Test 2: Shock

Question 1

MAP

Answer 1

map = DP + 1/3 (SP-DP)

or

map = DP + 1/3(PP)

Normal Map: 60-75mm Hg

Question 2

CO equation

Answer 2

CO = HR x Stroke Volume

Normal = 4-8 L/min

Total volume perfused per minute

Question 3

Pulse Pressure

Answer 3

systolic - diastolic

Question 4

Factors Affecting BP

Answer 4

1) CO, SV, HR (Increase in CO = increase in BP)
2) Viscosity (how thick/thin blood is)
3) Vascular Bed (vasodilation vs vasoconstriction)

Question 5

Shock

Answer 5

Abnormal metabolism
Systemic Reaction
Syndrome/condition that takes predictable pathway

Life threatening condition due to inadequate tissue perfusion causing possible cell dysfunction, cell death and organ failure

Body tries to compensate

Treatment goal is to intervene in first 1-2 hours before cellular damage occurs

Question 6

Pathophysiology of Shock

Answer 6

Compensation:

Decrease in BP/MAP
Brain activates SNS to release catecholines - epi/norepi
Vasoconstriction
MAP/BP Increase

Sustained
BP Decreases
BF Decreases (NO O2)
Hypoxemia
Ischemia
Cell Necrosis
LACTIC ACID
Tissue Injury/Death

(repeats LA/Tissue injury)

Organ Failure

Question 7

Hypovolemic Shock: What is it? What Causes it?

Answer 7

What is it:

Cold shock
LOW BLOOD VOLUME (Decrease BV = Decrease CO, BP/MAP)
Hypoxemia due to decreased perfusion
LOW FLUID VOLUME

Caused By:

Absolute loss/hemorrhagic - trauma, gi bleed, child birth
Relative/nonhemorrhagic - fluid shift from ascites/edema, burns, severe dehydration (vomiting, diarrhea, burns)

Common S/Sx:

Hypotension (<80 systolic) - cold, clammy skin
Tachycardia (>100bpm)
LOW central venous pressure (<2mm Hg)
LOW UOP (<30ml/hr)

Common Interventions:

Priority is hemodynamic stability, increase fluid volume

Lower head of bed to improve blood return - NEVER high fowler/”put the head low in hypovolemic/hypotension”
IV Normal Saline BEFORE vasopressors
Vasopressor - norepinephrine/dopamine

Put SPO2 on forehead

Question 8

Normal Central Venous Pressure

Answer 8

Normal = 2-6mm Hg
< 2 = threw - need fluid
> 6 = fix - too much fluid

Question 9

Hypovolemic Lab Profile: pH

Answer 9

7.35-7.45

With hypovolemia we suspect this to decrease and be ACIDIC

Question 10

Hypovolemic Lab Profile: PaCO2

Answer 10

35-45

With hypovolemia this should be higher

Question 11

Hypovolemic Lab Profile: PaO2

Answer 11

80-100

Hypovolemia: Decrease

Question 12

Hypovolemic Lab Profile: Lactic Acid

Answer 12

3-7mg
0.3-0.8

Hypovolemia: Increase

Question 13

Hypovolemic Lab Profile: HCT

Answer 13

F 37-47
M 42-52

Increase with fluid shift, dehydration
Decrease hemorrhage

Question 14

Hypovolemic Lab Profile: HgB

Answer 14

F 12-16
M 14-18

Increase fluid shift, dehydration
Decrease hemorrhage

Question 15

Hypovolemic Lab Profile: K

Answer 15

3.5-5

Increase dehydration, acidosis

Question 16

Cardiogenic: What is it? Common Causes? S/Sx, Key Treatments

Answer 16

What is it?

• Cold shock
• There is ENOUGH blood but heart not able to pump causing low BP and fluid build up in lungs
• Decrease CO = Decrease BP/MAP

Causes:

CHF
MI
Electrical burn
Dysrhythmia
Hypoglycemia
Acidosis

S/Sx:

JVD
Chest pain
Oliguria (<30ml/hr)
Confusion, Agitation due to decrease BF to brain

Treatment:
- Digoxin for more forceful contraction (HF)
- Dopamine to increase HR, BP (can cause tachycardia/arrythmia

Question 17

Obstructive Shock: What is it? Common Cause

Answer 17

What is it?

