Therapeutics I Exam VI (Hypovolemic and Cardiogenic Shock))

Question 1

Are things like hypovolemic and cardiogenic shock acute or chronic conditions?

Answer 1

These are acute and hyper-acute conditions

Question 2

Define tissue dysoxia.

Answer 2

The imbalance between oxygen supply and demand

Question 3

What are the four main types of shock?

Answer 3

-Hypovolemic
- cardiogenic
-distributive (sepsis, anaphylaxis)
- obstructive (very advanced shock)

Question 4

The total water within our bodies represents what percentage of our actual body weight?

Answer 4

60-70% of body weight. This means that if you weight 100lbs, you would have 60-70lbs of water in you.

Question 5

What two things make up total body water?

Answer 5

Intracellular fluid and extracellular fluid

Question 6

Intracellular fluid and extracellular fluid make up total body water. Intracellular fluid takes up around ________% of the total body water while extracellular fluid takes up around ________% of total body water.

Answer 6

67%
33%

Question 7

What two things make up extracellular fluid?

Answer 7

Interstitial fluid and intravascular fluid

Question 8

What is interstitial fluid?

Answer 8

This is the fluid between the cells.

Question 9

If edema is present, that means there is too much ___________ fluid.

Answer 9

Interstitial

Question 10

What is intravascular fluid?

Answer 10

This is your blood

Question 11

What two things make up intravascular fluid?

Answer 11

Cells (RBCs, WBCs, platelets) and plasma (water, proteins, albumin, clotting factors, etc)

Question 12

Interstitial fluid and intravascular fluid make up extracellular fluid (33% of TBW). Interstitial fluid makes up around _______% of extracellular fluid while intravascular fluid makes up around _________% of extracellular fluid.

Answer 12

75% of ECF
25% of ECF

Question 13

What is hemotocrit?

Answer 13

This is the percentage of blood that is actually red blood cells. It is typically between 45-50%

Question 14

What are some things that can cause insensible/unmeasurable fluid loss?

Answer 14

• surgery leading to loss of skin barrier
• wounds leading to loss of skin barrier
• fever
• mechanical ventilator leading to to increased respiratory losses
• Hyperventilation leading to increased respiratory losses
• hypermetabolism leading to increased water consumption

Question 15

Aldosterone causes renal ________ reabsorption and ______ will follow it.

Answer 15

Sodium
Water

Question 16

Vasopressin binding to its V1 receptor causes what to occur?

Answer 16

Arterial vasoconstriction

Question 17

Vasopressin binding to its V2 receptor causes what to occur?

Answer 17

Free water absorption from renal collecting duct

Question 18

Define hypovolemia.

Answer 18

Relative net loss of intravascular fluid volume

Question 19

Define shock.

Answer 19

A general state of circulatory dysfunction resulting in inadequate tissue perfusion and oxygen delivery, thus leading to tissue ischemia and cellular, tissue, and organ dysfunction and/or failure.

Question 20

Define hypovolemic shock.

Answer 20

State of intravascular volume depletion resulting in inadequate perfusion and tissue oxygen delivery.

Question 21

Fluid status within the body mainly affects what factor directly related to mean arterial pressure?

Answer 21

Preload

Question 22

In hypovolemic shock, there is not enough fluid in the vasculature, this causes _________ also know as _________ to decrease. This then lowers stroke volume, cardiac output, and therefore mean arterial pressure.

Answer 22

Preload also known as end disatolic volume

Question 23

Explain how hypovolemic shock effects preload.

Answer 23

In hypovolemic shock, the body does not have enough intravascular fluid. This means when the heart tries to fill in systole, not enough blood will enter the ventricles which will reduce myocardial stretching, also know as preload. When preload decreases, so does stroke volume which is the amount of blood the heart pumps out in every beat. When stroke volume decreases, that lowers cardiac output which lowers mean arterial pressure therefore reducing perfusion to important organs.

Question 24

How does the heart try to compensate in states of hypovolemic shock?

Answer 24

In response to a decreased preload, stroke volume, cardiac output, and mean arterial pressure, the body increases heart rate and tone (SVR).

Question 25

What are the general presentations for both hypovolemic and cardiogenic shock?

Answer 25

Decreased skin turgor (less elasticity), dry mucous membranes, dry axilla, cold extremities, and mental status changes

Question 26

What are the hemodynamic clinical presentations in hypovolemic shock?

Answer 26

Increased HR, Increased SVR, decreased preload, cardiac output, map, and urine output, and metabolic acidosis

Question 27

In a very general sense, what is typically the cause of hypovolemic shock states?

Answer 27

Severe bleeding/ hemorrhage (typically due to some traumatic injury)

Question 28

What are some more general causes of hypovolemia?

Answer 28

- Acute or chronic hemorrhage - Severe dehydration - GI losses (think diarrhea) - renal losses (think excessive peeing) - insensible fluid loss - decreased intake - capillary leaks due to inflammation

Question 29

What is the order of treatment goals for patient presenting with hypovolemic shock?

