question

determinants of cardiac output

answer

preload, afterload, contractility

question

4 determinantes of BP

answer

preload, afterload, contractility, heart rate

question

what clears lactic acid from body

answer

liver

question

lactic acid build up comes from

answer

shivering, grande mal seizure, sepsis

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no such thing as ______ with shock

answer

intervening too early

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three most important organs that the body preserves

answer

brain, lungs, kidneys

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tx for hyperkalemia

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best = 5-10 units regular insulin in 1 amp D50W (6 hours) short = calcium Lasix - why not? albuterol - last ditch effort Kayexalate dialysis

question

in sepsis, WBC could be

answer

increased or decreased

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look for _____levels for renal functions

answer

creatnine

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if creatnine levels are normal and BUN elevated, might be

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GI bleed

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fresh frozen plasma is given for

answer

clotting factors

question

preload problem associated with what kind of shock

answer

hypovolemic

question

afterload problems associated with what kind of shock

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distributive

question

contractility problems associated with what kind of shock

answer

cardiogenic

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if pt is tachypneaic

answer

acidodic

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pulmonary edema is unique to

answer

cardiogenic shock

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ignore

answer

ignore

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blood culture X2 means

answer

2 sites, 30 minutes apart

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if pt is septic _____ studies will be done

answer

coag

question

blood stasis in arterial system or venous capillary bed =

answer

decreased CVP and decreased PAP

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amacar inhibits

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clot degredation (no plasmin)

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ignore this card

answer

ignor

question

what is xigris

answer

activated protein c

question

xigris is given to

answer

inhibit thrombin formation in pts with sepsis

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xigris is also called

answer

drotrecogin alfa

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what is the class of dobutamine

answer

adrenergic direct acting B1 agonist

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why is dobutamine given for shock

answer

causes increased contractility, increased cardiac output without marked increase in heart rate

question

Lovenox is given for shock because

answer

anticoagulant (heparin)

question

hetastarch is a

answer

volume expander

question

three types of shock

answer

hypovolemic, cardiogenic, distributive

question

three types of distributive shock

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anaphylaxis, neurogenic, sepsis

question

Impaired tissue perfusion occurs when

answer

an imbalance develops between cellular oxygen supply and cellular oxygen demand

question

All Types of shock eventually result in

answer

impaired tissue perfusion & the development of acute circulatory failure or shock syndrome

question

in shock, cells switch from _____ metabolism to _____ metabolism

answer

aeorobic to anaerobic

question

describe patho of shock

answer

aerobic to anaerobic ----> lactic acid------> cells function ceases and swells--->membrane more permeable----->electorlytes and fluids seep in and out of cell------->Na+/K+ impaired-------> mitochodrial death and cell damage

question

four stages of shock

answer

Initial stage Compensatory stage Progressive stage - Irreversible or refractory stage -

question

initial stage of shock

answer

tissues are under perfused, decreased CO, increased anaerobic metabolism, lactic acid is building

question

compensatory stage of shock

answer

Reversible. SNS activated by low CO, attempting to compensate for the decrease tissue perfusion.

question

progressive stage of shock

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Failing compensatory mechanisms: profound vasoconstriction from the SNS ISCHEMIA Lactic acid production is high metabolic acidosis

question

Irreversible or refractory stage of shock

answer

Cellular necrosis and Multiple Organ Dysfunction Syndrome may occur DEATH IS IMMINENT!!!!

question

cardiovascular effects of shock

answer

No input equals no output. Shock is a CV stressor. Coronary artery disease can produce ischemia, arrhythmias, etc. Acidosis and hypoperfusion depresses myocardial function and impairs the ability to vasoconstrict.

question

pulmonary effects of shock

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Blood that does not go through the lungs does not get gas exchange. Oxygen falls; CO2 builds up. Acidosis, air hunger, and hyperventilation ensue. Shock lung may develop.

question

gastrointestinal effects of shock

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Stress ulcers, transmigration of gut flora into the blood stream, and liver dysfunction may develop

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neurologic effects of shock

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Altered level of consciousness and dysregulation of blood pressure by the vasomotor center in the brain.

