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Flashcards in Shock Deck (26)
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1
Q
Criteria to diagnose as shock
A
-Hypotension
-Tachycardia (often first symptom)
-Oliguria
-AMS (altered mental status *may be only presenting symptom*
***Peripheral hypoperfusion and impaired O2 delivery*** MOST IMPORTANT
2
Q
Basic progression of shock
A
-Arterial blood flow can not keep up with demand of tissues metabolic needs
-Resulting in hypoxia to the body as a whole
-Resulting in anaerobic metabolism to kick in at peripheral tissues
**Resulting in lactic acidosis (lactic acid build up, very bad)**

*Overall: Decreased oxygen to peripheral tissues*
3
Q
4 types of shock
A
Hypovolemic
Cardiogenic
Obstructive
Distributive
4
Q
Hypovolemic shock
A
-Decreased intravascular volume
-Due to loss of blood or fluid and electrolytes
-Blood loss from whatever reason (trauma, ruptured ectopic pregnancy, GI bleed, etc)
-Loss of fluid and electrolytes (N/V/D)
-Body will compensate by vasoconstricting, but after 15% loss of volume, shock sets in.
-Anything that decreases BP can cause shock; body responds by vasoconstriction
5
Q
S/S of Hypovolemic shock
A
-Oliguria, AMS, cool extremities, diaphoresis, pale
*Narrow pulse pressure (reduced stroke volume)
-DECREASED PCWP, CO, & venous return; Elevated TPR (HIGH output failure)
-Improves with fluids
6
Q
Cardiogenic shock
A
-From cardiac failure
-Heart can not maintain necessary cardiac output
-Definition: as evidence of tissue hypoxia due to decreased cardiac output in the presence of adequate intravascular volume
-Could be from MI, cardiomyopathy, valve dysfunction, arrhythmias
7
Q
S/S of Cariogenic shock
A
-Oliguria, mental status changes, diaphoresis, cool extremities, jugular venous pressure is elevated, pulmonary edema might be present with respiratory failure.
-LOW output failure (elev TPR, Low CO & venous return)
-ELEVATED PCWP (pulmonary wedge pressure)
-Blood pressure improves with fluids
8
Q
How to differ between cardiogenic and hypovolemic shock
A
**Cardiac echocardiogram**

*Hypovolemic shock: LV will be small due to poor filling, but maintains contractility* (not enough fluid to pump); but contractility is fine

Cardiogenic shock: decrease in LV contractility (THIS IS THE DIFFERENCE; problem with your heart, contractility on echo will be different)
9
Q
Obstructive shock
A
-Cardiac tamponade
-Tension pneumothorax (needle first remember, not chest tube)
-Massive PE
10
Q
Distributive shock (septic, SIRS, neurogenic, anaphylaxis)
A
-AKA vasodilatory shock
-Produces a decreases in systemic vascular resistance; resulting tissue hypoperfusion
11
Q
S/S of Distributive shock (septic, SIRS, neurogenic, anaphylaxis)
A
-Normal circulatory volume
-Low TPR, PCWP
-Elevated CO, venous return (HIGH output failure)
-Vasodilation (warm dry skin)
12
Q
SIRS
A
-type of distributive shock
-Systemic Inflammatory Response Syndrome
-Can occur from an infectious cause, or noninfectious (burns, pancreatitis, trauma, ischemia)
13
Q
Criteria for SIRS

TEST!
A
Need to have at least two of the following:
-Temp >100.4, or 90
-RR >20 or hyperventilation with a CO2 on abg 12 or 10% bands
14
Q
Septic shock
A
-SIRS + a source (uti, pneumonia, cellultis, meningitis)
*Most common type of distributive shock
-20-50% mortality
-Risks are age, DM, immunosupression, recent invasive procedures

**Shock in setting of DIC from trauma often is from sepsis**
15
Q
Most common agents that cause septic shock
A
gram negatives (E coli, Pseudomonas, Klebsiella)
16
Q
Neurogenic shock
A
-type of distributive shock
-Caused by traumatic spinal cord injury or by effects of an epidural, or spinal anesthetic
-Loss of sympathetic tone and systemic vascular resistance
-Hypotension WITHOUT a compensatory tachycardia
-A benign other type of neurogenic shock which can result in syncope is “vasovagal syncope”—caused by pain, gastric dilatation, or fright, producing hypotension, bradycardia, and syncope
17
Q
S/S of shock in general
A
-everything vasoconstricts (brain is last to be effected)
-Hypotension (this may be masked in early stages by compensatory mechanisms such as tachycardia, increased cardiac contractility, and vasoconstriction)
-Cool and mottled extremities (red blotches, usually starts in legs, bad sign)
-Splanchnic vasoconstriction can lead to oliguria (decreased urine output), bowel ischemia, hepatic dysfunction, MSOF (Multi system organ failure- all of the above put together)
-Altered mental status (AMS is very very common)
18
Q
Sepsis markers in blood
A
*Lactate* (very bad)
Procalcitonin
19
Q
General treatment
A
-ABC’s with prompt intervention
-Respiratory failure not uncommon—due to existing metabolic acidosis. Intubation can reduce O2 demand of respiratory muscles and allow improved oxygen delivery to other hypoperfused tissues.
-Will develop compensatory respiratory alkalosis (will need to be intubated)
-Monitor urinary output, possibly foley (may have renal failure)
-IVF for hypotension
20
Q
What to give first? Blood or saline?
A
Give blood before giving saline, need to increased oxygen carrying capacity, giving BLOOD is more important, can give O- blood immediately (don’t need to waste time typing)

-If you give them fluids when they are in shock, can make it worse (inducing CHF; try giving very small boluses)
21
Q
For Septic shock, the standard is to give
A
**GET 30 cc/kg (of weight) of fluid without exception, given all at once**
This is a standard- main goal is to reverse hypotension
22
Q
Early Goal Directed Therapy for Septic Shock

***Will be a patient case on this on the TEST****
A
- .9NS (saline) to achieve CVP 8-12 mm Hg
-Vasopressors to achieve MAP 65 mm Hg or greater
-PRBCs (packed red blood cells) to achieve Hgb of 10 or greater
*Results in lower mortality and morbidity*
23
Q
When to give Pressors
A
-When fluids don’t work to maintain blood pressure
-Need central line to give (central lines go in VEINS)
-Dobutamine, Norepinephrine (Levophed), vasopressin, dopamine
24
Q
Can't give Pressors through IV in arm because
A
it increases the pressure in that area, necrosis will happen in that area, can lose limb (VERY BAD, this can happen if you accidentally put central line in artery)

-central lines MUST go in veins
-To see if central line is in artery or vein- draw blood gas from central line, and draw a gas from a known artery, if they are the same- BAD (line is accidentally in artery, ABGs should be VERY different from artery and vein)
25
Q
When to use Corticosteroids
A
-Used when shock is due to adrenal insufficiency
-Otherwise, most articles do not show its routine use in shock beneficial

-Goal is to stop inflammation, but **only works when problem is adrenal insufficiency**
26
Q
Antibiotics are used for
A
Septic shock and SIRS
**Nursing home pts- treat for MRSA** Treat with Vancomycin