in DBP > 10 with standing

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5
Q

shock

A
  • inadequate tissue perfusion -> impaired cell metabolism
  • life threatening
  • commonly presents with hypotension
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6
Q

types of shock

A
  • hypovolemic
  • cardiogenic
  • distributive
  • obstructive
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7
Q

clinical presentation of shock

A
  • hypotension
  • tachycardia- often seen in young pts BEFORE hypotension
  • cool, clammy, cyanotic skin
  • tachypnea- RR> 20
  • oliguria- UO < 30-50 ml/hr
  • altered mental status
  • metabolic acidosis- late finding
  • hyperlactatemia- > 4 mmol/L
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8
Q

metabolic acidosis

A
  • be suspicious of shock, can also be from renal failure or toxins
  • hypotension
  • n/v
  • hyperkalemia
  • muscle twitching, decreased muscle tone, decreased reflexes
  • warm flushed skin
  • hyperventilation
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9
Q

imaging/dx studies for shock

A
  • ** DO NOT delay care to get imaging/ dx studies
  • EKG
  • portable chest and pelvic xray esp for trauma
  • POC US and FAST exam
  • labs
  • foley cath
  • UA/ culture
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10
Q

labs you order for shock

A
  • hcg in all women of child bearing age
  • CBC with diff
  • PT/PTT and INR
  • cardiac enzymes
  • serum lactate
  • liver and renal function
  • d dimer if considering PE
  • ABGs
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11
Q

foley catheter

A
  • reflects renal perfusion and important to determine pt volume status
  • always do prostate exam before inserting foley cath
  • caution in trauma if blood, pelvic fx, high riding or non-palpable prostate
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12
Q

treatment for all types of shock

A
  • initial- recognize shock
  • second- ID cause
  • O2, IV, monitor always
  • ABCDEs always
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13
Q

what is the SaO2 goal level for shock treatment

A
  • > 94%
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14
Q

what does ABCDE stand for

A
  • a- airway
  • b- breathing and ventilation
  • c- circulation with hemorrhage control
  • d- disability/ neuro status
  • e- exposure/ environmental control
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15
Q

IV fluid options for shock treatment

A
  • cystalloids are first line- normal saline or lactated ringers
  • blood substitutes- plasma or platelets
  • make sure IV fluids are warm to prevent hypothermia
  • blood substitutes are the only thing that improve O2 carrying capacity
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16
Q

why give IV fluids for shock

A
  • support circulating fluid volume
  • improve end organ perfusion
  • NO impact on O2 carrying capacity
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17
Q

gastric catheters and shock

A
  • reduce stomach distention and decrease aspiration risk
  • thick or semi solid contents will not come out of tube
  • must be attached to suction
  • passing of tube itself may induce vomitting
18
Q

types of hypovolemic shock

A
  • hemorrhagic- trauma, esophageal varices
  • non-hemorrhagic- burns, pancreatitis, sepsis
  • generally d/t decreased intravascular volume
19
Q

clinical presentation of hypovolemic shock

A
  • hypotension + tachycardia
  • pale, cool, clammy skin
  • change in mental status
  • dry mucus membranes
  • hematemesis
20
Q

when should you consider hypovolemic shock

A
  • trauma
  • heat exposure
  • excessive vomiting/ diarrhea
  • esophageal varices
  • back pain with ruptured AAA
21
Q

imaging/ diagnostics for hypovolemic shock

A
  • trauma- AP chest and pelvis, FAST exam, CT if stable
  • ruptured AAA- FAST exam
  • varices- EGD
22
Q

treatment or hypovolemic shock

A
  • ABCs, IV, O2, monitor
  • fluid resuscitation
  • splint any fx
  • surgery for definitive care
  • may need RBC transfusion to keep Hgb above 7
23
Q

cardiogenic shock

A
  • d/t cardiac failure with inability of the heart to maintain adequate tissue perfusion
  • MI, arrhythmia, valve disorder, ventricular septal rupture
24
Q

cardiogenic shock treatment

A
  • ABCs, IV, O2, monitor
  • ** exception to the rule that everyone gets normal saline- will exacerbate sx
  • positive inotropes
  • vasopressors
  • diuretics
  • catheterization if ongoing ischemia
  • intra-aortic balloon pump if failing medical therapy
25
Q

MI treatment

A
  • O2, IV, monitor
  • MONA
  • cath lab
  • antiplatelets
  • can give fluid challenge if no pulmonary edema
26
Q

dysrhythmia treatment

A
  • O2, IV, monitor
  • cardioversion vs defibrillation
  • antiarrhythmic
  • vasopressors
  • cath lab for pacemaker or defibrillator
27
Q

valvular insufficiency treatment

A
  • O2, IV, monitor

- POC US or echo then emergent surgery

28
Q

causes of distributive shock

A
  • sepsis
  • anaphylaxis
  • neurogenic
  • toxic shock
  • SIRS
  • end stage liver disease
29
Q

septic shock clinical presentation

A
  • fever (sometimes elderly do not mount fever)
  • hypotension despite fluid resuscitation
  • suspected septic source
  • +/- mental status change
30
Q

diagnosis of septic shock

A
  • CBC with diff, blood culture X2, UA with culture

- wound culture if present

31
Q

treatment of septic shock

A
  • empiric abx after culture
  • if abscess then I&D
  • if septic joint then wash out
32
Q

clinical presentation of anaphlyactic shock

A
  • inspiratory stridor
  • oral/ facial edema and hives
  • hypotension
  • hx of recent exposure to allergen
  • if pt is on mechanical ventilation may have sudden elevation in peak inspiratory pressures
33
Q

treatment of anaphylactic shock

A
  • ABCs, O2, IV, monitor
  • epinephrine**- SQ injection q 3-5 min prn
  • IV/IM benadryl*
  • IV ranitidine
  • albuterol neb
  • IV methylprednisolone
34
Q

neurogenic shock

A
  • spinal cord injury -> decreased sympathetic tone

- drop in BP WITHOUT compensatory increase in HR**

35
Q

clinical presentation of neurogenic shock

A
  • hypotension WITHOUT tachycardia
  • flaccid limbs
  • para/quadriplegia
  • absent deep tendon reflexes
  • absent sphincter tone
36
Q

imaging for neurogenic shock

A
  • protect c spine
  • AP, lateral, odontoid xrays
  • CT if stable
  • other level spinal films PRN
37
Q

treatment of neurogenic shock

A
  • ABCDEs, O2, IV, monitor
  • vasopressors after fluid challenge
  • keep MAP 85-90 mmHg for first 7 days
  • foley cath
38
Q

obstructive shock

A
  • physical impairment of adequate BV
  • medical emergency
  • tension pneumo, PE, tamponade, constrictive pericarditis, restrictive cardiomyopathy
39
Q

tension pneumothorax clinical presentation

A
  • tachypnea
  • unilateral pleuritic chest pain
  • diminished breath sounds
  • distended neck veins
  • tracheal deviation (late)
  • on mechanical vent may have sudden elevation in plateau pressures
40
Q

treatment for tension pneumo

A
  • emergent needle decompression above 2 or 3 rib at midclavicular line
  • followed by chest tube in 5th intercostal space at midaxillary line
41
Q

PE treatment

A
  • medical emergency
  • focus on O2 to stabilize pt
  • may need ventilatory support, hemodynamic support, and/or empiric anticoag
  • main stay of tx= anticoagulation
  • may require embolectomy

Clin Med II (16 decks)

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