shock syndromes - dr sing (copy)

2 hours = 10 questions

what kind of shock is this:

inadequate venous return due to reduced intravascular volume

a. hypovolemic

b. cardiogenic

c. obstructive

d. vasodilatory/distributive

a.

what kind of shock is this:

loss of pump (heart) function due to decreased cardiac contractility, valvular dysfunction, or arrhythmia

a. hypovolemic

b. cardiogenic

c. obstructive

d. vasodilatory/distributive

b.

what kind of shock is this:

extracardiac disruption in blood flow

a. hypovolemic

b. cardiogenic

c. obstructive

d. vasodilatory/distributive

c.

what kind of shock is this:

loss of vascular tone usually caused by sepsis

a. hypovolemic

b. cardiogenic

c. obstructive

d. vasodilatory/distributive

d.

explain hypovolemic shock

• extracellular volume depletion

  • from trauma, surgery, internal hemorrhage, etc.

• body responds by vasoconstriction of small vessels

• eventually leads to decreased CO

explain cardiogenic shock

• inadequate CO from cardiac dysfunction

  • caused by acute MI

• abrupt reduction of CO —> decr. MAP and DO2

• compensatory tachycardia and vasoconstriction

• left ventricle dilates to maintain SV

explain obstructive shock

• extracardiac obstruction of CV flow

  • impaired diastolic filling

    • preload is decreased

  • impaired systolic contraction

    • afterload is increased

explain vasodilatory/distributive shock

• systemic vasodilation

  • most commonly due to sepsis

• deficiency in vascular smooth muscle from activation of vasodilatory mechanisms or failure of vasoconstrictive pathways

explain how sepsis can lead to vasodilatory/distributive shock (septic shock)

• host immune response —> release of proinflammatory cytokines —> incr. NO production and vasodilation

  • lactate production and intracellular acidosis

    • cellular hyperpolarization and impaired vasoconstriction

  • incr. venous pooling and capillary leak lead to decr. preload and CO

in a hypovolemic shock state, what is the primary dysfunction?

a. decreased preload

b. decreased CO

c. decreased afterload

d. increased preload

a.

in a cardiogenic shock state, what is the primary dysfunction?

a. decreased preload

b. decreased CO

c. decreased afterload

d. increased preload

b.

in an obstructive shock state, what is the primary dysfunction?

a. decreased preload

b. decreased CO

c. decreased afterload

d. increased preload

b.

in a vasodilatory/distributive shock state, what is the primary dysfunction (both pre- and post-resuscitation)?

a. decreased preload

b. decreased CO

c. decreased afterload

d. increased preload

c.

tissue O2 consumption (VO2) is dependent on ______

DO2 (oxygen delivery to tissues)

T/F in shock, DO2 meets/exceeds VO2

FALSE - shock: DO2 does NOT meet VO2 needs

_______ can be used to assess adequacy of tissue oxygenation

venous oximetry

______ adrenoreceptors can be acivaed by exogenous catecholamines (drugs)

a. presynaptic

b. postsynaptic

b.

how does a patient with shock present?

• dizziness

• lightheadedness

• confusion

• decr. urine output

• obtundation (decr. alertness)

• tachycardia, tachypnea, hypotension

• impaired capillary refill (>3 seconds)

T/F a combined approach to diagnosis is necessary for early identification and classification of shock syndromes

TRUE

list tx goals for shock

1. correct underlying etiology

2. achieve and maintain adequate perfusion of tissues and organs

3. prevent end-organ damage associated with hypoperfusion

4. de-escalate/wean therapies when possible

5. decr. morbidity and mortality associated with shock

list the four phases of treatment

1. salvage

   1. identify/correct underlying etiology

   2. maintain minimum MAP and CO

2. optimization

   1. ensure adequate organ perfusion and DO2

3. stabilization

   1. prevent further end-organ damage

4. de-escalation

   1. facilitate recover and wean fluids/vasopressors

list the mainstays of therapy

1. correct underlying cause of shock

2. fluid resuscitation

3. vasopressor therapy

________ access for FLUID administration is a priority

IV

if large volumes of fluid are indicated, what is preferred?

2 IV catheters

large-bore peripheral IV lines

_______ access is preferred for VASOPRESSOR administration

central venous catheter

when does management/assessment of supportive/preventative care (pain mgmt, immobility assessment, sleep mgmt, etc.) take place?

a. salvage

b. optimization

c. stabilization

d. de-escalation

c.

what is the goal MAP typically targeted?

> 65 mmHg

T/F targeting absolute values of CO, SvO2, and ScvO2 is recommended

FALSE - don’t target absolute values

if blood pressure/perfusion goals cannot be achieved with fluid resuscitation alone, what do we do?

a. more fluid

b. vasopressors

c. diuretics

d. fluid restriction

b.

how is responsiveness to fluids defined?

