Shock

Question 1

Criteria to diagnose as shock

Answer 1

• Hypotension
• Tachycardia (often first symptom)
• Oliguria
• AMS (altered mental status may be only presenting symptom
• Peripheral hypoperfusion and impaired O2 delivery* MOST IMPORTANT

Question 2

Basic progression of shock

Answer 2

• Arterial blood flow can not keep up with demand of tissues metabolic needs
• Resulting in hypoxia to the body as a whole
• Resulting in anaerobic metabolism to kick in at peripheral tissues
• *Resulting in lactic acidosis (lactic acid build up, very bad)**

Overall: Decreased oxygen to peripheral tissues

Question 3

4 types of shock

Answer 3

Hypovolemic
Cardiogenic
Obstructive
Distributive

Question 4

Hypovolemic shock

Answer 4

• Decreased intravascular volume
• Due to loss of blood or fluid and electrolytes
• Blood loss from whatever reason (trauma, ruptured ectopic pregnancy, GI bleed, etc)
• Loss of fluid and electrolytes (N/V/D)
• Body will compensate by vasoconstricting, but after 15% loss of volume, shock sets in.
• Anything that decreases BP can cause shock; body responds by vasoconstriction

Question 5

S/S of Hypovolemic shock

Answer 5

• Oliguria, AMS, cool extremities, diaphoresis, pale
• Narrow pulse pressure (reduced stroke volume)
• DECREASED PCWP, CO, & venous return; Elevated TPR (HIGH output failure)
• Improves with fluids

Question 6

Cardiogenic shock

Answer 6

• From cardiac failure
• Heart can not maintain necessary cardiac output
• Definition: as evidence of tissue hypoxia due to decreased cardiac output in the presence of adequate intravascular volume
• Could be from MI, cardiomyopathy, valve dysfunction, arrhythmias

Question 7

S/S of Cariogenic shock

Answer 7

• Oliguria, mental status changes, diaphoresis, cool extremities, jugular venous pressure is elevated, pulmonary edema might be present with respiratory failure.
• LOW output failure (elev TPR, Low CO & venous return)
• ELEVATED PCWP (pulmonary wedge pressure)
• Blood pressure improves with fluids

Question 8

How to differ between cardiogenic and hypovolemic shock

Answer 8

Cardiac echocardiogram

Hypovolemic shock: LV will be small due to poor filling, but maintains contractility (not enough fluid to pump); but contractility is fine

Cardiogenic shock: decrease in LV contractility (THIS IS THE DIFFERENCE; problem with your heart, contractility on echo will be different)

Question 9

Obstructive shock

Answer 9

• Cardiac tamponade
• Tension pneumothorax (needle first remember, not chest tube)
• Massive PE

Question 10

Distributive shock (septic, SIRS, neurogenic, anaphylaxis)

Answer 10

• AKA vasodilatory shock

- Produces a decreases in systemic vascular resistance; resulting tissue hypoperfusion

Question 11

S/S of Distributive shock (septic, SIRS, neurogenic, anaphylaxis)

Answer 11

• Normal circulatory volume
• Low TPR, PCWP
• Elevated CO, venous return (HIGH output failure)
• Vasodilation (warm dry skin)

Question 12

SIRS

Answer 12

• type of distributive shock
• Systemic Inflammatory Response Syndrome
• Can occur from an infectious cause, or noninfectious (burns, pancreatitis, trauma, ischemia)

Question 13

Criteria for SIRS

TEST!

Answer 13

Need to have at least two of the following:

• Temp >100.4, or 90
• RR >20 or hyperventilation with a CO2 on abg 12 or 10% bands

Question 14

Septic shock

Answer 14

• SIRS + a source (uti, pneumonia, cellultis, meningitis)
• Most common type of distributive shock
• 20-50% mortality
• Risks are age, DM, immunosupression, recent invasive procedures

Shock in setting of DIC from trauma often is from sepsis

Question 15

Most common agents that cause septic shock

Answer 15

gram negatives (E coli, Pseudomonas, Klebsiella)

Question 16

Neurogenic shock

Answer 16

• type of distributive shock
• Caused by traumatic spinal cord injury or by effects of an epidural, or spinal anesthetic
• Loss of sympathetic tone and systemic vascular resistance
• Hypotension WITHOUT a compensatory tachycardia
• A benign other type of neurogenic shock which can result in syncope is “vasovagal syncope”—caused by pain, gastric dilatation, or fright, producing hypotension, bradycardia, and syncope

Question 17

S/S of shock in general

Answer 17

• everything vasoconstricts (brain is last to be effected)
• Hypotension (this may be masked in early stages by compensatory mechanisms such as tachycardia, increased cardiac contractility, and vasoconstriction)
• Cool and mottled extremities (red blotches, usually starts in legs, bad sign)
• Splanchnic vasoconstriction can lead to oliguria (decreased urine output), bowel ischemia, hepatic dysfunction, MSOF (Multi system organ failure- all of the above put together)
• Altered mental status (AMS is very very common)

Question 18

Sepsis markers in blood

Answer 18

Lactate (very bad)

Procalcitonin

Question 19

General treatment

Answer 19

• ABC’s with prompt intervention
• Respiratory failure not uncommon—due to existing metabolic acidosis. Intubation can reduce O2 demand of respiratory muscles and allow improved oxygen delivery to other hypoperfused tissues.
• Will develop compensatory respiratory alkalosis (will need to be intubated)
• Monitor urinary output, possibly foley (may have renal failure)
• IVF for hypotension

Question 20

What to give first? Blood or saline?

Answer 20

Give blood before giving saline, need to increased oxygen carrying capacity, giving BLOOD is more important, can give O- blood immediately (don’t need to waste time typing)

-If you give them fluids when they are in shock, can make it worse (inducing CHF; try giving very small boluses)

Question 21

For Septic shock, the standard is to give

Answer 21

GET 30 cc/kg (of weight) of fluid without exception, given all at once
This is a standard- main goal is to reverse hypotension

Question 22

Early Goal Directed Therapy for Septic Shock

Will be a patient case on this on the TEST*

Answer 22

• .9NS (saline) to achieve CVP 8-12 mm Hg
• Vasopressors to achieve MAP 65 mm Hg or greater
• PRBCs (packed red blood cells) to achieve Hgb of 10 or greater
• Results in lower mortality and morbidity*

Question 23

When to give Pressors

Answer 23

• When fluids don’t work to maintain blood pressure
• Need central line to give (central lines go in VEINS)
• Dobutamine, Norepinephrine (Levophed), vasopressin, dopamine

Question 24

Can’t give Pressors through IV in arm because

Answer 24

it increases the pressure in that area, necrosis will happen in that area, can lose limb (VERY BAD, this can happen if you accidentally put central line in artery)

• central lines MUST go in veins
• To see if central line is in artery or vein- draw blood gas from central line, and draw a gas from a known artery, if they are the same- BAD (line is accidentally in artery, ABGs should be VERY different from artery and vein)

Question 25

When to use Corticosteroids

Answer 25

- Used when shock is due to adrenal insufficiency - Otherwise, most articles do not show its routine use in shock beneficial -Goal is to stop inflammation, but **only works when problem is adrenal insufficiency**

Question 26

Antibiotics are used for

Answer 26

Septic shock and SIRS | **Nursing home pts- treat for MRSA** Treat with Vancomycin