Shock, C26 P164-170 Flashcards Preview

Section I, Surgical Recall Sixth Edition > Shock, C26 P164-170 > Flashcards

Flashcards in Shock, C26 P164-170 Deck (51):
1

What is the definition of shock?
P164

Inadequate tissue perfusion

2

What are the different types (5)?
P164

Hypovolemic
Septic
Cardiogenic
Neurogenic
Anaphylactic

3

What are the signs of shock?
P165

Pale, diaphoretic, cool skin
Hypotension, tachycardia, tachypnea
↓ mental status and pulse pressure
Poor capillary refill
Poor urine output

4

What are the best indicators of tissue perfusion?
P165

Urine output, mental status

5

What lab tests help assess tissue perfusion?
P165

Lactic acid (elevated with inadequate tissue perfusion), base deficit, pH from ABG (acidosis associated with inadequate tissue perfusion)

6

HYPOVOLEMIC SHOCK
What is the definition?
P165

Decreased intravascular volume

7

HYPOVOLEMIC SHOCK
What are the common causes?
P165

Hemorrhage
Burns
Bowel obstruction
Crush injury
Pancreatitis

8

HYPOVOLEMIC SHOCK
What are the signs?
P165

Early—Orthostatic hypotension, mild
tachycardia, anxiety, diaphoresis,
vasoconstriction (decreased pulse pressure
with increased diastolic pressure)
Late—Changed mental status, decreased BP,
marked tachycardia

9

HYPOVOLEMIC SHOCK
What are the signs/ symptoms with:
Class I hemorrhage (<15% or 750 cc blood loss)?P165

Mild anxiety, normal vital signs

10

HYPOVOLEMIC SHOCK
What are the signs/ symptoms with:
Class II hemorrhage (15%–30% or 750–1500 cc blood loss)?
P165

Normal systolic BP with decreased pulse
pressure, tachycardia, tachypnea, anxiety

11

HYPOVOLEMIC SHOCK
What are the signs/ symptoms with:
Class III hemorrhage (30%–40% or 1500–2000 cc blood loss)?
P165

Tachycardia (heart rate >120), tachypnea
(respiratory rate >30), decreased
systolic BP, decreased pulse pressure,
confusion

12

HYPOVOLEMIC SHOCK
What are the signs/ symptoms with:
Class IV hemorrhage ( >40% or >2000 cc
blood loss)?
P166

Decreased systolic BP, tachycardia (heart
rate >140), tachypnea (respiratory rate >35), decreased pulse pressure, confused
and lethargic, no urine output

13

HYPOVOLEMIC SHOCK
What is the treatment?
P166

1. Stop the bleeding
2. Volume: IVF (isotonic LR) then blood
products as needed

14

HYPOVOLEMIC SHOCK
How is the effectiveness of treatment evaluated:
Bedside indicator?
P166

Urine output, BP, heart rate, mental status, extremity warmth, capillary refill, body temperature

15

HYPOVOLEMIC SHOCK
How is the effectiveness of treatment evaluated:
Labs?
P166

pH, base deficit, and lactate level

16

HYPOVOLEMIC SHOCK
What usually causes failure of resuscitation?
P166

Persistent massive hemorrhage, requiring
emergent surgical procedure

17

HYPOVOLEMIC SHOCK
Why does decreased pulse pressure occur with early hypovolemic shock?
P166

Pulse pressure (systolic–diastolic BP) decreases because of vasoconstriction, resulting in an elevated diastolic BP

18

HYPOVOLEMIC SHOCK
What is the most common vital sign change associated with early hypovolemic shock?
P166

Tachycardia

19

HYPOVOLEMIC SHOCK
What type of patient does not mount a normal
tachycardiac response to hypovolemic shock?
P166

Patients on ℬ-blockers, spinal shock
(loss of sympathetic tone), endurance athletes

20

HYPOVOLEMIC SHOCK
Should vasopressors be used to treat hypovolemic shock?
P166

No

21

HYPOVOLEMIC SHOCK
Should patients with hypovolemic shock be put
into the Trendelenburg position?
P166

No

22

SEPTIC SHOCK
What is the definition?
P167

Documented infection and hypotension

23

SEPTIC SHOCK
What is the specific etiology?
P167

Most common—gram-negative septicemia
Less common—gram-positive septicemia,
fungus

24

SEPTIC SHOCK
What factors increase the susceptibility to septic
shock?
P167

Any mechanism that increases susceptibility to infection (e.g., trauma, immunosuppression, corticosteroids, hematologic disease, diabetes)

25

SEPTIC SHOCK
What complications are major risks in septic shock?
P167

Multiple organ failure, DIC, death

26

SEPTIC SHOCK
What are the signs/symptoms?
P167

Initial—vasodilation, resulting in warm skin and
full pulses; normal urine output
Delayed—vasoconstriction and poor urine
output; mental status changes; hypotension

27

SEPTIC SHOCK
What percentage of blood cultures is positive in
patients with bacterial septic shock?
P167

Only about 50%!

