Term
| What is the #1 category of shock seen in the ER? |
|
Definition
|
|
Term
| What causes hypovolemic shock? |
|
Definition
| inadequate circulating volume |
|
|
Term
| What causes cardiogenic shock? |
|
Definition
| inadequate cardiac pump function |
|
|
Term
| What causes distributive shock? |
|
Definition
| peripheral vasodilation and maldistribution of blood flow |
|
|
Term
| What causes obstructive shock? |
|
Definition
| extra-cardiac obstruction to blood flow |
|
|
Term
| What is important to note about vital signs in shock? |
|
Definition
no single vital sign or value is diagnostic of shock
vital signs are insensitive in detecting and assessing the severity of tissue hypoperfusion |
|
|
Term
| Why are vital signs not a good indication of shock? |
|
Definition
| body can compensate during early shock (preshock) and the vitals may be normal even though shock is coming on |
|
|
Term
| The ability of the body to compensate for blood loss __________ with age. |
|
Definition
|
|
Term
| What are the goals for resuscitation in shock? |
|
Definition
airway management
breathing management
circulation optimization
delivery of oxygen
endpoint achievement |
|
|
Term
| What is the order of shock resuscitation in trauma? |
|
Definition
CAB
circulation (stop large bleeds first!)
airway
breathing |
|
|
Term
| How is circulation optimization achieved? |
|
Definition
| look for large bleeds and control them with direct pressure or tourniquet |
|
|
Term
| How is airway management achieved physically? |
|
Definition
endotracheal tube
bag valve mask
pulmonary toilet (incentive spirometry) |
|
|
Term
| How is airway management achieved pharmacologically? |
|
Definition
-avoid sedatives
-volume resuscitation and vasoactive agents as needed to counteract reasons for shock |
|
|
Term
| How is breathing management achieved? |
|
Definition
making sure the pt breathes fully, not just monitoring rate and depth
mechanical ventilation can be your enemy |
|
|
Term
| Why can mechanical ventilation be your enemy? |
|
Definition
-positive pressure decreases preload and cardiac output, causing the pt to work harder
-be aware of consequences of using sedatives |
|
|
Term
| How is circulation optimization achieved? |
|
Definition
-isotonic crystalloids via bilateral IV full bore
-avoid Trendelenberg
-restore MAP to 60 mmHg (systolic pressure to 90 mmHg if no internal line) |
|
|
Term
| Why is delivery of oxygen important in shock? |
|
Definition
| body is in a hyperadrenergic state and therefore has increased O2 demand |
|
|
Term
| What can help to decrease the sympathetic drain on O2 resources during shock? |
|
Definition
|
|
Term
| What should your urine output goal be in treating shock? |
|
Definition
|
|
Term
| What should your central venous pressure (CVP) goal be in treating shock? |
|
Definition
|
|
Term
| What should you mean arterial pressure (MAP) goal be in treating shock? |
|
Definition
|
|
Term
| What should your central venous oxygen saturation goal be in treating shock? |
|
Definition
|
|
Term
| How do you determine the bicarb deficit? |
|
Definition
| (normal HCO3 - pt's HCO3) x 0.5 x body weight (kg) |
|
|
Term
| How should bicarb be given in shock, if necessary? |
|
Definition
give half slowly over 10-20 min and the other half over 6-8 hours
stop when arterial pH gets to 7.25 |
|
|
Term
| blood loss in Class I hemorrhagic shock |
|
Definition
|
|
Term
| blood loss in Class II hemorrhagic shock |
|
Definition
|
|
Term
| blood loss in Class III hemorrhagic shock |
|
Definition
|
|
Term
| blood loss in Class IV hemorrhagic shock |
|
Definition
|
|
Term
| pulse rate in Class I hemorrhagic shock |
|
Definition
|
|
Term
| pulse rate in Class II hemorrhagic shock |
|
Definition
|
|
Term
| pulse rate in Class III hemorrhagic shock |
|
Definition
|
|
Term
| pulse rate in Class IV hemorrhagic shock |
|
Definition
|
|
Term
| BP in Class I hemorrhagic shock |
|
Definition
|
|
Term
| BP in Class II hemorrhagic shock |
|
Definition
|
|
Term
| BP in Class III hemorrhagic shock |
|
Definition
|
|
Term
| BP in Class IV hemorrhagic shock |
|
Definition
|
|
Term
| RR in Class I hemorrhagic shock |
|
Definition
|
|
Term
| RR in Class II hemorrhagic shock |
|
Definition
|
|
Term
| RR in Class III hemorrhagic shock |
|
Definition
|
|
Term
| RR in Class IV hemorrhagic shock |
|
Definition
