Therapeutics - Shock Part 1

Question 1

shock is a syndrome of….

Answer 1

impaired tissue perfusion

Question 2

if shock is left untreated/undertreated, ____ eventually wanes and ____ can occur

Answer 2

compensation eventually wanes and decompensation can occur

Question 3

3 main types of shock and their general cause

Answer 3

hypovolemic (vol reduction)
cardiogenic (heart pump failure)
distributive (increased vascular compliance)

Question 4

septic shock falls under which of the 3 types

Answer 4

distributive

Question 5

true or false

determining the type of shock is not important to manage it

Answer 5

FALSE - it is important

Question 6

what is the hallmark of septic shock?
explain what it is

Answer 6

SIRS (systemic inflammatory response syndrome)
-profound vasodilation
-increased capillary permeability

Question 7

increased capillary permeability seen in septic shock causes what

Answer 7

edema - fluid leaves the intravascular compartment and goes into the interstitial compartmner

Question 8

septic shock most commonly occurs from what

Answer 8

infection (typically bacterial)

Question 9

explain when a patient meets SIRS criteria

Answer 9

have to meet 2 or more of these abnormalities:

-temperature
-high heart rate
-high respiration rate
-WBC high or low

Question 10

explain the criteria for someone to have sepsis

Answer 10

have to meet 2 or more of the SIRS criteria (temp, white count, respiration rate, heart rate), AND a suspected source of infection has to exist

Question 11

what is the main determinant of tissue perfusion and how is it calculated

Answer 11

MAP (mean arterial pressure) – average pressure that drives the blood throughout the organs

ABP + DBP + DBP
all divided by 3

Question 12

MAP is a function of….

Answer 12

cardiac output * systemic vascular resistance (SVR)

Question 13

cardiac output is a function of….

Answer 13

heart rate * stroke volume

Question 14

name some clinical presentation features of a shock patient

Answer 14

tachycardia (over 90)
tachypnea (over 20 breaths/min)
mental confusion
oliguria (less than 20mL/hour)
mental confusion
skin vasoconstriciton (cold and pale)
acidosis

systolic BP less than 90 or a DROP over 60 from baseline

Question 15

why do shock patients tend to have tachycardia (over 90 bpm) and tachypnea (over 20 breaths/min)

Answer 15

because the body is trying to compensate for the lack of blood flow and oxygen to the tissues

Question 16

3 signs of organ damage from shock

Answer 16

oliguria
mental confusion
metabolic acidosis

Question 17

when would we do invasive vs noninvasive hemodynamic monitoring in shock patients

Answer 17

invasive is only necessary in critically ill patients

noninvasive typically used - provides limited info but valuble info

Question 18

true or false

an echocardiogram is considered a NONINVASE hemodynamic monitoring strategy

Answer 18

true

Question 19

3 methods of invasive monitoring to watch hemodynamic control

Answer 19

arterial line
central venouos catheter
pulmonary artery catheter

Question 20

true or false

arterial lines used to monitor hemodynamics in shock patients can be used to administer meds

Answer 20

FALSE - only central venous catheter can

Question 21

which invasive hemodynamic monitoring method allows the measurement of CO (cardiac output) and PCWP (pulmonary capillary wedge pressure)

Answer 21

pulmonary artery catheter

Question 22

which value is the best indicator for preload? represents total body volume

Answer 22

PCWP (pulmonary capillary wedge pressure)

Question 23

name what is FIRST AFFECTED In each shock:

hypovolemic
cardiogenic
distributive

Answer 23

hypovolemic - decreased cardiac output and preload 9PCWP) is first

cardiogenic - decreased cardiac output is first

distributive - decreased SVR (systemic vascular resistance) is first

Question 24

true or false

all of the 3 types of shock cause an increased HR

Answer 24

true

Question 25

when EDV (end diastolic volume )is affected, what kind of shock is this? what about when ESY (end systolic volume) is affected

Answer 25

EDV affected - hypovolemic shock ESV affected - cardiogenic shock

Question 26

as mentioned, when a patient loses volume, compensation will occur and the SVR and heart rate will increase. what happens when these compensatory mechanisms are overcome

Answer 26

blood pressure will decrease, along with perfusion to orfans

Question 27

true or false in cardiogenic shock, cardiac output decreases, but this is NOT due to a loss in volume

Answer 27

true

Question 28

general treatment goals for shock patients

Answer 28

regain hemodynamic control reverse the cause! stop organ dysfunction

Question 29

goal for treatment in hypovolemic shock

Answer 29

correct inadequate tissue perfusion and oxygenation by INCREASING THE INTRAVASCULAR VOLUME

Question 30

as mentioned, in hypovolemic shock, we hope to fix inadequate tissue perfusion by increasing the intravacular volume what is an important consideration about this

Answer 30

DO NOT FLUID OVERLOAD! (Can cause something like pulmonary edema)

Question 31

3 potential options for fluid replacement in hypovolemic shock patient

Answer 31

crystalloids colloids blood

Question 32

what is the primary intervention in hypovolemic shock

Answer 32

infusion of IV fluids

Question 33

which fluid is considered 1st line in hypovolemic shock

Answer 33

crystalloids ( ie - dextrose, NS, LR, hypertonic saline

Question 34

differentiate between the general volumes of crystalloids vs colloids in hypovolemic shock patients

Answer 34

crystalloids - need a larger volume. this is bc colloids stay in the intravascular space more crystalloids shift more to the extravascular space

