Shock

Question 1

define shock

Answer 1

Shock is a state of impaired tissue perfusion resulting from circulatory failure brought on by various causes.

Question 2

shock analogy to car

Answer 2

Gas = blood and plasma
Fuel pump = heart
Fuel line = arteries and veins

Question 3

how is shock classified?

Answer 3

by the cause of inadequate perfusion

Question 4

categories of shock

Answer 4

hypovolemic (low on gas)
cardiogenic (bad fuel pump)
distributive (fueling 2 cars with 1 gas line)
obstructive (blockage in fuel line)

Question 5

cellular cascade in shock

Answer 5

similar for all causes of shock
–initially irreversible but w/o tx becomes irreversible

cell injury -> inflammation -> cell death

anaerobic metabolism -> glucose phosphorylation -> lactic acidosis

microvascular thrombosis -> depletion of clotting factors -> DIC

Question 6

3 stages of shock

Answer 6

compensated
uncompensated
irreversible

Question 7

compensated shock overview

Answer 7

Stage I or nonprogressive
compensatory mechanisms initiated
vital organs perfused
full recovery

Question 8

uncompensated shock overview

Answer 8

Stage II or progressive
compensatory mechanisms inadequate
vital organs hypoperfused
recovery more difficult

Question 9

irreversible shock overview

Answer 9

Stage III
compensatory mechanisms failed
cellular and organ death
refractory to tx

Question 10

overview of physiological of compensated shock

Answer 10

SNS response
RAAS
ADH
intracellular fluid shift

Question 11

SNS response in compensated shock

Answer 11

release of epi/norepi
vasoconstriction

increased HR, contractility, BP

Question 12

RAAS in compensated shock

Answer 12

increased serum sodium
water reabsorption

decrease urine, increase BP and CO

Question 13

ADH in compensated shock

Answer 13

renal reabsorption of sodium and water

decrease urine, increase BP and CO

Question 14

intracellular fluid shift in compensated shock

Answer 14

increased intravascular volume

increase BP and CO

Question 15

overview of physiology of uncompensated shock

Answer 15

altered capillary permeability
respiratory insufficiency 
cardiac depression
tissue hypoperfusion
brain hypoperfusion

Question 16

altered cap permeability in uncompensated shock

Answer 16

leakage into interstitial space

edema, decreased BP and perfusion

Question 17

respiratory insufficiency in uncompensated shock

Answer 17

pulm edema
VQ mismatch

crackles, dyspnea, increased RR

Question 18

cardiac depression in uncompensated shock

Answer 18

diminished venous return
ischemia of nonvital organs

decreased urine output
increased lactate
base deficit
mixed venous sat (below 65%)
cool skin
decreased peripheral pulses

Question 19

brain hypoperfusion in uncompensated shock

Answer 19

AMS

Question 20

define hypovolemic shock

Answer 20

blood, plasma, or fluid loos reduces circulating blood volume and cardiac output

most common type of shock

Question 21

common causes of hypovolemic shock

Answer 21

traumatic hemorrhage
(long bone/pelvic fx, solid organ rupture, open wounds)

nontraumatic hemmorrhage
(GI bleed, ruptured AA, posterior epistaxis)

fluid shifts
(peritonitis, massive crush injuries, severe burns)

non-blood fluid loss
(v/d, diaphoresis)

urinary fluid loss
(DKA, diabetes insipidus, diuretic abuse)

Question 22

hypovolemic shock assessment

Answer 22

ABCs
cause
labs
trend VS
MAP (above 60) (SBP + 2DP/3)
urine output
LOC

Question 23

parameters of hypovolemic shock

Answer 23

blood loss
HR
BP
RR
urine output
CNS

Question 24

Class I of hypovolemic shock

Answer 24

blood loss below 15%
HR below 100
BP normal
RR 14-20
Urine above 30ml/hr
CNS slightly anxious

