Shock I Flashcards
shock
arterial blood flow inadequate to meet tissue O2 demand
defined by CO, preload, and afterload
shock defined by
CO, preload, and afterload
pulmonary capillary wedge pressure
PCWP
-left atrial pressure
hypovolemic shock
decreased CO
decreased PCWP
increased SVR
hemorrhage, fluid loss, poor intake
systemic vascular resistance
SVR
afterload indicator
cardiogenic shock
decreased CO
increased PCWP
increased SVR
cardiomyopathy, arrhythmia, mechanical, obstruction (tamponade, PE, tension pneumo)
distributive shock
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
SBP < 90
marker for shock
markers for shock
- SBP < 90
- 3 windows - cutaneous - mottled, renal < 0.5, neuro - abnormal mentation
- blood lactate > 1
levito reticualris
giraffe looking skin
in shock
alcoholic, cirrhosis, ascites, vomiting, dry membranes, BP 70/50
hypovolemic shock
will see
- decreased CO
- decreased PCWP
- decreased CVP
- increased SVR
CVP
right atrial pressure
Tx of hypovolemic shock
0.9% saline - 1-2 liters wide open - continue based on BP, skin, urine, and mental status
PRBCs
goal - CVP 8-12mmHg
dobutamine
inotropic
dyspnea, BP 65/50, old MI, HR 140, cool skin, clammy skin, restless, basilar crackles, distended neck veins
cardiogenic shock
Tx of cardiogenic shock
O2 dobutamine (low BP) nitro (normal/high BP) AF post MI - NE, dopamine, milrinone
NE
vasopressor with some inotropic
dopamine
alpha agonist with some inotropic
-increases PCWP
milrinone
inotrope that also produce vasodilation
Tx for cardiogenic shock - if patient does not have that severe hypotension
becks triad
for cardiac tamponade
1 - distended neck veins
2 - muffled heart sounds
3 - hypotension
echocardiography with free space around ventricular wall
obstructive shock
obstructive shock
tension pneumo pericardial disease PE cardiac tumor left atrial mural thrombus obstructive valvular disease
SIRS
systemic immune response syndrome
-dysregulated inflammation related to autoimmune, pancreatitis, vasculitis, VTE, burns, surgery, etc.
usually respiratory alkalosis
respiratory alkalosis
with SIRS
labs in SIRS, sepsis, distributive shock
CMP ABG type and crossmatch coag parameters lactate blood culture
clustered gram positive cocci
staph
DAMPs
damage-associated molecular patterns
activate TLRs
PAMPs
pathogen-associated molecular patterns
activate TLRs
SIRS
TPR
- temp >38.3
- pulse > 90
- respirations > 20
with infection - becomes sepsis
WBC > 12,000 with bandemia >10%
sepsis
WBC < 4,000 with increased CRP and procalcitonin
sepsis
variables with sepsis
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
severe sepsis
involves at least ONE organ system
ARDS, AFR, DIC, serum lactate >4
unable to maintain MAP >60 after fluid resuscitation
septic shock
distributive shock
septic shock, anaphylaxis, adrenal insufficiency
SVR <800***
and elevated mixed venous O2 sat**
sepsis protocol
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
goal for septic shock
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
relative adrenal insufficiency
use hydrocortisone 50mg q6hrs
