Shock Evaluation and Management

Question 1

List the 4 vascular system components of perfusion.

Answer 1

Vascular system, air exchange, pump, fluid volume

Question 2

Equation for BP and CO

Answer 2

BP=COxPVR

CO=HR/SV

Question 3

How do you easily obtain perfusion pressure?

Answer 3

Approximate peripheral pulses - if extremities are perfused, than organs are perfused.

Question 4

Peripheral pulse approx:

Answer 4

Carotid 60, Femoral 70, Radial 80, Tibial 90

Question 5

What is the definition of shock progression?

Answer 5

Begins with injury, spread throughout body, MULTISYSTEM INSULT TO MAJOR ORGANS,

Question 6

What is the cycle of shock progression?

Answer 6

Inadequate perfusion, anaerobic processes, worsening hypoxia, CATECHOLAMINE release, cell death, RBC decrease

Question 7

Who cannot tolerate hypotension for even a short period of time?

Answer 7

People who are older, hypertension, and/or HEAD INJURY

Question 8

What are signs of compensated progression of shock?

How much blood (%) can be lost for this type?

Answer 8

Weakness, thirst, pallor, tachycardia, diaphoresis decreased urine output, weakened peripheral pulses/DELAYED CAP REFILL
15-25% loss of blood volume (1-2units) can be lost.

Question 9

What signifies progression from compensated to decompensated shock?

Answer 9

Initial rise in BP (cats), initial narrowing of pulse pressure (diastolic, check for a weak pulse), lactic acidosis.
Look for the CRASH.

Question 10

What age has the worst ability to compensate in hypovolemic shock?

Answer 10

ELDERLY CRASH FAST (atherosclerosis = less cat vasoconstrictive ability; live at higher BP/shock at higher pressures.)

Question 11

What are signs of decompensated progression of shock?

How much blood (%) can be lost for this type?

Answer 11

HYPOTENSION, weak or no peripheral pulse, PROLONGED CAP REFILL (more than 2sec).
30-45% (6+units) loss of blood volume

Question 12

What is the first sign of late shock - decompensated shock?

Answer 12

Hypotension.

Question 13

When looking for early signs of shock, what pulse rates do you look for in (1) suspected hemorrhage and (2) red flag for shock?

Answer 13

1) sustained pulse of more than 100

2) pulse rate of more than 120

Question 14

Does not having tachycardia rule out shock?

Answer 14

No - neurogenic shock has bradycardia.

Question 15

1) What does falling ETCO2 indicate?

2) What does ETCO2 less than 20mmHg?

Answer 15

1) hyperventilation or decreased oxygenation

2) Circulatory collapse, warning sign of worsening shock

Question 16

What are the 3 common shock syndromes?

Answer 16

Low-volume shock, high-space shock, mechanical shock.

Question 17

What is low volume shock?

Answer 17

Absolute hypovolemia. In severe blood loss cats cannot compensate with enough vasoconstriction.

Question 18

Clinical presentation of what type of shock?

Thready pulse, tachycardia, pale, flate neck veins.

Answer 18

low volume shock

Question 19

Neurogenic shock (primarily) or vasodilatory shock. Interruption of SNS with no cat release, so no vasoconstriction = space is “too large”.

Answer 19

What is high-space shock?

Question 20

Sepsis, drug overdose, neurogenic shock cause what type of shock?

Answer 20

Three causes of high space shock

Question 21

Describe differences (4) and similarities (1) between the high space shocks.

Answer 21

All - hypotension
Neurogenic - NO CATS, bradycardia, skin warm dry pink, paralysis or deficit (no chest mvmt)
Sepsis and Drug overdose - CATS, tachycardia, pale or flushed, no localized deficit, flat neck veins

Question 22

What is the most typical cause of neurogenic shock?

Answer 22

Spinal cord injury

Question 23

What is mechanical shock?

Answer 23

Obstruction of blood flow to or through the heart, slowing venous return and decreasing CO.

Question 24

Clinical presentation of mechanical shock.

Answer 24

Distended neck veins, cyanosis, catcholamine effects

Question 25

What are effects of catecholamines?.

Answer 25

Pallor, tachy, diaphoresis

Question 26

General management of shock state (4).

Answer 26

1) control bleeding
2) administer (Green) high-flow O2
3) maintain perfusion pressure (peripheral pulses)
4) treat the cause

Question 27

Management of un/controllable hemorrhage similarities (6).

Answer 27

1) Fluid bolus 20ml/kg
2) Cardiac monitor, ETCO2, SpO2
3) **Ongoing exam (physical or diagnostic)
4) High flow oxygen
5) Control bleeding
6) Large-bore IV access

Question 28

What do you NOT do in management of uncontrollable hemorrhage? Why?

Answer 28

Do not administer IV fluid. May cause increase in BP&raquo_space; lose blood and clotting factors.

Question 29

What does internal management of uncontrollable hemorrhage consist of?

Answer 29

Trauma surgical intervention

Question 30

What is the best FFP/platelet ratio to administer in uncrontrollable hemorrhage?

Answer 30

1:1

Question 31

What is special about large bone fractures? Pelvis?

Answer 31

They are self limited, UNLESS in the pelvis (asymptomatic until 3L lost)

Question 32

What are the types of internal hemorrhage from blunt trauma? Which of these calls for fluid admin for volume support?

Answer 32

1) large bone fracture - GIVE FLUID
2) internal blood vessel tear, laceration, or avulsion to internal organ - possible fluid, to maintain perfusion, but fluid may increase bleeding/death

Question 33

What is a special consideration for management of high-space, vasodilatory shock?

Answer 33

VASPORESSORS - for CCB overdose or sepsis

Question 34

What do you do for someone with severe head injury with hypovolemic shock?

Answer 34

Fluid admin and BP of 120 to maintain cerebral perfusion pressure of at least 60.

Question 35

What do you do for someone with nonhemorrhagic hypovolemic shock?

Answer 35

Same mgmt as controllable.

Fluid admin for volume replacement.

Question 36

What kind of shock is tension pneumothoarx and what do you do to treat?

Answer 36

Mechanical Shock.

DECOMPRESSION OF PLEURAL PRESSURE (needle then CT).

Question 37

Causes of mechanic shock (2)

Answer 37

1) Cardiac tamponade - blood fills potential space, heart cannot fill
2) Myocardial contusion - severe may cause AHF

Question 38

Management of cardiac tamponade (2).

Answer 38

1) PERICARDIOCENTESIS - cardiac arrest in minutes if not performed.
2) Fluid administration

Question 39

Management of myocardial contusion.

What do you NOT do for myocardial contusion?

Answer 39

1) cardiac monitoring and treat arrhythmias

2) Do NOT administer fluid.