Question 25

Class II of hypovolemic shock

Answer 25

``` blood loss 15-30% HR 100-120 BP normal RR 20-30 Urine 20-30 ml/hr CNS mildly anxious ```

Question 26

Class III of hypovolemic shock

Answer 26

``` blood loss 30-40% HR 120-140 BP decreased RR 30-40 urine output 5-20 ml/hr CNS anxious, confused ```

Question 27

Class IV of hypovolemic shock

Answer 27

``` blood loss > 40% HR > 140 BP decreased RR > 35 urine output negligible CNS confused, lethargic ```

Question 28

hypovolemic shock intervention overview

Answer 28

airway control bleeding, reduce fluid loss restore volume blood replacement

Question 29

fluid resuscitation in hypovolemic shock

Answer 29

1. isotonic crystalloids (NS, LR) 2. colloids 3. blood replacement

Question 30

define cardiogenic shock

Answer 30

inadequate tissue perfusion as a result of decreased CO despite adequate intravascular volume d/t myocardial pump failure

Question 31

most common cause of cardiogenic shock

Answer 31

MI, particularly of L ventricular anterior wall

Question 32

other causes of cardiogenic shock

Answer 32

``` MI, ischemia blunt cardiac trauma sustained dysrhythmias acute valvular dysfxn end stage cardiomyopathy ```

Question 33

sx of cardiogenic shock

Answer 33

reflects heart failure, inadequate tissue perfusion ``` cardiac CP tachypnea, crackles, pulm edema tachycardia, tachydsrhythmias, S3 AMS pale, cool, clammy minimal urine output hypotension ```

Question 34

cardiogenic shock assessment

Answer 34

``` ECG CXR ABG echo CBC, platelets, BMP, LFTs, RFTs lactate SvO2 less than 65% ```

Question 35

cardiogenic shock interventions

Answer 35

``` airway decrease preload increase contractility decrease afterload cardiac catheterization angioplasty treat dysrhythmias ```

Question 36

airway in managing cardiogenic shock

Answer 36

PEEP to force pulmonary edema fluid out of lung interstitium

Question 37

how to decrease preload in cardiogenic shock

Answer 37

semi-fowler or fowler nitro diuretics morphine

Question 38

how to increase contractility in cardiogenic shock

Answer 38

``` positive inotropes (dobutamine) intra-aortic balloon pump ```

Question 39

how to decrease afterload in cardiogenic shock

Answer 39

continuous nitro nitroprusside antiHTN

Question 40

definitive tx for cardiogenic shock

Answer 40

cardiac cath angioplasty treat dysrhythmias

Question 41

define distributive shock

Answer 41

abnormal distribution of intravascular volume as a result of - decreased sympathetic tone - increased vascular permeability - pooling of blood in venous, capillary beds

Question 42

types of distributive shock

Answer 42

anaphylactic septic neurogenic

Question 43

define anaphylactic shock

Answer 43

acute, life-threatening allergic rxn in individuals exposed to antigen to which they have previously become hypersensitive

Question 44

common antigens in anaphylactic shock

Answer 44

``` shellfish peanuts/tree nuts milk, eggs, wheat, soy food additives insects meds, latex, iodine ```

Question 45

unusual causes of anaphylaxis

Answer 45

exposure to cold | exercise

Question 46

difference between anaphylaxis and anaphylactic shock

Answer 46

anaphylaxis: normal circulation with risk of progression to shock anaphylactic shock: shock state with compromised circulation

Question 47

anaphylaxis vs anaphylactoid rxns

Answer 47

anaphylaxis IgE mediated and requires prior antigen exposure

Question 48

pathophysiology of anaphylactic shock

Answer 48

``` antigen re-exposure hypersensitive antibody response vasoactive mediator release massive vasodilation profound hypovolemia increased cap permeability, fluid shift, vascular collapse ```

Question 49

anaphylactic shock assessment

Answer 49

rapidly progressing sx onset begins with cutaneous manifestation ``` urticaria, erythema, pruritis dypsnea, cough throat tightness, stridor wheezing, bronchospasm syncope chest tightness, palpitations angioedema hypotension, tachycardia respiratory, cardiac arrest ```

Question 50

anaphylactic shock interventions

Answer 50

