shock states

Question 1

what is SIRS?

Answer 1

unchecked out of control systemic response of inflammatory/immune system- warning sign of what is to come

Question 2

SIRS criteria

Answer 2

diagnosis: 2+ presentHR gt 90RR gt 20 -or- PaCO2 lt 32T lt 36 -or- gt 38leuk- WBC lt 4k -or- gt 12k- OR gt 10% immature neutrophilsin high risk pts that can’t be explained by other causes

Question 3

SIRSinsult → pathophysiology x4

Answer 3

peripheral vasodilationcapillary permeabilitymicrovascular clottingcellular activation

Question 4

what is shock?

Answer 4

broad categoryinitiated by insult → inadequate tissue perfusion comp to cell metabo reqs → cellular hypoxia + end organ dysfxn

Question 5

what is compensated shock?

Answer 5

relatively stable may see early s/s shockcompensatory mechanisms: moderately effectivecause:- rapidly corrected = minimal residual effects- not corrected → uncompensated

Question 6

what is MODS? x3

Answer 6

uncompensated shock worsens → MODSinvolves 2+ organ systems (that weren’t previously failing)altered organ function in acutely ill patientsorgan system homeostasis cannot be achieved without interventioncompensatory mechanisms from compensated shock NO LONGER ADEQUATE

Question 7

geriatric population & shock

Answer 7

• progression rapid- reduced compensatory mechanisms- pre-existing comorbs (renal failure, lung disease, cardiomyopathy) INTERVENE STATE

Question 8

present in every type of shock

Answer 8

inadequate tissue perfsuion & cellular hypoxia

Question 9

hemodynamic goals of therapy for shock x7

Answer 9

• MAP gt 60- CVP 8-12- CI gt 2.1- UOP gt 0.5 mg/kg/hr- SaO2 gt 92%- SVO2 gt 70- serum lactate lt 2 mmol/L

Question 10

hypovolemic shock causes

Answer 10

• ABL/ongoing hemorrhage- non-hemorrhage fluid depletion– GI (v/d)– burns– polyuria– aggressive pharm diuresis– insensible losses

Question 11

can lose how much via insensible losses + how?

Answer 11

1L/day; diaphoresis, open burn wounds, vents

Question 12

hypovolemic shock is

Answer 12

loss or redistribution of volume… (blood, plasma, or other body fluids) which result in decreased intravascular volume

Question 13

obstructive shock is

Answer 13

mechanical obstruction impacting the cardiovascular system… that decreases ventricular filling and/or emptyingend result: ↓ CO, tissue perfusion, O2 delivery

Question 14

obstructive shock causes

Answer 14

↓ ventricular filling =- cardiac tamponade- tension pneumothorax- vena cava compression/thrombus- atrial mass or thrombus↓ ventricular emptying- PE (saddle embolism = sitting across either/both arteries)

Question 15

saddle embolism is

Answer 15

thrombus sitting across either/both arteriescauses ↓ ventricular emptying → obstructive shock

Question 16

cardiogenic shock is

Answer 16

occurs when heart fails as a pump↓ contractility → ↓ SVwhich leads to ↓ CO, BP → ↓ tissue perfusion

Question 17

cardiogenic shock causes

Answer 17

MI !!!!!!!!HFrEF exacerbation (ischemic v nonischemic)dysrhythmias (poor O2 at first, can exacerbate cardiogenic shock states)LV outflow tract obstruction (hypertrophic obstructive cardiomyopathy, muscle/tumor overgrowth is pretty uncommon)

Question 18

1 cause of cardiogenic shock

Answer 18

MI

Question 19

neurogenic shock is…

Answer 19

typically results from SCI w damaged symp pathways, usually seen in injuries T6 or higher- higher injury = greater symptoms- common in trauma or neuro patients↓ symp of organs distal to injury = stimulated by PS toneresults: bradycardia, massive vasodilation, inability to regulate body temp (hypothermia)EASIEST SHOCK TO SPOT

Question 20

anaphylactic shock is…

Answer 20

life threatening allergic reaction resulting in IgE mediated response or mast cell (non-IgE degranulation)- occurs following reexposure to specific antigen- immediate response causing release of histamines, prostaglandins, vasoactive mediatorsresults: massive vasodilation, capillary permeability, constriction of non-vascular smooth muscle (RESPIRATORY!!)triggers: drugs, foods, other (see lecture)s/s: see lecture

Question 21

*SEPSIS *

Answer 21

SIRS likely s/t infection; positive cultures add to validity but not required

Question 22

SEVERE SEPSIS

Answer 22

sepsis + at least 1 sign of hypoperfusion or organ dysfunction (new, not explained by other etiology)

Question 23

SEPTIC SHOCKmust know definition + pathophys/results

Answer 23

severe sepsis associated with refractory hypotension (BP lt 90/60) despite adequate fluid resus and/or serum lactate gt 4.0—release: endotoxins trigger overzealous release of inflammatory mediators (cytokines, interleukins, tumor necrosis factor, complement system)results: systemic vasodilation, widespread endothelial injury, activation of coagulation cascade

Question 24

septic shock pathophys + results

Answer 24

release: endotoxins trigger overzealous release of inflammatory mediators (cytokines, interleukins, tumor necrosis factor, complement system)results: systemic vasodilation, widespread endothelial injury, activation of coagulation cascade

Question 25

inflammatory response: goal of vasodilation

Answer 25

increase availability of - nutrients (O2, glucose)- neutrophils, macrophages, and their mediatorsto injured area

Question 26

inflammatory response: goal of microvascular permeability

Answer 26

increase availability of - nutrients- cells- mediatorsto injured area

Question 27

inflammatory response: goal of coagulation

Answer 27

• minimize blood loss- wall off injury

Question 28

inflammatory response: goal of cellular activation

Answer 28

WBCs –>- phagocytosis foreign debris + cells- wound microdebridement

Question 29

SIRS mediators: inflammatory cells

Answer 29

neutrophilsmacrophagesmast cellsendothelial cellsplatelets

Question 30

SIRS mediators: biochemical mediators

Answer 30

• tumor necrosis factor (TNF)- interleukins- platelet activating factor- arachidonic acid metabolites prostaglandins, leukotrienes, thromboxanes- toxic oxygen radicals- proteases

Question 31

SIRS mediators: plasma protein systems

Answer 31

• complement system- kinin- coagulation- fibrinolysis

Question 32

organ dysfunction and SIRS

Answer 32

ORGAN DYSFUNCTION STARTS EARLY

Question 33

SIRS mediators x3

Answer 33

biochemical mediatorsinflammatory cellsplasma protein systems