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Shock Flashcards

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1
Q

Shock is inadequate _____ that results from _______ to deliver sufficient ______ to sustain vital organ function.

A

Tissue perfusion; the failure of the CVS; oxygen and nutrients.

Also called hypoperfusion or circulatory failure

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2
Q

Conductance vessels

A

Arteries

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3
Q

Resistance vessels

A

Arterioles

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4
Q

Exhcnage vessels

A

Capillaries

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5
Q

Capacitance/storage vessels

A

Veins

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6
Q

Pediatric vs adult patient: Capable of more effective vasoconstriction? What is the consequence of this?

A

Pediatric; Greater ability to maintain normal blood pressure for a longer time in the presence of shock

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7
Q

Pressure exerted against the walls of the large arteries at the peak of ventricular contraction

A

Systolic blood pressure

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8
Q

Pressure exerted against the walls of large arteries during ventricular relaxation

A

Diastolic blood pressure

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9
Q

BP = ___ x ___?

A

BP = CO x TPR

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10
Q

Important formula for resistance?

A

Poiseuille’s Law
R = 8nl/(pi)r^4
where n = viscosity, l = length of blood vessel, r = radius of blood vessel

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11
Q

Pulse pressure reflects?

A

Stroke volume and aortic compliance (SV/AC) `

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12
Q

Narrowed pulse pressure reflects?

A

Increased TPR, EARLY sign of impending shock

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13
Q

Widened pulse pressure reflects?

A

Decreased TPR, seen in EARLY septic shock/warm shock/hyperdynamic shock

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14
Q

Early indicators of decreased tissue perfusion

A

Mottling, cool extremities

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15
Q

Late sign of cardiovascular compromise in a child

A

Hypotension

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16
Q

What happens to peripheral pulses when cardiac output is decreased?

A

Also decreased

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17
Q

CO = ___ x ___

A

CO = HR x SV

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18
Q

Primary method of increasing cardiac output in children?

A

Increase HR

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19
Q

Why are children dependent on an adequate HR to maintain cardiac output? *Also the rationale behind faster HR in infants –> slower HR as the child grows older

A

Due to the immaturity of the sympathetic innervation to the ventricles, the heart is unable to increase CO by increasing SV (EDV - ESV). The myocardia are less compliant and less able to generate tension during contraction, limiting SV. As these mature, children become more able to maintain cardiac output by increasing SV.

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20
Q

Circulating blood volume in:
Infants
Children
Adolescents and adults

A

Infants: 75-80 mL/kg
Children: 70-75 mL/kg
Adolescents and adults: 65-70 mL/kg

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21
Q

Physiologic reserves
Glycogen stores
Glucose requirements
Cardiovascular reserve

A

Glycogen stores: Less
Glucose requirements: More
Cardiovascular reserve: Greater CIRCULATING blood volume than adults, but less TOTAL blood volume; strong but limited reserves. Decompensate QUICKLY.

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22
Q

Compensated shock

A

Early shock, inadequate tissue perfusion without hypotension

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23
Q

Body’s sensors and compensatory mechanisms in shock?

A

Carotid sinus: Baroreceptor; decreased vagal firing rate when BP drops –> increased sympathetic outflow from the CNS –> increased HR, SV, TPR
Medulla, carotid bodies, aortic arch: Chemoreceptors; stimulated mostly by hypoxia, but also by hypercarbia and low pH –> increased RR to blow off CO2

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24
Q

Physical findings in compensated shock?