Answer 29

1. RESTORE PERFUSION AND OXYGEN DELIVERY TO TISSUES 2. Stop blood and fluid losses 3. Restore volume and maintain adequate oxygen delivery

Question 30

In order to get volume resuscitation in hypovolemic shock patients, what do we use?

Answer 30

We can use crystalloids like 0.9% NaCl or lactated rings, colloids like albumin, and give blood is they are bleeding.

Question 31

Vasopressors should only be initiated in hypovolemic shock once _______ _________ has been done.

Answer 31

Volume resuscitation. If the volume is not adequate yet, vasopressors will cause tissue ischemia. But in all honesty, vasopressors will only increase systemic vascular resistance and that really isn't the problem with hypovolemic shock.

Question 32

Why do we need to monitor temperature in someone experiencing hypovolemic shock?

Answer 32

If the person becomes too cold, the clotting factors within the blood getting infused will not work as well.

Question 33

What are crystalloids?

Answer 33

These are electrolyte solutions like 0.9% NaCl, lactated ringers, dextrose 5%.

Question 34

What are the pros of using crystalloids in hypovolemic shock?

Answer 34

They are usually inexpensive, readily available, and familiar for most staff.

Question 35

What are the cons of using crystalloids in hypovolemic shock?

Answer 35

It typically fills the extracellular space which is good but has limited intravascular volume expansion which is what we are really trying to increase in hypovolemic shock. Additionally, these can cause edema due to entering the interstitial space.

Question 36

What are the pros of using colloids like albumin in hypovolemic shock?

Answer 36

Albumin has much greater expansion into the intravascular space.

Question 37

What are the cons of using colloids like albumin in hypovolemic shock?

Answer 37

They are expensive, there is limited availability, and it can cause adverse reactions.

Question 38

T or F: D5W is commonly used to add volume in hypovolemic shock patients.

Answer 38

False. D5W will follow water and only about 10% of the total volume given will actually enter the intravascular space.

Question 39

What are different example of colloids?

Answer 39

Whole blood, packed RBCs, fresh frozen plasma, platelets, human albumin

Question 40

What is the most common crystalloid used in hypovolemic shock?

Answer 40

0.9% NaCl

Question 41

Most hypovolemic shock states are caused by intense bleeding. What are some hemostatic agents used in these acute conditions to stop bleeding?

Answer 41

TXA, desmopressin, activated factor VII, prothrombin complex, idarucizumab, and andexanet alfa

Question 42

Cardiogenic shock is typically an extension of what chronic condition?

Answer 42

Chronic heart failure

Question 43

What are the two types of acute heart failure?

Answer 43

Acute decompensated heart failure and cardiogenic shock

Question 44

Define cardiogenic.

Answer 44

Related to myocardial function

Question 45

Define cardiogenic shock.

Answer 45

Persistent hypotension, tissue hypoperfusion, and decreased oxygen delivery due to impaired cardiac function in the presence of adequate intravascular volume.

Question 46

In cardiogenic shock, the heart is not functioning properly, this means that __________ has decreased which directly decreases stroke volume, cardiac output, and then mean arterial pressure.

Answer 46

Contractility

Question 47

Hypovolemic shock disrupts ________ while cardiogenic shock disrupts _________.

Answer 47

Preload Contractility

Question 48

What are the two compensatory mechanisms that are activated in cardiogenic shock?

Answer 48

Increased heart rate and tone

Question 49

Thinking about the Frank-Starling curve, what would happen in cardiogenic shock patients if you gave them fluids?

Answer 49

Giving fluids in those with symptomatic heart failure and cardiogenic shock will actually cause them overload and decrease stroke volume and cardiac output.

Question 50

What are the hemodynamic clinical presentations in cardiogenic shock?

Answer 50

Increased heart rate and systemic vascular resistance, normal or high preload, decreased cardiac output, map, and urine output, and metabolic acidosis.

Question 51

If a patient is presenting with cardiogenic shock but is dehydration/hypovolemic, do you treat the fluid loss first or cardiogenic shock first?

Answer 51

First give fluids to correct the hypovolemia then fix the cardiogenic shock

Question 52

What are some causes of cardiogenic shock?

Answer 52

Myocardial injury or strain, mechanical heart issue, arrhythmias, prolonged bypass

Question 53

What is the order of treatment goals for patient presenting with cardiogenic shock?

Answer 53

1. RESTORE PERFUSION AND OXYGEN DELIVERY 2. Protect airway and give oxygen 3. Fluid management (not giving a bunch of fluids like you would in hypovolemic shock) 4. Prevent myocardial injury or hemodynamic compromise

Question 54

What is the first-line medication treatment for cardiogenic shock?

Answer 54

Inodilator like dobutamine

Question 55

What is the second-line medication treatment for cardiogenic shock?

Answer 55

Milrinone

Question 56

What are the 5 clinical endpoints for shock patients?

Answer 56

1. Maintain MAP 2. Maintain oxygen delivery 3. Normalize preload 4. normalize cardiac output 5. normalixe systemic vascular resistance

Question 57

What is the MOA of inodilators like dobutamine and milrinone?

Answer 57

These guys increase contractility of the heart while decreasing systemic vascular resistance through vasodilation.