Hemodynamics II

Question 1

What is shock?

Answer 1

Total body hypoperfusion; cardiovascular collapse.

Question 2

What is severe sepsis?

Answer 2

Sepsis with acute organ dysfunction.

Question 3

What is septic shock?

Answer 3

Severe sepsis with refractory arterial hypotension.

Question 4

What is acute kidney injury (AKI)?

Answer 4

Acute, reversible renal injury due to hypoperfusion or hypoxemia.

Question 5

What is acute tubular necrosis (ATN)?

Answer 5

AKI severe enough to cause necrosis of renal tubules.

Question 6

What is acute lung injury (ALI)?

Answer 6

Acute, non-cardiogenic pulmonary edema with damage to alveolar hyaline membranes.

Question 7

What is acute respiratory distress syndrome (ARDS)?

Answer 7

Acute, non-cardiogenic bilateral lung infiltrates and severe hypoxemia.

Question 8

What are the 3 most common types of shock?

Answer 8

1. Septic
2. Hypovolemic
3. Cardiogenic

Question 9

T or F. Shock is a syndrome, NOT a number.

Answer 9

T.

Question 10

What are the 4 clinical manifestations of shock?

Answer 10

1. Decreasing mental status
2. Decreasing urine output
3. Pulse
4. Skin characteristics

Question 11

What is the pulse and skin like in a patient in either hypovolemic or cardiogenic shock?

Answer 11

Pulse: weak, rapid, thready. Skin: cool, clammy, cyanotic.

Question 12

What is the skin like in a patient in septic shock?

Answer 12

Warm, flushed skin.

Question 13

T or F. The vital signs are late responders to shock, especially in young people.

Answer 13

T.

Question 14

Why is it important to figure out what type of shock a patient is in?

Answer 14

Different types require different treatment.

Question 15

Shock caused by bleeding is treated how?

Answer 15

Blood transfusion and stopping the bleed.

Question 16

What percentage of a patient’s blood volume is the dividing line between lethal and non-lethal hemorrhage?

Answer 16

50%.

Question 17

T or F. Septic shock is a subset of severe sepsis which is a subset of sepsis.

Answer 17

T.

Question 18

Septic shock is severe sepsis with addition of what?

Answer 18

Refractory hypotension.

Question 19

Is sepsis a positive blood culture?

Answer 19

Helllllllllllllllllllllllllllllllllllllllllllllllllll NO!

Question 20

What stimulates the release of inflammatory mediators that cause vasodilation and leaky blood vessels in septic shock?

Answer 20

PAMPs bind TLRs and other receptors on immune cells which activates them stimulating release.

Question 21

What are the 3 initial major cytokines in sepsis and septic shock? Others?

Answer 21

TNF, IL-1, and IL-6. IL-8, -12, -18, IFN-gamma, HMGB-1.

Question 22

What other molecules play a role in sepsis and septic shock?

Answer 22

PAF, C3a, C5a, PGI2, PGD2, PGE1, PGE2.

Question 23

What clotting factor is activated in sepsis that activates both the kinin and clotting cascades?

Answer 23

Factor X11a (Hageman factor).

Question 24

What protein activates the fibrinolytic system?

Answer 24

Kallikrein, a product of the kinin cascade.

Question 25

What fibrinolytic protein activates the complement cascade?

Answer 25

Plasmin.

Question 26

Kallikrein also activates what factor resulting in autocatalytic amplification of cascades in sepsis?

Answer 26

Factor XII.

Question 27

How do sepsis, severe sepsis, and septic shock lead to disseminated clotting in small vessels throughout the body?

Answer 27

Since they are pro-coagulant states, many clotting factors are activated.

Question 28

What is Disseminated Intravascular Coagulation (DIC)?

Answer 28

Widespread fibrin thrombi in arterioles, capillaries, and venules.

Question 29

DIC is a complication of what 4 things?

Answer 29

1. Severe infection 2. Advanced malignancies 3. Massive trauma 4. Various obstetric crises

Question 30

Where is DIC the worst?

Answer 30

Brain, heart, lungs, and kidneys.

Question 31

How does DIC sometimes lead to bleeding?

Answer 31

Thrombi consume clotting factors resulting in consumptive coagulopathy.

Question 32

Counter-regulatory mechanisms of sepsis lead to what 2 things?

Answer 32

1. Immunosuppression | 2. Compensatory Anti-inflammatory Response Syndrome (CARS)

Question 33

What 5 things can result in a syndrome that closely resembles sepsis?

Answer 33

1. Extensive burns 2. Extensive trauma 3. Acute pancreatitis 4. Extensive tissue necrosis 5. Toxic shock syndrome

Question 34

What are the 3 stages of shock? Describe each of them.

Answer 34

1. Non-progressive: reflex compensatory mechanisms maintain perfusion of vital organs 2. Progressive: worsening lactic acidosis, etc. 3. Irreversible: death results even if cause of shock is reversed

Question 35

What is the histological manifestation of shock in the brain?

Answer 35

Red dead neurons.

Question 36

When do red neurons become visible histologically? What do they look like?

Answer 36

After 12 hours. Shrunken and hypereosinophilic.

Question 37

In the early phase (first day) of ALI, what is present?

Answer 37

Alveolar edema: bubbly white fluid.

Question 38

In the intermediate phase (first week) of ALI, the edema is condensed into what?

Answer 38

Alveolar hyaline membranes.

Question 39

What is seen histologically in shock heart?

Answer 39

Myocardial coagulation necrosis or contraction band necrosis.

Question 40

What causes contraction band necrosis?

Answer 40

Reperfusion allows calcium in the cell which causes sarcomeres to hypercontract.

Question 41

Histologically, myocytes lack what 2 things after an acute MI?

Answer 41

1. Striations | 2. Nuclei

Question 42

What is the earliest finding of AKI?

Answer 42

Tubular epithelial edema.

Question 43

In later stages of a worse injury to the kidney, what is seen histologically?

Answer 43

Acute tubular necrosis.

Question 44

Can tubular epithelial cells regenerate and be replaced?

Answer 44

Yes.

Question 45

What 3 things are associated with shock liver?

Answer 45

1. Centrilobular necrosis 2. Sinusoids leak blood 3. High ALT and AST levels

Question 46

What 3 things are associated with shock bowel?

Answer 46

1. Hemorrhagic ischemic enteritis 2. Serosa appears dusky 3. High lactate and amylase levels

Question 47

What happens to adrenal glands in shock?

Answer 47

Cortical lipid depletion.

Question 48

If a patient is in septic shock due to meningococcus complicated with DIC, hemorrhage can do what to the adrenal glands? What does this do?

Answer 48

Completely wipe out adrenals. Massively contribute to shock b/c there is no source of epinephrine, cortisol, etc.

Question 49

What is Waterhouse-Friderichsen Syndrome?

Answer 49

When the adrenal glands are wiped out.