Shock + RUSH Protocol

Question 1

State of inadequate tissue perfusion leading to hypoxia and cell death

Answer 1

Shock

Question 2

Inflammatory response to microorganisms, or invasion of sterile host tissue

Answer 2

Infection

Question 3

Viable bacteria in the blood

Answer 3

Bacteremia

Question 4

T > 38 or < 36

HR > 90

RR > 20

WBC > 12,000 or < 4,000 or > 10% bands

PaCO₂ < 35

Answer 4

SIRS

(must meet at least 2 of the criteria)

Question 5

SIRS

+

Source of Infection

Answer 5

Sepsis

Question 6

Hypotension

+

Severe Sepsis

aka hypoperfusion causing hypoxia and cell death

Answer 6

Septic Shock

Severe Sepsis = sepsis + lactic acidosis, SBP < 90 or a drop > 40

Question 7

Who gets septic shock?

Answer 7

Anyone can

Increased risk for immunocompromised (DM, Medicated, Asplenic, etc.)

Increased risk for those at “extremes of age”

Question 8

Tx for septic shock

Answer 8

Abx (early goal directed therapy)

+

Fluid (most often crystalloid)

Question 9

4 Classic Types of Shock

Answer 9

1. Hypovolemic (secondary to hemorrhage or loss of other bodily fluid)
2. Cardiogenic
3. Distributive (sepsis, anaphylaxis, neurogenic shock)
4. Obstructive (pericardial tamponade, tension pneumo, PE)

Question 10

Classes of Hemorrhagic Shock

Answer 10

Class I-IV

You can lose up to 30% of your blood volume (Class II) before your BP begins to decrease (Class III)

Class IV: >2000 ml blood loss (40% or more),

HR > 140, RR > 35

Question 11

Tx for Hemorrhagic Shock

Answer 11

Find the bleeding
Stop the bleeding

*Reverse coagulopathies (ASA, Warfarin)

Replace blood and support patients

*Mainly applies to older patients

Question 12

Which areas of the body are you most likely to bleed to death from?

Answer 12

Abdomen

Femur/Thigh

Pelvis

Chest

Externally

Question 13

When do you start hypotensive resuscitation for someone in hemorrhagic shock?

Answer 13

If their BP drops below 80

Question 14

Difference between hypotensive resuscitation and tx for hypovolemic shock

Answer 14

Hypotensive resuscitation = give blood

Hypovolemic shock = give crystalloid

Question 15

Risk factors for anaphylaxis

Answer 15

Poorly controlled asthma

Previous anaphylaxis

Previous exposure to sensitizing agent

Question 16

Most common causes of anaphylaxis

Answer 16

Antibiotics (esp. B-lactam): 400-800 deaths

Insects: < 100 deaths

Food: 11 deaths

Question 17

Severe systemic hypersensitivity that may include hypotension or airway compromise

Answer 17

Anaphylaxis

IgE-dependent mast cell, basophil release

Question 18

Anaphylactoid

Answer 18

Non-IgE mediated

Same final common pathway as anaphylaxis

No sensitizing exposure required

Question 19

Primary Tx for anaphylaxis

Answer 19

Epi (no absolute contraindications)

0.1 mg IV or 0.3-0.5 mg IM (i.e., give less potent when IV)

Question 20

Stabilizing Treatment for Anaphylaxis

Answer 20

Intubate sooner rather than later

Fluid resuscitation for hypotension

Steroids

Antihistamines (H1 & H2)

Tx bronchospasm

Glucagon (if on β-blockers)

Question 21

Neurogenic Shock

Answer 21

Disruption of sympathetic outflow:

Blunt trauma (usually C-spine)

Sympathetic roots T1-L2

Unopposed vagal tone

Hypotension + Bradycardia

Question 22

Neurogenic Shock vs Spinal Shock

Answer 22

Spinal shock = total loss of spinal reflex activity AT AND BELOW injury level

Question 23

Tx of Neurogenic Shock

Answer 23

Assume hemorrhage (even w/ bradycardia)

