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What causes hypovolemic shock? (objective) - correct answers •Hypovolemic shock is due to reduced intravascular volume (reduced preload), which, in turn, reduces cardiac output •Can be broken into two causes: 1.Hemorrhage (bleeding from GI or trauma) 2.Other fluid loss (vomiting/diarrhea, burns, inadequate PO intake, third spacing) How should you initially treat hypovolemic shock? - correct answers - IV access and IV fluid bolus What causes cardiogenic shock? - correct answers •Cardiogenic shock is due to intracardiac causes of cardiac pump failure that result in reduced cardiac output (CO) •Types of cardiogenic shock:
- Cardiomyopathies
- Arrhythmias (atrial or ventricular)
- Mechanical abnormalities What evaluative test is needed in cardiogenic shock patients? - correct answers Echo Describe how cardiomyopathies cause cardiogenic shock - correct answers 1.MI with > 40% damage of LV or of any size when accompanied by severe extensive ischemia secondary to multi-vessel CAD 2.RV infarction
3.Acute exacerbation of heart failure in patients with severe underlying dilated cardiomyopathy 4.Stunned myocardium following prolonged ischemia or bypass 5.Myocardial depression secondary to progressive/advanced sepsis 6.Myocarditis What mechanical abnormalities can lead to cardiogenic shock - correct answers 1.Valvular defects: severe aortic or mitral valve insufficiency 2.Ventricular septal defects or rupture 3.Atrial myxomas: noncancerous primary heart tumor 4.Ruptured ventricular wall aneurysm What causes obstructive shock? - correct answers •Caused by extra-cardiac obstruction of blood flow (classified similar to cardiogenic shock) 1.Massive PE: CT chest with contrast is best, unless there is renal failure (V/Q scan) 2.Tension pneumothorax 3.Severe constrictive pericarditis/pericardial tamponade What causes distributive shock? - correct answers •Vasodilatory shock: consequence of SVR (severe peripheral vasodilatation)
- CO can increase Causes: 1.Septic shock (most common cause)
Compare and contrast SIRS, sepsis, and septic shock. - correct answers •SIRS: meets at least two of the criteria listed; SIRS is an inflammatory process (not necessarily always infectious) •Sepsis: SIRS (secondary to systemic response to infectious agent) and suggested infectious source (PNA, UTI); Sepsis is determined by the host immune system and the infecting organism •Severe sepsis: sepsis and end organ damage •Septic shock: severe sepsis and hypotension unresponsive to fluid resuscitation how is qSOFA interpreted? - correct answers •qSOFA: score ranges from 0 to 3 points •Presence of 2 or more qSOFA points near the onset of infection was associated with a greater risk of death or prolonged intensive care unit stay What determines SEVERE sepsis - correct answers •Sepsis plus organ dysfunction
- Neurologic: confusion, encephalopathy
- Lung: acute lung injury
- Heart: hypotension
- Liver: elevated AST/ALT and INR, hyperbilirubinemia
- Kidney: acute kidney injury, oliguria
- Hematologic: thrombocytopenia
- Metabolic: lactic acidosis Treatment for septic shock - correct answers •Antibiotics based on source (usually IV Zosyn and Vancomycin)
•IV fluids: 30 mL/kg •Trend lactic acid (< 4) •Trend vital signs (SBP > 90 mmHg) •Monitor cultures What is combined shock? - correct answers •All the different forms of shock can co- exist •Septic shock with hypovolemic shock (secondary to decreased oral intake/vomiting/diarrhea) with cardiogenic shock (secondary to septic component) and distributive shock (secondary to the effects of inflammatory process and cascades of anti-inflammatory processes on vascular permeability and vasodilation) What imaging may be considered when evaluating shock patients - correct answers •CTs of the head, chest, and/or abdomen with and without contrast •X-rays of chest and/or abdomen (KUB) •U/Ss of RUQ, abdomen, echo How can an EKG be helpful in shock evaluation? - correct answers •Helpful, especially early in the continuum of the disease process •If the patient is showing no evidence of disease, then the establishment of a normal EKG may be very telling if dynamic changes are established later in their course What labs may be considered in evaluation of shock - correct answers •CBC •BMP
How is circulation managed in a shock patient? - correct answers •Circulatory or hemodynamic stabilization begins with 2 large bore IV access (no smaller than 18 g)
- May need central access: PICC line, central line, or midline
- If a pressor is started, you need central access •+/- Trendelenburg position Describe where to place a central line, PICC line, and midline - correct answers •Central line: placed in femoral, IJ, or subclavian veins (central access) •PICC (peripherally inserted central catheter) line: placed in cephalic, basilic, brachial, or median cubital veins in the upper arm, and threaded so the catheter tip is in the lower segment of the superior vena cava (central access) •Midline: same veins as PICC but placed so that the catheter tip is near the level of the axilla (this is better than peripheral IV but not true central access) How long can a PICC line remain placed? what about a midline? What about peripheral IV catheters? - correct answers •PICC may remain 1 year •Midline may remain 6-8 weeks •As a comparison, peripheral IV catheters need to be changed every 72 hours What is used for fluid resuscitation in shock patients? what influences amount and rate of fluids? - correct answers •Isotonic crystalloid fluids (normal saline) •Amount and rate are determined by patient's presumed deficit, response to therapy, and age •Most commonly this will be a series of boluses