|
|
Term
| capillary refill in Class I hemorrhagic shock |
|
Definition
|
|
Term
| capillary refill in Class II hemorrhagic shock |
|
Definition
|
|
Term
| capillary refill in Class III hemorrhagic shock |
|
Definition
|
|
Term
| capillary refill in Class IV hemorrhagic shock |
|
Definition
|
|
Term
| urinary output in Class I hemorrhagic shock |
|
Definition
|
|
Term
| urinary output in Class II hemorrhagic shock |
|
Definition
|
|
Term
| urinary output in Class III hemorrhagic shock |
|
Definition
|
|
Term
| urinary output in Class IV hemorrhagic shock |
|
Definition
|
|
Term
| CNS status in Class I hemorrhagic shock |
|
Definition
|
|
Term
| CNS status in Class II hemorrhagic shock |
|
Definition
|
|
Term
| CNS status in Class III hemorrhagic shock |
|
Definition
|
|
Term
| CNS status in Class IV hemorrhagic shock |
|
Definition
|
|
Term
| fluid replacement for Class I hemorrhagic shock |
|
Definition
|
|
Term
| fluid replacement for Class II hemorrhagic shock |
|
Definition
|
|
Term
| fluid replacement for Class III hemorrhagic shock |
|
Definition
|
|
Term
| fluid replacement for Class IV hemorrhagic shock |
|
Definition
|
|
Term
|
Definition
| severe systemic reduction in tissue perfusion characterized by decreased cellular oxygen delivery and utilization as well as decreased removal of waste byproducts of metabolism |
|
|
Term
| Hypotension is/is not synonymous to shock. |
|
Definition
|
|
Term
| What are the mortality rates for cardiogenic and septic shock? |
|
Definition
cardiogenic >50%
septic >35% |
|
|
Term
| What are the determinants of blood pressure? |
|
Definition
vascular resistance (SVR)
heart rate (HR)
preload volume (EDV)
contractility (ESV) |
|
|
Term
| What is the formula for BP? |
|
Definition
|
|
Term
| What is the formula for CO? |
|
Definition
|
|
Term
| What is the formula for SV? |
|
Definition
|
|
Term
| What types of shock affect SVR? |
|
Definition
anaphylactic
neurogenic
septic
vasodilator drug-induced |
|
|
Term
| What are potential causes of shock that affect heart rate and therefore CO? |
|
Definition
tachycardia extremes
bradycardia extremes |
|
|
Term
| What type of shock affects EDV? |
|
Definition
|
|
Term
| What type of shock affects ESV? |
|
Definition
|
|
Term
| What are the 4 potential precipitators of shock? |
|
Definition
1. vasodilation (sepsis, anaphylaxis, drugs, cervical cord lesion)
2. extremes of heart rate
3. loss of preload volume (blood/volume loss)
4. loss of contractility (heart failure) |
|
|
Term
| What compensatory mechanism might you see with vasodilation and a loss of SVR? |
|
Definition
|
|
Term
| What compensatory mechanisms might you see with blood/fluid loss and a decreased EDV? |
|
Definition
-increased SVR
-increased diastolic BP
-narrowed pulse pressure
-increased sympathetic cholinergic sweating
-pt. is pale, thirsty, and cool |
|
|
Term
| What compensatory mechanisms might you see with loss of contractility and increased ESV? |
|
Definition
increased SVR to maintain BP
pt. is pale, thirsty, and cool |
|
|
Term
| Hypovolemic shock involves a primary derangement in _____. |
|
Definition
|
|
Term
| Cardiogenic shock involves a primary derangement in ______. |
|
Definition
|
|
Term
| Distributive shock involves a primary derangement in ______. |
|
Definition
|
|
Term
| Obstructive shock involves a primary derangement in _____. |
|
Definition
| SV (due to mechanical obstruction to preload) |
|
|
Term
| There is no one clinical or biological test to determine shock. If compensatory mechanisms are functioning early in shock, one may not see hypotension but instead an anxious patients maintaining a blood pressure. In these early stages (called preshock), symptoms can be subtle but provide an opportunity for early intervention. Waiting for full-blown shock leads to a loss of precious time, and an aggressive proactive approach should be pursued. |
|
Definition
|
|
Term
| What causes the cool skin associated with shock? |
|
Definition
| blood is shunted preferentially from nonessential organs (skin, GI tract) to the heart and brain |
|
|
Term
| In cardiogenic shock, left-sided heart failure manifests as __________ edema and right-sided heart failure manifests as ___________ edema. |
|
Definition
|
|
Term
| What type of shock is characterized by a "warm patient in shock?" |
|
Definition
|
|
Term