Question 35

general approach to the volume of crystalloids to be given in shock patients

Answer 35

1-2L (only 25% stays in intravascular space) of isotonic fluid as fast as possible, and then additional fluid as necessary

Question 36

4 examples of crystalloids

Answer 36

NS, hypertonic saline, lactated ringer's, dextrose

Question 37

*important crystalloid to AVOID when replacing fluid and why

Answer 37

D5W it is an ineffective osmole. water will not stay in the vein like normal saline and other things

Question 38

name some colloids which is preferred

Answer 38

albumin 5% (isotonic) or 25% (hypertonic), dextrans, hydroxyethyl starch(es) all are considered equally effective

Question 39

true or false compared to crystalloids, colloids need to be given for a longer duration and a LOWER volume

Answer 39

true

Question 40

potential concerns with albumin

Answer 40

-hypersensitivity reactions -potential increased mortality in burn/trauma patients -- but this is still inconclusive

Question 41

true or false effective osmoles stay in the extracellular space

Answer 41

TRUE - therefore, water also stays in the extracellular space (blood vessels) ineffective osmoles cross freely into the INTRACELLULAR space

Question 42

true or false in a hypovolemic shock patient, the decision to give blood transfusions is solely based on the hemoglobin and hematocrit

Answer 42

FALSE - not solely based on this based on clinical evidence - if pt is hypovolemic and has severe blood loss for instance

Question 43

some AE of giving blood transfusions for hypovolemic shock

Answer 43

electrolyte abnormalities hemolysis infectious disease immunosuppression, etc

Question 44

general goals when giving a blood transfusion in a hypovolemic shock patient

Answer 44

1 unit of packed red blood cells (~200mL) should increase the hemoglobin by 1g/dL and the hematocrit by 3%

Question 45

goal in treating CARDIOGENIC shock

Answer 45

correct inadequate perfusion and oxygenation by IMPROVING CARDIAC FUNCTION

Question 46

3 intervention choices for cardiogenic shock can they all be used together?

Answer 46

fluid challenge inotropic support vasodilators yes can use combo

Question 47

explain the fluid challenge and its effect for cardiogenic shock

Answer 47

purpose of the fluid challenge is to see if the patient is hypovolemic. if they are -- we have to correct that first or there will be AE will increase the PCWP the fluid challenge is done by giving a small amount of fluid like 100mL of normal saline, and then the cardiac output is reevaluated. if the cardiac output didnt improve from that volume added. it is UNLIKELY to benefit from more fluid and hypovolemia can be ruled out

Question 48

true or false if a patient's cardiac output increased with the fluid challenge, but cardiac output is still at goal, we can switch to an inotrope or vasodilator

Answer 48

false - can ADD inotropes or vasodilators as long as the patient's cardiac output did in fact respond to the fluid challenge

Question 49

explain what inotropic support does in patients with cardiogenic shock

Answer 49

increases MAP by increasing cardiac performance

Question 50

disadvantage of inotropic support for cardiogenic shock

Answer 50

while it does increase cardiac performance and thus MAP, it also increase heart oxygen consumption --- leading to potential increased mortality in heart failure patients

Question 51

true or false inotropes increase cardiac output by increasing heart rate, contractility, and ventricular wall tension

Answer 51

true

Question 52

explain the genera; approach and dosing to inotropic agents for cardiogenic shock it can only be given via what route?

Answer 52

give AFTER the volume has been repleted. titrate by 1-2mcg/kg/min every 10 mins to get to the LOWEST EFFECTIVE DOSE that achieves the goal but AVOID tachycardia only given through central line

Question 53

true or false if a cardiogenic shock patient's blood pressure is very low, we can give a vasodilator but do NOT give inotropic agents

Answer 53

FALSE DO NOT GIVE A VASODILATOR! inotropic agents are better option to not further decrease the BP

Question 54

goal MAP range for cardiogenic shock patients

Answer 54

75-80mmHg

Question 55

goal HR in cardiogenic shock patient

Answer 55

less than 110 bpm

Question 56

true or false inotropic agents can be given through central line ONLY

Answer 56

true

Question 57

name 3 potential inotropic agents for cardiogenic shock

Answer 57

dopamine dobutamine epinephrine

Question 58

dobutamine is ______ tachycardic than dopamine

Answer 58

LESS

Question 59

explain what happens as the dose of dopamine increases

Answer 59

2-5mcg/kg/min --- primarily only B1 stimulation that b blockers can inhibit 5-10mcg/kg/min - B1 AND alpha stimulation which usually increases the MAP and PCWP 15mcg-20mcg/kg/min and higher - primarily a1 stimulation that can cause cardiac irritability

Question 60

true or false dobutamine is less tachycardic than dopamine. It generally decreases the SVR and PCWP as the dose increases

Answer 60

true

Question 61

true or false the effects of dobutamine are impaired by beta blockers

Answer 61

true

Question 62

dose of dobutamine and its effect

Answer 62

2.5-15mcg/kg/min b1 and b2 stimulation that exceeds a1 constriction net vasodilation! but this is impaired by b blockers

Question 63

true or false as the dose of epinephrine increases, the SVR tends to decrease

Answer 63

false - as dose of epi increases SVR also tends to increase

Question 64

varying doses of epi and its effects

Answer 64

0.01-0.1 mcg/kg/min - B1 stimulation over 0.1mcg/kg/min - alpha 1 stimulation