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CEN > Shock > Flashcards

Shock Flashcards

1. Explain concepts related to the assessment of an emergency department patient experiencing a shock emergency. 2. Describe various patient presentations related to shock emergencies. 3. List interventions necessary for a patient presenting with a shock emergency.

1
Q

define shock

A

Shock is a state of impaired tissue perfusion resulting from circulatory failure brought on by various causes.

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2
Q

shock analogy to car

A

Gas = blood and plasma
Fuel pump = heart
Fuel line = arteries and veins

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3
Q

how is shock classified?

A

by the cause of inadequate perfusion

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4
Q

categories of shock

A

hypovolemic (low on gas)
cardiogenic (bad fuel pump)
distributive (fueling 2 cars with 1 gas line)
obstructive (blockage in fuel line)

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5
Q

cellular cascade in shock

A

similar for all causes of shock
–initially irreversible but w/o tx becomes irreversible

cell injury -> inflammation -> cell death

anaerobic metabolism -> glucose phosphorylation -> lactic acidosis

microvascular thrombosis -> depletion of clotting factors -> DIC

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6
Q

3 stages of shock

A

compensated
uncompensated
irreversible

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7
Q

compensated shock overview

A

Stage I or nonprogressive
compensatory mechanisms initiated
vital organs perfused
full recovery

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8
Q

uncompensated shock overview

A

Stage II or progressive
compensatory mechanisms inadequate
vital organs hypoperfused
recovery more difficult

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9
Q

irreversible shock overview

A

Stage III
compensatory mechanisms failed
cellular and organ death
refractory to tx

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10
Q

overview of physiological of compensated shock

A

SNS response
RAAS
ADH
intracellular fluid shift

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11
Q

SNS response in compensated shock

A

release of epi/norepi
vasoconstriction

increased HR, contractility, BP

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12
Q

RAAS in compensated shock

A

increased serum sodium
water reabsorption

decrease urine, increase BP and CO

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13
Q

ADH in compensated shock

A

renal reabsorption of sodium and water

decrease urine, increase BP and CO

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14
Q

intracellular fluid shift in compensated shock

A

increased intravascular volume

increase BP and CO

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15
Q

overview of physiology of uncompensated shock

A 
altered capillary permeability
respiratory insufficiency 
cardiac depression
tissue hypoperfusion
brain hypoperfusion
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16
Q

altered cap permeability in uncompensated shock

A

leakage into interstitial space

edema, decreased BP and perfusion

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17
Q

respiratory insufficiency in uncompensated shock

A

pulm edema
VQ mismatch

crackles, dyspnea, increased RR

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18
Q

cardiac depression in uncompensated shock

A

diminished venous return
ischemia of nonvital organs

decreased urine output
increased lactate
base deficit
mixed venous sat (below 65%)
cool skin
decreased peripheral pulses
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19
Q

brain hypoperfusion in uncompensated shock

A

AMS

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20
Q

define hypovolemic shock

A

blood, plasma, or fluid loos reduces circulating blood volume and cardiac output

most common type of shock

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21
Q

common causes of hypovolemic shock

A 
traumatic hemorrhage
(long bone/pelvic fx, solid organ rupture, open wounds)

nontraumatic hemmorrhage
(GI bleed, ruptured AA, posterior epistaxis)

fluid shifts
(peritonitis, massive crush injuries, severe burns)

non-blood fluid loss
(v/d, diaphoresis)

urinary fluid loss
(DKA, diabetes insipidus, diuretic abuse)

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22
Q

hypovolemic shock assessment

A 
ABCs
cause
labs
trend VS
MAP (above 60) (SBP + 2DP/3)
urine output
LOC
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23
Q

parameters of hypovolemic shock

A 
blood loss
HR
BP
RR
urine output
CNS
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24
Q

Class I of hypovolemic shock

A 
blood loss below 15%
HR below 100
BP normal
RR 14-20
Urine above 30ml/hr
CNS slightly anxious
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25
Q

