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Flashcards in Shock Deck (55)
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1

Why is hypotension bad

When blood isn't circulating, there is no tissue perfusion
Give fluid bolus!

2

What is hypotension vs shock

Hypotension is low blood pressure
Shock is greater oxygen demand than oxygen supply

3

What can shock lead to

with little tissue perfusion, no oxygen delivery, cellular HYPOXIA and metabolic malfunction
Can lead to cell death; end organ damage; multi system organ failure; death

4

What is systemic tissue perfusion determined by

MAP= CO x SVR
CO is HR x SV
SVR is influenced by vessel length, diameter, and fluid viscosity
-CO and SVR determine the etiology of shock

5

What are the stages of shock

Pre-shock: warm, COMPENSATED. tachycardia, perish vasoconstriction, low BP
Shock: compensation OVERWHELMED, signs of organ dysfunction. tachy, dyspnea, metabolic acidosis, oliguria, cold clammy skin
End organ dysfunction: Progressive organ dysfunction, irreversible, coma, death

6

What are the types of shock

Hypovolemic, Cariogenic, Distributive
(Obstructive, Neurogenic)

7

What is an arterial line

line put into radial/brachial/femoral artery to continuously monitor BP and get recurrent ABGs
NOT for meds

8

What is a central line

placed in vein for delivering critical meds and measuring CVP.
Appropriate for determining fluid status and resuscitation in shock
Can get a triple lumen, double lumen, dialysis cath, Swan-Ganz cath, or PICC line

9

What is a Peripherally Inserted Central line Catheter (PICC)

Sits on top of the heart, small diameter, can keep for a long time but has increased DVT risk

10

What is CVP

pressure near the right atrium that correlated "pre-load" or overall volume status. Can be measured with any central line
If CVP is elevated (5-15 mmHg normal), probably don't want to give many fluids

11

What is a Swan-Ganz catheter

goes through the RA, RV, and sits in the pulmonary artery. Good for patient in CARDIOGENIC shock

12

What hemodynamic parameters does a Swan-Ganz measure

Pulmonary capillary wedge pressure (norm 5-15)
Cardiac output (norm 4-8 L)
Systemic vascular resistance (norm 1000-1500)

13

What is the clinical presentation of all types of shock

Hypotension (SBP <90 or decrease >40)
Tachycardia (except neurogenic shock, brady)
Oliguria
Mental status change (confusion, lethargy)
Metabolic acidosis
Cold clammy skin (except early distributive and neurogenic- warm flushed)
Later: multi organ failure, coagulopathy

14

What happens in Hypovolemic shock

not enough intravascular volume causes decreased CO and decreased oxygen delivery

15

What are the causes of hypovolemic shock

hemorrhagic (trauma, GI bleed, internal hemorrhage, post-surgical)
Fluid loss (dehydration, n/v/d, burns, acute pancreatitis)

16

What is the pathophysiology of Hypovolemic shock

decreased blood volume leads to decreased SV
deceased SV leads to decreased CO and BP
decreased BP and volume leads to inadequate tissue perfusion (no oxygen)
Compensation: increased SVR (vessels constrict to shunt remaining blood from periphery to heart, lungs, etc)--baroreceptors sense low BP and activate SNS
Switch to Anaerobic metabolism

17

What are the hemodynamic parameters of hypovolemic shock

CVP: decreased
CO: decreased
SVR: increased

18

What does clinical presentation of hypovolemic shock depend on

Amount of blood loss: small is tolerated, large are not
Rate of loss: slow loss allows time for compensation, fast loss leads to shock s/s faster

19

What do hypovolemic shock patients present with complaints of

Hematemesis, hematochezia, melena
N/v/d
abdominal pain
evidence of trauma
Post-op

20

What are physical signs of hypovolemic shock

Dry oral mucosa
Hypotension, tachycardia, tachypnea, decreased JVP/CVP/urine output
Cold clammy extremities, decreased turgor
Confusion
(May be others with underlying pathology)

21

What diagnostic studies are needed for Hypovolemic shock

CBC, CMP, PT/INR (are they bleeding?)
Lactate (marker of tissue perfusion, increase during ANaerobic perfusion)
ABG
CXR/ chest CT
Abd XR/CT

22

What is increased lactate associated with

increased mortality
if high, there is not enough tissue perfusion

23

How do you manage hypovolemic shock

REPLACE VOLUME: crystalloid (saline), Colloid (albumin), blood (PRBC, FFP, Plts)
If SBP <70, can use vasopressors while restoring volume (emergency)

24

What should you monitor when managing hypovolemic shock

urine output, peripheral perfusion, mentation

25

What is Cariogenic shock

decreased CO due to pump failure

26

What are the etiologies of cariogenic shock

Ischemia (MI, cardiomyopathy)
Valvular HD (ruptures pap muscle/chords, ventricular septum rupture)
Arrhythmias (VFib, VTach, complete heart block, AFib, Aflutter)
Obstructive (extra cardiac)- massive PE, cardiac tamponade, tension PTX

27

What is the pathophysiology of cariogenic shock

Bad pump causes decreased BP and CO
decreased BP/CO turns SNS on, and cause decreased renal perfusion
decreased renal perfusion causes sodium and water retention (RAAS)
Increased filling pressure (CVP) causes volume overload in lungs (pulm edema)
Compensation: increased SVR

28

What are the hemodynamic parameters in Cariogenic shock

CVP: increased
PCWP: increased
CO: decreased
SVR: increased

29

What is the clinical presentation of cariogenic shock

CP
Dyspnea
Palpitations
Fatigue

30

What are the physical signs of cariogenic shock

tachycardia, tachypnea, hypotension
cool clammy extremities
increased JVP
muffled heart sounds, new murmur, tachycardia
deviated trachea
crackles if with pulmonary edema