Shock

Question 1

Define shock

Answer 1

state of inadequate tissue perfusion

Question 2

6 categories of shock and common etiologies

Answer 2

Hypovolemic - hemorrhage, dehydration
Distributive - sepsis, SIRS
Obstructive - PE, cardiac tamponade, tension pneumo
Cardiogenic -MI, CHF, valves
Neurogenic - spinal injury

Question 3

Pathophysiology of hypovolemic shock

Answer 3

low preload -> low SV -> low CO -> low BP

PVR increases to compensate

Question 4

Pathophysiology of distributive shock

Answer 4

adequate preload but maldistribution of blood flow with open capillary beds

dilated vessels -> reduction in PVR -> low BP

Question 5

Examples of distributive shock

Answer 5

Septic shock
Adrenal insufficiency
SIRS

Question 6

Cardinal signs of SIRS

Answer 6

o Fever or hypothermia
o Leukocytosis or leukopenia
o Tachypnea
o Tachycardia 
o Infectious or non-infectious (burns, pancreatitis, multiple trauma)

Question 7

What spinal cord injuries cause neurogenic shock?

Answer 7

injury at or above thoracolumbar sympathetic roots leading to loss of sympathetically mediated vasomotor tone

• vascular tone is primarily mediated by sympathetic nervous system

Question 8

Causative agents of sepsis

Answer 8

95% are microbes of normal flora that cause disease in immunocompromised

5% classic pathogens: strep pneumo, meningitis, enterobacteria, etc.

Question 9

Renal complications of sepsis

Answer 9

Oliguria
Azotemia
Proteinuria
ATN
Lyte abnormalities

Question 10

Issues with coagulation in sepsis

Answer 10

Liver produces less clotting factors
Thrombocytopenia
DIC

Question 11

SIRS is defined by the presence of 2 or more of the following findings:

Answer 11

• Hypothermia or fever
• HR > 90
• RR > 20 or, on ABG, a PaCO2 less than 32 (tachypnea or hypocapnia due to hyperventilation)
• WBC count less than 4,000, or greater than 12,000, or greater than 10% band forms (leukopenia, leukocytosis, or bandemia)

Question 12

Treatment of sepsis or septic shock

Answer 12

• Eliminate infection: abx, change catheters
• Hemodynamic support: increase intravascular volume with vasopressors (dopamine, norepinephrine)
• Respiratory support: supplement O2, ETT
• Renal support
• Metabolic support: nutrition, bicarb for severe metabolic acidosis, transfusion, control glucose, keep patient warm
• Misc: Steroids, anticoags, COX inhibitors

Question 13

What is APACHE II Scores?

Answer 13

One of several ICU scoring systems, and arguably the best known “severity of disease classifications”

Patient “scored” on 12 physiologic parameters - BP, pulse, RR, temp, age, Hct, Na, K, creatinine etc.

Score 1-71; higher scores correlate with sicker patients

Question 14

General pathophysiology of DIC

Answer 14

widespread intravascular fibrin formation in response to excess blood proteases

sustained coagulation results in using up coagulation factors and platelets which causes bleeding

Question 15

Most sensitive indicator of DIC

Answer 15

fibrin degradation products (FDP)

Question 16

Signs/sx’s of DIC

Answer 16

range from oozing from venipuncture site, petechiae, and ecchymosis to severe bleeding in GI, Pulmonary or CNS systems

Question 17

Treatment of DIC

Answer 17

• Treat underlying cause
• Replace clotting factors and platelets prn
• Control coagulation state–with meds such as heparin?
• Support patient – i.e. ventilator, dialysis, transfusion, etc.