Shock
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| Define shock | A state of inadequate organ perfusion and tissue oxygenation.
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| Give four causes of shock, with the most common listed first | Hemorrhagic, Cardiogenic, Neurogenic, Septic
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| Describe neurogenic shock | Hypotension without tachycardia or vasoconstriction (low, low, open)
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| What percentage of blood is in the venous system? | 70%
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| What is the earliest measurable circulatory sign of shock? | Tachycardia
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| The initial step in managing shock in injured patients is to | recognize its presence
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| The second step in managing shock in injured patients is to | identify the probable cause of the shock state
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| Identifying shock in trauma patients is directly related to | the mechanism of injury
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| How does tension pneumothorax produce shock? | by reducing venous return
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| What does not cause shock? | isolated brain injuries
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| Neurogenic shock results from extensive injury to | the CNS or Spinal Cord
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| Spinal cord injury causes shock via | vasodilitation and relative hypovolemia
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| Septic shock in trauma patients must be considered when | arrival at ER has been delayed by many hours
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| What is the most common cause of shock in the injured patient? | hemorrhage
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| Formula for Cardiac Output (CO) | CO = HR x SV
L/min = beats/min x cc/beat / 1000
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| Stroke Volume (SV) is determined by what three factors? | 1-Preload
2-Myocardial contractility
3-Afterload
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| Preload is determined by what three factors? | 1-venous capacitance
2-volume status
3-difference between venous systemic pressure and right atrial pressure
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| Volume of venous blood returned to heart determines | myocardial muscle fiber length after ventricular filling at end of diastole
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| Myocardial contractility is | the pump that drives the system
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| Afterload is | systemic (peripheral) vascular resistance to the forward flow of blood
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| Progressive vasoconstriction of ___ ___ ___ preserves blood flow to the ___ ___ ___. | cutaneous, muscle, and visceral circulation kidneys, heart, and brain
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| Acute circulating volume depletions leads to | increase in HR to preserve CO
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| Endogenous catecholamines increases | peripheral vascular resistance
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| Increased peripheral vascular resistance increases ____ and decreases ____ and does ____. | diastolic BP pulse pressure little to increase organ perfusion
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| Restore venous return to normal by ____ | volume repletion
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| Initial compensatory metabolic shift | anaerobic
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| Anaerobic metabolism leads to (2) | 1-formation of lactic acid
2-metabolic acidosis
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| Steps in cellular death (7) | 1-loss of cellular membrane integrity
2-swelling of ER
3-mitochondrial damage
4-lysosomes rupture and release digestive enzymes
5-Na and H2O enter cell
6-cell swells
7-intracellular calcium deposition occurs
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| What helps combat cell death? | isotonic electrolyte solutions
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| Three things to do in shock resuscitation | 1-oxygenation
2-ventilation
3-fluid resuscitation
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| Goals in treatment of hemorrhagic shock (2) | 1-control of hemorrhage
2-restoration of adequate circulating volume
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| Contraindicated in treatment of hemorrhagic shock | vasopressors
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| Most injured patients with hypovolemic shock | require a surgeon
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| Two categories of shock | 1-hemorrhagic
2-non-hemorrhagic
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| Attention to shock directed to (4) | 1-pulse rate
2-respiratory rate
3-skin circulation
4-pulse pressure
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| Two earliest physiologic responses to volume loss | tachycardia and cutaneous vasoconstriction
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| Patient is cool and tachycardic | in shock until proven otherwise
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| Tachycardia in infant | > 160
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| Tachycardia in preschool-age child | > 140
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| Tachycardia in children from school age to puberty | > 120
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| Tachycardia in adult | > 100
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| Elderly patients may not exhibit tachycardia in shock because of (3) | 1-limited cardiac response to catecholamine stimulation
2-concurrent use of medications (B-blockers)
3-pacemaker
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| Hg and Hct for estimating acute blood loss | unreliable
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| Primary focus in hemorrhagic shock | identify and stop hemorrhage promptly
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| Five types of nonhemorrhagic shock | 1-cardiogenic shock
2-cardiac tamponade
3-tension pneumothorax
4-neurogenic shock
5-septic shock
