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Flashcards in Shock + RUSH Protocol Deck (44):
1

State of inadequate tissue perfusion leading to hypoxia and cell death

Shock

2

Inflammatory response to microorganisms, or invasion of sterile host tissue

Infection

3

Viable bacteria in the blood

Bacteremia

4

T > 38 or < 36

HR > 90

RR > 20

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

PaCO2 < 35

SIRS

(must meet at least 2 of the criteria)

5

SIRS

+

Source of Infection

Sepsis

6

Hypotension

+

Severe Sepsis

 

aka hypoperfusion causing hypoxia and cell death

Septic Shock

 

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

7

Who gets septic shock?

Anyone can

 

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

 

Increased risk for those at "extremes of age"

8

Tx for septic shock

Abx (early goal directed therapy)

+

Fluid (most often crystalloid)

9

4 Classic Types of Shock

  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)

10

Classes of Hemorrhagic Shock

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

11

Tx for Hemorrhagic Shock

Find the bleeding
Stop the bleeding

*Reverse coagulopathies (ASA, Warfarin)

Replace blood and support patients

 

*Mainly applies to older patients

12

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

Abdomen

Femur/Thigh

Pelvis

Chest

Externally

13

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

If their BP drops below 80

14

Difference between hypotensive resuscitation and tx for hypovolemic shock

Hypotensive resuscitation = give blood

 

Hypovolemic shock = give crystalloid

15

Risk factors for anaphylaxis

Poorly controlled asthma

Previous anaphylaxis

Previous exposure to sensitizing agent

16

Most common causes of anaphylaxis

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

Insects: < 100 deaths

Food: 11 deaths

17

Severe systemic hypersensitivity that may include hypotension or airway compromise

Anaphylaxis

 

IgE-dependent mast cell, basophil release

18

Anaphylactoid

Non-IgE mediated

Same final common pathway as anaphylaxis

No sensitizing exposure required

19

Primary Tx for anaphylaxis

Epi (no absolute contraindications)

 

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

20

Stabilizing Treatment for Anaphylaxis

Intubate sooner rather than later

Fluid resuscitation for hypotension

Steroids

Antihistamines (H1 & H2)

Tx bronchospasm

Glucagon (if on β-blockers)

21

Neurogenic Shock

Disruption of sympathetic outflow:

Blunt trauma (usually C-spine)

Sympathetic roots T1-L2

Unopposed vagal tone

Hypotension + Bradycardia 

22

Neurogenic Shock vs Spinal Shock

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

23

Tx of Neurogenic Shock

Assume hemorrhage (even w/ bradycardia)

Stop secondary injury

Fluids

Pressors 

24

Cardiogenic Shock

Decreased cardiac output despite adequate volume (tissue hypoperfusion)

Usually results from AMI

25

Diagnosis of Cardiogenic Shock

EKG

Echo

CXR

Labs

Monitoring

26

Tx of Cardiogenic Shock

ABC support

Reperfusion of MI (thrombolytics, PCI)

Intraaortic Balloon Pump

27

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

Cardiogenic

DO NOT give fluids

"Big toe" should feel cool

28

Only type of shock that you give Blood

Hemmorhagic 

CVP should be low

"Big toe" should feel cool

29

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

Septic

Anaphylactic (normal CVP)

Neurogenic

30

When are pressors helpful?

Typically, they do not improve meaningful outcomes

 

Exception = anaphylaxis (i.e., EPI)

31

Norepinepherine

(Levophed)

Pressor used for sepsis

32

Dobutamine

Pressor used for cardiogenic shock

(strict β stimulant so watch out for drop in BP via vasodilation)

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?

Septic Shock

 

KEY FINDINGS: extremities are cool, bruising/crepitus at pelvis, Hgb low, and CVP low

 

...change diagnosis to Hemorhagic shock (pelvic fx)

34

What 3 categories does RUSH access?

Pump (Estimate of EF, Tamponade, PE)

Tanks (IVC, eFast, Pulmonary)

Pipes (Aorta, DVT)

35

Which transducers are used during the FAST exam?

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)

36

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

Contractility

Pericardial Effusion/Tamponade

RV strain (indictive of PE)

37

What are the views of the heart on ultrasound?

Parasternal (short/long)

Subxiphoid

Apical 4 Chamber

38

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

During volume resuscitation

or 

When the following are suspected:

Tamponade, PE, Tension pneumo (all would show abnormally large IVC)

39

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

RUQ, LUQ, Pelvic

40

How to look for a tension pneumo on ultrasound

Use high frequency linear array

Look for abscence of sliding (use M mode if not sure)

 

41

What is a "comet tail" on ultrasound

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

42

AAA on ultrasound

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)

43

Pericardial effusion

vs

Pleural effusion

 

Difference on ultrasound

Pericardial = "rat tail"

 

A person can have both

44

PATCH MD

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