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shock Flashcards

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1
Q

what is shock

A

Impaired O2 delivery/utilization

Increased O2 consumption

asymmetry in supply and demand

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2
Q

why do we care about shock

A

hypo-perfusion

When it becomes irreversible (cells start to die) > multi-organ failure and death

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3
Q

what decreases supply

A

Pump failure

Decreased total blood volume

Poor vascular tone (vessels can’t be leaky)

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4
Q

What can increase demand?

A

Exercise
Infection
Meds/toxins
Hypermetabolic states (hyperthyroidism, pregnancy, anemia)

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5
Q

poor vascular tone

A

leaky blood vessels

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6
Q

kidney failure looks like

A

increase in Cr

fluid retention
(urine output is decreased)

might need a catheter

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7
Q

loss of perfusion to the brain looks like

A 
altered mental state
agitation
loc 
confusion
intracerebral bleeding
coma
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8
Q

loss of perfusion to the lungs can result in

A

acute respiratory distress

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9
Q

drugs that cause shock

A

prescription medications

toxins

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10
Q

BP

A

CO times SVR (systemic vascular resistance)

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11
Q

co

A

SV (amt of blood you are pushing out)

times HR

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12
Q

anaphylaxis and toxins have a direct effect on

A

SVR (systemic vascular reserve)

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13
Q

What happens when we don’t have O2

A

We go through the process of fermentation. We get a build up of lactate

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14
Q

what happens when you get a lactic acid build up?

A

You get lactate build up bc it disrupts the electrolyte balances in the cell. We see influx of Ca++ and it triggers a process called apoptosis.

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15
Q

respiratory complications of

A

tachypnea
SOB
can go into ARDS
(lungs fill with fluid and lungs are crying bc they are not getting enough oxygen),

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16
Q

The normal blood lactate concentration in unstressed patients is

A

0.5-1 mmol/L.

something around 2

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17
Q

Early sign shock

A

MAP decreased 10 mmHG

effective compensation

O2 is still getting to vital organs and

increased heart rate

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18
Q

what are compensatory signs

A

MAP down 10-15 mm Hg
increased RENIN and ADH

–>vasoconstriction

decreased PP
increased HR
decreased pH 
restless
apprehensive
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19
Q

progressive signs (intermediate)

A

decreased MAP 20 mm Hg

tissue organ hypoxia
decreased UO
decreased pH
weak rapid pulse

sensory changes

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20
Q

refractory signs irreversible

A

excessive cell organ damage

multisystem failure and decreased pH

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21
Q

this is where you start to see cellular damage. Kidneys start to fail

A

Progressive signs of shock

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22
Q

Coagulation of shock

A

PT/INR will be elevated, DIC is present (purpura, INR will be through the roof)

