SR 26 - Shock Flashcards
What are the signs of shock?
Pale, diaphoretic, cool skin Hypotension, tachycardia, tachypnea Decreased mental status and pulse pressure Poor capillary refill Poor urine output
What are the best indicators of tissue perfusion?
Urine output
Mental status
What lab tests help assess tissue perfusion?
Lactic acid (elevated with inadequate tissue perfusion) Base deficit pH from ABG (acidosis associated with inadequate tissue perfusion)
What is the definition of hypovolemic shock?
Decreased intravascular volume
What are common causes of hypovolemic shock?
Hemorrhage, burns, bowel obstruction, crush injury, pancreatitis
What are the early signs of hypovolemic shock?
Orthostatic hypotension, mild tachycardia, anxiety, diaphoresis, vasocontriction (decreased pulse pressure with increased diastolic pressure)
What are the late signs of hypovolemic shock?
Changed mental status, decreased BP, marked tachycardia
Amount of blood loss and signs/symptoms with Class I hemorrhage
Amount of blood loss and signs/symptoms with Class II hemorrhage
15-30% or 750-1500cc of blood
Normal systolic BP with decreased pulse pressure, tachcyardia, tachypnea, anxiety
Amount of blood loss and signs/symptoms with Class III hemorrhage
30-40% or 1500-2000cc of blood
Tachycardia (>120), tachypnea (>30), decreased SBP, decreased pulse pressure, confusion
Amount of blood loss and signs/symptoms with Class IV hemorrhage
> 40% or >2000cc of blood
Decreased SBP, tachycardia (>140), tachypnea (>35), decreased pulse pressure, confused and lethargic, no urine output
What is the treatment of hypovolemic shock?
Stop any bleeding
IVF (isotonic LR) then blood products, as needed
How do you evaluate the effectiveness of treatment for hypovolemic shock?
Urine output, BP, HR, mental status, extremity warmth, capillary refill, body temperature
pH, base deficit, lactate level
What usually causes failure of ressucitative treatment of hypovolemic shock?
Persistent massive hemorrhage, requiring emergent surgical procedure
What does decreased pulse pressure occur with early hypovolemic shock?
Vasocontriction leads to an elevated DBP
What is the most common vital sign change associated with earl hypovolemic shock?
Tachycardia
What type of pateint does not mount a normal tachycardiac response to hypovolemic shock?
Patients on B-blockers
Spinal shock (loss of sympathetic tone)
Endurance athletes
What is the definition of septic shock?
Documented infection and hypotension
What is the etiology of septic shock?
Most common - G- septicemia
Less common - G+ septicemia, fungus
Major complications of septic shock?
Multiple organ failure, DIC, death
Signs and symptoms of septic shock?
Initial - vasodilation, resulting in warm skin and full pulses, normal urine output
Delayed - vasoconstriction and poor urine output, mental status changes, hypotension
Associated - fever, hyperventilation, tachycardia
Associated lab findings in septic shock?
Early - hyperglycemia/glycosuria, respiratory alkalosis, hemoconcentration, leukopenia
Late - leukocytosis, acidosis, elevated lactic acid
What is the treatment of septic shock?
Volume - IVF Antibiotics - empiric, then narrowed by cultures Drainage of infection Pressors PRN Zygris PRN
What is Zygris?
Activated protein C, shown to decrease mortality in septic shock and multiple organ failure
Define cardiogenic shock
Cardiac insufficiency
Impaired cardiac output results in inadequate tissue perfusion
Causes of cardiogenic shock?
MI, papillary muscle dysfunction, massive cardiac contusion, cardiac tamponade, tension pneumothorax, cardiac valve failure
What are signs/symptoms of cardiogenic shock on exam?
Dyspnea, rales, pulsus alternans (increased pulse with greater filling following a weak pulse), loud pulmonic component of S2, gallop rhythm
What are the vital sign changes seen with cardiogenic shock?
Hypotension, decreased CO, elevated CVP/wedge pressure, decreased urine output, tachycardia
What are the signs seen on CXR in cardiogenic shock?
Pulmonary edema
What is the treatment of cardiogenic shock?
Based on diagnosis/mechanism
CHF - diuretics and afterload reduction (i.e. ACEI), +/- pressors
LVF (MI) - pressors, afterload reduction
What are the last resort support mechanisms in cardiogenic shock?
Intra-aortic ballon pump (IABP)
Ventricular assist device (VAD)
What is the definition of neurogenic shock?
Inadequate tissue perfusion from loss of sympathetic vasoconstrictive tone
What are the common causes of neurogenic shock?
Spinal cord injury:
- Complete transection of spinal cord
- Partial cord injury with spinal shock
- Spinal anesthesia
Signs and symptoms of neurogenic shock?
Hypotension and bradycardia
Neurologic deficit
Why are heart rate and BP decreased in neurogenic shock?
Loss of sympathetic tone
But you need to rule out hypovolemia and hemorrhagic shock
What is the treatment for neurogenic shock?
IV fluids
Vasopressors - only for hypotension refractory to fluid resuscitation
What is spinal shock?
Complete flaccid paralysis immediately following spinal cord injury
May or may not be associted with circulatory shock
What is the lowest reflex available to the examiner?
Bulbocavernous reflex
Contract of the anal spincter upon compression of the glands penis or clitoris
What ist eh lowest level voluntary muscle?
External anal sphincter
What are the classic findings associated with spinal cord shock?
Hypotension
Bradycardia or lack of compensatory tachycardia
What are the treatment options for anaphylactic shock?
BASE
- Benadryl
- Aminophylline
- Steroids
- Epinephrine
