Shock & Anaphylaxis Flashcards
Define Shock
role of BP levels and the defintion of shock
Shock: a state of cellular and tissue hypoxia; resulting from decreased oyxgenation delivery, increased consumption of oxygen, inadequate utalization of oxygen or a combo. of these processes
- commonly, shock occurs in the state of hypotension BUT does not always have to: could have normal pressures or high pressures
- thus, no clear MAP or SBP can define a state of shock
if not treated acutely, shock cna be irreversibale and lead to organ damange
what is the MAP
calculated
how is it helpful and used
MAP = mean arterial pressure: helps to get an idea of the average arterial pressure throughout one cardiac cycle
the components of MAP = cardiac output (how much) and then the vascular resistance (the radius of the vessels the blood is flowing through)
MAP = CO x SR
calculated with numbers: MAP = DBP + 1/3 PP
where the PP = pulse pressure (SBP - DBP)
furthermore –> the CO is the HR x SV
where HR = heart rate (beating)
where SV = stroke volume (the preload (amoutn in the LV) and Inotropy (force of contraction)
stroke volume = amount in the tank x force of the sqeeuze
the SVR = the diametere of the pipes, the radius of the vessels
Oxygenation Delivery Equation
sometimes, the blood pressure isnt the issue which is causing the shock –> but rather the ability to properly drop off oxygen and uptake the CO2 at the level of the tissue delivery
Delivery of O2 = cardiac output (Q) x (Hb x SaO2 (the arterial oxygen saturation x1.34 + (PaO2 (oxygen dissolved in the blood) x 0.003)
essentially:
- there is a componente of the cadriac output
- the component of the amout of arterial O2 saturataion and hemoglobin
- and a component of the amout of o2 saturated in the blood
these all account for the ability of blood to properly carry oxygen to its target
Shock: 4 types
Distrubutive Shock
- the most common type: think septic shock (most of the ICU cases of shock are this)
Hypovolemic Shock
- lack of flow
- hemorrhagic shockk
Cardiogenic Shock
- think pump failure
Obstructive Shock
- a back flow from the heart
General Management of Shock pt. (any type)
overall goal: we need to improve their ocygen delivery to prevent end organ damage
- treat the underlying issue
- add in resuscitaion measures to ensure good BP, cardiac output, oxygen content and decrease oycgen demand
- watch the perfusion state and add in supportive care
Blood Pressure Management
- goal of a MAP >65 : for most pts.
- use fluids and vasopressors to help increase the volume and therefore pressure
- Fluids = isotonic (LR, NS, blood) to help increase volume
- Vasopressors = NE, phenylephrine and vasopressin to vasoconstrict and decrease vessel size to increase pressure
Cardiac Output
- preload: increase fluids to increase the tank
- inotropy: give inotrope (things to increase force of squeeze: epinephrine, doubutamine, milrinone)
Oxygenation
- if the Hbg is low = give RBC to increase Hgb
- Oxygenation Saturation = give supplemental O2, intubate
- Oxygen Demand = sedational, mechanial vent or anipyretics (decrease fever, decrease demand)
How do you Monitor your pt. while giving these Resuscitation Measures (Bp, cardiac, oxygen)
Blood Pressure Monitoring
- invasive arterial line or Bp cuff
Clinical Monitoring
- mental status
- HR
- Urine Output goal = > o.5 cc/kg/hr to stay above AKI range
- oxygen sat
- central venous pressure (through the central line) normal is 0-5 mmHg , 12+ is elevated
Lactate Monitoring
- to watch for metabolic derangements: see if cells are able to work
- normal < 2
ScVO2: Central Venous Oxygen Saturation
- measures the O2 saturation that is retunring to the heart
- normal = 60-80%
- if this is low: it means the cells are taking a low of the O2 from whats being delivered: indicating you aren’t providing them with enough oxygen!!! poor O2 delivery
- if its high (like spetic shock) it can be because the body isnt able to dump the o2 to the target so its comign right back
Creatinine = for kidney function
LFTs= for liver function
can also use POCUS to look at herat and lung volume status
Hypovolemic Shock
Etiology & Types
Symptoms
Etiology
- Hypovolemic = low volume, poor perfusion to the tissues as a result of lack of circualtion intravascular volume + decreased CO because decreased volume
Types
- Hemorrhagic: blood loss, MVA/trauma, GI bleed, surgery, ruptured AAA
- Non-Hemorrhagic: think other rapid fluid losses
- GI losses: V/D
- Skin losses: burns
- Renal Losses: excessive diuretics
- Third-spacing = edema via pancreatitis or cirrhosis)
Symptoms of Hypovolemic Shock
- think low volume = no blood = COLD extremities
- increased capi. refill (takes longer)
- dry mucous membranes
- flat nondistended veins
if its a Trauma…
- primary and secondary assessment (head-toe PE)
- FAST: see
- CT –> if able to be transported and need to find the source this wat
if its not a trauma
- GI Bleed –> CT scan or endscopy
- Ruptured AAA –> US or CT angiogram
Hypovolemic Shock
Treatment
Treatment = restore the intravascular volume
- vasopressors = can be used as a bandaid fix: to temporarily help with fluid resuscitaion: but ultimate need is that there needs to be increase fluids somehow
- ensure good vascualr acces site is obtained
Non-Hemorrhagic Shock = isotonic crystalloid fluids (LR or NS)
Hemorrhagic Shock = blood products with balanced resuscitation (a bit of all types of blood)
Treatment Goal #2: Prevent the Further Loss of Volume
- treat the source, etc.