When are vasopressors used for hypotensive shock patients - correct answers •Used when there is an inadequate response to volume resuscitation or contraindications to volume repletion (fluid overload) •Most effect when there is vascular volume and least effect when volume is depleted •However, vasopressors may be provided prior to the completion of volume repletion (earlier in certain patients) What is the goal MAP for shock resuscitation with vasopressors - correct answers •Goal: restore MAP to > 65 mmHg
- This may reduce cardiac and neurological complications secondary to persistent compromise How do we avoid tissue ischemia when using vasopressors? - correct answers •Must have a central access to avoid tissue ischemic injury •Can decrease capillary blood flow in some areas of the body (particularly the gut) Know the dosing of the following pressors: Phenylephrine, norepinephrine, vasopressin, and dopamine - correct answers •Phenylephrine (Neo): 50-150 mcg/min •Norepinephrinie (Levo), Epinephrine: 5-20 mcg/min •Vasopressin: 0.04 U/min •Dopamine, Dobutamine: 5-20 mcg/kg/min
MOA of Phenylephrine (Neo-Synephrine) - correct answers •predominantly acts on alpha-adrenergic receptors, so it has considerable vasoconstriction
- No iontropic or chronotropic effects Indication for Phenylephrine in shock - correct answers •most commonly used for shock with tachycardia (i.e. Afib with RVR) MOA of vasopressin - correct answers •stimulates the AVPR1a (V1) receptor by causing vasoconstriction of vascular smooth muscle Indication for vasopressin - correct answers •normally not used by itself or as a first line, works great as an additive to Levophed MOA of dopamine - correct answers •stimulates both adrenergic and dopaminergic receptors
- Lower doses (< 10 mg) are mainly dopaminergic stimulating and produce renal and mesenteric vasodilation
- Higher doses (> 10 mcg) are alpha-adrenergic stimulating and produce vasoconstriction with increased SVR Indications for dopamine in shock - correct answers •cardiogenic shock, hypotension with bradycardia
MOA of dobutamine - correct answers •increases myocardial contraction and vasodilation in order to improve cardiac output and mesenteric and renal blood flow
- Can cause hypotension to worsen Indication for dobutamine for shock - correct answers •septic shock with depressed cardiac function and/or cardiogenic shock What should be done for extravasation of vasopressor agents - correct answers •Any extravasation (infiltration) of vasopressor agents necessitates prompt, local administration of phentolamine and the cessation of the agent due to tissue necrosis risk What should be done for shock patients not responding to pressors - correct answers consider adding:
- Stress dose steroids to treat adrenal insufficiency, check cortisol level (may lead to ACTH stim test)
- Sepsis protocol: Vitamin C, thiamine, and IV Solu-cortef (IV steroid) What is the goal SpO2 for shock patients? - correct answers •Ensure that peripheral oxygen saturation has returned to 92% or greater
- Best observed with reliable monitoring: ABG/VBG, SpO2 (pulse ox) What is the use of arterial line in shock management - correct answers •radial and femoral arteries, great for frequent ABGs and to monitor arterial blood pressures
•If EtCO2 is high (i.e., accumulating too much between breaths), begin by ventilating at a slightly faster rate Describe the use of pulmonary artery catheterization in shock management what is it indicated for? - correct answers •Pulmonary Artery Catherization (Swan- Ganz catheter): allows direct, simultaneous measurement of pressures in the right atrium, right ventricle, pulmonary artery, and the filling pressure (wedge pressure) of the left atrium
- The most common indications for PAC placement are the evaluation and/or management of patients with unexplained or unknown volume status in shock, severe cardiogenic shock, and suspected or known pulmonary arterial hypertension Describe the use of echo in shock management - correct answers •check for EF and any other cardiac abnormalities What labs should be monitored while treating shock? - correct answers •Urine output
- Low urine output could be lack of perfusion to kidneys •Trend lactic acid •Procalcitonin Recall the normal ranges and goals for SBP, MAP, CVP, lactic acid, urine output, SpO2, and EtCO2. - correct answers •Urine output: > 0.5 mL/kg/hr (35 mL/hour for average 70 kg adult) •Central venous pressure (CVP): 8-12 mmHg •MAP: > 65 mmHg
•SBP: > 90 mmHg •SpO2: ≥ 92% •EtCO2: 10-20 mmHg for adequate compressions, 35-45 normal •Lactic acid: < 4 What is the goal of fluid resuscitation? What are the consequences of failing to resuscitate? - correct answers •Fluid resuscitation maintains or corrects intravascular volume with the intention of supporting cardiac output for the purposes of tissue perfusion •Failure to perform this adequately can result in complications to the patient, particularly end organ damage and death Define hypovolemia - correct answers •any condition of extracellular volume reduction that, when severe, produces clinically appreciable reduction in tissue perfusion Why is intravascular volume important? How is intravascular volume regulated? - correct answers •Important for the transportation of nutrients (oxygen) and wastes to maintain body functions •Body normally tries to regulate intravascular volume with: ‒ADH and the kidneys (RAAS) ‒Thirst center ‒Baroreceptors
