Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
83 Cards in this Set
- Front
- Back
|
What is Shock by definition?
|
Inadequete tissue perfusion
|
|
|
What is absolute hypotension?
|
Systolic BP <90
|
|
|
What is relative hypotension?
|
Drop of resting systolic by 40 mm Hg
|
|
|
What does aerobic vs anaerobic metabolism convert 1 mole glucose to?
|
Aerobic: 36 mole ATP
Anaerobic: 2 mol ATP + 2 mol lactic acid |
|
|
What happens when lactate builds up?
|
Acidosis which worsens enzymatic processes!
|
|
|
What are 4 types of afferent signals that operate in shock?
|
-Pain
-Hypovolemia -O2, CO2, H+ -Protein signals |
|
|
What reflexive effector response is activated by PAIN?
|
-The ANS
-Hypothalamic-Pituitary-Adrenal axis |
|
|
What reflexive effector response does hypovolemia activate, and via what receptors?
|
Baroreceptors and volume receptors in the Heart, Aorta, and Carotid SINUS
|
|
|
Where are the chemical sensors for O2/CO2/H+ found?
|
-Aorta
-Carotid bodies |
|
|
What are the 3 efferent system responses activated in shock?
|
-Cardiovascular
-Neuroendocrine -Immunologic |
|
|
What are the 5 types of shock?
|
-Septic
-Neurogenic -Anaphylactic -Cardiogenic -Hypovolemic |
|
|
What do you have to do when evaluating the patient in shock?
|
INITIAL THERAPY SIMULTANEOUSLY!!
|
|
|
What are 5 tests you should order during the initial investigation of shock?
|
-CXR
-EKG -ABG/electrolytes -CBC -Swan ganz catheter |
|
|
What will the CXR tell you about shock?
|
If the cause might be Cardiac, Septic, or extracardiac ie PE
|
|
|
What will the CBC help observe for?
|
Infection
|
|
|
What is the Swanganz catheter useful for in evaluating shock?
|
Determining the diagnosis and monitoring response to therapy
|
|
|
What are the 2 main general goals in treating shock?
|
-Maintain BP
-Ensure adequete tissue perfusion and oxygen supply/demand balance |
|
|
What is the algorithm that helps remember how to treat shock?
|
VPR
Volume - vascular volume Pump - inotropy of the heart Rate - heartrate |
|
|
What is the rule for how much fluid to give in fluid loss?
|
For every liter lost, give 3 liters LR or 1 liter colloid
|
|
|
When would you want to give MORE fluids?
|
Sepsis
|
|
|
What is the rule for the max limit to giving fluids?
|
-When O2 drops due to either hemodilutional anemia or pulm edema
|
|
|
What are 5 common causes of HYPOVOLEMIC shock?
|
-Hemorrhage
-Burns -Bowel obstruction -Crush injury -Pancreatitis |
|
|
What are the 5 early effects of hypovolemic shock?
|
-Orthostatic hypotension
-Mild tachycardia -Anxiety -Diaphoresis -Vasoconstriction |
|
|
What are the 3 LATE effects of hypovolemic shock?
|
-Altered mental status
-Severe decreased BP -Marked tachycardia |
|
|
What are the 3 general classes of hypovolemic shock?
|
Mild - <20% loss
Mod - 20-40% loss Severe - >40% loss |
|
|
What happens in mild hypovol shock, and what are the 3 manifestations?
|
Decreased perfusion to NONvital tissues
-Cold clammy skin -Pale color -Anxiety |
|
|
What happens in mod hypovol shock, and what are the 4 manifestations?
|
Decreased perfusion to VITAL structures (liver/kidneys/intestines)
-Oliguria/anuria -Decreased BP -Agitation |
|
|
What happens in severe hypovol shock and what are the 2 added manifestations?
|
Decreased perfusion to BRAIN and HEART - mental status changes and hypotension
|
|
|
What are 3 labs that indicate severe hypovolemic shock?
|
-Systemic acidosis
-increased BUN -increased creatinine |
|
|
How do you restore IV volume and increase BP in hypovolemic shock?
|
Give LR or normal saline - ISOTONIC
|
|
|
If hypovolemic shock is due to hemorrhage, what should you also give with IVFluids?
|
pRBCs
|
|
|
What is the minimum Hct that you must maintain, and what is optimal?
|
Must be >24% minimum, >30% is optimal
|
|
|
How is the effectiveness of treatment for hypovolemic shock monitored?
|
By measuring urine output
|
|
|
What type of shock should be managed in a way that is opposite from that for hypovolemic?
|
Cardiogenic - do NOT give fluids!
|
|
|
What are 2 common causes of cardiogenic shock?
|
-Cardiac insufficiency
-LV failure |
|
|
What are 6 things that can cause cardiac insufficiency?
|
-MI
-Valve damage -Papillary muscle damage -Cardiac contusion -Cardiac tamponade -Tension pneumothorax |
|
|
What are the 5 hallmark signs and symptoms of cardiogenic shock?
|
-Dyspnea
-Rales -pulsus alternans -Loud pulmonic compnt of S2 -Gallop rythm |
|
|
What are 5 associated signs of cardiogenic shock?
|
-Hypotension
-Low cardiac outpus -High pulm wedge pressure -Low urine output -High heartrate (possibly) |
|
|
What is a diagnostic finding in cardiogenic shock?
|
Pulmonary venous congestion on CXR
|
|
|
What is the treatment for cardiogenic shock based on?
|
The mechanism of disease - DO NOT GIVE FLUIDS!
