shocky

Question 1

hypotension
bradycardia
warm, dry skin

classic signs of

Answer 1

neurogenic shock

Question 2

clinical hallmark of neurogenic shock

Answer 2

very ↓ SVR + signs of excessive PS activity (ex: bradycardia)

Question 3

every shock needs

Answer 3

• find and treat cause
• maximize O2 support
• fluid resuscitation (except cardiogenic - diurese to decrease preload first)
• glucose control = good outcomes

Question 4

why epinephrine for anaphylaxis?

Answer 4

decreases basophil and mast cell degranulation

vasoconstricts

reverses airway constriction

Question 5

anaphylaxis: volume results x3

Answer 5

vasodilation
peripheral pooling
relative hypovolemia

(d/t increase capillary permeability)

Question 6

four systems activated with septic shock

Answer 6

complement, coagulation, kinin systems, cellular immunity

Question 7

hypovolemic shock class I

Answer 7

0-15% loss

minimal tachycardia (usually no Δ in BP, RR, pulse pressure)
delayed cap refill (loss of 10%)

Question 8

hypovolemic shock class II

Answer 8

15-30% loss

tachycardia, tachypnea, pulse pressure
cool/clammy, delayed cap refill
slight anxiety

Question 9

hypovolemic shock class III

Answer 9

30-40% loss

significant tachycardia, tachypnea, SBP
oliguria
confusion or agitation

Question 10

hypovolemic shock class IV

Answer 10

greater than 40% loss

significant tachycardia, tachypnea, BP, pulse pressure (or no DBP)
oliguria/anuria
LOC
cold & pale

Question 11

these patients may not have tachycardia in response to hypovolemia

Answer 11

BB, CCB, or pacemakers

Question 12

plasma cascades activated in MODS

Answer 12

complement, kallikrein‐kinin, coagulation, fibrinolytic

Question 13

reperfusion injury

Answer 13

organ damage occurring after reestablishment of blood flow post-ischemia

O2 radicals attack already damaged tissues

seen in MODS

Question 14

myocardial depression in MODS d/t

Answer 14

caused by: myocardial depressant factor (MDF), TNF, IL‐1 → cardiac contractility

alterations: α‐adrenergic receptors (heart)

myocardial hypoxia

Question 15

primary MODS

Answer 15

initial organ insult (usually d/t ischemia, impaired perfusion) results in inflammatory response / ex: shock, trauma, thermal injury, soft tissue necrosis, invasive infection

hypoperfusion both local (in organs) & generalized (gen not always seen)

stress response initiated, not usually as exaggerated as secondary - neutrophils primed can lead to secondary

Question 16

secondary MODS

Answer 16

results from another insult (often mild), NOT primary MODS, but after latent period since primary - organs different from primary site

primed neutrophils go bananas disproportional to insult = inflammation self-perpetuates

primed macrophages release mediators to further damage endothelium

Question 17

MODS monitoring consideration

Answer 17

primary hard to monitor, secondary has an established pattern

Question 18

secondary MODS phase: approximately 24 hours post-event

Answer 18

low‐grade fever, tachycardia, tachypnea, dyspnea, altered mental status, general hyperdynamic and hypermetabolic state

Question 19

secondary MODS phase: 24 to 72 hours

Answer 19

lung failure begins; ARDS possible

Question 20

secondary MODS phase: 7 - 10 days

Answer 20

intensification of hypermetabolic/hyperdynamic state; bacteremia w enteric organisms common; development of hepatic, intestinal, and renal failure

Question 21

secondary MODS phase: 14 - 21 days

Answer 21

↑ severity of renal & liver failure; encephalopathy w AMS (confusion - deep coma); hematologic & myocardial failure = late manifestations; death

Question 22

secondary MODS phases x4

Answer 22

24ish - fever, tachy, AMS, general hyperdynamic/hypermetabolic

24-72 lung failure begins, possible ARDS

7-10 worsened hyper state, gut bacteremia common, development of hepatic, intestinal, renal failure

14-21 worsened renal/liver failure (liver develops early but not detectable until late), encephalopathy = AMS (coma possible), heme & myocardial failure = late manifestation, death