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23
Q

effect on kidneys

A

decreased urine output, get creatinine

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24
Q

cardiac markers of shock

A

tachycardia, chest pain, EKG disturbances

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25
Liver effects
hypotensive, LFTs (AST/ALT in the 1000s --> this is shock liver), bilirubin and albumin can be high
26
your vascular tone is failing (leaky blood vessels)
i. Distributive shock
27
Distributive shock what is happening
Something is telling them to dilate and it causes leakage of nutrients into the interstitium. So even though your blood volume is good, your blood vessels are leaky so they are not getting the nutrients SUPPLY
28
hypovolemic
not enough gas in your tank. Pump is working and vascular tone is good but don’t have enough volume SUPPLY
29
Cardiogenic shock
DEMAND pump failure can't get the blood where it needs to be NO FLUIDS fluid in lungs--> need to intubate--> sedation drops pressure--> coding
30
obstructive shock
SUPPLY | everything is working but there is something blocking and you're not getting O2
31
peritoneal signs of hypovolemic shock
rigid abdomen blood is irritating
32
hemorrhagic hypovolemic shock can look like
* Trauma * GI Bleed * AAA rupture * Ruptured ectopic pregnancy (call the OB) * Post-partum hemorrhage
33
hypovolemic tx can look like
pressor fluids blood
34
Non-hemorrhagic causes of hypovolemic (4)
* GI loss (vomiting/diarrhea) * Inadequate intake * Environmental/neglect * Burns
35
if you loose 700 mL of blood or 15% BV you are what class of shock
class I normally HR increased
36
class 3 of shock
``` 1500-2000 loss of 30-40% BV HR >120 RR 30-40 decreased systolic blood pressure urine output decreased 5-15 mL ```
37
class 2 of shock
``` 750-1500 15-30% >100 20-30 rr NORMAL bp ``` 20-30mL UO
38
class IV of shock
``` >2000 mL >40% >140 >35 RR greatly decreased systolic BP UO minimal ```
39
in hypovolemic shock you want to start IV with a
crystalloid maybe colloid for cardiac and pulmonary complications
40
TX of hypovolemic shock
1. ABCs 2. Good IV access 3. VOLUME – start with crystalloid 4. Blood if bleeding (massive transfusion protocol) 5. Pressors - Norepinephrine 6. Definitive management (stop bleeding, OR/endoscopy if needed, treat underlying condition)
41
71 y/o M, hx of HTN, DM, prior stents with CP/SOB/dizziness/weakness for the last 5 hours VS: 96.2 104 72/50 27 91% 4L NC what type of shock would you suspect i. Ill appearing, dyspneic ii. Tachycardic iii. Crackles in both lungs iv. 2+ pitting edema to knees bilaterally
cardiogenic shock picture need an ECG bedside echo
42
causes of cardiogenic shock (5)
``` MI or infarction valvular disease cardiomyopathy myocarditis toxins ```
43
Tx of cardiogenic shock
i. ABCs (C also for Call Cardiology!!) ii. Oxygenation/Intubation iii. IV access iv. Careful fluid resuscitation v. Inotropes/Vasopressors (Dobutamine/Norepinephrine) vi. Definitive management (cath lab for stent/balloon pump vs. OR for CABG/valve replacement)
44
a. A 23 y/o healthy M presents with weakness, chills, nausea and abdominal pain for 3 days b. VS: 103.2 117 71/45 22 100% on RA c. Exam i. Ill appearing, +rigors ii. Dry MM iii. Abdomen uncomfortable to palpation, particularly in the lower quadrants, +rebound/guarding i. WBC 29 ii. Creatinine 2.9 iii. Lactic acid 4 iv. UA: no signs of infection
distributive shock
45
WBC normal
4.5-11
46
normal creatinine
.8-1.4
47
reasons for distributive shock
septic shock anaphylactic shock neurogenic shock
48
what is the reason for septic shock
Overwhelming systemic infection
49
common causes of Anaphylactic shock
a. Food b. Medication c. Contrast d. Insects
50
reasons for neurogenic shock
spinal cord injury is an example
51
in general how should we treat distributive shock
* ABCs * IV access * Fluids * Vasopressors (Norepinephrine)
52
septic shock tx
* Look for source! * Antibiotics (broad) * Source control (surgery if needed)
53
anaphylactic shock tx
* Epinephrine (0.3mg IM) * Steroids * H1/H2 blockers * Decontamination
54
neurogenic shock tx
* C collar/stabilize spine * Atropine/pressors * Steroids controversial * NSG intervention
55
what would obstructive shock look like on a ecg on CXR on echo
low voltage CXR shows – cardiomegaly ECHO shows --- large pericardial effusion w/ cardiac tamponade
56
causes of obstructive shock
1. Cardiac tamponade 2. Tension pneumothorax 3. Pulmonary embolism 4. Severe aortic stenosis
57
how does Cardiac tamponade create shock TX
Tamponade = can’t fill the heart Obstruction = pericardial effusion • Pericardiocentesis
58
how does tension pneumothorax cause shock
can’t fill the heart Obstruction = air in chest; with mediastinal shift and tracheal deviation • Chest tube
59
Pulmonary embolism as a cause of shock
can’t fill the heart a. Obstruction = large clot in PA • Thrombolytics/anticoagulation
60
Severe aortic stenosis
can’t pump out into aorta a. Obstruction = stenotic aortic valve • Valve replacement
61
what does a pt in shock look like ?
i. Ill appearing ii. Abnormal vitals (hypotension, tachycardia) iii. Weak pulses iv. Mental status changes v. Cool/clammy extremities
62
what does assessment look like in a pt with shock
i. BP (?Art line/central line for CVP) ii. Lactate clearance iii. Hemoglobin (>10) iv. Urine output (>0.5 ml/kg/hr)
63
SNS neurotransmitters
noraderenaline and adrenaline
64
B1 receptor
both increases heart rate and contractility and speed
65
B2
stimulation leads to vasodilation
66
A1
stimulation causes vasoconstriction
67
catecholamine release that in response to a drope in CO
epinephrine | norepinephrine
68
septic shock
LPS toxins cause nitric oxide release from cell damage compliment cascade triggered causing mor vasodilation TNF causes more release of inflammatory chemicals damagining the endothelial cells and making them leaky procoagulant-TF also released leads to clotting and bloackages and further decreased profusion
69
how does distributive shock look different
MVO2 shock can be normal

Emergency Medicine (28 decks)

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