Shock Notes3

Shock Study online at quizlet.com/_1b5yot 1.

4 ways to arrive at cellular hypoxia (shock)

—hypovolemia, cardiac dysfunction, vascular failure, or obstructive processes that impair cardiac filling.

2.

big overview of shock (key point, Dx, etc)

A state of organ hypoperfusion with resultant cellular dysfunction and death. ● Mechanisms may involve decreased circulating volume, decreased cardiac output, and vasodilation, sometimes with shunting of blood to bypass capillary exchange beds. ● Symptoms include altered mental status, tachycardia, hypotension, and oliguria. ● Diagnosis is clinical, including BP measurement and sometimes markers of tissue hypoperfusion (eg, blood lactate, base deficit). ● Treatment is with fluid resuscitation, including blood products if necessary, correction of the underlying disorder, and sometimes vasopressors.

3.

pro tip: it's important to recognize when shock is coming!

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4.

Shock- Pathophysiology

● Reduced perfusion -> hypoxia -> anaerobic metabolism ○ Lactic acidosis -> cell damage -> cell death ● Inflammatory and clotting cascades triggered ○ cytokines, leukotrienes, tumor necrosis factor, Nitric oxide ("cytokine storm" in influenza A, H1N1) ● Vasodilation -> hypotension -> hypoperfusion ● Leukocyte and platelet adhesion to endothelium ○ clotting system activation with fibrin deposition ● Endothelial cell dysfunction -> inc microvascular permeability (causes microvascular permiability, leads to third space, leads to hyptension) ○ third space, translocation of enteric bacteria (gives peritonitits) ● Neutrophil apoptosis inhibited -> increases inflammatory mediators (shock is overwhelming display of force) PRO TIP -- so not only do we need to think about fluids, but a ton of other things.

5.

pathophysiology cont.

Compensation ● inc oxygen extraction ● adrenergic and sympathetic mediated vasoconstriction and tachycardia ○ inc cardiac output ● release of corticosteroids, renin, glucose

6.

Graphic Organizer

7.

multiple organ dysfunction

Most common in septic shock 10% of pts with severe traumatic injury Lungs inc membrane permeability alveoli dysfunction and inflammation hypoxia, acute lung injury, ARDS ● Kidneys ○ acute tubular necrosis -> ARI ● Heart ○ dec. contractility and compliance ○ dec. cardiac output ● GI tract ○ ileus, submucosal hemorrhage, hepatocellular necrosis, dec. production of clotting factors

8.

shock sxs

● Lethargy, confusion, and somnolence are common. ● Pale, cool, clammy, and often cyanosis ○ earlobes, nose, and nail beds. ○ capillary filling time is prolonged ● Diaphoresis ● Peripheral pulses are weak and rapid (Kuhn likes to feel radial pulse); ○ only femoral or carotid pulses are palpable. ● Tachypnea and hyperventilation ● BP low (< 90 mm Hg systolic) or unobtainable ● Urine output is low.

9.

shock index (used in trauma, used to clue us into shock)

Shock Index hypovolemic shock HR / SBP (HR divided by systolic BP) 0.5 - 0.7 normal

SIRS (also used) (systemic inflammatory response syndrome)

● Temperature 38°C (100.4°F) ● Heart rate >90 beats per minute ● Tachypnea > 20 breaths per minute ● White blood cell count 12,000 cells/mm³ or the presence of greater than 10% immature neutrophils (band forms) 2 OR MORE CRITERIA PRESENT (should lead to evaluation to make sure)

10.

SIRS

Infectious and Noninfectious ● Sepsis ● Trauma, burns, pancreatitis, ischemia, and hemorrhage ● Complications of surgery ● Adrenal insufficiency ● Pulmonary embolism ● Complicated aortic aneurysm ● Cardiac tamponade ● Anaphylaxis ● Drug overdose

11.

HYPOVOLEMIC SHOCK

Decrease in intravascular volume, decreased preload > reduced stroke volume. * Hemorrhage ● Increased losses body fluids ● Inadequate fluid intake

12.

Signs of Successful Resuscitation

1. 2. 3. 4. 5. 6.

13.

Hypovolemic Shock- Treatment

Stop bleeding or fluid loss Crystalloid infusion 20cc/kg IV bolus which is a good couple liters (lactated ringers...most use normal saline except in someone hypovolemic due to renal failure?!?!) no advantage to colloids (eg, albumin, blood is a colloid) Reassessment Massive transfusion protocols PRBCs : FFP : Platelet : cryoprecipitate (I think he said that now they do a 1:1:1:1 kinda thing)

14.

CARDIOGENIC SHOCK

Reduction in Cardiac Output primary cardiac disorder

Improved blood pressure Improving level of consciousness Improving peripheral perfusion Decreasing tachycardia Decreasing lactate Normalizing pH

15.

