Shock + RUSH Protocol Flashcards
State of inadequate tissue perfusion leading to hypoxia and cell death
Shock
Inflammatory response to microorganisms, or invasion of sterile host tissue
Infection
Viable bacteria in the blood
Bacteremia
T > 38 or < 36
HR > 90
RR > 20
WBC > 12,000 or < 4,000 or > 10% bands
PaCO2 < 35
SIRS
(must meet at least 2 of the criteria)
SIRS
+
Source of Infection
Sepsis
Hypotension
+
Severe Sepsis
aka hypoperfusion causing hypoxia and cell death
Septic Shock
Severe Sepsis = sepsis + lactic acidosis, SBP < 90 or a drop > 40
Who gets septic shock?
Anyone can
Increased risk for immunocompromised (DM, Medicated, Asplenic, etc.)
Increased risk for those at “extremes of age”
Tx for septic shock
Abx (early goal directed therapy)
+
Fluid (most often crystalloid)
4 Classic Types of Shock
- Hypovolemic (secondary to hemorrhage or loss of other bodily fluid)
- Cardiogenic
- Distributive (sepsis, anaphylaxis, neurogenic shock)
- Obstructive (pericardial tamponade, tension pneumo, PE)
Classes of Hemorrhagic Shock
Class I-IV
You can lose up to 30% of your blood volume (Class II) before your BP begins to decrease (Class III)
Class IV: >2000 ml blood loss (40% or more),
HR > 140, RR > 35
Tx for Hemorrhagic Shock
Find the bleeding
Stop the bleeding
*Reverse coagulopathies (ASA, Warfarin)
Replace blood and support patients
*Mainly applies to older patients
Which areas of the body are you most likely to bleed to death from?
Abdomen
Femur/Thigh
Pelvis
Chest
Externally
When do you start hypotensive resuscitation for someone in hemorrhagic shock?
If their BP drops below 80
Difference between hypotensive resuscitation and tx for hypovolemic shock
Hypotensive resuscitation = give blood
Hypovolemic shock = give crystalloid
Risk factors for anaphylaxis
Poorly controlled asthma
Previous anaphylaxis
Previous exposure to sensitizing agent
Most common causes of anaphylaxis
Antibiotics (esp. B-lactam): 400-800 deaths
Insects: < 100 deaths
Food: 11 deaths
Severe systemic hypersensitivity that may include hypotension or airway compromise
Anaphylaxis
IgE-dependent mast cell, basophil release
Anaphylactoid
Non-IgE mediated
Same final common pathway as anaphylaxis
No sensitizing exposure required
Primary Tx for anaphylaxis
Epi (no absolute contraindications)
0.1 mg IV or 0.3-0.5 mg IM (i.e., give less potent when IV)
Stabilizing Treatment for Anaphylaxis
Intubate sooner rather than later
Fluid resuscitation for hypotension
Steroids
Antihistamines (H1 & H2)
Tx bronchospasm
Glucagon (if on β-blockers)
Neurogenic Shock
Disruption of sympathetic outflow:
Blunt trauma (usually C-spine)
Sympathetic roots T1-L2
Unopposed vagal tone
Hypotension + Bradycardia
Neurogenic Shock vs Spinal Shock
Spinal shock = total loss of spinal reflex activity AT AND BELOW injury level
Tx of Neurogenic Shock
Assume hemorrhage (even w/ bradycardia)
Stop secondary injury
Fluids
Pressors
Cardiogenic Shock
Decreased cardiac output despite adequate volume (tissue hypoperfusion)
Usually results from AMI
Diagnosis of Cardiogenic Shock
EKG
Echo
CXR
Labs
Monitoring
Tx of Cardiogenic Shock
ABC support
Reperfusion of MI (thrombolytics, PCI)
Intraaortic Balloon Pump
Only type of shock where CVP (central venous pressure is HIGH)
Cardiogenic
DO NOT give fluids
“Big toe” should feel cool
Only type of shock that you give Blood
Hemmorhagic
CVP should be low
“Big toe” should feel cool
What types of shock will make your “big toe” (extremities) warm?
Septic
Anaphylactic (normal CVP)
Neurogenic
When are pressors helpful?
Typically, they do not improve meaningful outcomes
Exception = anaphylaxis (i.e., EPI)
Norepinepherine
(Levophed)
Pressor used for sepsis
Dobutamine
Pressor used for cardiogenic shock
(strict β stimulant so watch out for drop in BP via vasodilation)
85 y.o. woman found unresponsive beside bed
Only available history = Alzheimer’s
HR 115, BP 70, PO2 88%, Glucose 170
What Dx is most likely?
Septic Shock
KEY FINDINGS: extremities are cool, bruising/crepitus at pelvis, Hgb low, and CVP low
…change diagnosis to Hemorhagic shock (pelvic fx)
What 3 categories does RUSH access?
Pump (Estimate of EF, Tamponade, PE)
Tanks (IVC, eFast, Pulmonary)
Pipes (Aorta, DVT)
Which transducers are used during the FAST exam?
Phased array for cardiac (small footprint is good for b/w ribs)
Curvilinear array for abdomen (45x as many crystals = higher quality, but more rib shadows)
What 3 things are you looking for with the heart on ultrasound?
Contractility
Pericardial Effusion/Tamponade
RV strain (indictive of PE)
What are the views of the heart on ultrasound?
Parasternal (short/long)
Subxiphoid
Apical 4 Chamber
When do you want to monitor the IVC more closely on ultrasound?
During volume resuscitation
or
When the following are suspected:
Tamponade, PE, Tension pneumo (all would show abnormally large IVC)
Beside the heart, what are the other 3 views for the FAST exam
RUQ, LUQ, Pelvic
How to look for a tension pneumo on ultrasound
Use high frequency linear array
Look for abscence of sliding (use M mode if not sure)
What is a “comet tail” on ultrasound
An artifact created by fluid in the lungs (indicating pulmonary edema)
AAA on ultrasound
Abdominal Aortic Aneurysm
Look for aorta that is > 3 cm (abnormal)
Must measure from outer wall to outer wall
Remember: 2/3 of AAA’s rupture retroperitoneally (meaning they will not show up on US when doing an eFAST, must rely on measurement)
Pericardial effusion
vs
Pleural effusion
Difference on ultrasound
Pericardial = “rat tail”
A person can have both
PATCH MD
P: pulmonary embolism
A: acidosis
T: tension pneumo
C: cardiac tamponade
H: hyopvolemia, hypoxia, hypothermia, hypo/hyperkalemia
M: MI
D: drugs
Ultrasound can diagnosis everything in bold
