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109 Cards in this Set
- Front
- Back
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Define shock |
Blood flow and oxygen delivery to the tissues are disturbed leading to tissue hypoxia with compromised cellular metabolic activityorgan dysfunction |
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What is the key characteristic of shock |
Organ dysfunction |
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What are the types of shock |
Hypokalemic cardiogenic distributed obstructive |
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What are types of distributive shock |
Septic anaphylaxis and neurogenic |
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Stage one of shock |
Early changes at cellular level nonspecific reversible hard to tell if somebody is even shock |
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Stage II of shock |
Compensatory mechanisms hyperventilating catecholamines response renin angiotensin response your body is trying to correct |
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Stage III of shock |
Can be irreversible vasopressin release to help correct or include that pressure |
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Stage four of shock |
Final is reversible several vicious cycle |
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Define hypovolemic shock |
Medical or surgical condition in which fluid loss results in multiple organ failure due to an inadequate circulating volume and inadequate perfusion |
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Hypokalemic loss is secondary to |
Rapid blood loss |
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Class one hypovolemic shock |
Less than 15% |
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Class to hypovolemic shock |
10 to 30% |
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Class III hypovolemic shock |
31 to 40% |
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Class for hypovolemic shock |
Greater than 40% |
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Hypovolemic shock can be treated with what three things |
Crystalloids colloids and blood |
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Internal causes of hypovolemic shock |
Third spacing leakage of fluid from intestines capillaries into walls and lumina of intestines Long bone fracture pooling of extravascular compartments impaired Venus return caused by obstruction of vena cava extensive belly surgery |
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What are examples of third spacing |
Ascites peritonitis edema |
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How does abdominal surgery lead to hypovolemic shock |
It sucks up a lot of the fluids so you need a lot of fluid replacement to prevent hypovolemic shock |
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External causes of hypovolemic shock |
Hemorrhage G.I. renal loss exudative lesions or burns excessive diaphoresis |
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G.I. causes of external hypovolemic shock |
vomiting diarrhea poor oral intake large NG tube aspirate fistula |
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renal causes of hypovolemic shock |
Diabetes insipidus SIADH Addison's disease die uretic |
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bodies Manifestations of hypovolemic shock |
Weak lightheaded confuse decreased blood pressure increased heart rate |
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Hemodynamic manifestations of hypovolemic shock |
Decreased blood pressure increased heart rate low cardiac output low cardiac index low CVP low wedge pressure high Svr due to compensation low svo2 |
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First go to for replacement in hypovolemic shock |
Crystaloids |
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Why are crystalloids the first go to for hypovolemic shock |
Cheap convenient no adverse effect rapidly distributed across intravascular and interstitial spaces |
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Examples of crystalloids |
Lactated ringers normal saline |
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Benefits of lactated ringer |
It has sodium chloride lactate in water good volume expander and buffers out acidosis |
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qualities of normal saline for hypovolemic shock |
Increases plasma volume used when no loss of red blood cells has occurred needs 2 to 4 times that of colloid to achieve equivalent hemodynamic response volume expansion is transient fluid can accumulate in interstitial space and cost pulmonary edema |
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Goal of blood products in hypovolemic shock |
HeMetacritic 30 |
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How far one unit of packed rbc increasing hematocrit and hemaglobin by |
3ML/decimeters and hemoglobin by 1 g/dl |
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Why do we use fresh frozen plasma |
Replaced clotting factors |
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Ratio of packed rbc to fresh frozen plasma |
For every 4 to 5 units of packed RBCs infuse one unit of FFP |
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Went do we use platelets |