Class II of hypovolemic shock

A 
blood loss 15-30%
HR 100-120
BP normal
RR 20-30
Urine 20-30 ml/hr
CNS mildly anxious
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26
Q

Class III of hypovolemic shock

A 
blood loss 30-40%
HR 120-140
BP decreased
RR 30-40
urine output 5-20 ml/hr
CNS anxious, confused
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27
Q

Class IV of hypovolemic shock

A 
blood loss > 40%
HR > 140
BP decreased
RR > 35
urine output negligible 
CNS confused, lethargic
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28
Q

hypovolemic shock intervention overview

A

airway
control bleeding, reduce fluid loss
restore volume
blood replacement

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29
Q

fluid resuscitation in hypovolemic shock

A
  1. isotonic crystalloids (NS, LR)
  2. colloids
  3. blood replacement
30
Q

define cardiogenic shock

A

inadequate tissue perfusion as a result of decreased CO despite adequate intravascular volume d/t myocardial pump failure

31
Q

most common cause of cardiogenic shock

A

MI, particularly of L ventricular anterior wall

32
Q

other causes of cardiogenic shock

A 
MI, ischemia
blunt cardiac trauma
sustained dysrhythmias
acute valvular dysfxn
end stage cardiomyopathy
33
Q

sx of cardiogenic shock

A

reflects heart failure, inadequate tissue perfusion

cardiac CP
tachypnea, crackles, pulm edema
tachycardia, tachydsrhythmias, S3
AMS
pale, cool, clammy
minimal urine output
hypotension
34
Q

cardiogenic shock assessment

A 
ECG
CXR
ABG
echo
CBC, platelets, BMP, LFTs, RFTs
lactate
SvO2 less than 65%
35
Q

cardiogenic shock interventions

A 
airway
decrease preload
increase contractility
decrease afterload
cardiac catheterization
angioplasty
treat dysrhythmias
36
Q

airway in managing cardiogenic shock

A

PEEP to force pulmonary edema fluid out of lung interstitium

37
Q

how to decrease preload in cardiogenic shock

A

semi-fowler or fowler
nitro
diuretics
morphine

38
Q

how to increase contractility in cardiogenic shock

A 
positive inotropes (dobutamine)
intra-aortic balloon pump
39
Q

how to decrease afterload in cardiogenic shock

A

continuous nitro
nitroprusside
antiHTN

40
Q

definitive tx for cardiogenic shock

A

cardiac cath
angioplasty
treat dysrhythmias

41
Q

define distributive shock

A

abnormal distribution of intravascular volume as a result of

  • decreased sympathetic tone
  • increased vascular permeability
  • pooling of blood in venous, capillary beds
42
Q

types of distributive shock

A

anaphylactic
septic
neurogenic

43
Q

define anaphylactic shock

A

acute, life-threatening allergic rxn in individuals exposed to antigen to which they have previously become hypersensitive

44
Q

common antigens in anaphylactic shock

A 
shellfish
peanuts/tree nuts
milk, eggs, wheat, soy
food additives
insects
meds, latex, iodine
45
Q

unusual causes of anaphylaxis

A

exposure to cold

exercise

46
Q

difference between anaphylaxis and anaphylactic shock

A

anaphylaxis: normal circulation with risk of progression to shock

anaphylactic shock: shock state with compromised circulation

47
Q

anaphylaxis vs anaphylactoid rxns

A

anaphylaxis IgE mediated and requires prior antigen exposure

48
Q

pathophysiology of anaphylactic shock

A 
antigen re-exposure
hypersensitive antibody response
vasoactive mediator release
   massive vasodilation
   profound hypovolemia
   increased cap permeability, fluid shift, vascular collapse
49
Q

