Shock an Fluid Rescucitation Flashcards
What are the clinical alterations seen in shock?
- hypotension
- tachycardia
- tachypnea
- altered mental status
- oliguria/anuria
- skin changes
- metabolic derangements (Anion gap metabolic acidosis, BUN/Cr, Coagulation factors, lactic acidosis, changes in SVO2/ScVO2)
what are the 4 major types of shock?
Hypovolemic
Distributive
Cardiogenic
Obstructive
Hypovolemic Shock:
- causes
- PE findings
- describe how each of the following are affected:
- -CVP
- -PCWP
- -SVO2
- -SVR
- -CO
- -Pulse pressure
- -DBP
- -extremities
- -cap refill
Causes:
-hemorrhage, GI/GU losses, dehydration
PE findings:
- diarrhea, polyuria, poor intake
- flat, non-distended neck veins
CVP: LOW (preload; filling pressure in the right side of the hear)
PCWP: LOW (wedge pressure)
SVO2: LOW (how much O2 is still attached to hgb right before entering RA)
SVR: HIGH (body tries to compensate by vasoconstriction)
CO: LOW
Pulse pressure: LOW
DBP: LOW
Extremities: cold/clammy
cap refill: greater than 2 seconds
T/F: significant drops in blood pressure are generally not manifested until class III hemorrhage develops and up to 30% of pts blood volume has been lost.
Describe the classes of hemorrhage according to ATLS.
True.
Class 1: blood volume up to 15%. HR is minimally elevated or normal, no change in BP, pulse pressure, or RR.
Class II: 15-30% blood volume loss and manifested clinically as tachycardia (HR100-120), tachypnea (RR20-24), and decreased pulse pressure. SBP doesnt change much. Skin is cool and clammy, cap refill may be delayed.
Class III: 30-40% blood volume loss; significant drop in BP andd changes in mental status. HR greater than 120BPM, RR is markedly elevated, urine output is diminished, cap refill is delayed.
Class IV: greater than 40% blood loss leading to significant depression in blood pressure and mental status. SBP less than 90, most are in hypotensive shock. Pulse pressure is narrow, tachycardia is marked, urine output is minimal or absent. Skin is cold, pale, and cap refill is delayed.
What are the signs of hypovolemia?
- mild-moderate hypovolemia
- blood volume loss at least 15%
- blood volume loss of at least 40%
mild/moderate: resting tachycardia
Blood volume loss of 15%: orthostatic hypotension (decrease in SBP of more than 20mmhg and/or increase in hear rate of 20BPM when moving from lying to standing)
Blood volume loss of at least 40%: supine hypotension.
What is the triad of death?
Coagulopathy, metabolic acidosis, hypothermia. (this is a viscious cycle; one thing leads to the next..)
Who requires Massive Transfusion products required?
What is the protocol for this?
Indications? (how many units of blood are required)
Transfusion for severe ongoing hemorrhage; for trauma patients with ongoing hemorrhage that is unlikely to be controlled quickly or adequately.
Protocol:
-Immediate transfusion of blood products, 1:1:1 ratio of PRBC, FFP, and platelets.
Indications:
-when pt requires more than 4 units of PRBC over one hour or 10 or more units in over 12-24hrs.
Cardiogenic Shock:
- causes
- PE findings
- describe how each of the following are affected:
- -CVP
- -PCWP
- -SVO2
- -SVR
- -CO
- -Pulse pressure
- -DBP
- -extremities
- -cap refill
Causes: “pumps broken”
- ischemia
- cardiomyopathy
- mechanical
- arrhythmia
PE:
- chest pain
- orthopnea
- PND
- JVD
- Peripheral/pulmonary edema
- S3 gallop
CVP: HIGH
PCWP: HIGH
SVO2: LOW
SVR: HIGH
CO: LOW
PULSE PRESSURE: NARRROW/LOW
DBP: LOW
EXTREMITIES: COLD
CAP REFILL: GREATER THAN 2 SECONDS
Tx cardiogenic shock
Tx: improve CO while reducing myocardial workload.
- be careful with IV fluids
- consider inotropic and.or vasopressor support
- manage underlying cause (revascularization, rhythm conversion, etc)
Distributive Shock
- cause
- PE findings
- describe how each of the following are affected:
- -CVP
- -PCWP
- -SVO2
- -SVR
- -CO
- -Pulse pressure
- -DBP
- -extremities
- -cap refill
Cause:
“Pipes are the wrong size”
-loss of fluid into the extravascular thrid space
-sepsis, neurogenic injury, anaphylaxis, adrenal crisis
PE:
- Hx of known allergy
- spinal injury
- fever/infectious sx
- warm edematous extremities
CVP: LOW (+/-)
PCWP: LOW (+/-)
SVO2: HIGH (train is sent out of the station but its going too fast for the passengers to get off at any of the stops)
SVR: LOW
CO: HIGH (+/-)
PULSE PRESSURE: WIDE/NARROW
DBP: LOW
EXTREMITIES: WARM
Tx of anaphylactic shock
Tx of adrenal crisis
Tx neurogenic shock
-anaphylactic shock
IV fluid boluses
IV antihistamines
IV corticosteroids
IM epi
-Adrenal Crisis:
support hemodynamics with IV fluids and pressors as necessary
-stress dose steroids (hydrocortisone, 50mg q8hr)
-Neurogenic shock
IV fluids
pressor support
Atropine, dopamine, transcutaneous pacing as necessary for bradycardia
Obstructive Shock:
- causes
- PE findings
- describe how each of the following are affected:
- -CVP
- -PCWP
- -SVO2
- -SVR
- -CO
“Youve got yourself a stopped pipe”
Cause:
- impaired cardiac filling
- cardiac tamponade, pericarditis, tension pneumo, PE
PE findings:
- Becks Triad (low arterial pressure, distended neck veins, distant muffled heart sounds)
- asymmetric breath sounds
- friction rub
- pulsus paradoxus
CVP: +/- PCWP: +/- SVO2: +/- SVR: HIGH CO: LOW
Obstructive SHock:
- treatment for each of the following:
- -cardiac tamponade
- -pulmonary embolism
- -tension pneumothorax
Cardiac tamponade: IV fluids, emergent pericardiocentesis
Pulmonary embolism: IV fluids, vasopressor support, thrombolytics?
Tension pneumo: IV fluid, emergent needle thoracostomy followed by chest tube
When it all hits the fan keep your algorithm simple… what are the 4 categories you should start with for your DDX?
Hypovolemic
Distributive
Cardiogenic
Obstructive
What are the general principles of resuscitation?
What hgb level requires blood transfusion?
-A, B, C’s
Hemodynamic/ventilatory support:
- improve the components of oxygen delivery/consumption
- decrease tissue metabolic demands (consider mechanical ventilation)
Assessment and optimization of fluid status
Management of underlying condition.
-Previously a target Hgb of 10 was recommended until the TRICC Trial, now transfusion goal is hgb of 7, unless cardiac ischemia.