| What are potential causes of hypovolemic shock? |
|
Definition
traumatic hemorrhage
nontraumatic hemorrhage
volume loss |
|
|
Term
| What are potential causes of cardiogenic shock? |
|
Definition
dysrhythmias
cardiomyopathy
mechanical (valvular, ruptures) |
|
|
Term
| What are potential causes of distributive shock? |
|
Definition
anaphylaxis
sepsis
neurogenic
drug-induced vasodilation
adrenal insufficiency |
|
|
Term
| What are potential causes of obstructive shock? |
|
Definition
tension pneumothorax
pericardial disease (tamponade, pericarditis)
massive PE
auto PEEP from mechanical ventilation |
|
|
Term
| What is first priority in managing shock? |
|
Definition
| maintain vital functions while exploring the potential cause |
|
|
Term
| What are indications for endotracheal intubation in shock? |
|
Definition
pt. cannot protect the airway
GCS <9 in trauma
extremes of respiratory rate
hypoxic despite supplemental oxygen |
|
|
Term
| What is a reasonable next step after ABCs have been evaluated, overt causes have been addressed, and the patient is not in severe pulmonary edema? |
|
Definition
| fluid challenge with 20 cc/kg of isotonic crystalloid |
|
|
Term
| What is a contraindication for a fluid challenge in a patient in shock? |
|
Definition
| pulmonary edema due to cardiogenic shock |
|
|
Term
| What labs need to be obtained in shock? |
|
Definition
CBC
coagulation studies
electrolytes
BUN, Cr
ABGs
serum lactate
blood cultures (septic)
cardiac enzymes (cardiogenic)
type and crossmatch
UA |
|
|
Term
| _______ blood gas and _________ ________ may be inaccurate in shock. |
|
Definition
|
|
Term
| What is usually the best way to stop external hemorrhage? |
|
Definition
|
|
Term
| What does shock from hemothorax or hemoperitoneum require? |
|
Definition
| urgent operative intervention |
|
|
Term
| What should be done for massive blood loss from a pelvic fracture? |
|
Definition
| manual stabilization in a sling |
|
|
Term
| How should femur fractures be managed to control bleeding? |
|
Definition
| splint with external traction device |
|
|
Term
| What is the best crystalloid to give in shock? |
|
Definition
|
|
Term
| When should blood be given to a patient in hemorrhagic shock? |
|
Definition
| early if not readily responding to crystalloid infusion of 40 cc/kg |
|
|
Term
| What type of blood should be given for immediate need in an unstable patient? |
|
Definition
| un-crossmatched O-negative packed RBCs |
|
|
Term
| What does nontraumatic hemorrhagic shock require? |
|
Definition
| operative intervention (ectopic pregnancy, ruptured AAA, GI bleed) |
|
|
Term
| What is the treatment for hemorrhagic shock due to GI bleed? |
|
Definition
NG tube placement
PPI
H2 blockade
octreotide infusion (variceal bleed) |
|
|
Term
| Shock from fluid loss or third spacing should respond to _________ infusion. |
|
Definition
|
|
Term
| What are the signs of successful initial resuscitation? |
|
Definition
improved BP
improving level of consciousness
improving peripheral perfusion
decreased tachycardia
decreasing lactate
normalizing pH |
|
|
Term
| Cardiogenic shock from tachydysrhythmias should be treated with __________. |
|
Definition
|
|
Term
| How are bradydysrhythmias treated? |
|
Definition
immediate transcutaneous pacing
atropine may be tried first |
|
|
Term
| What is the most common cause of cardiogenic shock? |
|
Definition
| MI (particularly anterior STEMI) |
|
|
Term
| What is the treatment for cardiogenic shock? |
|
Definition
-oxygen
-ASA
-heparin
-"gentle" fluid challenges (250 cc) if no overt pulmonary edema |
|
|
Term
| What medications should be avoided with cardiogenic shock? |
|
Definition
-nitrates
-beta blockers
-calcium channel blockers
-clopidogrel can be delayed (CABG likely) |
|
|
Term
| What is necessary in cardiogenic shock to guide therapy? |
|
Definition
| pulmonary artery catheter placement |
|
|
Term
| What drugs should be given in cardiogenic shock? |
|
Definition
| vasopressors (dopamine, NE, dobutamine) |
|
|
Term
| What patients are likely to be among the most challenging with regard to airway management in shock? |
|
Definition
|
|
Term
| What should patients with anaphylaxis and bronchospasm get? |
|
Definition
| beta agonist aerosol or epinephrine |
|
|
Term
| What is the treatment for anaphylactic shock? |
|
Definition