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renal effects of shock

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Acute tubular necrosis may occur after only 20 minutes of hypoperfusion. Renal failure produces hyperkalemia, acidosis, and other derangements of fluid and electrolyte balance.

question

tests for shock

answer

Blood gases Blood count (WBC, H&H) Electrolytes Renal function Liver function Cardiac enzymes, EKG Lactic acid levels CXR

question

nursing monitoring for shock

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Frequent vital signs and assessment Foley CPV +/- Swan-Ganz Catheter Arterial line (almost always with pressors)

question

general tx for shock

answer

Fluids First! "Dopamine don't work on an empty tank." Usually crystaloids. No proven advantage with colloids. blood xfusion pressors

question

special note about calcium and blood transfusion

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frequent tranfusion tends to produce hypocalcemia by binding free calcium in the recipient's blood despite fact that calcium based product is added to blood

question

pressors are only given in what unit of hospital

answer

ICU or step down

question

pressors are almost always given through

answer

central IV

question

if pressor is given in peripheral IV, must be

answer

monitored very frequently. Infiltration of dopamine and Levophed can cause tissue necrosis

question

if a pressor infiltrates

answer

stop the infusion, disconnect the line and aspirated from the hub. Then pull the catheter and start new IV. Then call the MD

question

If a vasoactive agent infiltrates

answer

Regitine (phentolamine) 5-10 mg in 10 ml NS should be infiltrated into the site in no more than 12 hours.

question

pressors should always be given using a

answer

pump

question

piggyback pressors?

answer

Usually not piggybacked with anything else (problems with rate changes, compatibility, etc

question

_____and _______are common side effects of pressors

answer

Tachycardia and arrhythmias

question

note for subq meds like Insulin given when someone is receiving pressors

answer

Subq meds like insulin may not as readily absorbed with intense vasoconstriction

question

hypovolemic shock is a ______problem cardiogenic shock is a ______ problem distributive shock is a _______problem

answer

hypovolemic shock is a volume problem cardiogenic shock is a pump problem distributive shock is a vessel problem

question

most common causes of hypovolemic shock

answer

Hemorrhage Dehydration (Third Spacing)

question

Third-space losses are common in

answer

postoperatively and in patients who have intestinal obstruction, pancreatitis, or cirrhosis.

question

Major examples of third spaces include

answer

the peritoneal cavity and pleural cavity.

question

pathophysiology of hypovolemic shock

answer

Decreased intravascular volume leads to.... Decreased venous return (Preload) leads to... Decreased ventricular filling (Preload, PAWP) leads to.... Decreased stroke volume (HR, Preload, & Afterload) leads to ..... Decreased CO(cardiac output) leads to...(Compensatory mechanisms) Inadequate tissue perfusion

question

15% fluid loss (750mL)=

answer

compesatory mechanism maintains CO (cardiac output)

question

15-30% fluid loss (750-1500mL) =

answer

hypoxemia, decreased BP & UOP

question

30-40% fluid loss (1500-2000mL)=

answer

impaired compensation and profound shock along with severe acidosis

question

40-50% fluid loss

answer

refractory stage loss of volume = death

question

clincal presentation of hypvolemic shock

answer

Tachycardia and tachypnea Weak, thready pulses Hypotension Skin cool & clammy Mental status changes Decreased urine output: dark & concentrated

question

what caution should be exercised with hematocrit

answer

may take up to 72 hours to equilibrate

question

tx for hypovolemic shock

answer

Crystaloids: Normal Saline, Lactated Ringers Blood as indicated

question

causes of cardiogenic shock

answer

Most common cause is anterior MI May also be obstructive (cardiac tamponade, pulmonary embolism, tension pneumothorax)

question

patho of cardiogenic shock

answer

Falling cardiac output (LV failure) leads to falling cardiac output and blood pressure Pulmonary congestion and right-sided heart failure follow left-sided heart failure