Stop secondary injury

Fluids

Pressors

Question 24

Cardiogenic Shock

Answer 24

Decreased cardiac output despite adequate volume (tissue hypoperfusion)

Usually results from AMI

Question 25

Diagnosis of Cardiogenic Shock

Answer 25

EKG Echo CXR Labs Monitoring

Question 26

Tx of Cardiogenic Shock

Answer 26

ABC support Reperfusion of MI (thrombolytics, PCI) Intraaortic Balloon Pump

Question 27

Only type of shock where CVP (central venous pressure is HIGH)

Answer 27

Cardiogenic DO NOT give fluids "Big toe" should feel cool

Question 28

Only type of shock that you give Blood

Answer 28

Hemmorhagic CVP should be low "Big toe" should feel cool

Question 29

What types of shock will make your "big toe" (extremities) warm?

Answer 29

Septic Anaphylactic (normal CVP) Neurogenic

Question 30

When are pressors helpful?

Answer 30

Typically, they do not improve meaningful outcomes Exception = anaphylaxis (i.e., EPI)

Question 31

Norepinepherine | (Levophed)

Answer 31

Pressor used for sepsis

Question 32

Dobutamine

Answer 32

Pressor used for cardiogenic shock (strict β stimulant so watch out for drop in BP via vasodilation)

Question 33

85 y.o. woman found unresponsive beside bed Only available history = Alzheimer's HR 115, BP 70, PO₂ 88%, Glucose 170 What Dx is most likely?

Answer 33

Septic Shock KEY FINDINGS: extremities are cool, bruising/crepitus at pelvis, Hgb low, and CVP low ...change diagnosis to Hemorhagic shock (pelvic fx)

Question 34

What 3 categories does RUSH access?

Answer 34

**Pump** (Estimate of EF, Tamponade, PE) **Tanks** (IVC, eFast, Pulmonary) **Pipes** (Aorta, DVT)

Question 35

Which transducers are used during the FAST exam?

Answer 35

**Phased array** for cardiac (small footprint is good for b/w ribs) **Curvilinear array** for abdomen (45x as many crystals = higher quality, but more rib shadows)

Question 36

What 3 things are you looking for with the heart on ultrasound?

Answer 36

**Contractility** **Pericardial Effusion/Tamponade** **RV strain** (indictive of PE)

Question 37

What are the views of the heart on ultrasound?

Answer 37

Parasternal (short/long) Subxiphoid Apical 4 Chamber

Question 38

When do you want to monitor the IVC more closely on ultrasound?

Answer 38

During volume resuscitation or When the following are suspected: Tamponade, PE, Tension pneumo (all would show abnormally large IVC)

Question 39

Beside the heart, what are the other 3 views for the FAST exam

Answer 39

RUQ, LUQ, Pelvic

Question 40

How to look for a tension pneumo on ultrasound

Answer 40

Use high frequency **linear array** Look for abscence of sliding (use M mode if not sure)

Question 41

What is a "comet tail" on ultrasound

Answer 41

An artifact created by fluid in the lungs (indicating pulmonary edema)

Question 42

AAA on ultrasound

Answer 42

Abdominal Aortic Aneurysm Look for aorta that is **\> 3 cm (abnormal)** Must measure from **outer wall to outer wall** Remember: 2/3 of AAA's rupture retroperitoneally (meaning they will not show up on US when doing an eFAST, must rely on measurement)

Question 43

Pericardial effusion vs Pleural effusion Difference on ultrasound

Answer 43

Pericardial = "rat tail" A person can have both

Question 44

PATCH MD

Answer 44

**P: pulmonary embolism** A: acidosis **T: tension pneumo** **C: cardiac tamponade** **H: hyopvolemia, hypoxia**, hypothermia, hypo/hyperkalemia **M: MI** D: drugs **Ultrasound can diagnosis everything in bold**