Cardiogenic Shock Tx:

Cardiogenic Shock- Treatment Tachydysrhythmias- cardioversion Bradydysrhythmias- pacing STEMI- revascularization Supportive: ASA, O2, Heparin Vasopressors (for hypovolemic shock): Norepinephrine, Dobutamine, Dopamine

16.

pro tip: when you see multiple organ failure....TREAT AGGRESSIVELY

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17.

Pro Tip: 3 most common 'pressors >>

Norepinephrine, Dobutamine, Dopamine

18.

Vasoactive receptors

Alpha-1 adrenergic receptors sympathetic nerve endings on smooth muscle cells and on myocardial cells Alpha-2 adrenergic receptors systemic vasculature leads to vasoconstriction and increased systemic blood pressure β1 and β2-adrenergic receptors both located within the myocardium β2 receptors also being located vascular and bronchial smooth muscle. positive ionotropic and chronotropic effects within the myocardium smooth muscle relaxation in the bronchial tree and elsewhere Dopamine receptors smooth muscle of renal, splanchnic, coronary, and ' cerebrovascular beds vasodilation within these vascular beds

19.

drugs affecting which receptors

(i think he said norepinephrine is the go to in ED)

20.

DISTRIBUTIVE SHOCK

Distributive Shock Dec. intravascular volume caused by arterial or venous vasodilation Anaphylaxis Endotoxin induced sepsis Spinal cord injury Drugs: nitrates, opioids, Viagra

21.

ANAPHYLACTIC SHOCK (remember this is on a spectrum)

Airway: angioedema and bronchospasm EpiPen Beta- agonist aerosol (albuterol is most common) H1 and H2 blockers (H1...benadryl.....H2 ranitidine) Steroids (prednisone...classic orally....dexamethasone for kids.....sodium hydrol IV?!)

22.

NEUROGENIC SHOCK (high thoracic or cervical injury..........legs and or arms can't move)

Loss of vascular tone from high spinal lesion loss of feedback loop from autonomic ganglia Warm skin, hypotension, +/- tachycardia Fluids and vasopressors with alpha activity

23.

SEPTIC SHOCK (Key points)

SIRS ● Temperature 38°C(100.4°F) ● Heart rate >90 beats per minute ● Tachypnea > 20 breaths per minute ● White blood cell count 12,000 cells/mm³ or the presence of greater than 10% immature neutrophils (band forms) 2 or more criteria present SIRS + infection = sepsis Sepsis + organ dysfunction = severe sepsis Sepsis + cellular hypoxemia = septic shock

24.

septic shock (points)

SIRS associated with decreased SVR -> hyperdynamic compensation -> impaired contractility from myocardial depressants and hypoxemia. Elevated serum lactate levels (> 4) evidence of tissue hypoperfusion. Gram-negative rods (classic....E Coli...Pseudomonas) Fluids!!! (eg, 3 liters of fluid for the little old lady exampe.....in ER it's common to get 3 or 4 liters for sepsis mgmnt. Much more than you'd think is normal) Antibiotics --- early antibiotic, broad spectrum, even if it's the wrong one just do it and kinda hope you get lucky Steroids (maybe...that is, some do and some don't) Early goal directed therapy

25.

OBSTRUCTIVE SHOCK

Mechanical factors that interfere filling or emptying of the heart or great vessels. tension pneumo, cava compression, cardiac tamponade, atrial tumor or clot (mechanical interference with ventricular filling) Interference with ventricular emptying (PE)

26.

obstructive shock (Tx), Tension Pneumo

Tension pneumothorax dec breath sounds, tracheal deviation respiratory distress and shock needle decompression

27.

Tx: pericardial tamponade

Pericardial tamponade hypotension, JVD, muffled heart sounds Beck's triad Pericardiocentesis (Best way to Dx is ultrasound) * Not that common

28.

Tx: Massive PE

Chest pain, syncope, tachypnea, hypotension JVD, RV strain on EKG (and seen on echo) Surgical embolectomy Thrombolytics TPA works great for pt with large PE (not small or moderate PEs though) Also given to Pt in shock. Kuhn says he's seen TPA work in about 30 min. IV.

"very common"

29.

summary points

A state of organ hypoperfusion with resultant cellular dysfunction and death. ● Mechanisms may involve decreased circulating volume, decreased cardiac output, and vasodilation, sometimes with shunting of blood to bypass capillary exchange beds. ● Symptoms include altered mental status, tachycardia, hypotension, and oliguria. ● Diagnosis is clinical, including BP measurement and sometimes markers of tissue hypoperfusion (eg, blood lactate, base deficit). ● Treatment is with fluid resuscitation, including blood products if necessary, correction of the underlying disorder, and sometimes vasopressors.