Cold Shock
Physical obstruction preventing blood from moving forward (similar to cardiogenic)
Poor chest recoil - Decrease CO = Decrease BP/MAP

Common Cause:

Cardiac Tamponade (Fluid in heart)
Trauma
Scarring outside chest
Scarring/burns
Pneumothorax

Question 18

Warm Shock

Answer 18

Caused by inflammatory response which causes vasodilation

Question 19

Cold Shock

Answer 19

Causes vasoconstriction and cold/clammy

Question 20

Distributive Shock:

Answer 20

Warm Shock b/c vasodilation
Inflammatory response through entire body

Types:

Neurogenic
Chemical - anaphylaxis or sepsis

Question 21

Neurogenic Shock: What is it? Caused by? Monitor for?

Answer 21

SCI to T6 or higher
Monitor for s/sx of autonomic dysreflexia

Question 22

Chemical Shock: Anaphylaxis - what is it? Key treatment?

Answer 22

What is it?

• Severe allergic Reaction
• Allergy introduced - mast and basophils cells released and produce histamine system wide - decreased tissue perfusion

Key Treatments:
#1 Epinephrine (1st) for 1st sign
#2 Diphydreomine (benadryl)
#3 Albuterol

Question 23

What does histamine cause?

Answer 23

Vasodilation ( decrease CO = decrease bp/map)
Increased HR
Increase capillary permeability causing fluid shift to 3rd space/swelling

Question 24

Sepsis Shock: What is it? S/Sx? Treatment Priorities?

Answer 24

1 Fluid Replacement

Caused by bacteria, widespread infection or sepsis

Key S/sx:
- Hypotension (<80 systolic, cold clammy skin)
- gi upset
- AMS
- HIGH WBC >10,000
- HIGH TEMP to low temp <96F

Treatment:

#2 Culture
#3 Broad Spectrum Antibiotic
#4 Vasopressors
#5 Sedation to decrease metabolic demand
#6 Medication to prevent ulcer - PPI, H2 block

Question 25

Initial Stage of Shock: Patho, S/Sx

Answer 25

Patho Decrease in map by 10 mm Hg BELOW baseline Anaerobic metabolism w/o S/Sx "I'm not getting enough pressure" which turns on baroreceptors, brain, SNS/catecholines epi/norepi, vasoconstriction and increase BP S/Sx: Increase Diastolic BP (systolic normal) NARROW PP Increase HR Increase RR Dizziness Restlessness Pallor Common Interventions: - ABC - O2 via nasal canula

Question 26

Compensatory Stage of Shock

Answer 26

- Non-progressive - Decrease MAP by 10-15mm HG below baseline - Medical intervention needed to save life Patho: SNS Kicks on to increase VS, RAAS kicks on Decrease BP --> Shunting BF to vital organs --> kidney --> RAAS --> vasoconstriction -->reuptake H20/NA --> UO decrease, Na/K increase S/Sx: Decrease UO (declining) Increase HR Increase RR Decrease SpO2 Increase K, NA Hypoactive BS Increase Azotemia Nausea

Question 27

Progressive Stage of Shock

Answer 27

Decrease MAP by >20 below baseline Lactic acid >3 is worrisome LA damaging healthy tissue Pathophysiology Decrease BF --> ischemia --> tissue necrosis --> increase LA --> tissue injury --> increase LA --> Mods S/Sx Metabolic acidosis Absent BS Cheyene Stokes - fast/shallow breathing Anuria Increase LA (anything >3 is worrisome) Decrease SpO2 Increase liver enzymes

Question 28

Refractory Shock: what is it? S/Sx? Pathophysiology

Answer 28

Poor prognosis Pathophysiology Tissue cell death --> increase LA --> cell death --> microthrombi --> decrease bf -- ischemic --> tissue necrosis --> increase LA --> cell death S/Sx: Bleeding Ashen Pupils blown Mottled Coma MODS DIC Decrease HR, BP, SpO2