Shock

Question 1

MAP equation

Answer 1

MAP=CO x SVR

Question 2

SVR determinants

Answer 2

Vessel length, diameter.

Blood viscosity.

Question 3

Stage of shock

Answer 3

1. Pre-shock: (compensated/warm) Hypotension, Peripheral vasoconstriction, Tachycardia.
2. Shock: Overwhelmed compensatory mechanism.
   S/S end organ dysfxn-Tachycardia, dyspnea, metabolic acidosis, oliguria, confusion, cool clammy skin
3. End-organ dysfxn: Progressive dysfxn. Irreversibe damage-Coma-Death.

Question 4

Shock types (5)

Answer 4

1. Hypovolemic
2. Cardiogenic
3. Obstructive
4. Neurogenic (injury loss of SNS)
5. Distributive (Sepsis, etc. Decreases TVR)

Question 5

PCWP

Answer 5

Estimates L atrial pressure
Increased: Cardiogenic
Decreased: Hypovolemic & Neurogenic (or normal)

Question 6

CO

Answer 6

Increased: Early septic (hyperdynamic response)
Decreased: All else (may be normal in neurogenic)

Question 7

SVR

Answer 7

Increased: Cardiogenic, Hypovolemic, Late Septic (vasodilation)
Decreased: Early septic (vasodilation), Neurogenic

Question 8

Hypovolumic etiology

Answer 8

1. Blood loss (Post-surgical, GI bleed, trauma)

2. Fluid loss (Dehydration, Burns, Acute pancreatitis)

Question 9

Hypovolumic Pathophysiology

Answer 9

Decreased: blood vol, preload, SV, CO, BP, tissue perfusion
Compensate: Increase SNS, SVR. Blood shunted to vital organs.
Anaerobic metabolism builds Lactate up.

Question 10

Hypovolumic parameters

Answer 10

1. CO decreased
2. PCWP/CVR decreased
3. TVR increased

Question 11

Hypovolumic clinical sx

Answer 11

1. Greater loss at higher rate=poorly tolerated
2. Sx depend on cause
   Hematemesis/Melena/Hematochezia
   N/V/D
   Abdominal pain
   Post-op

Question 12

Hypovolumic PE signs

Answer 12

Dry mucosa
Extremities: cool, clammy, decreased tugor
Decreased BP/JVP/CVP
Increased heart rate
Decreased urine output
Confused mental status
Post-op bleeding-Abdominal pain & distention

Question 13

Hypovolumic diagnostic tests

Answer 13

1. CBC (h&h), CMP, PT/INR (bleeding)
2. Lactate (increase assoc with mortality)
3. ABG
4. Other: CXR, AXR

Question 14

Hypovolemic treatment

Answer 14

1. Treat issue
2. Replace volume
   Crystalloid/Colloid/Blood (PRBC, FFP, Plts)
3. Monitor urine, perfusion, mentation

Vasopressor only if SBP<70, dire situation.
(Already vasoconstrict as compensatory)

Question 15

Cardiogenic/Obstructive etiology

Answer 15

1. Ischemia (MI, CM)
2. Valve ds (Severe AS, ruptured chordae tendinae/septum)
3. Arrhythmia (Vtach/Vfib/Complete heart block)

Obstructive: PE, tamponade, tension pneumothorax

Question 16

Cardiogenic pathophysiology

Answer 16

Decrease CO, BP,
Decrease renal perfusion-Increase Na/H2O retention
Increase CVP/PCWP-fluid back up in lungs (caution fluids)
Compensatory: Increase SNS, SVR

Question 17

Cardiogenic parameters

Answer 17

1. CO decrease
2. CVP/PCWP increase
3. TVR increase

Question 18

Cardiogenic clinical presentation

Answer 18

CP, Dyspnea, Fatigue, Palpitations

Question 19

Cardiogenic PE signs

Answer 19

Increased JVP, crackles, tachypnea (fluid in lungs)
Muffled heart sounds (tamponade)
Deviated trachea (tension pneumo)
New murmur
Cool, clammy extremities

Question 20

Cardiogenic Dx studies

Answer 20

Same as hypovolumic plus…
Cardiac enzymes (nonspecific)
Echocardiogram
CXR:
Tamponade-enlarged cardiac silhouette
Pneumo-lost vascularity, deviated trachea

Question 21

Cardiogenic treatment

Answer 21

1. Treat issue (cath, ACLS, decompression, pericardiocent)
2. Cardio consult
3. Caution with fluids (back up into lungs)
4. Meds: Inotropes-Dobutamine (increase contractility)
   Anti-arrhythmics, diuretics, vasopressors, HF meds.
   Last line: LVAD, ECMO, transplant

Question 22

Distributive etiology

Answer 22

Sepsis
Adrenal insufficiency
Liver disease
Anaphylaxis
Drugs/Meds

Question 23

Septic pathophysiology

Answer 23

Increased O2 demand & Endotoxins

Inadequate perfusion & cell hypoxia

Question 24

Early septic patho

Answer 24

Vasodilation & hyperdynamic heart

Decreased SVR, BP. Increased CO. Compensates well, but short.

Question 25

Late septic patho

Answer 25

Vasoconstriction. Due to hypovolumia (leaking) & decreased BP. Increased SNS, HR, SVR. Increased SVR decreases perfusion further.

Question 26

Sepsis clinical presentation

Answer 26

Increased HR, temp, fever Decreased BP. Early-warm. Late-cool. Confused.

Question 27

Sepsis Parameters

Answer 27

A) Early 1. CO increased 2. SVR decreased 3. CVR decreased (due to SVR decreasing) B) 1. CO (+/-) usually decreased 2. CVR usually decreased (plasma leaking) 3. SVR increased

Question 28

Septic dx studies

Answer 28

Same (including lactate) | + Blood cultures

Question 29

Septic treatment

Answer 29

1. Goal-directed therapies 2. ID problem (culture before AB, Empiric based on likely) 3. Fluid 4. Vasopressors (NE) 5. Ventilator if needed

Question 30

Septic mortality rate

Answer 30

35-60% 1 mo.

Question 31

Neurogenic etiology

Answer 31

1. Spinal cord injury | 2. Brainstem injury (closed head trauma)

Question 32

Neurogenic pathophysiology

Answer 32

1. Unopposed PNS, disrupted SNS 2. Decreased HR & SVR (Vasodilation) 3. SNS normally released NE/Epi from TL SC

Question 33

Neurogenic PE signs

Answer 33

1. Warm extremities (vasodilations) 2. Anal sphincter: decreased tone 3. LOC change, Para/quad, DTR increased or gone 4. HR normal or gone (ONLY one normal or decrease HR) 5. BP decreased

Question 34

Neurogenic parameters

Answer 34

1. CO normal or decreased 2. CVR decreased 3. TVR decreased

Question 35

Neurogenic dx studies

Answer 35

1. same 2. Spinal CT/MRI 3. Head CT/MRI 4. XR

Question 36

Neurogenic treatment

Answer 36

Neuro consult! | Address issues, volume replacement.