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| Myocardial dysfunction may be caused by (4) | 1-blunt cardiac injury
2-cardiac tamponade
3-air embolus
4-myocardial infarction
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| Blunt cardiac injury suspected with MOI | rapid deceleration
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| Cardiac tamponade and pericardial fluid can be determined by | FAST
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| Four signs of Cardiac Tamponade | 1-tachycardia
2-muffled heart sounds
3-dilated, engorged neck veins
4-hypotension resistant to fluid therapy
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| Temporarily relieves tension pneumothorax | needle decompression
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| Management of cardiac tamponade | 1-thoracotomy
2-pericardiocentesis (temporary)
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| Prevents return of air to lung in tension pneumothorax | flap-valve mechanism
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| How can spinal cord injury cause shock? | loss of sympathetic tone causing hypotension
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| Classic picture of neurogenic shock (2) | hypotension without (1) tachycardia or (2) cutaneous vasoconstriction
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| What do you not see with neurogenic shock? | a narrow pulse pressure
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| Septic shock may occur in patients with | penetrating abdominal trauma and contamination of peritoneum
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| Hemorrhage is defined as | an acute loss of circulating blood volume
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| Normal adult blood volume percent of body weight | 7
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| 70 kg male has circulating blood volume of approximately | 5 L
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| Blood volume of obese patients | based on ideal weight
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| Blood volume for child calculated as | 8 to 9% of body weight (80-90 mL/kg)
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| Volume replacement is guided by | patient's response to initial therapy
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| Class I hemorrhage characterstics | as if donated one unit of blood
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| Class II hemorrhage characterstics | uncomplicated, requiring crystalloid fluids
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| Class III hemorrhage characterstics | complicated, requiring crystalloid infusion and, perhaps, blood
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| Class IV hemorrhage characterstics | preterminal, patient will die within minutes
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| Blood loss (mL) in hemorrhage classes | I up to 750
II 750-1500
III 1500-2000
IV > 2000
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| Blood loss (%) in hemorrhage classes | I up to 15%
II 15-30%
III 30-40%
IV >40%
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| Pulse rate in hemorrhage classes | I <100
II 100-120
III 120-140
IV > 140
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| Blood pressure in hemorrhage classes | I normal
II normal
III decreased
IV decreased
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| Pulse pressure in hemorrhage classes | I normal or increased
II decreased
III decreased
IV decreased
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| Respiratory rate in hemorrhage classes | I 14-20
II 20-30
III 30-40
IV > 35
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| Urine output (mL/hr) in hemorrhage classes | I >30
II 20-30
III 5-15
IV negligible
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| CNS/Mental state in hemorrhage classes | I slightly anxious
II mildly anxious
III anxious, confused
IV confused, lethargic
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| Fluid replacement in hemorrhage classes | I crystalloid
II crystalloid
III crystalloid and blood
IV crystalloid and blood
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| Fractured tibia or humerus blood loss may be | up to 750 mL
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| Fractured femur blood loss may be | up to 1500 mL
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| Amount of blood with pelvic fracture retroperitoneal hematoma | up to several liters
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| Nonresponse to fluid administration indicates (3) | 1-persistent blood loss 2-unrecognized fluid losses or 3-nonhemorrhagic shock
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| How do major soft tissue injuries and fractures compromise hemodynamics? | 1-blood lost into site of injury 2-edema in injured soft tissue
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| Tissue edema is result of fluid shift from | plasma into extravascular, extracellular space
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| Fluid shift results in | depletion of intravascular volume
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| What occurs simultaneously in shock? | the diagnosis and treatment
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| Three important factors in physical exam in shock | 1-vital signs 2-urinary output 3-level of consciousness
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| Priorities for circulation in shock (3) | 1-controlling obvious hemorrhage 2-obtaining adequate IV access 3-assessing tissue perfusion
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| When undressing the patient, it is essential to | prevent hypothermia
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| Gastric dilation may cause (2) | 1-unexplained hypotention 2-cardiac dysrhythmia (bradycardia from vagal stimulation)
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| Unconscious with gastric distenstion | rise of aspiration, could be fatal
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| Proger position of gastric tube ____ obviate risk of aspiration | does not
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| Bladder catheterization used for (2) | 1-assessment of hematuria 2-monitoring urinary output
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| Poiseuille's law | rate of flow proportional to the fourth power of radius of cannula, and inversely related to length
