Shock II

Question 1

What is shock?

Answer 1

State of inadequate tissue perfusion leading to hypoxia and cell death

Question 2

What causes septic shock?

Answer 2

Infection –> Bacteremia –> SIRS/sepsis –> shock

Infection: Inflammatory response to microorganisms or invasion of sterile host tissue

Bacteremia: Viable bacteria in the blood

SIRS/Sepsis: Systemic inflammatory response to infection (and other insults)

Shock: Hypoperfusion causing hypoxia and cell death

Question 3

What are the SIRS/Sepsis criteria?

Answer 3

T > 38degC

RR > 20

HR > 90

WBC > 12

–> easy to have these SIRS criteria for other reasons, so context is key

Question 4

What is the mortality of septic shock?

Answer 4

20-80% mortality

–> highly lethal

Question 5

Who is at risk of septic shock?

Answer 5

Anyone can get it

Most at risk: Immunocompromised
DM
Medicated (transplant/RA)
IVDA
Hospitalized
Asplenic
ESRD

Extremes of Ages

Question 6

What is the treatment for septic shock?

Answer 6

1. ANTIBIOTICS!

as well as Early goal directed therapy
–> Goals are to treat and normalize:
Central venous pressure with fluids
Mean Arterial Pressure with vasoactive agents
ScvO2 with transfusion of RBCs until HCT > 30%
–> in that order

Question 7

Who is at risk of hemorrhagic Shock?

Answer 7

Anyone can get it

Young are more at risk due to high-risk behavior

Traumatic and Atraumatic causes

Question 8

What is the treatment for hemorrhagic shock?

Answer 8

Treatment Basics:
Find the bleeding
Stop the bleeding
Reverse coagulopathies (ASA, warfarin)
Replace blood and support patients

Hypotensive resuscitation for traumas

Question 9

What are the most common causes of anaphylaxis?

Answer 9

Antibiotics (esp. B-lactam)

Insects (hymenoptera)

Food (shellfish, nuts)

Question 10

What is anaphylaxis?

Answer 10

Severe systemic hypersensitivity that may include hypotension or airway compromise

–> IgE-dependent mast cell, basophil release

Question 11

What is an anaphylactoid response?

Answer 11

Non-IgE mediated

• Same final common pathway as anaphylaxis
• No sensitizing exposure required

Question 12

What are clinical features of anaphylaxis?

Answer 12

Angioedema

Diffuse Urticaria

Others: abdominal pain, N/V/D, Bronchospasm, rhinorrhea, conjunctivitis

Hypotension

Question 13

What is the immediate treatment of anaphylaxis?

Answer 13

Epinephrine

–> NO absolute contraindications

Question 14

What are long-term treatments for anaphylaxis (after epi)?

Answer 14

• Airway - intubate sooner than later
• Fluid resuscitation for hypotension
• Steroids
• Antihistamines (H1 & H2)
• Tx bronchospasm
• Glucagon (if on B-blockers because they prevent epi from working well)

Question 15

What causes neurogenic shock?

Answer 15

• *- Disruption of sympathetic outlfow**
• -> blunt trauma - usually C-spine
• -> Sympathetic roots T1-L2
• -> Unopposed vagal tone

Leads to Hypotension, bradycardia

- Not spinal shock (total loss of spinal reflex activitiy at/below injury level)

Question 16

How do you treat neurogenic shock?

Answer 16

Assume hemorrhage and treat accordingly (even w/bradycardia)

Cord damage is done - but must prevent secondary injuries (lack of glucose, O2, etc)

Provide fluids and pressors (phenylephrine)

Question 17

What is cardiogenic shock? What causes it?

Answer 17

Decreased cardiac output despite aequate volume - tissue hypoperfusion

–> common
Usually results from AMI

Other causes:
Chordae rupture
Decompensated CHF
Myocarditis
Sepsis
Toxins

Question 18

How is cardiogenic shock diagnosed?

Answer 18

EKG

Echo

CXR

labs

Monitoring

–> all trying to pinpoint the cause of the shock

Question 19

How is cardiogenic shock treated?

Answer 19

ABC support and varies based on cause:

Reperfusion of MI (thrombolytics, PCI)
Intraaortic Balloon pump
Tox treatment

Question 20

Why are pressors used?

Answer 20

Although they are helpful in the Tx of anaphylaxis, pressors otherwise do not improve meaningful outcomes

• May help return of spontaneous circulation (ROSC)
• May help intact neurological survival

But do not treat underlying derangements (except in anaphylaxis)

Question 21

What pressors are used for what type of shock?

Answer 21

Norepi (alpha): Sepsis

Epi (Beta>alpha): Anaphylaxis

Phenylepherine (alpha): 2nd line

Dobutamine (beta): cardiogenic

Dopamine (beta): Multiple