Shock

Question 1

Clinical end points used to Identify shock

Answer 1

• SBP < 90mmHg
• MAP < 65mmHg
• Elevated lactate > 4mmol/l

Question 2

Impaired O2 utilization

Answer 2

• Anaerobic metabolism takes over

- Much less effective than aerobic metabolism

Question 3

Shock is driven by what

Answer 3

• Reduced cardiac output (CO)

- Reduced systemic vascular resistance (SVR)

Question 4

Cardiogenic Shock Cause

Answer 4

-Problem with the pump

Question 5

Cardiogenic Shock Treatment

Answer 5

• Make it PUMP
• Vasopressor
• Inotrope
• Diuresis (Cautious)
• AVOID Beta blockers and calcium channel blockers (-inotropes)

Question 6

Hypovolemic shock cause

Answer 6

-Hole in the bucket

Question 7

Hypovolemic shock treatment

Answer 7

• Stop bleeding/fluid loss
• Fluids (LR, NS or D5W)
• Vasopressors

Question 8

Neurogenic shock cause

Answer 8

-Vasodilation with out compensatory tachycardia

Question 9

Neurogenic shock treatment

Answer 9

• Fluids
• Vasopressors
• Inotropes

Question 10

Anaphylactic shock (distributive shock) Cause

Answer 10

• Allergic

- Immune/ inflammatory response

Question 11

Anaphylactic shock (Distributive shock) treatment

Answer 11

• Steroids
• Antihistamines
• Fluids
• Epinephrine
• Antivenom if available

Question 12

Septic shock (distributive shock) cause

Answer 12

• Bacteremia
• Endo/exotoxins
• LPS gram negative
• Gram positive bugs

Question 13

Septic shock (distributive shock) treatment

Answer 13

• remove/ suppress the infection
• Fluids
• Vasopressors
• Abx
• Source control

Question 14

Sustained shock can lead to what

Answer 14

-Multi organ dysfunction syndrome (MODS)

Question 15

Primary MODS

Answer 15

• Damage to organ system directly related to a specific insult
• Usually due to trauma or thermal injury

Question 16

Secondary MODS

Answer 16

• Exaggerated response of immune system to secondary insults

- Leading to further organ dysfunction and worsening outcomes

Question 17

Common causes of hypovolemic shock

Answer 17

• Bleeds
• Burns
• Trauma

Question 18

Cardiogenic shock presentation

Answer 18

• Pulmonary edema
• Hypotension
• Weak pulse
• Cool extremities

Question 19

Cardiogenic shock treatment for patients with STEMI

Answer 19

• PCI or CABG
• Fibrinolytic if PCI or CABG cannot be done
• Aortic balloon pump

Question 20

Name the three different types of “Distributive” shock

Answer 20

• Neurogenic
• Anaphylactic
• Septic

Question 21

New scoring system for Sepsis

Answer 21

Must have 2 of the following

• RR > 22
• Altered mental status
• SBP < 100

Question 22

Hour 1 bundle for sepsis patients

Answer 22

• Measure lactate levels
• Blood cultures
• Broad spectrum abx
• Fluids (hypotension or > lactate)
• Vasopressors (MAP < 65)

Question 23

Target of vasopressor therapy

Answer 23

-MAP > 65mmHg

Question 24

Examples of vasopressors

Answer 24

• Norepinephrine
• Vasopressin
• Epinephrine
• Phenylephrine
• Dopamine

Question 25

Which vasopressor is first line

Answer 25

-Norepinephrine

Question 26

Drug class of dobutamine

Answer 26

-Inotropic agent

Question 27

When should abx be administered by

Answer 27

-With in the first hour of septic shock recognition

Question 28

When do we use IV hydrocortisone

Answer 28

-Patients with hemodynamic instability despite fluid and vasopressor therapy

Question 29

When do you initiate insulin therapy

Answer 29

-two blood glucose measurements > 180mg/dL

Question 30

Who gets DVT prophylaxis?

Answer 30

- Everyone - LMWH or UFH - Enoxaparin is preferred

Question 31

Induction medications for intubation

Answer 31

- Etomidate - Ketamine - Midazolam - Propofol

Question 32

Paralytic medications

Answer 32

- Succinylcholine - Rocuronium - Vecuronium

Question 33

General approach to treatment of pain

Answer 33

- Should be individualized - Use minimum effective dose - Administer preemptively

Question 34

What drug class is first line for non-neurologic pain

Answer 34

- IV opioids | ex. fentanyl, morphine, hydromorphone

Question 35

Daily sedation interruption purpose

Answer 35

- Allows for assessment of neurologic function | - May prevent drug accumulation and overdose

Question 36

What are the monitoring parameters for daily sedation interruption

Answer 36

3/4 of the following - Open eyes - Maintain eye contact - Squeeze hand, stick out tongue - Wiggle toes

Question 37

Benzos or non-benzos?

Answer 37

-Non benzos are preferred over benzos

Question 38

List two benzos commonly used

Answer 38

- Midazolam | - Lorazepam

Question 39

List two non benzos commonly used

Answer 39

- Propofol | - Precedex

Question 40

Where does propylene glycol toxicity come from?

Answer 40

-Diluent in parenteral lorazepam formulations