Bleeding as a result of low platelet count less than 50,000 |
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What are examples of colloids |
Starches gelatins plasmin albumin |
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Benefits of colloids |
Greater and more sustained increase in plasma volume with associated improvement of cardiovascular function and oxygen transport |
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when are colloids given |
When volume loss is due to Burns third spacing or bowel obstructoins |
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These synthetic plasma expanders or synthetic colloid |
hetastarch (hespan) dextran |
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How much colloids are given over 24hours |
No more than 1 L of dextran or Hespan over 24hrs |
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When getting colloids with the monitor for |
Pulmonary edemacoagulopathy anaphylaxis increased bleeding worsening renal failure |
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Benefits of colloids |
It keeps fluids in the vessels longer |
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What is military anti-shock trousers MAST |
External counterpressure device applied to splints fracture of pElvis and Long bone to tapenade bleed |
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Benefit of military anti-shock trousers |
compression redistributes bloodflow from prayer for circulation increases vital organ perfusion |
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What is contraindicated in hypovolemic shock |
Vasopressin until circulating volume has been restored |
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define cardiogenic shock |
Decreasing cardiac output and evidence of tissue hypoxia in the presence of adequate volume |
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This is the leading cause of death in acute myocardial infarction |
Cardiogenic shock unless there is aggressive highly experienced technical care |
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Causes of cardiogenic shock |
Acute myocardial infarction arrhythmia CHF pulmonary embolism tension pneumothorax Tampanode dissecting aortic aneurysm myocarditis end stage CM septic shock any form of severe myocardial damage surgical or spontaneous damage to valves valvular |
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Valvular diseases that can cause cardiogenic shock |
Aortic mitral regurgitation ruptured intraventricular septum rupture of Free wall large RV infraction |
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Bodies manifestation of cardiogenic shock |
Hypotension in the absence of hypovolemia Oliguria Altered mental status Cyanotic Cool extremities Cool mottled extremities Rapid faint pulse Jugular vein distention Crackles In Longs Peripheral edema Tachycardia |
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Hemodynamic manifestation of cardiogenic shock |
Ejection fraction less than 20% Low cardiac output Low cardiac index High central venous pressure High wedge pressure High Svr Low Svo2 Wedge pressure greater than 15 Cardiac index less than 2.1 |
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When someone is in cardiogenic shock what should you order to establish the cause
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Echocardiogram |
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Management of cardiogenic shock |
Improve pump performance and cardiac output Intubate Central line Arterial line Fluid resuscitation to correct hypovolemia Intra-aortic balloon pump Percutaneous intervention CABG Thrombolytics |
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These medications are given to manage cardiogenic shock |
Aspirin heparin diuretic dopamine dobutamine levophed milrinone morphine isoproterenol diuretics nipride lidocaine amiodarone |
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Why is milrinon given an cardiogenic shock |
It's a positive inotrope increases cardiac contractility |
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why morphine given in cardiogenic shock |
Reduces anxiety and pain reduces catecjolamine |
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Define obstructive shok |
Inadequate cardiac output as a result of impaired ventricular filling due to mechanical obstruciton problem |
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Most common cause of a obstructive shock |
Pulmonary embolism |
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Causes of obstructive shock |
Pulmonary embolism tension pneumothorax acute cardiac Tampanode Obstructive valvular disease Disease of pulmonary vasculature |
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Hemodynamics of obstructive shock |
low cardiac output Low cardiac indexHigh central venous pressure low wedge pressure Hi SVR Low Svo2 |
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Why are these hemodynamic results of a obstractive shock there |
Because blood is not moving from the right to the left so right-sided pressures will be elevated and left-sided precious will be low |
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Very indicative of obstructive process |
Right-sided pressures are elevated while left-sided pressures Ar low |
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Management of obstractive shock |