``` remove antigen IM epi 1:1000, rpt in 15-20 min airway high-flow O2 IV fluid reusc vasopressors for hypotension IV epi inhaled beta-2 agonists (albuterol) antihistamine (H1 and H2) corticosteroids admission epi teaching ```

Question 51

define SIRS

Answer 51

cluster of sx of systemic inflammation w/ or w/o infection can be seen w/ acute pancreatitis, major trauma, burns

Question 52

define sepsis

Answer 52

2 SIRS criteria w/ known/suspected infection

Question 53

define severe sepsis

Answer 53

sepsis with organ dysfxn cardiovascular failure -> hypotension resp failure -> hypoxia renal failure -> oliguria/azotemia hematologic failure -> coagulopathy

Question 54

define septic shock

Answer 54

sepsis with hypotension despite adequate fluid resuscitation

Question 55

MODS

Answer 55

multiple organ dysfxn syndrome progressive failure of initially uninvolved distant organs following severe infectious or noninfectious insults

Question 56

sx of septic shock

Answer 56

``` mentation skin HR RR urine output acid/base values temp ```

Question 57

sx of hyperdynamic (warm) sepsis

Answer 57

``` CNS malaise, tired, restless skin warm, flushed, dry HR elevated, full pulses RR > 20/min urine output decreased acid/base respiratory alkalosis temp fever, shaking, chills ```

Question 58

sx of hypodynamic (cold) sepsis

Answer 58

``` CNS decreasing LOC, stupor, coma skin cold, clammy, pale mottled HR tachycardia, weak, thready pulses RR tachypneic, shallow urine decreased, anuria acid/base metabolic and resp alkalosis temp hypothermic, mottled ```

Question 59

septic shock interventions

Answer 59

``` fluid resuscitation positive inotropes, vasopressors remove infectious sources wound, blood cultures ABXs ```

Question 60

define neurogenic shock

Answer 60

loss of sympathetic stimulation, resulting in pure parasympathetic stimulation massive vasodilation body unable to compensate for drop in CO

Question 61

causes of neurogenic shock

Answer 61

spinal cord injury above T6 spinal anesthesia brain injury

Question 62

sx of neurogenic shock

Answer 62

parasympathetic (rest/digest) is unopposed ``` bradycardia bradypnea hypotension warm, dry, flushed full pulses priapism ```

Question 63

neurogenic shock interventions

Answer 63

ABCs to prevent secondary cord injury fluids resuscitation vasopressors atropine

Question 64

define obstructive shock

Answer 64

cardiac output and tissue perfusion are inadequate because of resistance to ventricular filling

Question 65

causes of obstructive shock

Answer 65

pericardial tamponade tension pneumothorax PE

Question 66

interventions for obstructive shock

Answer 66

correct underlying condition tamponade: pericardiocentesis and surgery tension pneumo: needle thoracotomy and chest tube PE: anticoagulation or thrombolytics

Question 67

incidence of pediatric shock

Answer 67

hypovolemia most common septic shock also seen, especially in neonates, due to immature immune system cardiogenic shock d/t toxic ingestion or sustained VT

Question 68

hypovolemic shock in pediatrics

Answer 68

higher metabolic rate higher body surface to volume ratio inability to voice sx

Question 69

assessing pediatric shock

Answer 69

``` dry mucous membranes no tears poor skin turgor sunken fontanels delayed cap refill child abuse IV/IO access ```

Question 70

geriatric hypovolemic shock

Answer 70

``` prone to dehydration meds, diuretics decreased thirst response limited mobility use caution with fluid resuscitation ```

Question 71

geriatric septic shock

Answer 71

pneumonia, urosepsis AMS respiratory alkalosis normotheria or hypothermia