Distributive Shock
Etiology & Causes
Etiology
- distrubutive shock = shock caused by VASODILATION - severe within the periphery
- aka called vasodilatory shock (too much distrubution)
Causes
Septic Shock (MC) : bodywide dysregulation due to infection
SIRS: non-infectious
- after burns, cardaic arrest or pancreatitis (so like no infection cause of inflammatory response)
Neurogenic Shock
- severe spinal cord injury/TBI = lost innervation to the nerves so cant regulate autonomic pathways that keep vascular tone
Anaphylaxis
- IgE mediated reaciton
Drug or Toxin Induced
- drug OD, sedation meds, spider bites, etc.
Endocrine Shcok
- adrenal: adrenal crisis
- thyroid: myxedema coma (hypothyroid)
Distrubutive Shock
Symptoms
Symptoms
- pt. will be WARM to touch at the extremities because they are periphearlly dilated
if sepsis…
- fever, sigsn of infection
- eleated WBC & cultures
if neruogenic…
- lost muscular tone, parlysis, bradycardia
if anaphylaxis
- uricarid, edema, stridor, flushing, itching
Drug OD
- obtunded, dec. respiratory drive
- postive toxins in blood and urine
adrenal
- fever, coma, hyperpigmented skin
- hyperkalemia, hyponatremia, low cortisol
myxedema
- non-pitting edema, bradycardia, hypoventilation
- elevated TSH, low T4, hypoglycemic
Distrubutive Shock
Treatment
Treatment
- FLUIDS but EARLY EARLY intervention with vasopressors: because this is a need to peripherally vasoconstrict so fluids wont help as much
- give vasopression, norepi & phenylephrine
Treat the underlying causes
sepsis: abx + steroids
neurogenic: surgery
anaphylaxis: epi and antihistamine
OD: supportive + detox.
Adrena crisis: IV hydrocortisones + fuldracortisone
Myxedema: IV levothyroxine
Anaphylaxis
define
pathology
Define = a serious and life threatening genearlized or systemic hypersensitivty reactino
- IgE mediated reaction
- kids = food
- adults = medications or insects
other things incude: contrast for imaging, NSAIDS, dextrans, biologic agents
Patho
- contact with allergen
- releases IgE
- IgE binds to histamine = released all its mediators
- triggers huge overdramatic reaction to the allergen
Anaphylaxis
Symptom Presentation & Diagnosis
Symptoms
MC: skin : flushing, ithcy, hives, angioedema, piloerection
Oral/Respiratory:
- ithcy, edema of lipds/tongue, runny nose, itchy throat, stridor
- dyspnea, cough, wheeze, cyanosis
GI
- N/V/D
CV
- syncope, chest pain, hypotension, palpations
Neuro
- anxiety, impending doom, HA, confusion
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Diagnosis
World Allergy Org
- acute onset of illness (minutes to hours)
- involving the skin and or mucosa
- at least ONE of the following
- 1. respiratory compromise
- 2. circulatory compromise
- 3. severe GI symptoms
OR
other definition for dx.
- acute exposure
- acute onset of one of the following
- 1. hypotension
- 2. bronchospams
- 3. larynegeal invovlment
- so no skin findings needed for this dx.
Labs (not needed for diagnosis but can help)
Tryptase: from mast cells (but only high when right after expsoure, then falls
Histamine: even smaller window to get than tryptase
Treatment and Emergency Management of Anaphylaxis
- remove the agent
- assess the airway, breathing and circulation: may need to intubate
- Epinephrine: IM repeated every 5-15 minutes up to 3 doses
- IV Fluids: NS or LR
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Add on Anti-Histamines
- H1 (certirazine, diphenhydramine)
- H2 (famotadine)
Add on Bronchodilators
- albuterol
Add on
- IV Methylprenisolone
If Refractory
- Epinephrine infusion & monitoring
- Vasopressors (help close the vessels)
- ECMO
Long Term Management
- monitor becuase of biphasic reaction
- D/C with an epipen and action plan
Cardiogenic Shock
Etiology and Causes
Symptoms
Diagnosis
Etiology: a pump failure: intracardiac pathology that leads to a failure of the heart’s ability to pump the blood through
Causes
- Large MI
- Decom. CHF (HFrEF)
- unstable arrythmia: brady or tachy: just improper
- Valvular dysfunction
Diagnosis
- COLD EXTREMITIES: since there is no blood flow to them
- a narrow pulse pressure (bad squeeze)
- distended bneck veins (blood is backed up waiting to get out
_________________ these are needed for Dx.
ECG: to see if STEMI, arrythmia, etc.
ECHO: TTE or TEE: see heart function or strucutre
Labs: BNP, trops. CK-MB and ScVo2 (see O2 delivery)