removal of any known antigen
early administration of epinephrine
beta agonist aerosol
H1 and H2 histamine blockade
steroids |
|
|
Term
| What can be done for mild cases of anaphylactic shock? |
|
Definition
| pt can be d/c after 6 hour observation with prescription for self-injector epi pen for future life-threatening symptoms |
|
|
Term
| Moderate to severe cases of anaphylactic shock require __________. |
|
Definition
|
|
Term
| What causes septic shock? |
|
Definition
| exaggerated release of inflammatory mediators causing widespread organ dysfunction |
|
|
Term
| What is the hallmark of septic shock? |
|
Definition
| SIRS (systemic inflammatory response syndrome) |
|
|
Term
|
Definition
2 or more of the following:
-temp >38C or <36C
-HR >90 bpm
-RR >20 or PaCO2 <32
-WBC >12,000 or <4,000 or >10% bands |
|
|
Term
| What organisms are most commonly the cause of septic shock? |
|
Definition
|
|
Term
| Who is at greatest risk for developing septic shock? |
|
Definition
trauma
wounds
diabetes
extremes of age
immunocompromised |
|
|
Term
| What toxin is associated with toxic shock syndrome? |
|
Definition
| TSST 1 (toxic shock syndrome toxin 1) |
|
|
Term
| What are the clinical manifestations of toxic shock syndrome? |
|
Definition
SIRS
hypotension
erythematous rash |
|
|
Term
| What is the treatment for septic shock? |
|
Definition
resuscitation
target antimicrobials
drainage of any abscess (if present)
early endotracheal intubation |
|
|
Term
| What is the best antibiotic choice for an immunocompetent patient in septic shock? |
|
Definition
3rd or 4th generation cephalosporin
vancomycin |
|
|
Term
| What type of antimicrobial therapy to immunocompromised patients require in septic shock? |
|
Definition
| overlapping coverage for gram-positive and gram-negative aerobes and anaerobes and possibly viral or fungal causes |
|
|
Term
| What 2 things are not recommended in septic shock? |
|
Definition
high-dose steroids
aggressive glucose control insulin therapy |
|
|
Term
| What is indicated as an adjunctive treatment for septic shock in those with severe sepsis and high risk of death? |
|
Definition
recombinant human-activated protein C
(drotrecogin alfa or RHAPC) |
|
|
Term
| What are contraindications for the use of RHAPC in septic shock? |
|
Definition
elevated baseline risk of bleeding
hx of recent surgery
intracranial hemorrhage |
|
|
Term
| What causes neurogenic shock? |
|
Definition
| loss of vascular tone due to paralysis from a cervical cord spinal lesion |
|
|
Term
| What is the treatment for neurogenic shock? |
|
Definition
-aggressive evaluation of other potential causes
-fluid challenge of 20 cc/kg x 2
-treat to endpoint of MAP >90 mmHg
-vasopressors with alpha activity (if volume replacement unsuccessful) |
|
|
Term
| What is the key point in neurogenic shock? |
|
Definition
| not assuming the cause is only neurogenic until all other sources of traumatic shock have been excluded |
|
|
Term
| What drugs can cause drug-induced vasodilation distributive shock? |
|
Definition
beta blockers
calcium channel blockers |
|
|
Term
| What is the hallmark of presentation of drug-induced shock? |
|
Definition
| hypotension and warm skin without any compensatory tachycardia |
|
|
Term
| What do you give for beta blocker toxicity? |
|
Definition
glucagon 5-10mg IV
then 2-5 mg/hour |
|
|
Term
| What can you give for calcium channel blocker toxicity? |
|
Definition
glucagon 5-10 mg IV, then 2-5 mg/hr
calcium gluconate 10% 10-20 cc |
|
|
Term
| How is tension pneumothorax diagnosed? |
|
Definition
clinically
-unilateral decreased breath sounds
-unilateral chest hyperresonance
-tracheal deviation
-respiratory distress and shock |
|
|
Term
| What are clinical manifestations of pericardial tamponade? |
|
Definition
hypotension
elevated JVP
pulsus paradoxus
Kussmaul's sign (inc. SBP w/inspiration) |
|
|
Term
| What is the best test for diagnosing pericardial tamponade? |
|
Definition
|
|
Term
| What are clinical manifestations of massive PE? |
|
Definition
chest pain
syncope
tachypnea
hypotension
signs of acute RV overload with JVD
EKG changes |
|
|
Term
| What is the treatment for massive PE? |
|
Definition
vasopressor (norepinephrine)
thrombolytics (if no contraindication)
immediate surgical embolectomy (if feasible) |
|
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