Shock + syncope

Question 1

Shock is determined by

Answer 1

low CO or low SVR

Question 2

What does this indicate:
Heart cannot pump enough blood to meet metabolic demands of the body–

Cold, clammy, cyanosis, AMS
Elevated JVP
Respiratory distress

Answer 2

cardiogenic shock

Question 3

Cardiogenic shock is caused by

Answer 3

Intracardiac causes of cardiac pump failure → reduced CO
Cardiomyopathic (MI, HF), arrhythmic, mechanical causes

Vasoconstriction and LOW CO

Question 4

What do these diagnostics indicate:
Cardiac index < 2.2L/min/m (CO/BSA)
UO <.5 ml/kg/hr
Hypotension:
SBP<90
MAP<65-70
Decrease in SBP >40
Drop in SBP >10-20 and pulse increase >15 = vascular depletion
Lactic acid >1.5mm/lt
High cardiac enzymes, BNP

Answer 4

cardiogenic shock

Question 5

What is diagnostic for cardiogenic shock?

Answer 5

TTE
Decrease in LV contractility but LV itself is full + dilated (can’t push out volume)
PCWP>15

Question 6

What is the first thing you do with a patient with shock?

Answer 6

ABCs + establish monitoring
Cardiac monitor w/ BP cuff
ABGs repeated
Central cath/swan-ganz for detailed monitor

VIP treatment – evaluate whether you need to:
Ventilate (O2)
Infuse (IV fluid resuscitation)
Pump (vasoactive agents)

Question 7

______ often initial DOC in cardiogenic, septic, + hypovolemic shock

Answer 7

norepinephrine

Question 8

_____ first line in cardiogenic shock with low CO and mainted BP

Answer 8

dobutamine

Question 9

Do you give fluids to cardiogenic shock patients?

Answer 9

Yes, but in small increments. If they are overloaded, they will not benefit

Question 10

If your patient has cardiogenic shock from an MI, consider –

Answer 10

immediate percutaneous coronary revascularization when MI is recognized
Balloon pump/ECMO for BP support
Blood circulatory devices
Transcutaneous/transvenous pacemaker
Urgent hemodialysis/filtration for kidney injury

Question 11

Medications for shock include

Answer 11

Vasoactive therapy
Steroids
Antibiotics
Sodium bicarbonate

Question 12

Only shock associated with high CO and low SVR

Answer 12

distributive shock

Question 13

What type of shock:
Hypotension

Warm extremities in early stages often noted in these patients
SIRS
Tachycardia, AMS

Bounding pulses, flushing → bradycardia (neurogenic)

Answer 13

distributive

Question 14

Severe peripheral vasodilation and maldistribution of blood flow – septic vs non septic (inflammatory, neurogenic, anaphylactic)
MC

Answer 14

distributive

Question 15

What would indicate septic shock?

Answer 15

+ cultures, elevated lactate

Question 16

What would indicate anaphylactic shock?

Answer 16

angioedema, pruritus, hives, HOTN

Question 17

What would indicate hypoadrenal shock?

Answer 17

low glucose, HOTN, refractory to fluids and pressors

Question 18

How do you treat septic shock?

Answer 18

fluids + antibiotics + norepinephrine

Question 19

If a patient remains HOTN with fluids in septic shock, you should

Answer 19

give norepinephrine may be indicated to raise MAP

Question 20

How do you treat anaphylactic shock

Answer 20

airway + epinephrine + antihistamines + steroids, observe

Question 21

How do you treat neurogenic shock?

Answer 21

fluids + pressors + steroids

Question 22

How do you treat hypoadrenal shock?

Answer 22

hydrocortisone IV

Question 23

What does this indicate:
Flattened neck veins, dry mucous membranes, delayed capillary refill, low skin turgor, pale cool and dry extremities and skin

Tachycardia first initial change → HOTN

Generally no respiratory distress

Answer 23

hypovolemic shock

Question 24

Reduced intravascular volume – hemorrhagic (trauma) vs nonhemorrhagic (GI, skin, renal losses)

Answer 24

hypovolemic shock

Question 25

What would be seen on labs with hypovolemic shock?

Answer 25

Elevated lactate, low CO + preload, high SVR Decreased PCWP

Question 26

What would be seen on echo for hypovolemic shock? (differentiate from cardiogenic)

Answer 26

TTE = LV will be small but contractile force present

Question 27

How do you treat hemorrhagic shock?

Answer 27

blood + fluids (crystalloids)

Question 28

How do you treat non-hemorrhagic shock?

Answer 28

fluids

Question 29

Vasopressors indicated if

Answer 29

Continued HOTN Preserved CO After adequate fluid resuscitation like epinephrine, norepinephrine, dopamine, vasopressin, phenylephrine, dobutamine

Question 30

Inotropes if

Answer 30

Low CO High filling pressure

Question 31

What does this indicate Beck’s triad = hypotension, JVD, muffled heart sounds Severe respiratory distress, cool/clammy skin

Answer 31

obstructive shock

Question 32

Due to extracardiac causes of pump failure (pulmonary vascular vs mechanical) like PE, pneumothorax, CHD, aortic dissection

Answer 32

obstructive shock

Question 33

What does this indicate Pneumothorax, PE → bedside US, CT-PA, EKG, CXR, D-dimer, ABGs Increased PCWP

Answer 33

obstructive shock

Question 34

How do you treat obstructive shock

Answer 34

Relieve obstruction + stabilize patient → oxygen + fluids + vasopressors

Question 35

What does this indicate Motionless + limp, cool extremities, weakened pulse + shallow breathing Light-headedness, sense of impending faint Sweating, palpitations, nausea, visual “blurring”, diminution of hearing, pallor

Answer 35

syncope

Question 36

Transient loss of consciousness with loss of postural tone

Answer 36

syncope

Question 37

vasovagal - fear, pain, carotid sinus, defecation/coughing syncope

Answer 37

reflex/vasodepressor

Question 38

postural change in elderly/diabetic, low BV, meds, alcohol syncope

Answer 38

orthostatic

Question 39

arrhythmic like AV block, pause, vtach, bigeminy, SVT, structural disease like AS, HCM syncope

Answer 39

cardiogenic

Question 40

orthostatic syncope is

Answer 40

drop in SBP >20, DBP >10

Question 41

in syncope, important to know

Answer 41

onset, positioning, and detailed HPI, knowing provocative factors

Question 42

PE for syncope must include

Answer 42

Orthostatic vitals FULL cardiac exam Neuro exam EKG

Question 43

Can also consider in syncope to check

Answer 43

Checking glucose Basic labs Tilt table Ambulatory EKG CNS imaging EEG if seizure concern

Question 44

How do you treat syncope?

Answer 44

Treat cause + prodromal symptoms – counterpressure maneuvers like leg crossing, lower body muscle tensing, hand grip, arm tensing Immediate response: assist patient, lay supine, assess VS, observe other signs, call for assistance, attempt to arouse patient