Shock

Question 1

What is the definition of  shock?

Answer 1

Inadequate tissue perfusion

Question 2

What are the different types of shock (5)?

Answer 2

Hypovolemic Septic Cardiogenic Neurogenic Anaphylactic

Question 3

What are the signs of shock?

Answer 3

Pale,diaphoretic,coolskin Hypotension, tachycardia, tachypnea T mental status and pulse pressure, Poor capillary refill,
Poor urine output

Question 4

What lab tests help assess tissue perfusion?

Answer 4

Lactic acid (elevated with inadequate tissue perfusion),base deficit, pH rom ABG (acidosis associated with inadequate tissue perfusion)

Question 5

What is the defInition of hipovolemic shock

Answer 5

Decreased intravascular volume

Question 6

What are the common causes of hypovolemic shock?

Answer 6

• Hemorrhage
• Burns
• Bowel obstruction
• Crush injury
• Pancreatitis

Question 7

What are the signs of hypovolemic shock?

Answer 7

Early—Orthostatic hypotension, mild tachycardia, anxiety, diaphoresis, vaso- constriction (decreased pulse pressure with increased diastolic pressure)
Late—Changed mental status, decreased BP, marked tachycardia

Question 8

What are the signs/ symptoms with:
Class I hemorrhage
(  15%or 750 cc blood loss)?

Answer 8

Mild anxiety, normal vital signs

Question 9

What are the signs/ symptoms with:

Class II hemorrhage (15%–30%or 750– 1500 cc blood loss)?

Answer 9

Normal systolic BP with decreased pulse pressure, tachycardia, tachypnea, anxiety

Question 10

What are the signs/ symptoms with:

ClassIIIhemorrhage (30%–40%or1500– 2000 cc blood loss)?

Answer 10

Tachycardia(heartrate. 120),tachypnea (respiratoryrate. 30),decreasedsystolic BP, decreased pulse pressure, con usion

Question 11

What are the signs/ symptoms with:

Class IV hemorrhage (  40%or 2000 cc bloodloss)?

Answer 11

Decreased systolic BP, tachycardia (heart rate . 140), tachypnea (respiratory rate
. 35),decreasedpulsepressure,conused and lethargic, no urine output

Question 12

What is the treatment of hypovolemic shock?

Answer 12

1. Stop the bleeding
2. Volume: IVF (isotonic LR) then blood
   products as needed

Question 13

What usually causes failure of resuscitation of hypovolemic shock?

Answer 13

Persistentmassivehemorrhage,requiring emergent surgical procedure

Question 14

Why does decreased pulse pressure occur with early hypovolemic shock?

Answer 14

Pulse pressure (systolic–diastolic BP) decreases because o  vasoconstriction, resulting in an elevated diastolic BP

Question 15

What is the most common vital sign change associated with early hypovolemic shock?

Answer 15

Tachycardia

Question 16

What type of  patient does not mount a normal tachycardiac response to hypovolemic shock?

Answer 16

Patients on B -blockers, spinal shock (loss o sympathetic tone), endurance athletes

Question 17

Should vasopressors be used to treat hypovolemic shock?

Answer 17

No

Question 18

Should patients with hypovolemic shock be put into the Trendelenburg position?

Answer 18

No

Question 19

What is the definition of septic shock?

Answer 19

Documented in ection and hypotension

Question 20

What is the specific etiology of septic shock??

Answer 20

Most common—gram-negative septicemia Less common—gram-positive septicemia,
fungus

Question 21

What actorsincreasethe susceptibility to septic shock?

Answer 21

Any mechanism that increases susceptibility to infection (e.g., trauma, immunosuppression, corticosteroids, hematologic disease, diabetes)

Question 22

Whatcomplicationsaremajor risks in septic shock?

Answer 22

Multipleorgan ailure,DIC,death

Question 23

What are the signs/ symptoms of septic shock?

Answer 23

Initial—vasodilation, resulting in warm skin and ull pulses;normal urine output
Delayed—vasoconstriction and poor urine output; mental status changes; hypotension

Question 24

Whatpercentageo blood cultures is positive in patients with bacterial septic shock

Answer 24

Only about 50%!

