Exam 3: Shock, Sepsis, Respiratory Flashcards
What is Hypovolemic shock?
Impaired tissue perfusion resulting from severely diminished circulating volume.
Loss of intravascular fluid volume.
What is the difference between absolute and relative hypovolemic shock?
- Absolute hypovolemia: fluid is lost via hemorrhage, GI loss, drainage, diuresis or diabetes insipidus.
- Relative hypovolemia: internal, extravascular loss into interstitial or intracavitary space (third spacing).
Hypovolemic symptoms?
Hypotension, tachycardia, anasarca, ascites
Decreased blood flow to the heart, because the volume is in the periphery or in cavities or it has let the body
Why are they tachypnea: they are trying to oxygenate the tissues, compensate
Urine output would be diminished: potassium , sodium, creatine
Anxiety, restlessness, confusion: because brain is not being oxygenated
Flat neck veins because there is no volume to fill them: will not see jugular vein distention on these patients
What is cariogenic shock?
Systolic or Diastolic dysfunction result in compromised Cardiac Output (CO). Pathophysiology: -Myocardial Infarction (MI) -Structural Problem -Arrhythmia
-Results in impaired tissue perfusion and impaired cellular metabolism
Symptoms of cariogenic shock?
What will they look like: low BP, fast HR, the harder the heart works the higher the oxygen demand is, high RR.
Pulmonary congestion: crackles in lungs because fluid cant move forward because of insufficient pump
Neck vein distention
What labs are you looking for? Troponin, BNP, potassium, CRP, sodium, potassium, BUN, creatine
Give lasixs to get rid of some of the fluid so the heart doesn’t have to work so hard!!! ON test !!
What is Distributive Shock ?
Blood volume is not lost but is distributed to the interstitial tissues where it cannot circulate and deliver oxygen
Caused by loss of sympathetic tone, blood vessel dilation, pooling of blood in venous and capillary beds, capillary leak
Neural-induced distributive shock
Chemical-induced distributive shock
(Dilate out , a lot of fluid could cause capillary leak
Chemical induced: loss of vascular tone, what would happen in your lungs?… you would fill up with fluid and drown immediately
)
What is vasogenic shock?
Impaired tissue perfusion resulting from damage or dysfunction of the sympathetic nervous system.
-This type of shock is uncommon, and may be associated with trauma, anesthesia, spinal shock.
Occurs following spinal cord injury at T5 or above.
-Results in massive, uncompensated vasodilatation due to the loss of SNS vasoconstrictor tone.
Symptoms of vasogenic shock?
Bradycardic,
Placeothermia: taking on the temp of their surronding
Nausea, vomiting, decreased urine output
- Profound Hypotension, narrow pulse pressure
- The parasympathetic nervous system is activated and un-opposed resulting in bradycardia
- SVR, PAOP, CVP, CO
- Pulmonary dysfunction related to level of injury
- Poikilothermia, absence of sweating
*Anxiety, restlessness, confusion
Nausea, vomiting, decreased urine output
What is anaphylactic shock?
- Impaired tissue perfusion resulting antigen-antibody reaction releasing histamine into the bloodstream.*
- May be caused by contrast media, drugs, blood transfusions, food allergies, insect stings, snake bites.
- Capillary permeability increases, arteriolar dilation occurs.
- Blood return to the heart decreases dramatically
Misc. anaphylactic shock info
Impaired tissue perfusion resulting antigen-antibody reaction releasing histamine into the bloodstream.
May be caused by contrast media, drugs, blood transfusions, food allergies, insect stings, snake bites.
Capillary permeability increases, arteriolar dilation occurs.
Blood return to the heart decreases dramatically
True or false
Zyrtec works as well as an epi-pen
True
Anaphylactic shock symptoms
- Hypotension, narrow pulse pressure
- SVR, PAOP, CVP, CO
- Stridor, tachypnea, wheezing
- Hives, itching, flushed warm skin
- Anxiety, restlessness, confusion, seizures
- Nausea, vomiting, diarrhea, abdominal cramping
What is obstructive shock?
- Caused by problems that impair the ability of the normal heart muscle to pump effectively
- Heart is normal, but conditions outside the heart prevent either adequate filling of the heart or adequate contraction of the healthy heart muscle
- Pericarditis, Cardiac tamponade
Uniqueness of obstructive shock
Not cardiogenic shock because the heart is normal, its something outside the heart causing the problem
Cardiac tamponade: fluid in the pericardium causes the ventricles to not be able to fill
Pericarditis is another example of obstructive shock
Stages of shock
- Initial stage (early shock)
- Nonprogressive stage (compensatory stage)
- Progressive stage (intermediate stage)
- Refractory stage (irreversible stage)
Initial stage of shock
- Initial stage may not be clinically apparent.
