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Neonatal Pathophysiology > Shock States > Flashcards

Shock States Flashcards

1
Q

What is shock?

A

A complex state of circulatory dysfunction resulting in insufficient oxygen and nutrient delivery to satisfy tissue requirements

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2
Q

Why is early intervention of shock so important?

A

To interrupt the cycle: decreased blood flow & decreased available oxygen > tissue hypoxia > anaerobic metabolism > metabolic acidosis > irreversible cellular change > cellular death

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3
Q

How are hypotension and shock related?

A

hypoTN is distinct from shock, but can indicate a late uncompensated shock state

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4
Q

What might cause a dampened wave form on a recently placed arterial line?

A

1) air in the transducer
2) air in the tubing
3) a clot in the system

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5
Q

What are the clinical signs of shock?

A
  • tachycardia
  • poor/reduced perfusion
  • prolonged cap refill
  • respiratory distress
  • poor tone
  • poor color
  • cold extremities (with normal core temp)
  • lethargy
  • narrow pulse pressure
  • A’s & B’s
  • tachypnea
  • metabolic acidosis
  • weak pulse
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6
Q

How should adequate UOP in the hypoTN neonate be interpreted?

A

If BP is low, but UOP is WNL, aggressive intervention may not be necessary; renal perfusion is not adversely affected
* exception: infant with septic shock and hyperglycemia with osmotic diuresis

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7
Q

How can a history of birth asphyxia inform your interpretation of hypoTN?

A

Birth asphyxia may be a/w myocardial dysfunction and may indicate cardiogenic shock

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8
Q

What influences CO?

A

HR x SV

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9
Q

How does a neonate affect their CO?

A

Neonates have limited myocardial compliance, and therefore, can increase their output by increasing their HR

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10
Q

What factors negatively affect cardiac output?

A
  • decreased preload
  • increased afterload
  • decreased myocardial contractility
  • electrolyte, mineral or energy imbalances
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11
Q

What is preload?

A

the end diastolic volume at the beginning of systole (accounted for by the “stretch” of the ventricles caused by volume of blood that returns from venous circulation)

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12
Q

Why does a decreased preload negatively affect your CO?

A

With decreased venous return, you don’t have enough blood to push out for systemic perfusion

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13
Q

What is afterload?

A

ventricular pressure at the end of systole (Ejection stops, and systole is complete- because the ventricular pressure developed by the myocardial contraction is less than the arterial pressure. This determines the end-systolic volume (ESV).

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14
Q

Why does increased afterload negatively affect CO?

A

Increased systemic resistance is difficult for the heart to pump against and therefore, systemic perfusion is limited

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15
Q

Why does decreased myocardial contractility negatively affect CO?

A

If myocardial ctx is poor or ineffective, systemic perfusion will be inadequate

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16
Q

What electrolytes have a significant on cardiac function?

A
  • calcium
  • potassium
  • glucose
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17
Q

What are the different types of shock states?

A
  • hypovolemic
  • cardiogenic
  • distributive
  • obstructive
  • dissociative
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18
Q

What is included in the term distributive shock?

A
  • septic
  • neurogenic
  • adrenal
  • anaphylactic
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19
Q

What should be considered in differential of shock v. inborn error of metabolism?

A

Some inborn errors resulting in hypoglycemia or hyperammonemia can mimic the presentation of shock (ex: galactosemia, maple syrup urine disease, etc..)

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20
Q

What is the most common form of shock in the neonate?

A

Hypovolemic

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21
Q

What is hypovolemic shock the result of?

A

Inadequate blood volume

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22
Q

What is the etiology of hypovolemia in the neonate?

A
  • antepartum hemorrhage
  • postpartum hemorrhage
  • non-hemorrhagic losses
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23
Q

What conditions create a hypovolemic state secondary to antepartum hemorrhage?

A

1) placental hemorrhage (abruptio placentae & placenta previa)
2) TTTS
3) Fetomaternal hemorrhage
4) Difficult delivery (often a/w asphyxia)
5) Umbilical cord injury
6) Birth injuries (spleenic and hepatic rupture)

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24
Q

What conditions create a hypovolemic state secondary to postpartum hemorrhage?

