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What is shock?

Failure to deliver oxygen and substrates to meet the metabolic demands of the tissue beds

supply < demand

oxygen delivery < oxygen consumption


What are the 4 types of shock?

Hypovolemic shock - ex: hemorrhage, volume depletion, interstitial fluid redistribution

Cardiogenic shock - due to heart failure --> pump failing--> fluid back into lungs --> hypoxemic
-* need to improve heart function

Extra-cardiac obstructive shock
(Obstructive) - external pressure on the heart impair heart contraction or filling (tension pneumo, PE, aortic dissection, tamponade)

Distributive shock - loss of vasomotor control --> dilation ==> shunt blood away from the system


What are the goals of treatment of shock?

decrease demand (treat hyperthermia, reduce work of breathing --> ventilation)

increase supply (improve preload (give fluid), improve contractility, dec after load, dec HR, improve O2)

treat the underlying cause


What is the #1 cause of mortality from MIs?

cardiogenic shock


What determines the treatment of cardiogenic shock?

where the heart is affected

LV =bypass, stent, intraaortic balloon pump

fluid and inotropes with PA cath monitoring


What determines the acuity of the obstructive shock? What are the treatments for tampanade vs. PE?

Rate of development of the obstruction (how fast the shock occurred)

tampanade--> pericardiocentesis

acute PE --> thrombolytic


What is the classic feature of distributive shock? What is an example of this?


(SIRS--> Septic shock)


What is SIRS? What is sepsis?

Systemic Inflammatory Response Syndrome (SIRS): 2 or more of the following:

T>38C or 90
RR>20 (or PaCO212K, 10%bands

sepsis: Confirmed or suspected *INFECTION* accompanied by SIRS


What is severe sepsis?

Presence of sepsis + organ hypoperfusion or dysfunction

Organ hypoperfusion:
Elevated lactic acid
Abnormal peripheral circulation

Organ dysfunction:


What is septic shock?

Presence of severe sepsis, plus refractory hypotension

SBP<65 or 40mmHg drop compared to baseline

Unresponsive to fluid challenge of 20-40ml/kg

Vasopressor dependency after adequate volume resuscitation


What is the first priority in any pt with severe sepsis or septic shock?

stabilization of airway and breathing


Can hypo perfusion occur in the absence of hypotension?


over time this will get worse and develop Hypotension


What are some signs of hypo-perfusion?

-Cool, vasoconstricted skin due redirection of blood flow to the core organs
-->Patients with early sepsis may have warm, flushed skin

-Obtundation or restlessness

-Oiguria or anuria

-Elevated Lactic acid level

*may have normal BP


SIRS criteria but cool and clammy and normal BP?

think pt may be going into septic shock


Why is crystalloid or colloid fluid given to sepsis pts?

get the CVP > 12 mmHg


When should antibiotics be given for sepsis? What type of antibiotic?

Broad-spectrum antibiotic within 1 hour recognition septic shock.

Blood cultures before antibiotics --> can adjust meds based on culture results


What is the drug of choice for septic pt with hypotension?

norepinephrine (or epinephrine if NE doesn't work)

only use dobutamine with low CO


What are the signs to look for to determine adequacy of resuscitation?

Capillary refill < 2 sec

Adequate pulses

Warm limbs

Normal mental status

Urine output > 1 mL/kg/hr

Adequate blood pressure

Improved base deficit

Decreased lactate

SvO2 > 70%


A 45-year-old man with acute cholecystitis is noted to have a fever of 38.3°C (101°F), hypotension, and altered sensorium. His hematocrit is noted to be 24%. Broad-spectrum antibiotics and intravenous saline are administered, and, although his Central Venous Pressure is 10 and his Mean Arterial Pressure is 80, his Scvo2 (mixed venous o2) remains

D. RBC Transfusion

hematocrit is 24--> super anemic --> give blood first

if hematocrit was higher, dobutamine would have been a good answer


A 35-year old female is having panic attack and she is breathing at RR-28/min. Her ABG on room air shows pH 7.5, Paco2 of 29 and HCo3 of 24. What is her underlying acid base disorder?
A. acute respiratory alkalosis
B chronic respiratory alkalosis
C. Acute respiratory acidosis
D. Chronic respiratory acidosis

A. acute respiratory alkalosis

bicarb is normal --> NOT chronic