Shock Flashcards
Clinical end points used to Identify shock
- SBP < 90mmHg
- MAP < 65mmHg
- Elevated lactate > 4mmol/l
Impaired O2 utilization
- Anaerobic metabolism takes over
- Much less effective than aerobic metabolism
Shock is driven by what
- Reduced cardiac output (CO)
- Reduced systemic vascular resistance (SVR)
Cardiogenic Shock Cause
-Problem with the pump
Cardiogenic Shock Treatment
- Make it PUMP
- Vasopressor
- Inotrope
- Diuresis (Cautious)
- AVOID Beta blockers and calcium channel blockers (-inotropes)
Hypovolemic shock cause
-Hole in the bucket
Hypovolemic shock treatment
- Stop bleeding/fluid loss
- Fluids (LR, NS or D5W)
- Vasopressors
Neurogenic shock cause
-Vasodilation with out compensatory tachycardia
Neurogenic shock treatment
- Fluids
- Vasopressors
- Inotropes
Anaphylactic shock (distributive shock) Cause
- Allergic
- Immune/ inflammatory response
Anaphylactic shock (Distributive shock) treatment
- Steroids
- Antihistamines
- Fluids
- Epinephrine
- Antivenom if available
Septic shock (distributive shock) cause
- Bacteremia
- Endo/exotoxins
- LPS gram negative
- Gram positive bugs
Septic shock (distributive shock) treatment
- remove/ suppress the infection
- Fluids
- Vasopressors
- Abx
- Source control
Sustained shock can lead to what
-Multi organ dysfunction syndrome (MODS)
Primary MODS
- Damage to organ system directly related to a specific insult
- Usually due to trauma or thermal injury
Secondary MODS
- Exaggerated response of immune system to secondary insults
- Leading to further organ dysfunction and worsening outcomes
Common causes of hypovolemic shock
- Bleeds
- Burns
- Trauma
Cardiogenic shock presentation
- Pulmonary edema
- Hypotension
- Weak pulse
- Cool extremities
Cardiogenic shock treatment for patients with STEMI
- PCI or CABG
- Fibrinolytic if PCI or CABG cannot be done
- Aortic balloon pump
Name the three different types of “Distributive” shock
- Neurogenic
- Anaphylactic
- Septic
New scoring system for Sepsis
Must have 2 of the following
- RR > 22
- Altered mental status
- SBP < 100
Hour 1 bundle for sepsis patients
- Measure lactate levels
- Blood cultures
- Broad spectrum abx
- Fluids (hypotension or > lactate)
- Vasopressors (MAP < 65)
Target of vasopressor therapy
-MAP > 65mmHg
Examples of vasopressors
- Norepinephrine
- Vasopressin
- Epinephrine
- Phenylephrine
- Dopamine
Which vasopressor is first line
-Norepinephrine
Drug class of dobutamine
-Inotropic agent
When should abx be administered by
-With in the first hour of septic shock recognition
When do we use IV hydrocortisone
-Patients with hemodynamic instability despite fluid and vasopressor therapy
When do you initiate insulin therapy
-two blood glucose measurements > 180mg/dL
Who gets DVT prophylaxis?
- Everyone
- LMWH or UFH
- Enoxaparin is preferred
Induction medications for intubation
- Etomidate
- Ketamine
- Midazolam
- Propofol
Paralytic medications
- Succinylcholine
- Rocuronium
- Vecuronium
General approach to treatment of pain
- Should be individualized
- Use minimum effective dose
- Administer preemptively
What drug class is first line for non-neurologic pain
- IV opioids
ex. fentanyl, morphine, hydromorphone
Daily sedation interruption purpose
- Allows for assessment of neurologic function
- May prevent drug accumulation and overdose
What are the monitoring parameters for daily sedation interruption
3/4 of the following
- Open eyes
- Maintain eye contact
- Squeeze hand, stick out tongue
- Wiggle toes
Benzos or non-benzos?
-Non benzos are preferred over benzos
List two benzos commonly used
- Midazolam
- Lorazepam
List two non benzos commonly used
- Propofol
- Precedex
Where does propylene glycol toxicity come from?
-Diluent in parenteral lorazepam formulations
