Shock + syncope Flashcards
Shock is determined by
low CO or low SVR
What does this indicate:
Heart cannot pump enough blood to meet metabolic demands of the body–
Cold, clammy, cyanosis, AMS
Elevated JVP
Respiratory distress
cardiogenic shock
Cardiogenic shock is caused by
Intracardiac causes of cardiac pump failure → reduced CO
Cardiomyopathic (MI, HF), arrhythmic, mechanical causes
Vasoconstriction and LOW CO
What do these diagnostics indicate:
Cardiac index < 2.2L/min/m (CO/BSA)
UO <.5 ml/kg/hr
Hypotension:
SBP<90
MAP<65-70
Decrease in SBP >40
Drop in SBP >10-20 and pulse increase >15 = vascular depletion
Lactic acid >1.5mm/lt
High cardiac enzymes, BNP
cardiogenic shock
What is diagnostic for cardiogenic shock?
TTE
Decrease in LV contractility but LV itself is full + dilated (can’t push out volume)
PCWP>15
What is the first thing you do with a patient with shock?
ABCs + establish monitoring
Cardiac monitor w/ BP cuff
ABGs repeated
Central cath/swan-ganz for detailed monitor
VIP treatment – evaluate whether you need to:
Ventilate (O2)
Infuse (IV fluid resuscitation)
Pump (vasoactive agents)
______ often initial DOC in cardiogenic, septic, + hypovolemic shock
norepinephrine
_____ first line in cardiogenic shock with low CO and mainted BP
dobutamine
Do you give fluids to cardiogenic shock patients?
Yes, but in small increments. If they are overloaded, they will not benefit
If your patient has cardiogenic shock from an MI, consider –
immediate percutaneous coronary revascularization when MI is recognized
Balloon pump/ECMO for BP support
Blood circulatory devices
Transcutaneous/transvenous pacemaker
Urgent hemodialysis/filtration for kidney injury
Medications for shock include
Vasoactive therapy
Steroids
Antibiotics
Sodium bicarbonate
Only shock associated with high CO and low SVR
distributive shock
What type of shock:
Hypotension
Warm extremities in early stages often noted in these patients
SIRS
Tachycardia, AMS
Bounding pulses, flushing → bradycardia (neurogenic)
distributive
Severe peripheral vasodilation and maldistribution of blood flow – septic vs non septic (inflammatory, neurogenic, anaphylactic)
MC
distributive
What would indicate septic shock?
+ cultures, elevated lactate
What would indicate anaphylactic shock?
angioedema, pruritus, hives, HOTN
What would indicate hypoadrenal shock?
low glucose, HOTN, refractory to fluids and pressors
How do you treat septic shock?
fluids + antibiotics + norepinephrine
If a patient remains HOTN with fluids in septic shock, you should
give norepinephrine may be indicated to raise MAP
How do you treat anaphylactic shock
airway + epinephrine + antihistamines + steroids, observe
How do you treat neurogenic shock?
fluids + pressors + steroids
How do you treat hypoadrenal shock?
hydrocortisone IV
What does this indicate:
Flattened neck veins, dry mucous membranes, delayed capillary refill, low skin turgor, pale cool and dry extremities and skin
Tachycardia first initial change → HOTN
Generally no respiratory distress
hypovolemic shock
Reduced intravascular volume – hemorrhagic (trauma) vs nonhemorrhagic (GI, skin, renal losses)
hypovolemic shock
What would be seen on labs with hypovolemic shock?
Elevated lactate, low CO + preload, high SVR
Decreased PCWP
What would be seen on echo for hypovolemic shock? (differentiate from cardiogenic)
TTE = LV will be small but contractile force present
How do you treat hemorrhagic shock?
blood + fluids (crystalloids)
How do you treat non-hemorrhagic shock?
fluids
Vasopressors indicated if
Continued HOTN
Preserved CO
After adequate fluid resuscitation
like epinephrine, norepinephrine, dopamine, vasopressin, phenylephrine, dobutamine
Inotropes if
Low CO
High filling pressure
What does this indicate
Beck’s triad = hypotension, JVD, muffled heart sounds
Severe respiratory distress, cool/clammy skin
obstructive shock
Due to extracardiac causes of pump failure (pulmonary vascular vs mechanical) like PE, pneumothorax, CHD, aortic dissection
obstructive shock
What does this indicate
Pneumothorax, PE → bedside US, CT-PA, EKG, CXR, D-dimer, ABGs
Increased PCWP
obstructive shock
How do you treat obstructive shock
Relieve obstruction + stabilize patient → oxygen + fluids + vasopressors
What does this indicate
Motionless + limp, cool extremities, weakened pulse + shallow breathing
Light-headedness, sense of impending faint
Sweating, palpitations, nausea, visual “blurring”, diminution of hearing, pallor
syncope
Transient loss of consciousness with loss of postural tone
syncope
vasovagal - fear, pain, carotid sinus, defecation/coughing syncope
reflex/vasodepressor
postural change in elderly/diabetic, low BV, meds, alcohol syncope
orthostatic
arrhythmic like AV block, pause, vtach, bigeminy, SVT, structural disease like AS, HCM syncope
cardiogenic
orthostatic syncope is
drop in SBP >20, DBP >10
in syncope, important to know
onset, positioning, and detailed HPI, knowing provocative factors
PE for syncope must include
Orthostatic vitals
FULL cardiac exam
Neuro exam
EKG
Can also consider in syncope to check
Checking glucose
Basic labs
Tilt table
Ambulatory EKG
CNS imaging
EEG if seizure concern
How do you treat syncope?
Treat cause + prodromal symptoms – counterpressure maneuvers like leg crossing, lower body muscle tensing, hand grip, arm tensing
Immediate response: assist patient, lay supine, assess VS, observe other signs, call for assistance, attempt to arouse patient