•It is the extracellular levels of electrolytes that we report clinically What minerals are important in the intracellular space? What minerals are important in the extracellular space? - correct answers •Intracellular space has large amount of potassium, moderate magnesium, little sodium, little chloride •Extracellular space (which includes interstitial and intravascular space) has large amount of sodium chloride and small amounts of calcium, phosphate, potassium, magnesium Describe how the extracellular space is further divided into additional compartments - correct answers •The intravascular compartment contains blood, which is essential to transport electrolytes, gases, nutrients, wastes, etc. throughout the body •The interstitial space (also called "tissue space") surrounds tissue cells and is filled with interstitial fluid, including lymph, continually being refreshed by the blood capillaries and recollected by lymphatic capillaries, allowing for movement of ions, proteins, and nutrients across the cell barrier •The transcellular compartment is a small part as well (about 1% of the extracellular space) What is interstitial fluid? What is its function? - correct answers •Interstitial fluid is the transport vessel (media) for electrolytes, gases, nutrients, wastes, etc. between the vascular compartment and cells in the body •Aids the body in times of hemorrhage and volume loss •It does this with a mucopolysaccharide gel/sponge like material that fills the tissue space, held by collagen fibers, and aids in even distribution of interstitial fluid, preventing the outflow of water from the capillaries
Describe the transcellular compartments and the function of transcellular fluid - correct answers •Portion of total body water contained within the epithelial-lined spaces •Examples: cerebrospinal fluid, ocular fluid, joint fluid, and pleural fluid‒All contain fluid that is only found in their respective epithelium-lined spaces •Function of transcellular fluid is lubrication of these cavities and electrolyte transport •Normally, 1% •Under certain health conditions, fluid can accumulate in these areas, called the "third space" Describe how third spacing occurs - correct answers •Unusual accumulation of fluid in a transcellular space or interstitial space from an intravascular space •Physiological concept that body fluids may collect in a "third" body compartment that isn't normally perfused with fluids •Regarded as the "third space" as it is not readily available for exchange with the rest of the extracellular fluid •Examples: pleural effusions, ascites, edema •In all its simplicity, volume restoration is easily relegated to three initial keys to survival: what are these? - correct answers 1.Crystalloids 2.Emergency release blood 3.Patient's blood type (delivered)
•"Liquid portion" of blood, 92% water •Protein salt solution in which RBCs, WBCs, and PLTs are suspended •55% of blood is plasma •Unconcentrated source of clotting factors, independent of the platelets What is the universal donor for FFP - correct answers •Unlike packed red blood cells, AB is the fresh frozen plasma universal donor −Their plasma does not contain the antibodies that may cross react with recipient antigens Indications for FFP - correct answers •Correction of bleeding that is likely due to factor deficiencies and reversal of anticoagulants −Coumadin: reversal is Vitamin K −Pradaxa: reversal is Praxbind −Eliquis and Xarelto: reversal is Andexxa •Can be used in angioedema (suggested by case reports, no controlled trials have been performed) What is cryoprecipitate? - correct answers •Fresh frozen plasma that has been thawed and then centrifuged and the precipitate is collected •Contains a concentration of clotting factors Indications for cryoprecipitate - correct answers −Hemophilia
−Von Willebrand's disease MC transfused blood product - correct answers RBCs Indications for RBC transfusion - correct answers •Generally, transfuse if Hgb < 7 g/dL or active blood loss •If an individual has hemodynamic instability from active blood loss, then immediate transfusion may be necessary (common in trauma) •Often crystalloid therapy is provided with blood transfusion What should be ordered when possible before blood transfusion? What type of blood is used if there is no time for this evaluation? - correct answers •Type and cross is important to get as soon as feasible •No time? Then emergency release blood (O negative) −Universal donor: O negative −Institution based guidance: PRBCs, FFP, PLT What is a massive transfusion and when is it used? - correct answers •Massive transfusion is > 10 units of blood in 24 hours •In a massive hemorrhage, do not forget the FFP and PLT −Big traumas will often get a ratio of 1:1:1 of RBCs, FFP, and PLT −Improved outcomes in these cases when administered earlier −Remember lethal triad in trauma