A

1) coagulation disorders (DIC, coagulopathies)
2) vitamin K deficiency
3) iatrogenic (ex: loss of arterial catheter)
4) adrenal hemorrhage
5) ICH (subdural or subgaleal)
6) pulmonary hemorrhage
7) circumcision wound

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25
Q

What conditions create a hypovolemic state secondary to non-hemorrhagic losses?

A

1) umbilical cord obstruction (cord, true knot, entanglement)
2) insensible water loss
3) diuretic use
4) sepsis
5) heat stress
6) vomiting/ diarrhea
7) GI abnormalities
8) Dehydration

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26
Q

What increase the risk for a subgaleal hemorrhage?

A

The likelihood of tearing the emissary vein is increased with a spontaneous, instrument assisted delivery (especially vacuum)

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27
Q

Why are fluid boluses not effective in correcting hypoTN in the septic neonate?

A

With an infx, endotoxins are released from invading organism affecting the integrity of the capillary wall. The resultant severe capillary leak permits fluid to seep into the interstitium.

28
Q

What is cardiogenic shock?

A

Inadequate tissue perfusion secondary to myocardial dysfx and implies primary failure of the heart as a pump

29
Q

What is the etiology of cardiogenic shock?

A

1) severe intrapartum or postpartum asphyxia
2) metabolic and/or electrolyte imbalances
3) congenital heart defects
4) cardiomyopathies
5) PPHN and severe RDS
6) PDA
7) Arrhythmias/ dysrhythmias
8) Infectious agents
9) Hypoxemia and/or metabolic acidosis

30
Q

What metabolic problems can create a state of cardiogenic shock?

A

Severe hypoglycemia (IDDM), hypocalcemia and academia can cause decreased CO with a decrease in BP.

31
Q

How do inborn errors and adrenal insufficiency p/w cardiac involvement?

A

Both states can p/w congestive heart failure, arrhythmias, cardiomyopathy and conduction disturbances

32
Q

What congenital cardiac defects p/w shock?

A

Left-sided obstructive lesions are the most common (after PDA closure); other defects can present with shock, but not as commonly

33
Q

How do hemodynamically significant PDAs in ELBW infants present?

A

Can cause cardiac failure and hypoTN; may not appreciate a murmur (r/t lack of turbulent blood flow).

34
Q

What infectious agents are likely to cause myocarditis?

A

Bacterial, viral and protozoan

35
Q

How do infectious agents contribute to cardiogenic shock?

A

Can cause myocarditis > myocardial dysfunction in addition to septic shock

36
Q

What arrhythmias increase the risk for cardiogenic shock?

A

Dysrhythmias that cause a decrease in cardiac output, including: SVT, v Tach, v Fib, complete AV block, atrial flutter

37
Q

What is distributive shock?

A

There are abnormalities within the vascular beds that can cause blood volume to be distributed inadequately to organs and tissues. There is not a definite volume loss but inappropriate vasodilation, dysfx of the endothelium with a capillary leak, loss of vascular tone, or combo. Bc the intravascular fluid vol is maldistributed, signs of shock present.

38
Q

How does sepsis create a state of distributive shock?

A

Endotoxemia occurs , with release of vasodilatory substances and resulting in intravascular hypotension

39
Q

What organisms are usually responsible for septic shock?

A
  • Gram Neg: E. coli, klebsiella, enterobacter, pseudomonas and proteus
  • Can occur with Gram Pos
  • Viruses: HSV and enteroviruses
  • Fungal infx: candida (primarily in ELBW)
40
Q

What is a likely consequence of sepsis?

A

In the presence of bacterial infx, many complicated systemic reactions occur that result in circulatory insufficiency (DIC)

41
Q

What is the clinical presentation of sepsis as it relates the respiratory system?

A 
increased WOB
tachypnea
apnea
gasping (ominous sign of impending heart failure- think metabolic acidosis)
desaturations
42
Q

What is the clinical presentation of sepsis as it relates the cardiac system?

A

pulses may be difficult to palpate (compare pulses)
peripheral poor perfusion
prolonged capillary refill
tachycardia > bradycardia
heart size on CXR
enlarged: CHF, myocardial dysfx
compressed: impaired filling & ctx

43
Q

What is the clinical presentation of sepsis as it relates the integumentary system?

A

cyanotic
pallor (when you don’t have enough hgb to be cyanotic)
extremities are cool and mottled

44
Q

What is the clinical presentation of sepsis as it relates to BP?