|
|
|
What are the 5 things to do to treat cardiogenic shock dt MI?
|
-Give O2
-IV Nitro if BP is high enough -Intraaortic balloon pump -Coronary angiography -Angioplasty or Bypass |
|
|
What are the 2 treatments to give if cardiogenic shock is post CPB?
|
-Inotropic agents
-Intraaortic balloon counterpulsation |
|
|
What are 4 intotropic agents?
|
-Dopamine
-Dobutamine -Amrinone -Milrinone |
|
|
What are 2 ways that Dopamine works, and what are 2 effects?
|
-Stimulates B1-adrenergics and Epi release
-+Inotropy and Stimulates Epi release |
|
|
How does Dobutamine compare to Dopamine?
|
-Also stimulates B1-adrenergics
-NO change in HR or SVR |
|
|
How are Amrinone and Milrinone different from Dopa/Dobutamine?
|
They are pos inotropes, but vasoDILATORS
|
|
|
So when should you reserve Amrinone and Milrinone use for?
|
Last resort
|
|
|
What are the physiologic changes that cause SEPTIC shock?
|
-Decreased SVR
-Decreased intravasc Vol -Increased cap permeability -Microvascular pooling and cardiac dysfunction |
|
|
What is the most common cause of septic shock?
|
Gram negative septicemia
|
|
|
How does the initial presentation of septic shock compare to that of hypovolemic?
|
VASODILATION
-Warm skin -Full pulses -Normal urine output |
|
|
What is the DELAYED effect seen in septic shock?
|
VasoCONstriction leading to
-Poor urine output -AMS -Hypotension |
|
|
When are blood cultures pos for septic shock?
|
only 50% of the time!
|
|
|
What are the associated findings in a patient in septic shock?
|
-Fever
-Hyperventilation |
|
|
What are 4 early lab findings in septic shock?
|
-Hyperglycemia/glucosuria
-Respiratory alkalosis -Hemoconcentrated -Leukopenia |
|
|
What are 3 late lab findings in septic shock?
|
-Leukocytosis
-Acidosis -Lactic acid increase |
|
|
What is the first step in treatment of septic shock?
|
Identify and eliminate the nidus of infection
|
|
|
What is step 2 in treatment of septic shock?
|
Maintain tissue perfusion - blood cultures for 2days min to see sterility
|
|
|
What are 4 measures that tell you if you're maintaining adequete tissue perfusion?
|
Pulse ox >92%
Hb > 10 g/dl PAWP 14-18 mm Hg Albumin >2 g/dl |
|
|
What else would you give in addition to maintaining adequete tissue perfusion?
|
Pressors
|
|
|
What are 6 pressors?
|
-Dopamine
-Dobutamine -Epi -Norepi -Isoproterenol -Phenylephrine |
|
|
What is step 3 in treatment of septic shock?
|
Interrupt the inflammatory response that LEADS to shock
|
|
|
What IS neurogenic shock?
|
The loss of the ever-important Sympathetic Vasoconstrive response
|
|
|
What is a common cause of neurogenic shock?
|
Spinal trauma
|
|
|
What is a key way to distinguish between neurogenic and hypovolemic shock?
|
BRADYcardia instead of tachy
|
|
|
What is the treatment for neurogenic shock?
|
IV Fluids
|
|
|
What are the 3 physiologic changes in response to allergic anaphylactic shock?
|
-Increased vascular permeability
-Vasodilation -Smooth muscle constriction |
|
|
What are 4 treatments for anaphylactic shock?
|
-Establish airway
-Epi -Benadryl -Steroids |
|
|
How do all types of shock affect the heart?
|
When systemic BP drops, coronary perfusion is decreased and can lead to ischemia.
|
|
|
How does shock affect the kidneys?
|
When renal perfusion is low it activates the RAA axis; if it continues there is renal ischemia and anuria.
|
|
|
Which becomes ischemic first; the heart or kidney?
|
Kidney
|
|
|
Up to what mean BP will the brain apply compensatory mechanisms for decreased BP?
|
>60 mm Hg
|
|
|
What are CO, PCWP, and SVR in hypovolemic shock?
|
CO - low
PCWP - low SVR - increased |
|
|
What are CO, PCWP, and SVR in cardiogenic shock?
|
CO - low
PCWP - increased SVR - increased |
|
|
What are CO, PCWP, and SVR in extracardiac shock?
|
CO - low
PCWP - increased SVR - increased |
|
|
How can you tell apart cardiogenic vs extracardiac shock?
|
Based on phys exam - muffled heart sounds and pulsus paradoxis in extracardiac dt tamponade
|
|
|
What is pulsus paradoxus?
|
A decrease in systolic BP >10 mm Hg on inspiration
|
|
|
What are CO, PCWP, and SVR in distributive/septic shock?
|
CO - HIGH
PCWP - low SVR - LOW |
|
|
What does the swan-ganz catheter measure?
|
Left heart pressure via the pulmonary artery pressure, approximates LA pressure
|
|
|
What are the indications for placing a Swan-Ganz catheter?
|
-Shock
-Monitor effects of inotropes, pressors, or fluid therapy |
|
|
What are 3 possible complications of placing a Swan-ganz cath?
|
-Pulm hemorrhage
-Venous thrombosis -Cardiac arrythmia |
|
|
Where is a central line placed?
|
At the junction of the RA and SVC
|
|
|
What does placing a central line allow us to estimate?
|
CVP - fluid status
|
|
|
What are 4 possible complications of placing a central line?
|
-Cardiac tamponade
-Pneumothorax -Catheter embolism -Vascular injury |