anaphylactic shock assessment

A

rapidly progressing sx
onset begins with cutaneous manifestation

urticaria, erythema, pruritis
dypsnea, cough
throat tightness, stridor
wheezing, bronchospasm
syncope
chest tightness, palpitations
angioedema
hypotension, tachycardia
respiratory, cardiac arrest
50
Q

anaphylactic shock interventions

A 
remove antigen
IM epi 1:1000, rpt in 15-20 min
airway
high-flow O2
IV
   fluid reusc
   vasopressors for hypotension
IV epi
inhaled beta-2 agonists (albuterol)
antihistamine (H1 and H2)
corticosteroids
admission
epi teaching
51
Q

define SIRS

A

cluster of sx of systemic inflammation
w/ or w/o infection
can be seen w/ acute pancreatitis, major trauma, burns

52
Q

define sepsis

A

2 SIRS criteria w/ known/suspected infection

53
Q

define severe sepsis

A

sepsis with organ dysfxn

cardiovascular failure -> hypotension

resp failure -> hypoxia

renal failure -> oliguria/azotemia

hematologic failure -> coagulopathy

54
Q

define septic shock

A

sepsis with hypotension despite adequate fluid resuscitation

55
Q

MODS

A

multiple organ dysfxn syndrome

progressive failure of initially uninvolved distant organs following severe infectious or noninfectious insults

56
Q

sx of septic shock

A 
mentation
skin
HR
RR
urine output
acid/base values
temp
57
Q

sx of hyperdynamic (warm) sepsis

A 
CNS malaise, tired, restless
skin warm, flushed, dry
HR elevated, full pulses
RR > 20/min
urine output decreased
acid/base respiratory alkalosis
temp fever, shaking, chills
58
Q

sx of hypodynamic (cold) sepsis

A 
CNS decreasing LOC, stupor, coma
skin cold, clammy, pale mottled
HR tachycardia, weak, thready pulses
RR tachypneic, shallow
urine decreased, anuria
acid/base metabolic and resp alkalosis
temp hypothermic, mottled
59
Q

septic shock interventions

A 
fluid resuscitation 
positive inotropes, vasopressors
remove infectious sources
wound, blood cultures
ABXs
60
Q

define neurogenic shock

A

loss of sympathetic stimulation, resulting in pure parasympathetic stimulation

massive vasodilation
body unable to compensate for drop in CO

61
Q

causes of neurogenic shock

A

spinal cord injury above T6
spinal anesthesia
brain injury

62
Q

sx of neurogenic shock

A

parasympathetic (rest/digest) is unopposed

bradycardia
bradypnea
hypotension
warm, dry, flushed
full pulses
priapism
63
Q

neurogenic shock interventions

A

ABCs to prevent secondary cord injury
fluids resuscitation
vasopressors
atropine

64
Q

define obstructive shock

A

cardiac output and tissue perfusion are inadequate because of resistance to ventricular filling

65
Q

causes of obstructive shock

A

pericardial tamponade
tension pneumothorax
PE

66
Q

interventions for obstructive shock

A

correct underlying condition

tamponade: pericardiocentesis and surgery

tension pneumo: needle thoracotomy and chest tube

PE: anticoagulation or thrombolytics

67
Q

incidence of pediatric shock

A

hypovolemia most common

septic shock also seen, especially in neonates, due to immature immune system

cardiogenic shock d/t toxic ingestion or sustained VT

68
Q

hypovolemic shock in pediatrics

A

higher metabolic rate
higher body surface to volume ratio
inability to voice sx

69
Q

assessing pediatric shock

A 
dry mucous membranes
no tears
poor skin turgor
sunken fontanels
delayed cap refill
child abuse
IV/IO access
70
Q

geriatric hypovolemic shock

A 
prone to dehydration
   meds, diuretics
   decreased thirst response
   limited mobility
use caution with fluid resuscitation
71
Q

geriatric septic shock

A

pneumonia, urosepsis

AMS
respiratory alkalosis
normotheria or hypothermia

CEN (12 decks)

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