Question 25

What are the associated findings of septic shock?

Answer 25

Fever, hyperventilation, tachycardia

Question 26

What are the associated lab findings of septic shock?

Answer 26

Early—hyperglycemia/glycosuria, respiratory alkalosis, hemoconcentration, leukopenia Late—leukocytosis, acidosis, elevated lactic acid (Note: Identi ying organism is important to direct treatment/antibiotics)

Question 27

What is the treatment of septic shock?

Answer 27

1. Volume (IVF) 2. Antibiotics (empiric, then by cultures) 3. Drainage o in ection 4. Pressors PRN 5. Zygris®PRN

Question 28

What is the definition of cardiogenic shock?

Answer 28

Cardiac insu  ciency; le  ventricular ailure (usually), resulting in inadequate tissue perfusion

Question 29

What are the causes of cardiogenic shock?

Answer 29

MI, papillary muscle dys unction, massive cardiac contusion, cardiac tamponade, tension pneumothorax, cardiac valve failure

Question 30

What are the signs/symptoms on exam of cardiogenic shock?

Answer 30

``` Dyspnea Rales Pulsus alternans (increased pulse with greater f lling ollowing a weak pulse) Loud pulmonic component o S2 Gallop rhythm ```

Question 31

What are the associated vital signs/parameters of cardiogenic shock?

Answer 31

Hypotension, decreased cardiac output, elevated CVP/wedge pressure, decreased urine output (low renal blood  flow), tachycardia (possibly)

Question 32

What are the signs on CXR of cardiogenic shock?

Answer 32

Pulmonary edema

Question 33

What is the treatment of cardiogenic shock?

Answer 33

``` Based on diagnosis/mechanism: 1. CHF: diuretics and a afterload reduction (e.g., ACE inhibitors), with or without pressors 2. Left ventricular failure (MI): pressors, afterload reduction ```

Question 34

What are the last resort support mechanisms of cardiogenic shock?

Answer 34

Intra-aortic balloon pump (IABP), ventricular assist device (VAD)

Question 35

What is the definition of neurogenic shock?

Answer 35

Inadequate tissue perfusion from loss of sympathetic vasoconstrictive tone

Question 36

What are the common causes of neurogenic shock?

Answer 36

Spinal cord injury: | Complete transection of spinal cord Partial cord injury with spinal shock Spinal anesthesia

Question 37

What are the signs/ symptoms of neurogenic shock?

Answer 37

Hypotension and bradycardia, neurologic deficit

Question 38

Why are heart rate and BP decreased in neurogenic shock?

Answer 38

Loss of sympathetic tone | but hypovolemia [e.g., hemoperitoneum] must be ruled out

Question 39

What are the associated findings of neurogenic shock?

Answer 39

Neurologic def cits suggesting cord injury

Question 40

What MUST be ruled out in any patient where spinal shock is suspected?

Answer 40

Hemorrhagic shock!

Question 41

What is the treatment of neurogenic shock?

Answer 41

IV  fluids (vasopressors reserved  or hypotension refractory to  fluid resuscitation)

Question 42

Whatpercentageo patients with hypotension and spinal neurologic deficits have hypotensiono purely neurogenic origin?

Answer 42

About 67% (two thirds) of patients

Question 43

What is spinal shock?

Answer 43

Complete  flaccid paralysis immediately following spinal cord injury; may or may not be associated with circulatory shock

Question 44

What is the lowest reflex available to the examiner?

Answer 44

Bulbocavernous reflex: checking or contraction of the anal sphincter upon compression o the glans penis or clitoris

Question 45

What is the lowest level voluntary muscle?

Answer 45

External anal sphincter

Question 46

What are the classic findings associatedwithspinalcord shock?

Answer 46

Hypotension Bradycardiaorlacko compensatory tachycardia

Question 47

What is the acronym or treatmentoptions or anaphylactic shock?

Answer 47

“BASE”: - Benadryl - Aminophylline - Steroids - Epinephrine