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Flashcards in Shock + Arrhythmias Deck (33):
1

Hemodynamic findings in the different types of shock

(CVP, PCWP, SVR( Hypovolemic - dec, dec, inc Cardiogenic -LVF - norm, incr, incr -RVF - incr, norm, incr -Both - inc, inc, inc Distributive -Early - dec, dec, dec -Late - inc, inc, dec Obstructive - inc, inc, inc

2

Type of shock w/ highest mortality

Cardiogenic - 65-90%

3

Downstream effects of shock for types of shock

all similar - ischemia, decreased perfusion

4

Stages of Shock

Initial - hypoxia, lactic acidosis Compensatory - catecholamine release, cytokine release, hyperventilation Progressive - microsludging, increased blood viscosity, metabolic acidosis, MODs Refractory - irreversible organ and tissue damage, ATP to adenosine

5

Systemic response to shock

Increased CO Tachypnea Decreased renal, GI, UT function Blood shunting to vital organs Vasoconstriction

6

Organs and their damage

Kidney - tubular necrosis Lung - ARDS Liver - elevated enzymes, congestion GI - ischemia, hemorrhage, peritonitis

7

LV myocardial tissue and cardiogenic shock

Loss of >40% of LV tissue = correlates w/ cardiogenic shock development

8

Cardiogenic shock; hemodynamics

Systolic BP of >90mmHg or loss of >30 mmHg Reduced CI Increased PCWP

9

Cardiogenic shock; treatment

If BP <90 mmHg - use positive inotropes to stabilize -Increase filling time -Increase perfusion and coronary perfusion ----Vasopressors - NE, Epi, Vasopressin ----Positive inotropes - dobutamine, dopamine, milrinone ----IABP, assist devices *Use inoconstrictors - NE, Epi, dopamine (NeED

10

Cardiogenic shock; myocardial damage

Decreased CO = tachycardia = increased myocardial O2 demand Increased wall stress Lactic acidosis - damages myocardium ALL COMPENSATORY MECHANISM LEAD TO INCREASED O2 DEMAND AND FURTHER DAMAGE

11

Cardiogenic shock; compensation

SNS activation RAAS activation Overall increase in preload and afterload = increased O2 demand = increased damage and worsening shock

12

Cardiogenic shock; diagnosis

Lactic acid levels - correlate w/ mortality Echo - fast, quick diagnosis

13

Septic shock; stages

SIRS to Sepsis to Severe Sepsis Septic Shock to MODs

14

Septic shock; SIRS

Two of the following criteria -Tachypnea -WBC 12000 -Tachycardia -Hyperthermic or Hypothermic

15

Septic shock; Sepsis criteria

SIRS + presence of an infection

16

Septic shock; Septic shock criteria

Presistent hypotension; SIRS + Infection + Hypotension

17

What is MODs (septic shock)

Multiple organ dysfunction syndrome -Primary - directly injured by infection -Secondary - due to host response to infection; inflammation

18

What is special about septic shock?

All other forms of shock can lead to septic shock

19

Septic shock treatment

Fluid resuscitation: use crystalloids --renal damage --use albumin if high levels of crystalloids are indicated Vasopressors -NE = first choice -add vasopressin if needed Dobutamine - if myocardial dysfunction occurs W/in 3 hours - measure lactate level, empirical Ab therapy, crystalloid if hypotensive or lactate > 4mmol/L W/in 6 hours - apply vasopressors, remeasure lactate

20

Hypovolemic shock; hemorrhagic shock therapy

Volume therapy -crystalloids, albumin, etc. -Use blood products if O2 delivery < O2 need (class III, IV)

21

Anaphylactic shock treatment

Volume therapy - crystalloids Epinephrine

22

What are the supraventricular arrhythmias

Sinus tachycardia Atrial premature beat

SVTs- atrial flutter, atrial fibrillation, paroxysmal SVTs

Paroxysmal SVTs- AVNRT, Atrioventricular reentry tachycardia (WPW and non-WPW)

23

What is sinus tachycardia

Inc SNS/dec PNS = >100 bpm

Normal EKG/waves

24

What is atrial premature beat

-due to automaticity or reentry

-3 or more premature beats = atrial tachycardia

-Abnormal p-wave

25

What is atrial flutter

-reentry - tricuspid annulus circuit

----tricuspid caval isthmus

----counterclockwise -Saw tooth appearance

-Tx

----rate control

----rhythm control

----------Flecainide = paradoxical VT; 1:1 A:V conduction ----------Electric cardioversion

26

What is atrial fibrillation

-multiple reentry circuits and foci - atrial and pulmonary vein

------------chaotic

-Tx

-----anticoagulants - CHA2DS2VASc score

-----Rate control

-----Rhythm control - cardioversion if >48 hours

27

What is AVNRT

-most common paroxysmal SVT -two AV nodal pathways - fast and slow

-two directions

-------down slow + up fast = typical

-------down fast + up slow = atypical

-Tx

------Acute - adenosine, valsalva maneuver, rate control ------Class I and III rhythm control

------Abalation of slow pathway; removal of fast = AV block

28

What is atrioventricular reentry tachycardia

-Presence of an accessory pathway (fast)

------anterograde = WPW

------retrograde = non-WPW

29

What is WPW

-Sinus rhythm

------Early ventricular depolarization through accessory path = disorganized, wide QRS

------Late ventricular depolarization through AV node = delta wave

-Tx - DO NOT USE RATE CONTROL

-------Acute = cardioversion

-------IV amiodarone + procainamide

-------Catheter ablation of accessory pathway

30

What is PVC

-Ectopic ventricular foci

-Wide QRS, no p-wave or retrograde p-wave

->20% PVCs = systolic dysfunction

-Tx = observation or beta-blocker

31

What is VT

-3 or more PVCs in series

--------sustained = >30 seconds

--------unsustained = <30 seconds

-Wide QRS + >100 bpm

-Torsades de Pointes = polymorphic VT

--------Acute = Mg, isoproterenol (shortens QT)

--------Chronic = beta-blocker, ICD

-Tx

-------Cardioversion; sedate if patient is stable

 

32

What is VFib Tx

-Tx - immediate defibrillation

---------IV amiodarone

33

SNS/PNS effects on ANS regulation

 

SNS - increase phase 4 slope, decreased threshold

 

PNS - decreased phase 4 slope, increased threshold, decreased diastolic membrane potential

 

*PNS dominates at rest