A

May be normal or low; late sign of cardiac decompensation; 4 extremity pressures; evaluate pulse pressure

45
Q

What is the normal pulse pressure for preterm and full term infants?

A

PT: 15-25
FT: 25-30

46
Q

What is indicated by a narrow pulse pressure?

A
  • vasoconstriction
  • heart failure
  • poor CO
  • cardiac compression
47
Q

What is indicated by a widened pulse pressure?

A

large aortic run-off lesions (PDA, truncus, AV malformations)

48
Q

What is the clinical presentation of sepsis as it relates the GU system?

A

Evaluation of UOP will aid in the assessment of end organ perfusion
* red flag: <1mL/kg/h or a declining UOP, especially with there are other signs of hypoperfusion

49
Q

How should bradycardia with other signs of severe shock be interpreted?

A

As an impending sign of arrest

50
Q

What causes a murmur and how should the presence of one be interpreted?

A

A murmur is caused by turbulent blood flow; pathologic murmurs are typically present with other signs

51
Q

What labs are indicated for the evaluation of sepsis?

A 
blood gas: hypoxemia, acidosis
glucose: may be elevated r/t a catecholamine surge
electrolytes: Na & K
Ionized Ca: myocardial fx
Liver fx: if liver took a hit
Renal fx: if kidneys took a hit
Coag studies: DIC
Blood lactate: met acidosis
CBC c diff: evaluate for sepsis
 BCX: evaluate for sepsis
 Cardiac enzymes: evaluate for myocardial damage
 ammonia level: inborn error
52
Q

What lab should be ordered to evaluate state of fetomaternal hemorrhage?

A

Kleihauer-Betke tests MOB for fetal erythrocytes

53
Q

What is the goal of treatment for shock?

A

Increasing cardiac output > increases tissue perfusion > increases tissue oxygenation > decreases anaerobic metabolism > decreases lactic acid build up > increases pH

54
Q

What are examples of crystalloid solutions used for volume replacement with hypovolemic shock?

A

NS, LR

55
Q

What are the advantages of crystalloid solutions used for volume replacement with hypovolemic shock?

A
  • isotonic
  • readily available
  • cheap
  • no risk of hypersensitvity reactions
  • no religious objections
  • does not interact with infectious agents
56
Q

What are the disadvantages of crystalloid solutions used for volume replacement with hypovolemic shock?

A

has very low molecular weight, and therefore, doesn’t stay in the vascular space long if there is severe capillary leak (lost to the interstitium or intracellular space)

57
Q

What are solutions used for volume replacement with hypovolemic shock?

A

crystalloid solutions

colloid solutions

58
Q

What are examples of colloid solutions used for volume replacement with hypovolemic shock?

A

blood, albumin and plasma

59
Q

What are the advantages of colloid solutions used for volume replacement with hypovolemic shock?

A

preserve high osmotic pressure in the blood, longer acting, helpful with congenital cardiac patients

60
Q

What are the disadvantages of colloid solutions used for volume replacement with hypovolemic shock?

A
  • not readily available
  • expensive
  • risk of hypersensitivity reactions
  • religious objections
  • may interact with infectious agents
61
Q

Why might an infant with a history of chronic blood loss in a state of severe hypovolemic shock not tolerate volume boluses?

A

if there has been chronic anemia, the heart may not tolerate rapid volume expansion (ex: congestive heart failure)

62
Q

What is the treatment goal for a patient in cardiogenic shock?

A

correct the underlying problems that may negatively affect heart function

63
Q

Why is the administration of Na HCO3 (4.2%) controversial in the treatment of cardiogenic shock?

A

because HCO3 converts to CO2 in H2O (make sure they are adequately ventilating); will drive up CO2 more

64
Q

What medications may be used for the treatment of cardiogenic shock?

A
  • volume expanders
  • Na HCO3
  • Dopamine Hydrochloride (most common inotrope)
  • Dobutamine
  • Epi
65
Q

What is the treatment goal for a patient in septic shock?

A

involves a combination of hypovolemic and cardiogenic shock therapies

66
Q

What are some of the causes of bradycardia?

A
  • hypoglycemia
  • apnea
  • abdominal distension
  • increased ICP
  • beta blockers
67
Q

Why should Na HCO3 be carefully considered before administering to a PT baby?

A

if given too quickly can increase risk of IVH

Neonatal Pathophysiology (17 decks)

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