Study These Flashcards
A 
Narrow pulse pressure, normal SBP
Normal to mild increase in HR
Mild increase in RR
Mild decrease in urine output
Mental status changes such as restlessness, irritability, confusion
Pale mucous membranes
25
Hypotensive shock
Occurs when compensatory mechanisms begin to fail
26
Physical findings in hypotensive shock?
Fall in SBP, DBP; weak central pulses, thready peripheral pulses Moderate tachycardia, possible dysrhythmias Moderate increase in RR, possible respiratory fatigue or failure Marked decrease in urine output Agitation, lethargy Pale or cyanotic mucous membranes
27
What does pulse quality reflect?
Adequacy of peripheral perfusion
28
What are the four types of shock?
Hypovolemic Distributive Cardiogenic Ostructive
29
Sudden decrease in the circulating blood volume relative to the capacity of the vascular space Ex. hemorrhage, plasma loss, fluid and electrolyte loss, endocrine disease
Hypovolemic shock
30
Distributive shock
Altered vascular tone --> peripheral vasodilation --> increases the size of the vascular space and alters the distribution of the available blood volume --> RELATIVE hypovolemia Ex. septic shock, anaphylactic shock, neurogenic shock
31
Cardiogenic shock
Impaired cardiac muscle function leads to decreased cardiac output and inadequate tissue oxygenation Ex. conduction abnormalities, cardiomyopathy, congenital heart disease
32
Obstructive
Obstruction to ventricular filling or the outflow of blood from the heart Ex. tension pneumothorax, massive pulmonary embolus, cardiac tamponade
33
A 5-year-old child presents with a 3-day history of vomiting and diarrhea. On physical exam, he has poor skin turgor, has cool extremities, and is irritable. What is/are the type/s of shock involved?
Hypovolemic shock due to fluid and electrolyte loss.
34
A 12-year-old child was involved in a vehicular crash when his bike collided with a speeding car. He was not wearing a helmet, and his head hit the sidewalk when he was thrown off his bike. On PE, he is unresponsive to any kind of stimulus, hypotensive, bradycardic, with irregular respirations. Breath sounds are decreased in the left lung field, no neck vein distension. He has weak peripheral pulses and cool extremities. What type/s of shock is/are involved?
Distributive: Neurogenic, involvement of cervical spine will present with hypotension and bradycardia Possible hypovolemic: Decreased breath sounds in the left lung field may indicate a hemothorax, and there may also be other sources of internal hemorrhage (abdominal, pelvic fracture)
35
Four clinical findings to assess dehydration
Abnormal general appearance Capillary refill >2s Dry mucous membranes Absent tears
36
Priorities in emergent care of a pediatric patient in hypovolemic shock?
Control fluid loss | Restore vascular volume
37
How do you perform fluid resuscitation in children?
20 cc/kg of isotonic crystalloid solution (ex. pNSS or pLR) Assess response after EACH BOLUS: increased work of breathing, development of crackles Generally, 3 mL fluid: 1 mL blood lost
38
What should be the next steps to consider if the patient does not respond to the initial fluid resuscitation?
``` Blood transfusion (if hemorrhagic etiology) Use of vasopressors --> when shock remains refractory after 60-80 cc/kg bolus ```
39
How is hypoglycemia managed?
Newborn: 5-10 cc/kg D10W Infants and children: 2-4 cc/kg D25W Adolescents: 1-2 cc D50W *In Harriet Lane though, it's just 2 cc/kg D10 W for newborns
40
What is the most common type of distributive shock in children?
Septic shock
41
What are the two stages of septic shock?
Early/warm shock/hyperdynamic phase: Where endotoxins prevent catecholamine-induced vasoconstriction --> peripheral vasodilation --> increased cardiac output to maintain adequate oxygen delivery Late/cold shock/hypodynamic phase: Inflammatory mediators cause cardiac output to fall --> compensatory increase TPR --> cool extremities (cold shock)
42
Goals in emergent management of a patient in septic shock?
``` Restore hemodynamic instability Identify and control infectious organism Limit inflammatory response Support CVS Enhance tissue perfusion Ensure nutritional therapy ```
43
Initial therapeutic endpoints in resuscitation of septic shock
``` Capillary refill <2 s Normal BP for age Normal pulses Warm extremities UO > 1 cc/kg/hr Normal mental status ```
44
Other therapeutic considerations in septic shock:
Inotropic support Mechanical ventilation Correction of glucose, iCa, other electrolyte abnormalities Broad-spectrum antibiotic
45
What pressor is given for warm shock with low BP?
Norepinephrine: 0.1 - 2 mcg/kg/min
46
What pressor is given for cold shock with normal BP?
Dopamine: 2-20 mcg/kg/min (5-20 in Harriet Lane); this is medium dose, acts more on beta receptors, increases cardiac contractility with little effect on vascular resistance
47
What is given for cold shock with low BP?
Epinephrine: 0.1 mcg/kg/min
48
What is the mainstay of treatment in anaphylaxis?
Epinephrine 0.01 mcg/kg of 1:1000 (1 mg/mL), IM at anterolateral thigh Then support with fluids, salbutamol for bronchospasm, methyprednisolone, diphenhydramine
49
Goals in the emergent management of cardiogenic shock?
``` Reduce myocardial oxygen demand Improve preload Reduce afterload Improve contractility Correct dysrhythmias ```
50
How do you perform fluid resuscitation in a patient with cardiogenic shock?
Small fluid bolus (5-10 cc/kg) given over 10-20 minutes
51
When are vasopressors given in those with cardiogenic shock?
Significant hypotension Unresponsive to fluid resuscitation Volume overloaded
52
Intropes with vasoconstrictor effect
Epinephrine, norepinephrine, dopamine (at high doses)
53
Inotropes with vasodilator effect
Dopamine (at low doses), isoprotenerol, dobutamine, amrinone, milrinone
54
Possible causes of obstructive shock
Cardiac tamponade Tension pneumothorax CHD Massive pulmonary embolism
55
Site for needling?
2nd ICS, insert 14- or 16-G needle on top of the 3rd rib, remove needle once there is a popping sound or give, then leave catheter in place
56
In babies with signs of decompensation due to CHD, what should you administer?
IV infusion of PGE1 (ex. alprostadil) to keep DA patent
57
In cases where peripheral vascular access cannot be found, what is the next step?
Intraosseus route, in the ff locations: Proximal tibia: 1-3 cm below and medial to the tibial tuberosity in the flat surface of the tibia Distal tibia: 1-2 cm proximal to the medial malleolus in the midline Distal femur: 2-3 cm above femoral condyles in the midline Head of humerus: Two finger widths below coracoid process and acromion
58
Remove IO access by?
24 hrs to prevent osteomyelitis

PALS (2 decks)

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