Maintain blood-pressure while initiating treatment for underlying cause Fluid and use of vasopressors may preserve blood pressure while more definitive measures like thrombolytic or surgery is considered |
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Distributive shock is separated into what |
Septic anaphylaxis neurogenic |
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define distributive shock |
Impairs distribution of blood flow |
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Define anaphylaxis |
Immediate hypersensitivity reaction severe antibody antigen response leads to decreased tissue perfusion and initial general shock response |
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In anaphylactic shock what will always be present |
One or both of hypotension and respiratory difficulty |
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Causes of anaphylactic shock |
Food is number one cause diagnostic agents- Allergy extracts vaccine dye Blood products Environmental agents Like latex Pollen mold animal products dust Drugs-antibiotics acetylsilic acid Narcotics dextran anesthetic Venom |
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Manifestations of anaphylactic shock |
Hypotension tachycardia arrhythmia from vasodilation resp: BronchospasmLaryngeal edemaLump in throatDysphasia hoarsenessDyspnea stridorWheezing rails rhonchi hypoxia skin: pruritis erythema uriticaria angioedema cns: restlessness uneasiness apprehension feeling of impending doomDecreased level of consciousness GI: Diarrhea abdominal cramp metallic taste |
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Treatment of shock |
Discontinue trigger Epinephrine Intubate To maintain airway Antihistamine H2 bLocker AminophyllineOr Albuterol for bronchospasm Volume Expanders for hypotension Corticosteroids Inotropic agents Lay flat to help with Venus return Education |
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How is epinephrine given in anaphylactic shock |
.5 to 1ml of 1:1000 IM or SQ, inhaled for mild to moderate edema IV for compromise circulation 1:10,000 ETT 2-2.5 times the usual dose of 1:10,000 may reeat 1:10,000 in ten minute interval until dsired effect is achieved or adverse effect occurs |
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Antihistamines given in anaphylactic shock |
Diphenhydramine 10 to 15 mg IV may need 100 mg maximum is 400 mg per day |
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H2 blocker for anaphylactic |
Zantac 50 mg IV or po |
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Corticosteroids in anaphylactic shock |
Methylprednisone 125 to 250 mg IV hydrocortisone 5 mg per kilogram IM or slow IV push |
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Hemodynamic response in anaphylactic shock |
Decreased cardiac output Decrease cardiac index Decreased Central venous pressure Decreased pulmonary wedge pressure Decrease SVR |
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define neurogeic shock |
disturbance in nervous system that cuses massive vasdilation causing increased vascular capacity as a result ofinterruption in or loss of sympathetic innervation
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causes of neurogenic shock |
spinal cord injury, loss of sympathetic vasoconstrictor tone, sympathetic outlow disrupted, disease of brain sem, high levels of spinal anesthesia, vasomotor center depression, drugs that block sympathetic activity like bblocker and clonidine |
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qualities of neurogenic shock |
blood voluem normal cardiac fucntion is norml hypotension bradycardai warm dry skin decreased svr hypothermia
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hemodynamics of neurogenic shock |
low everything low CO, CVP PCWP SVR and SVo2 |
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treatmetn of neurogenic shock |
remove cause, fluids initial differnetiate neurogenic from hypovolemic vassopressors if fluids is not successful atropine treat hypothermia |
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initial treatment of neurogenic shock |
fluids |
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difference between heurogenic and hypovolemic |
neurogenic = warm dry skin and brady hypovolemic - cool moist skin and tacy |
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sirs criteria |
temp >38C or <36C hr >90 rr >20 paCO2 <32 wbc >12 wbc <4 10% bands |
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defien sepsis |
2 ormore sirs plus source of infection |
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severe sepsis |
sepsis associated with organ dysfucntion and lactic aciosis oliguria hypoxemia coagulation disorder mental status change
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septic shock |
sepsis with hypotension despite adequate fluid resusitation along with perufsio abnormalities
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qulities of ealry septic shock |
aka hyperdynamic warm chilsl fever warm flushed skin mental confusion normal or slighly elevated bp increase hr and rr decreases PaO2 despite O@ therapy increased SVO2 decreased PCWP, CVP and svr CO normal orincreased |
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qualities of hypodynamic shock |
