distributive shocks

Question 1

distributive shocks are characterized by…

Answer 1

massive vasodilation

Question 2

3 types of distributive shocks

Answer 2

• neurogenic
• anaphylactic
• septic

Question 3

describe neurogenic shock

Answer 3

Rare and usually transitory
Massive dilation of blood vessels as a result of the loss of sympathetic tone

Question 4

causes of neurogenic shock

Answer 4

Injury to spinal cord
Spinal anesthesia
Emotional stress, severe pain or drug overdose

Question 5

clinical manifestations of neurogenic shock

Answer 5

Hypotension
Bradycardia
Hypothermia

Question 6

treatment of neurogenic shock

Answer 6

Treat or remove cause
Volume replacement
Vasopressors

Question 7

descrieb anaphylactic shock

Answer 7

Characterized by massive dilation and increased capillary permeability
“Antigen-Antibody” reaction
Release of vasoactive substances

Question 8

what does histamine do in anaphylactic shock

Answer 8

Causes vasodilation
Decreased vascular resistance
Decreased BP

Question 9

what does serotonin do in anaphylactic shock

Answer 9

Increased capillary permeability
Decreased circulating blood volume
Decreased BP

Question 10

what are some causes of anaphylactic shock

Answer 10

Drugs
Contrast media
Blood and blood products
Insect bites or stings
Foods

Question 11

signs and symptoms of anaphylactic shock

Answer 11

Pruritis
Erythema
Urticaria
Angioedema
Laryngeal edema
Hypotension

Question 12

treatment of anaphylactic shock

Answer 12

PREVENTION!
Remove antigen
Reverse effects of vasoactive substances
Maintain airway – intubation
Corticosteroids
Fluid resuscitation
May need + inotropes and/or vasopressors

Question 13

what is sepsis

Answer 13

Life-threatening organ dysfunction due to a dysregulated host response to infection

Question 14

what is septic shock

Answer 14

sis plus hypotension not responsive to fluid resuscitation, along with perfusion abnormalities

Question 15

clinical signs of sepsis

Answer 15

Change in mental status (GCS < 15)
Tachypnea (RR > 22)
Hypotension (SBP < 100)
Tachycardia
Fever (or hypothermia)
Fatigue, malaise, chills
Nausea and/or vomiting
Increased WBC with left shift (or decreased)

Question 16

early recognition of sepsis

Answer 16

Vitals
- SIRS criteria v. qSOFA

Labs
- Lactate
- Coags
- Liver function
- Renal function
- Procalcitonin

Question 17

QSOFA utilizes 3 criteria, what are they

Identifies patients with suspected infections

Answer 17

1 point low BP (<100 mmHg)
1 point altered mentation (GCS<15)
1 point high respiratory rate (>22 bpm)

Question 18

SIRS criteria

Answer 18

Temp > 38 degrees C
Heart rate > 90 beats/min
RR > 20 or PaCO2 < 32
WBC > 12,000 or >10% bands (immature)

2 or more = SIRS

Question 19

describe SIRS

Answer 19

Systemic inflammatory response syndrome

Complex system in place throughout the body to localize inflammation
Inflammation, thrombosis & fibrinolysis
Can occur for other reasons (other types of shock, trauma, surgery)

Question 20

whos at risk for sepsis

Answer 20

Although everyone is at risk for developing sepsis from minor infections, it is more likely to develop in people who:

are very young or old
have a weakened immune system
have wounds/injuries from burns/trauma
have addictive habits
have IV’s, foleys, wound drainage, etc.

Question 21

name some HAIs

Answer 21

Central line associated bloodstream infections (CLABSI)
Catheter-associated UTIs (CAUTI)
Surgical site infections (SSI)
Ventilator-associated pneumonia (VAP)

Question 22

central line bundle

Answer 22

Proper hand hygiene
Maximum barrier precautions upon insertion
Chlorhexidine skin antisepsis
Avoidance of the femoral vein
Daily review of line necessity with prompt removal of unnecessary lines

Question 23

describe diagnosing the source of sepsis

Answer 23

Appropriate cultures
- Urine, sputum, wound

Blood cultures
- Minimum 2 cultures
- 1 percutaneous
- 1 from each vascular access > 48 hrs.

Question 24

when should blood cultures be obtained?

After administering the antibiotic
After obtaining the urine culture
After giving the patient prn Tylenol
Before administering the antibiotic

Answer 24

Before administering the antibiotic

Question 25

1hr resuscitation bundle for sepsis and septic shock

Answer 25

Measure lactate level Obtain blood cultures prior to administration of antibiotics Administer broad spectrum antibiotics Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L Apply vasopressors if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure ≥ 65 mm Hg Remeasure lactate if initial lactate elevated (>2mmol/L)

Question 26

clinical manifestations of early septic shock

Answer 26

Skin is pink, warm and dry CO is normal or elevated - Due to catecholamine release (epi and norepi) Decreased afterload Increased respiratory rate Changes in Mental status As shock progresses, fluid leaks from vascular compartment and patient develops hypovolemia.

Question 27

hemodynamic profile of a patient in early septic shock

Answer 27

Preload is decreased - CVP is low - PCWP (PAOP) is low Afterload is decreased - SVR is low - BP is decreased HR is increased - Contractility appears normal or increased - CO/CI is normal or increased

Question 28

treatment of early septic shock

Answer 28

Continue fluid administration and antimicrobial agents Corticosteroids Supportive care - DVT & Stress ulcer prophylaxis - Managing hemodynamics - Mechanical ventilation if needed - Electrolyte & glycemic control

Question 29

describe progression of septic shock

Answer 29

Capillary walls have increased permeability - Fluid leaves vascular space enters interstitial and intra-cellular space Decreased circulating blood volume Increased blood viscosity Interstitial and intra-cellular edema Compensatory mechanisms are failing Tissue perfusion is decreased Mitochondrial damage – cells can’t use oxygen SIRS leads to MODS

Question 30

what is MODS

Answer 30

Multiple Organ Dysfunction Syndrome Progressive physiologic failure of 2 or more separate organ systems Homeostasis cannot be maintained without intervention.

Question 31

clinical manifestations of late septic shock

Answer 31

Cold, clammy skin Edema (total body) – Anasarca Low cardiac output Severe hypotension

Question 32

hemodynamic profile of a patient in late septic shock

Answer 32

Preload is increased - CVP is higher than previously - PCWP (PAOP) is higher than previously Afterload is increased - SVR is high Contractility is decreased - BP and CO/CI are very low

Question 33

treatment of late septic shock

Answer 33

Continue supportive care Vasopressors Inotropes Corticosteroids Consider limitation of support