SV or CO increase of >10%

what is preferred to assess fluid responsiveness?

a. BP

b. CVP

c. PaO2

d. dynamic markers (pulse pressure variation, passive leg raising test)

d.

what nonpharm therapy is done for all shock patients?

secure airway and ventilation

the goal of fluid resuscitation is to _______

increase venous return (preload)

________ are generally the initial fluid of choice

a. isotonic crystalloids

b. colloids

c. blood products

a.

relatively _________ are recommended for resuscitation

what is the exception?

relatively large volumes

except in cardiogenic shock

_______ are first-line for volume expansion in shock

isotonic crystalloids

what crystalloids are preferred?

saline solutions with Na concentrations nearing normal Na serum concentration

list the crystalloid products

• 0.9% sodium chloride (NS)

• lactated ringer’s (LR)

• plasma-lyte A

• 3% sodium chloride

• 5% dextrose/0.45% sodium chloride

• 5% dextrose

the use of colloids is controversial, but how do we use them?

replacement or conjunction with crystalloids

what is the theoretical advantage of using colloids over isotonic crystalloids?

less loss to interstitial space

incr. intravascular oncotic pressure

list the colloid products

• 5% albumin

• 25% albumin

• hydroxyethyl starch

• dextran

what kind of shock are blood products typically reserved for?

hemorrhagic shock

when using blood products, a conservative transfusion threshold of Hgb ≤ _____ g/dL is typically recommended

a. 5

b. 7

c. 9

d. 11

b.

list the blood products

• packed red blood cells (pRBCs)

• fresh frozen plasma

• platelets

• cryoprecipitate

• prothrombin complex concentrates (PCCs)

in sepsis _______ crystalloid is recommended within 3 hours of shcok recognition

30 mL/kg

T/F excessive fluid administration is associated with higher mortality

TRUE

until the bleeding source is controlled (hemorrhagic/traumatic shock), what is goal MAP and SBP?

MAP ≤ 60 mmHg

SBP ≤ 90 mmHg

_______ may reduce all-cause mortality in trauma/TBI patients

tranexamic acid (antifibrinolytic)

_______ induces vasoconstriction note: he said they’re used interchangeably

a. vasopressor

b. inotrope

a.

________ increases cardiac contractility note: he said they’re used interchangeably

a. vasopressor

b. inotrope

b.

when are vasopressors/inotropes required?

resuscitation is not/no longer indicated or fails to achieve BP goal

how do we choose what vasopressor/inotrope to use?

basically just follow the institution’s protocol

what are the only vasopressors/inotropes that are commercially available premixes? (SATA)

a. dopamine

b. norepinephrine

c. phenylephrine

d. dobutamine

a. d.

how do you treat/reverse peripheral vasoconstriction from an extravasation-associated tissue injury?

intradermal phentolamine (alpha-antagonist), or

topical nitroglycerin paste

what is the first line vasopressor in most shock states?

a. norepinephrine (levophed)

b. epinephrine (adrenalin)

c. phenylephrine (biorphen; vazculep; neo-synephrine)

d. dopamine

a.

in septic shock, when do we give norepinephrine?

MAP ≥ 65 not achieved with fluid resuscitation

what is a catecholamine/adrenergic agonist with strong vasopressor effect, increases SVR, and causes reflex bradycardia?

norepinephrine

what is a catecholamine/adrenergic agonist that has strong inotropic effect at low doses and strong vasopressor effect at high doses (high doses are needed in shock)?

epinephrine

what vasopressor is superior in young adults?

epinephrine

what vasopressor has increased hyperlactatemia and hyperglycemia compared to others?

epinephrine

what is a sympathomimetic amine/adrenergic agonist with primarily vasopressor effect?

phenylephrine

what vasopressor is an option in shock patients with tachyarrhythmia?

phenylephrine

what is a catecholamine/adrenergic agonist with more inotropic effect in low doses and vasopressor and inotropic effect in moderate-high doses, and not as effective at achieving MAP goals?

dopamine

what vasopressor impedes gastric motility and can lead to gut ischemia?

dopamine

what is a synthetic catecholamine/adrenergic agonist with primarily inotropic effect?

dobutamine

what vasopressor has a larger increase in CO and is used in cardiogenic shock?

dobutamine

what primarily has vasopressor effect leading to incr. SVR and promotes H2O retention in distal tubules and collecting ducts?

vasopressin

________ is used as add on in distributive shock if not meeting goals with norepinephrine alone

vasopressin

what ha primarily vasopressor effect and is used in refractory distributive shock?

angiotensin II (Giapreza)

what effect do low-dose corticosteroids have in vasopressor-dependent shock?

• improves hemodynamics

• leads to more rapid shock reversal

• shortens duration of vasopressor support

what can be added to NE/vasopressin regimens in septic shock still requiring moderate-high dose NE?

IV hydrocortisone

list the steps of integrated shock management

• prioritize ABCs

• identify underlying cause

• if fluid responsive administer initial fluid challenge (crystalloids preferred)

• if unresponsive to fluids initiate vasopressor/inotropic therapy

if pt responds to initial therapy of vasopressors/inotropes, what do we do when taking them off?

slowly wean, titrate down every 10 minutes