aka late cold clammy skin tacyacardia decreased bp ncreased svr rep failure ards metaboic acidosis d/t lactic acidosso oliguria edema
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hemodynamics of sepsis |
high CO than low low CVP than high Low PCWP than high low svr low svo2 than high ( dieing and not using o2 this is a bad sigN)
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bad sign in sepsis |
high svo2. means they are not using o2 |
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lab values in sepsis |
elevated lactate UO <0.5 for more than2 hours despite fludi resus acute lung injury with pao2/fiot <250 in absence of pneumonia or <200 in presenc eof pneumonia creat >2 bilirubin >2 platelte <100 |
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GOAL FOR THE First 6 hours of resusitation |
cvp 8-12 map >65 Uo >0/5ml/kg/hr scvo2 70% svo2 65%
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sepsis and antimicrobiaals |
iv within 1 hour of septic shock or severe sepsis initial emperic therwpay good for bacteria and fungus and penetrate into tossues procalcitonin or other biomarker for pts who appeared septic but have no source of infection emperic ab for 3-5 days deescelate as soon as suscptibility is known duration of therapy 7-10 days longer for : slow response, undrainable foci, bacteremia with s. aureus, immunologic deficiency including neutropenia
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treatment for p. aeruginosa |
extended pectrum beta lactam and aminoglycoside or floruoquinolone |
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treatmetn of septic shocj from streptococcos pneumonia |
beta lactam and macrolide |
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SEPSIS AND INFECTION PREVENTION |
oral chlorhexidine to reduce VAP |
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sepsis within 3 hours |
keep cvp between 8-12, measure lactate bc befire ab broad specturm ab crystalloids 30ml/kg/hr for hypotension or lactate >4 |
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sepsis within 6 hours |
vasopressors for hypotension not repsonding to fluids, keep map >65 if perssitant hypotension measure cvp and scvo2 remeasur lactate |
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target goals for resusitation |
cvp >8 scvo2 >70% normla lactate uo > 0.5ml/kg/hr is good indicator of good cvp |
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SEPSIS hemodynamic reccomendations |
crystalloids fluid of chocie if substantial amounts of crystalloids needed give albumin 30ml/kg to start
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vasopressor recocmendation in sepsos |
vasopressor initially to target map of 65 norepinephirne is first choice than epnephrine can be added vasopressin 0.03u/min added with intent to rtaise map or decrease NE dose dopamine in highly selected pts ex pt with low risk of tacyarrtyhmia or relative bradycardia phenelephirne only when NE is ass with arrythmia, CO is high and bp is low, salvage therapy all pts with vasopressior need an a line |
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inotrope reccomnedation |
dobutamine up to 20mcg or added to vasopressor THERAPY IF ELEVATED CADIAC FILLING PRESSURE AND LOW co OR ONGOING HYPOPERFUSION DESPITE ADEQUATE map
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CORTICOSTEROID RECCOMENDATION |
only if fluid resus and vasopressor isnt working. give hyddrocortisone iv as a continuous flow |
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blood reccomendaitons |
transfuse of <7 target 7-9 dont use ffp in absence of bleeidng platletes given prophylactically if <10,000 with no bleeidng, <20 if significant risk for bleeding, >50,000active bleeidng, surgury or invasive procedure |
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mechanicl venitlation of sepsis induced ards reccomendation |
TV 6ml/kg plateut pressure adn initial goal is <30 apply peep, higher levels recruipment prone ig pao2/fio2 <100 mechanical ven maintian hob 30-45degrees adn prevent vap NIV weaning protocol adn spontaeous breahting tirals against using PAC conservative fluid therapy
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sedation and neuromuscular blocake recocmndations |
minimize sedation avoidn NMBA in septic without ards no greatehr than 48 hours for pts with early sepsis induced ards adn pao2/fiao2 <150 |
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glucose contorl reccomendaiton |
protocols when 2 consec levels are >180 target upper limit of<180 instead of <110 monitor every 1-2 hours caution with getting POC |
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renal reccomendation |
hemodyalysis requirements are same in pts with severe sepsis and arf dont use NA bicarb to improve hemodynamics with ph >7.15 |
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dvt reccomentaitons |
lmwh if createni clearance <30ml use dalteparin or anothe rlmwh or ufh sever sepsis - combo drugs and ipc
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stress ulcer prophylais |
h2 blcoerks or ppi ppi is prefered no risk factos o not need prophylaxis |
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nutrition reccomendaiond |
give oral /enteral as tolerated rather than fasting low dose feeding in first week iv glucose and enteral rather than tpn
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