Shock I

Question 1

shock

Answer 1

arterial blood flow inadequate to meet tissue O2 demand

defined by CO, preload, and afterload

Question 2

shock defined by

Answer 2

CO, preload, and afterload

Question 3

pulmonary capillary wedge pressure

Answer 3

PCWP

-left atrial pressure

Question 4

hypovolemic shock

Answer 4

decreased CO
decreased PCWP
increased SVR

hemorrhage, fluid loss, poor intake

Question 5

systemic vascular resistance

Answer 5

SVR

afterload indicator

Question 6

cardiogenic shock

Answer 6

decreased CO
increased PCWP
increased SVR

cardiomyopathy, arrhythmia, mechanical, obstruction (tamponade, PE, tension pneumo)

Question 7

distributive shock

Answer 7

vasodilatory - warm

increased CO
decreased SVR
decreased PCWP

sepsis, TSS, anaphylaxis, toxin, spinal cord injury

normal to high central venous O2 sat

blood to skin

Question 8

SBP < 90

Answer 8

marker for shock

Question 9

markers for shock

Answer 9

1. SBP < 90
2. 3 windows - cutaneous - mottled, renal < 0.5, neuro - abnormal mentation
3. blood lactate > 1

Question 10

levito reticualris

Answer 10

giraffe looking skin

in shock

Question 11

alcoholic, cirrhosis, ascites, vomiting, dry membranes, BP 70/50

Answer 11

hypovolemic shock

will see

• decreased CO
• decreased PCWP
• decreased CVP
• increased SVR

Question 12

CVP

Answer 12

right atrial pressure

Question 13

Tx of hypovolemic shock

Answer 13

0.9% saline - 1-2 liters wide open - continue based on BP, skin, urine, and mental status

PRBCs

goal - CVP 8-12mmHg

Question 14

dobutamine

Answer 14

inotropic

Question 15

dyspnea, BP 65/50, old MI, HR 140, cool skin, clammy skin, restless, basilar crackles, distended neck veins

Answer 15

cardiogenic shock

Question 16

Tx of cardiogenic shock

Answer 16

O2
dobutamine (low BP)
nitro (normal/high BP)
AF
post MI - NE, dopamine, milrinone

Question 17

NE

Answer 17

vasopressor with some inotropic

Question 18

dopamine

Answer 18

alpha agonist with some inotropic

-increases PCWP

Question 19

milrinone

Answer 19

inotrope that also produce vasodilation

Tx for cardiogenic shock - if patient does not have that severe hypotension

Question 20

becks triad

Answer 20

for cardiac tamponade

1 - distended neck veins
2 - muffled heart sounds
3 - hypotension

Question 21

echocardiography with free space around ventricular wall

Answer 21

obstructive shock

Question 22

obstructive shock

Answer 22

tension pneumo
pericardial disease
PE
cardiac tumor
left atrial mural thrombus
obstructive valvular disease

Question 23

SIRS

Answer 23

systemic immune response syndrome
-dysregulated inflammation related to autoimmune, pancreatitis, vasculitis, VTE, burns, surgery, etc.

usually respiratory alkalosis

Question 24

respiratory alkalosis

Answer 24

with SIRS

Question 25

labs in SIRS, sepsis, distributive shock

Answer 25

CMP
ABG
type and crossmatch
coag parameters
lactate 
blood culture

Question 26

clustered gram positive cocci

Answer 26

staph

Question 27

DAMPs

Answer 27

damage-associated molecular patterns

activate TLRs

Question 28

PAMPs

Answer 28

pathogen-associated molecular patterns

activate TLRs

Question 29

SIRS

Answer 29

TPR

• temp >38.3
• pulse > 90
• respirations > 20

with infection - becomes sepsis

Question 30

WBC > 12,000 with bandemia >10%

Answer 30

sepsis

Question 31

WBC < 4,000 with increased CRP and procalcitonin

Answer 31

sepsis

Question 32

variables with sepsis

Answer 32

inflammatory
-WBC levels high, or elevated CRP and procalcitonin

hemodynamic
-SBP < 90, MAP < 70

organic dysfunction
-PaO2 0.5
INR >1.5
ileus
platelets < 100,000
bilirubin >4
hyperprolactinemia
decreased cap refill

Question 33

severe sepsis

Answer 33

involves at least ONE organ system

ARDS, AFR, DIC, serum lactate >4

Question 34

unable to maintain MAP >60 after fluid resuscitation

Answer 34

septic shock

Question 35

distributive shock

Answer 35

septic shock, anaphylaxis, adrenal insufficiency

SVR <800***

and elevated mixed venous O2 sat**

Question 36

sepsis protocol

Answer 36

within 2 hours pt with infection, SIRS, dysfunction of one organ

1 - serum lactate
2 - 2x blood cultures
3 - 2 18 gauge lines
4 - antibiotics
5 - 2L normal saline
6 - CBC and BMP
7 - O2 sat >90
8 - NE if shock present
9 - transfer - lactate >4, SBP <60 after 2 L normal saline

Question 37

goal for septic shock

Answer 37

maintain CVP 8-12
fluids - 5L in 6 hrs
maintain MAP >65
cardiac index 2-4

NE - vasopressor
phenylephrine - warm shock
E - anaphylactic shock
vasopressin - potentiates NE

maintain CV O2 sat - >70
PRBCs

dobutamine

goal - reduce lactate by 20% in first 2 hours

Question 38

relative adrenal insufficiency

Answer 38

use hydrocortisone 50mg q6hrs