shock Flashcards
how much blood does the normal heart pump at rest?`
- 5 L/min
absolute hypotension
- SBP < 90
relative hypotension
- drop in SBP > 40
- remember that normotension in geriatrics may indicate hypotension
orthostatic hypotension
- drop in SBP > 20 with standing
- drop in DBP > 10 with standing
shock
- inadequate tissue perfusion -> impaired cell metabolism
- life threatening
- commonly presents with hypotension
types of shock
- hypovolemic
- cardiogenic
- distributive
- obstructive
clinical presentation of shock
- 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
metabolic acidosis
- 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
imaging/dx studies for shock
- ** 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
labs you order for shock
- 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
foley catheter
- 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
treatment for all types of shock
- initial- recognize shock
- second- ID cause
- O2, IV, monitor always
- ABCDEs always
what is the SaO2 goal level for shock treatment
- > 94%
what does ABCDE stand for
- a- airway
- b- breathing and ventilation
- c- circulation with hemorrhage control
- d- disability/ neuro status
- e- exposure/ environmental control
IV fluid options for shock treatment
- 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
why give IV fluids for shock
- support circulating fluid volume
- improve end organ perfusion
- NO impact on O2 carrying capacity
gastric catheters and shock
- 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
types of hypovolemic shock
- hemorrhagic- trauma, esophageal varices
- non-hemorrhagic- burns, pancreatitis, sepsis
- generally d/t decreased intravascular volume
clinical presentation of hypovolemic shock
- hypotension + tachycardia
- pale, cool, clammy skin
- change in mental status
- dry mucus membranes
- hematemesis
when should you consider hypovolemic shock
- trauma
- heat exposure
- excessive vomiting/ diarrhea
- esophageal varices
- back pain with ruptured AAA
imaging/ diagnostics for hypovolemic shock
- trauma- AP chest and pelvis, FAST exam, CT if stable
- ruptured AAA- FAST exam
- varices- EGD
treatment or hypovolemic shock
- ABCs, IV, O2, monitor
- fluid resuscitation
- splint any fx
- surgery for definitive care
- may need RBC transfusion to keep Hgb above 7
cardiogenic shock
- d/t cardiac failure with inability of the heart to maintain adequate tissue perfusion
- MI, arrhythmia, valve disorder, ventricular septal rupture
cardiogenic shock treatment
- 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
MI treatment
- O2, IV, monitor
- MONA
- cath lab
- antiplatelets
- can give fluid challenge if no pulmonary edema
dysrhythmia treatment
- O2, IV, monitor
- cardioversion vs defibrillation
- antiarrhythmic
- vasopressors
- cath lab for pacemaker or defibrillator
valvular insufficiency treatment
- O2, IV, monitor
- POC US or echo then emergent surgery
causes of distributive shock
- sepsis
- anaphylaxis
- neurogenic
- toxic shock
- SIRS
- end stage liver disease
septic shock clinical presentation
- fever (sometimes elderly do not mount fever)
- hypotension despite fluid resuscitation
- suspected septic source
- +/- mental status change
diagnosis of septic shock
- CBC with diff, blood culture X2, UA with culture
- wound culture if present
treatment of septic shock
- empiric abx after culture
- if abscess then I&D
- if septic joint then wash out
clinical presentation of anaphlyactic shock
- 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
treatment of anaphylactic shock
- ABCs, O2, IV, monitor
- epinephrine**- SQ injection q 3-5 min prn
- IV/IM benadryl*
- IV ranitidine
- albuterol neb
- IV methylprednisolone
neurogenic shock
- spinal cord injury -> decreased sympathetic tone
- drop in BP WITHOUT compensatory increase in HR**
clinical presentation of neurogenic shock
- hypotension WITHOUT tachycardia
- flaccid limbs
- para/quadriplegia
- absent deep tendon reflexes
- absent sphincter tone
imaging for neurogenic shock
- protect c spine
- AP, lateral, odontoid xrays
- CT if stable
- other level spinal films PRN
treatment of neurogenic shock
- ABCDEs, O2, IV, monitor
- vasopressors after fluid challenge
- keep MAP 85-90 mmHg for first 7 days
- foley cath
obstructive shock
- physical impairment of adequate BV
- medical emergency
- tension pneumo, PE, tamponade, constrictive pericarditis, restrictive cardiomyopathy
tension pneumothorax clinical presentation
- tachypnea
- unilateral pleuritic chest pain
- diminished breath sounds
- distended neck veins
- tracheal deviation (late)
- on mechanical vent may have sudden elevation in plateau pressures
treatment for tension pneumo
- emergent needle decompression above 2 or 3 rib at midclavicular line
- followed by chest tube in 5th intercostal space at midaxillary line
PE treatment
- 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