- Metabolism begins to shift from aerobic to anaerobic.
- Lactic acid (removed via the blood and broken down in the liver) accumulates.
- Oxygen needs increase while oxygen availability decreases.
(Metabolism goes from Using oxygen to not using oxygen
Product of anaerobic met. Is lactic acid
Lactic acid starts to accumulate!!! ON TEST!
)
Nonproggressive stage of shock
- Compensatory mechanisms are activated to overcome sequelae of anaerobic metabolism and to maintain homeostasis.
- Neural, hormonal, and biochemical compensatory mechanisms are activated.
- Clinical presentation demonstrates the imbalance of oxygen supply and demand.
- Initial finding: Hypotension
- Neural compensation: SNS responds to the decrease in cardiac output (hypotension).
- Epinephrine and Norepinephrine are released.
- Blood flow is shunted to the most vital organs.
(Kidneys get activated the baroreptors release renin, adh, aldosterone, ephnephrine, nor-epinephrine…why do they release all of that….vasoconstriction, trying to save sodium to retain fluid, to keep bp up and homeostasis, and conserve water
Lactic acid comes too
If you recognize this early enough you can reverse the process
Notice the trend that your patient is hypotensive, decrease in cardiac output
Blood flow is shunted to the heart, brain, lungs, the gut
)
Progressive stage of shock
- This stage begins as the compensatory mechanisms fail.
- Capillary permeability increases, allowing fluid and proteins to leak from the intravascular space into the interstitial space. (Third spacing, Anasarca)
- Circulating volume is depleted.
Fun facts about shock
In cardiogenic shock you do not wanna give fluid, what if they are hypotensive and the doctor orders lasix…after administering the med their bp might drop more but after getting rid of the fluid their bp might come back up …it is ok to give diuretics
What makes neurogenic shock unique?
Neurogenic Shock: their pulse will be low, bradycardia …that’s what’s unique about neurogenic..usually pulse is high in shock
Progressive stage of shock: pulmonary
- Pulmonary arteriolar constriction
- Pulmonary capillary leak
- Alveolar edema and decreased surfactant
- Vasoconstriction and bronchoconstriction
- Tachypnea, crackles, increased work of breathing
- Likely to develop ARDS
Crackles in the lungs, they will get harder and harder to oxygenate
Surfactant helps keep alevoli inflated and the right degree of moistness
Disseminated intravascular coagulation…..ON TEST!!! Know what it is
??
Refractory stage of shock
- The final stage*
- Profound hypotension and hypoxemia
- Multisystem organ failure
- Recovery is very unlikely
Diagnostic studies for shock
Labs: CBC, Hgb, Hct, WBC, DIC Screen Electrolytes, BUN, Creatinine, --Liver panel -ABG, Lactate -Blood cultures -Chest x-ray -12 Lead ECG
Trend of the labs;
Platelets, INR, HgB, Hematocrit, D-dimer (used for DVT and pulmonary embolus, important in looking at coagulation…ON TEST)
Collaborative Care: Fluid Resuscitation for shock
**Cardiogenic shock is the exception here
Crystalloids vs. Colloids debate
Replace to goal CVP, PAOP, or UO
Monitor pulmonary status
Monitor for compartment syndrome
Consider vasoactive drugs (continuous infusion)
Crystalloids vs colloids
Crystalloid …normal saline for anyone who needs fluid resuscitation
Colloids tend to make platelets slippery
If patients hemoglobin is low and you give them more fluids you may lower hemoglobin further, so check hemoglobin when giving fluid, might need some RBCs
Collaborative Care: Drug Therapy for shock
- Vasoactive agents
- Sympathomimetic agents
- Vasodilator agents
Levophed is the primary choice
Dopamine is the sedond choice
Both are vasoactive , clamp down and constrict
Dobutamine
- inotrope
- squeezes ventricles, makes you have a better contraction which gives you better cardiac output
What is SIRS?
**Systemic inflammatory response to an insult (infection, injury, ischemia, infarct)
- Inflammatory cells are activated causing the release of mediators, damage to endothelium, and hypermetabolism.
- Vasodilatation and capillary permeability
- Phagocytation of foreign debris occurs and the coagulation cascade is activated.
True of false
In acute respiratory failure the patient is always hypoxemic
True