Question 23

late manifestation of secondary MODS

Answer 23

hematologic & myocardial failure

Question 24

major burn injury when and what it involves

Answer 24

burn greater than 20% BSA in adults

associated with massive evaporative H2O losses & flux of large amounts of fluid/electrolytes in tissues

manifestations: generalized edema & circulatory hypovolemia

Question 25

major burn injury manifestations x2

Answer 25

generalized edema & circulatory hypovolemia

Question 26

burn shock

Answer 26

phenomenon consisting of both hypovolemic cardiovascular component & cellular component

Question 27

burn shock: immediate (acute) phase

Answer 27

hypovolemia - massive losses d/t ↑ cap permeability persisting ~24hr after injury

loss of electrolyte homeostasis contribute to shock

Question 28

burn shock: ebb phase

Answer 28

cardiac contractility diminished during initial 24‐hr resuscitation period → blood shunting away from liver, kidney, gut

hallmark of burn shock: CO w precipitous ↓ often result in inadequate perfusion of most tissues at capillary level

normal blood vol doesn’t result in restoration of normal CO d/t phenomenon called myocardial depression

↓ viscera perfusion = ↓ viscera function; ↓ gut barrier function

Question 29

burn shock: end point

Answer 29

state in which individual able to maintain adequate UOP for 2hr w IVF admin rate equal to individual’s calculated maintenance rate;
“capillary seal”

Question 30

capillary seal

Answer 30

term describing vascular status of patient at burn shock endpoint

Question 31

hallmark of burn shock

Answer 31

CO w precipitous ↓ often result in inadequate perfusion of most tissues at capillary level

Question 32

myocardial depression in burn shock

Answer 32

phenomenon during ebb phase - normal blood vol doesn’t result in restoration of normal CO

Question 33

burn + fluid resuscitation = inevitable

Answer 33

massive edema developing in burned and unburned areas

• can result in airway obstruction (requiring intubation)
• can result in increased pulmonary edema (already there d/t inhalation injury)

Question 34

fluid resuscitation in burn

Answer 34

(ex: LR) involves infusion of fluid at rate faster than the loss of circulating volume; eventually results in improved outcome of massively burned patients
- hallmark (precipitous CO decrease)
- massive edema (inevitable)

first 24 hours crucial

Question 35

3 critical elements of major burn injury survival

Answer 35

• meticulous wound management
• adequate fluids/nutrition (massive amounts IVF required)
• early surgical excision/grafting (autograft)

Question 36

first degree burn

Answer 36

involve the superficial skin without loss of protective function
- partial-thickness injury involving only epidermis, without injury to underlying dermal/subcutaneous tissue

Question 37

second-degree burn

Answer 37

superficial (blister formation) or superficial involving partial skin thickness with a waxy white appearance and no involvement of dermal appendages

• superficial-partial thickness injury vs deep-partial thickness injury

Question 38

third-degree burn

Answer 38

involve full skin thickness + often underlying tissues

• painless
• can be life threatening d/t hypovolemic shock + metabolic + immunologic responses
• full-thickness injury involving destruction of entire epidermis, dermis, often underlying SQ tissue; bone/muscle can be involved

Question 39

partial‐thickness burn manifestations

Answer 39

• local pain, erythema
• no blisters until ~ 24 hrs after injury
• skin peeling 24-48 hours or slightly red

heals 3-5 hours

Question 40

superficial partial‐thickness burn manifestations

Answer 40

• painful
• thin‐walled, fluid‐filled blisters develop w/in MINUTES of injury

heals 21-28 days

Question 41

deep partial‐thickness burn manifestations

Answer 41

• waxy white skin surrounded by margins of superficial partial-thickness injury
• skin may peel off in sheets
• indistinguishable from full‐thickness injury until 7 - 10 days when skin buds & hair appear

heals 30 days to months

Question 42

full thickness burn manifestations

Answer 42

• white, cherry red, or black
• delineation between normal & burned skin not accompanied by significant color change
• blisters rare, wound dry/leathery

won’t heal, needs skin graft