28

SEPTIC SHOCK
What are the associated findings?
P167

Fever, hyperventilation, tachycardia

29

SEPTIC SHOCK
What are the associated lab findings?
P167

Early—hyperglycemia/glycosuria, respiratory
alkalosis, hemoconcentration, leukopenia
Late—leukocytosis, acidosis, elevated lactic acid
(Note: Identifying organism is important
to direct treatment/antibiotics)

30

SEPTIC SHOCK
What is the treatment?
P167

1. Volume (IVF)
2. Antibiotics (empiric, then by cultures)
3. Drainage of infection
4. Pressors PRN
5. Zygris® PRN

31

SEPTIC SHOCK
What is Zygris®?
P168

Activated protein C, shown to decrease mortality in septic shock and multiple organ failure

32

CARDIOGENIC SHOCK
What is the definition?
P168

Cardiac insufficiency; left ventricular failure (usually), resulting in inadequate tissue perfusion

33

CARDIOGENIC SHOCK
What are the causes?
P168

MI, papillary muscle dysfunction, massive cardiac contusion, cardiac tamponade,
tension pneumothorax, cardiac valve failure

34

CARDIOGENIC SHOCK
What are the signs/symptoms on exam?
P168

Dyspnea
Rales
Pulsus alternans (increased pulse with greater
filling following a weak pulse)
Loud pulmonic component of S(2)
Gallop rhythm

35

CARDIOGENIC SHOCK
What are the associated vital signs/parameters?
P168

Hypotension, decreased cardiac output,
elevated CVP/wedge pressure, decreased
urine output (low renal blood flow), tachycardia (possibly)

36

CARDIOGENIC SHOCK
What are the signs on CXR?
P168

Pulmonary edema

37

CARDIOGENIC SHOCK
What is the treatment?
P168

Based on diagnosis/mechanism:
1. CHF: diuretics and afterload reduction
(e.g., ACE inhibitors), with or without pressors
2. Left ventricular failure (MI):
pressors, afterload reduction

38

CARDIOGENIC SHOCK
What are the last resort support mechanisms?
P168

Intra-aortic balloon pump (IABP),
ventricular assist device (VAD)

39

NEUROGENIC SHOCK
What is the definition?
P168

Inadequate tissue perfusion from loss of
sympathetic vasoconstrictive tone

40

NEUROGENIC SHOCK
What are the common causes?
P168

Spinal cord injury:
- Complete transection of spinal cord
- Partial cord injury with spinal shock
- Spinal anesthesia

41

NEUROGENIC SHOCK
What are the signs/symptoms?
P169

Hypotension and bradycardia, neurologic deficit

42

NEUROGENIC SHOCK
Why are heart rate and BP decreased?
P169

Loss of sympathetic tone
(but hypovolemia [e.g., hemoperitoneum]
must be ruled out)

43

NEUROGENIC SHOCK
What are the associated findings?
P169

Neurologic deficits suggesting cord injury

44

NEUROGENIC SHOCK
What MUST be ruled out in any patient where spinal shock is suspected?
P169

Hemorrhagic shock!

45

NEUROGENIC SHOCK
What is the treatment?
P169

IV fluids (vasopressors reserved for hypotension refractory to fluid resuscitation)

46

NEUROGENIC SHOCK
What percentage of patients with hypotension and spinal neurologic deficits have hypotension of purely neurogenic origin?
P169

About 67% (two thirds) of patients

47

NEUROGENIC SHOCK
What is spinal shock?
P169

Complete flaccid paralysis immediately
following spinal cord injury; may or may
not be associated with circulatory shock

48

NEUROGENIC SHOCK
What is the lowest reflex available to the examiner?
P169

Bulbocavernous reflex: checking for
contraction of the anal sphincter upon
compression of the glans penis or clitoris

49

NEUROGENIC SHOCK
What is the lowest level voluntary muscle?
P169

External anal sphincter

50

NEUROGENIC SHOCK
What are the classic findings associated with spinal cord shock?
P169

Hypotension
Bradycardia or lack of compensatory
tachycardia

51

MISCELLANEOUS
What is the acronym for treatment options for
anaphylactic shock?
P169

“BASE”:
Benadryl
Aminophylline
Steroids
Epinephrine