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| Best site for IV | forearms and antecubital veins
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| Central lines second best IV access location | femoral, jugular, or subclavian
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| Central line techniques (2) | 1-Seldinger 2-saphenous vein cutdown
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| In ER, central lines often not | sterile, and should be changed
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| Priority of IV access in kids under 6 | IV - IO - Central
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| Determinant for selecting proper IV access | experience and skill of doctor
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| After jugular or subclavian CVP | CXR
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| Usual fluid bolus | NS or LR, 1-2 L for adults, 20 mL/kg for kids
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| Ratio of crystalloid replacement to blood loss | 3-for-1 rule
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| Goal of resuscitation in shock | restore organ perfusion
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| If BP raised rapidly and bleeding not controlled | increased bleeding may occur
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| Fluid consideration in blunt trauma | avoid hypotention
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| Fluid consideration in penetrating trauma | control bleeding
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| Fluid resuscitation with continued bleeding referred to as (4) | 1-controlled resuscitation 2-balanced resuscitation 3-hypotensive resuscitation 4-permissive hypotension
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| Signs suggesting perfusion is returning to normal | 1-blood pressure 2-pulse pressure 3-pulse rate
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| Indicator of renal perfusion | volume of urinary output
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| pH status in early hypovolemic shock | respiratory alkolosis due to tachypnea
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| pH status in long-standing or severe shock | severe metabolic acidosis due to anaerobic metabolism
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| What should not be used for metabolic acidosis secondary to hypovolemic shock? | sodium bicarbonate
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| Key determinant of subsequent therapy | patient's response to initial fluid resuscitation
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| Differentiate hemodynamically stable vs hemodynamically normal | 1-stable: persistent tachycardia, tachypnea, and oliguria, underresuscitated and still inshock 2-normal: no signs of inadequate tissue perfusion
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| Tri-fold response to fluid administration | 1-rapid 2-transient 3-minimal or no
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| Main purpose of blood transfusion | restore oxygen-carrying capacity of intravascular volume
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| Blood product priority | Crossmatched, Type-specific, O (neg for females)
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| Blood for transient responders | Type-specific
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| Blood for rapid responders | Crossmatched
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| Can be warmed in microwave | crystalloids
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| Can not be warmed in microwave | blood products
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| How do you warm blood? | pass thru IV fluid warmer
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| Blood replacement with major hemothorax | autotransfusion
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| Most patient receiving blood transfusion ____require calcium supplementation. | do not
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| Ohm's Law | V (blood pressure) = I (cardiac output) x R (systemic vascular resistance
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| Increase BP ____equated with increase CO. | should not be
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| Elderly decrease in sympathetic activity | deficit in receptor response to catecholamins
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| Consideration in volume resuscitation in elderly | early invasive monitoring
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| Blood volume in athlete | may increase 15 to 20%
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| Cardiac output in athlete | may increase sixfold
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| SV in athlete | may increase 50%
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| Resting pulse in athlete can average | 50
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| Intoxicated trauma patient may have hypothermia due to | vasodilation
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| Hypothermia is best treated by | prevention
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| Most common complication of treating hemorrhagic shock | inadequate volume replacement
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| Most common cause of poor response to fluid therapy in shock | obscure hemorrhage
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| Ideal position for tip of catheter in central line | superior vena cava just proximal to RA
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| Risks of central line placement (6) | 1-infection 2-vascular injury 3-nerve injury 4-embolization 5-thrombosis 6-pneumothorax
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| CVP monitoring reflects | right heart function
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| Consider when patient fails to respond to therapy in shock | 1-cardiac tamponade 2-tension pneumothorax 3-ventilatory problems 4-unrecognized fluid loss 5-acute gastric distention 6-myocardial infraction 7-diabetic acidosis 8-hypoadrenalism 9-neurogenic shock
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| In trauma, assume shock is | hypovolemic
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| Basic management principle, again, in shock | stop the bleeding and replace the volume loss
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