question

lungs for hypovolemic shock

answer

clear with air hunger

question

lungs for cardiogenic shock

answer

rales, rhonchi

question

tx for cardiogenic shock

answer

Fix volume first - "Dopamine don't work on an empty tank." Revascularization (stent, CABG) as indicated. Address PE, pneumothorax as indicated. Pressors - Levophed or dopamine IABP (intra-aortic balloon pump)

question

distributive shock overview

answer

Inadequate perfusion of tissues through maldistribution of blood flow Intravascular volume is maldistributed because of alterations in blood vessels Cardiac pump & blood volume are normal but blood is not reaching the tissues

question

types of distributive shock

answer

Anaphylactic Shock Neurogenic Shock Septic Shock (Most Common)

question

sepsis syndrome represents

answer

the systemic inflammatory response triggered by an infection in the host and is mediated by chemical messengers

question

manifestations of sepsis syndrome

answer

Tachycardia, tachypnea, fever, and immune system activation

question

Systemic inflammatory response syndrome (SIRS) - a non-specific insult that includes ≥ 2 of the following symptoms:

answer

Temperature > 38 C or 90 beats/min Respiratory rate > 20/min, or paO2 12,000/mm3 or 10% bands

question

warm then cold is specific to

answer

septic shock

question

tx for septic shock

answer

Fix volume first - "Dopamine don't work on an empty tank." Find and treat infectious agent aggressively Pressors - Levophed or dopamine Glycemic control (BS<150) elevated blood sugar has a procoagulant effect and impairs neutrophil function Nutritional support - sepsis burns calories

question

what is the surviving sepsis resuscitation bundle 6 h

answer

measure lactate----------> culture----->antibiotics----->BP fluids 20-30 mL /kg and pressors MAP >65---------->CVP >8 and SvcO2> 70%

question

pt is sepsis or septic shock often in state of

answer

fluid deficit

question

on average how much fluid needed in first 6 hours of resuscitation

answer

5 liters

question

Sepsis CVP should be maintained at a level of

answer

8-12 mmHg

question

CVP intubated pt with positive pressure ventilation level should be

answer

12-16mmHg

question

D-Dimer is indication of

answer

recent coagulation

question

D-Dimer is usless if recent

answer

surgery

question

tx of DIC

answer

Treat the underlying cause Heparin to slow coagulation Replenish clotting factors Supportive care

question

blood is primarily in the

answer

venous system

question

if more than____ vital organs shut down, there is a VERY high mortality rate

answer

3

question

definition of shock is

answer

is a condition in which the cardiovascular system fails to perfuse tissues adequately

question

An impaired cardiac pump, circulatory system, and/or volume can lead to

answer

compromised blood flow to tissues

question

pulmonary capillary wedge pressure is really a measure of function of

answer

left atrium

question

jugular venous pulse is measure of function of

answer

right atrium

question

in all types of shock, everything goes down except

answer

heart rate which goes up in all types and pulses and skin temp is different

question

what happens with pulses in shock

answer

hypovolemic and cardiogenic pulses go down septic goes up then down

question

what happens with skin temp in shock

answer

hypovolemic and cardiogenic is cool septic is warm then cool

question

sepsis is triggered by

answer

inflammation

question

SIRS stands for

answer

systemic inflammatory response syndrome

question

need two of the following criteria to get SIRS

answer

temp 100.4 (36 / 38 Celsius) RR > 20 or PACO2 < 32 mmHg WBC 12000 (may also see 10% bands) HR > 90

question

definition of Sepsis

answer

SIRS + presumed/ known source

question

definition of severe sepsis

answer

sepsis + organ hypoperfusion

question

septic shock definition

answer

sepsis + shock refractory to fluid resucitation

question

tx of sepsis

answer

early recognition antibiotics fluid resucitation source removal

question

examples of colloids are

answer

blood, plasma, albumin

question

examples of crystalloids are

answer

NS, ringer's lactate, dextrose

question

in cardiogenic shock the heart loses ___% of it's pumping ability

answer

40%

question

the most common etiology for cardiogenic shock is

answer

MI with left ventricular failure

question

A telltale symptom of cardiogenic shock is a systolic blood pressure less than

answer

90 mmHg

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