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Shock Flashcards

1
Q

What is shock?

A

Inadequate tissue perfusion

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2
Q

What are the 5 different types of shock?

A
  1. Hypovolemic
  2. Septic
  3. Cardiogenic
  4. Neurogenic
  5. Anaphylactic
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3
Q

What are the signs of shock?

A

Pale, diaphoretic, cool skin, hypotension, tachycardia, tachypnea, decreased mental status, decreased pulse pressure, poor capillary refill, poor urine output

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4
Q

What are the best indicators of tissue perfusion?

A

Lactic acid (elevated with inadequate tissue perfusion), base deficit, pH from ABG (acidosis associated with inadequate tissue perfusion)

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5
Q

What is hypovolemic shock?

A

Decreased intravascular volume

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6
Q

What are the common causes of hypovolemic shock?

A

Hemorrhage, burns, bowel obstruction, crush injury, pancreatitis

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7
Q

What are the signs of hypovolemic shock?

A

Early: Orthostatic hypotension, mild tachycardia, anxiety, diaphoresis, vasoconstriction (decreased pulse pressure with increased diastolic pressure).
Late: Changed mental status, decreased BP, marked tachycardia.

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8
Q

What are the signs and symptoms of class I hemorrhage (

A

Mild anxiety, normal vital signs

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9
Q

What are the signs and symptoms of class II hemorrhage (15-30% or 750-1500 cc blood loss)?

A

Normal systolic BP with decreased pulse pressure, tachycardia, tachypnea, anxiety

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10
Q

What are the signs and symptoms of class III hemorrhage (30-40% or 1500-2000 cc blood loss)?

A

Tachycardia (HR > 120), tachypnea (RR > 30), decreased systolic BP, decreased pulse pressure, confusion

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11
Q

What are the signs and symptoms of class IV hemorrhage (> 40% or 2000 cc blood loss)?

A

Decreased systolic BP, tachycardia (HR > 140), tachypnea (RR > 35), decreased pulse pressure, confused and lethargic, no urine output

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12
Q

What is the treatment for hypovolemic shock?

A
  1. Stop the bleeding

2. Volume (IVF like LR then blood products as needed)

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13
Q

What is a bedside indicator for treatment of hypovolemic shock?

A

Urine output, BP, HR, mental status, extremity warmth, capillary refill, body temperature

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14
Q

What labs can be used to determine the effectiveness of the treatment of hypovolemic shock?

A

pH, base deficit, and lactate level

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15
Q

What usually causes failure of resuscitation from hypovolemic shock?

A

Persistent massive hemorrhage, requiring emergent surgical procedure

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16
Q

Why does decreased pulse pressure occur with early hypovolemic shock?

A

Pulse pressure (systolic - diastolic BP) decreases because of vasoconstriction, resulting in an elevated diastolic BP

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17
Q

What is the most common vital sign change associated with early hypovolemic shock?

A

Tachycardia

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18
Q

What type of patient does not mount a normal tachycardic response to hypovolemic shock?

A

Patients on beta-blockers, spinal shock (loss of sympathetic tone), endurance athletes

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19
Q

Should vasopressors be used to treat hypovolemic shock?

A

No

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20
Q

Should patients with hypovolemic shock be put into Trendelenburg position?

A

No

21
Q

What is septic shock?

A

Documented infection and hypotension

22
Q

What is the specific etiology of septic shock?

A

Most common: gram-negative septicemia

Less common: gram-positive septicemia, fungus

23
Q

What factors increase the susceptibility to septic shock?

A

Any mechanism that increases susceptibility to infection (e.g. trauma, immunosuppression corticosteroids, hematologic disease, diabetes)

24
Q

What complications are major risks in septic shock?

A

Multiple organ failure, DIC, death

25
Q

What are the signs and symptoms of septic shock?

A

Initial: Vasodilation (warm skin and full pulses), normal urine output.
Delayed: Vasoconstriction, poor urine output, mental status changes, hypotension.

26
Q

What percentage of blood cultures is positive in patients with bacterial septic shock?

A

50%

27
Q

What are the associated findings with septic shock?

A

Fever, hyperventilation, tachycardia

28
Q

What are the associated lab findings with septic shock?

A

Early: Hyperglycemia, glycosuria, respiratory alkalosis, hemoconcentration, leukopenia.
Late: Leukocytosis, acidosis, elevated lactic acid.

29
Q

What is the treatment for septic shock?

A
  1. Volume (IVF)
  2. Antibiotics (empiric, then by cultures)
  3. Drainage of infection
  4. Pressors PRN
  5. Zygris PRN
30
Q

What is Zygris?

A

Activated protein C, shown to decrease mortality in septic shock and multiple organ failure

31
Q

What is cardiogenic shock?

A

Cardiac insufficiency.

Left ventricular failure (usually), resulting in inadequate tissue perfusion.

32
Q

What are the causes of cardiogenic shock?

A

MI, papillary muscle dysfunction, massive cardiac contusion, cardiac tamponade, tension PTX, cardiac valve failure

33
Q

What are the signs and symptoms of cardiogenic shock?

A

Dyspnea, rales, pulsus alternans (increased pulse with greater filling following a weak pulse), loud pulmonic component of S2, gallop rhythm, hypotension, decreased cardiac output, elevated CVP/wedge pressure, decreased urine output, tachycardia (possibly)

34
Q

What are the signs of cardiogenic shock on CXR?

A

Pulmonary edema

35
Q

What is the treatment for cardiogenic shock?

A
  1. CHF: Diuretics and afterload reduction (e.g. ACE inhibitors +/- pressors).
  2. Left ventricular failure (MI): pressors, afterload reduction.
36
Q

What are the last resort support mechanisms for cardiogenic shock?

A

IABP, VAD

37
Q

What is neurogenic shock?

A

Inadequate tissue perfusion from loss of sympathetic vasoconstrictive tone

38
Q

What are the common causes of neurogenic shock?

A

Complete transection of spinal cord, partial cord injury with spinal shock, spinal anesthesia

39
Q

What are the signs and symptoms of neurogenic shock?

A

Hypotension, bradycardia, neurologic deficit

40
Q

Why are HR and BP decreased in neurogenic shock?

A

Loss of sympathetic tone (but hypovolemia must be ruled out)

41
Q

What are the associated findings with neurogenic shock?

A

Neurologic deficits suggesting cord injury

42
Q

What must be ruled out in any patient where spinal shock is suspected?

A

Hemorrhagic shock

43
Q

What is the treatment for neurogenic shock?

A

IVF (vasopressors reserved for hypotension refractory to fluid resuscitation)

44
Q

What percentage of patients with hypotension and spinal neurologic deficits have hypotension of purely neurogenic origin?

A

67%

45
Q

What is spinal shock?

A

Complete flaccid paralysis immediately following spinal cord injury.
May or may not be associated with circulatory shock.

46
Q

What is the lowest reflex available to the examiner?

A

Bulbocavernous reflex (checking for contraction of the anal sphincter upon compression of the glans penis or clitoris)

47
Q

What is the lowest level voluntary muscle?

A

External anal sphincter

48
Q

What are the classic findings associated with spinal cord shock?

A

Hypotension, bradycardia (or lack of compensatory tachycardia)

49
Q

What is the acronym for treatment options for anaphylactic shock?

A

BASE:

Benadryl, Aminophylline, Steroids, Epinephrine

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