Book Review CH 30-32

Q. What is the definition of shock?

A. Shock is a circulatory insufficiency that results in an imbalance between o2 supply and demand leading to global tissue hypoperfusion and metabolic acidosis

Q. What are the four classifications of shock?

A. 1. Hypovolemic (M/C) 2. Cardiogenic 3. Distributive 4. Obstructive

Q. What is the formula for MAP and how reliable is a normal BP reading in shock states?

A. MAP = CO x SVR MAP= cardiac output x systemic vascular resistance Blood pressure may not fall if there is an increase in peripheral vascular resistance Take home : shock can occur with normal blood pressure

Q. What are the 5 autonomic responses to a shock state?

A. Arteriolar vasoconstriction (to re-distribute blood from skin, muscle, kidneys and splanchnic visera) Increase in heart rate (try to increase CO) Venous constriction (increase venous return) Release of epi, norepi, dopamine and cortisol Release of ADH and activation or renin-angiotensin system

Q. What are the SIRS criteria?

A. Two or more of the following: Temp. > 38 (100.4) or < 36 (96.8 heart rate >90 Resp. rate > 20 breaths/ min WBC >12 or < 4

Q. Define central venous/ mixed venous oxygen saturation?

A. Reflects the physiologic efforts to meet 02 demands. Normal is 65- 75 If it falls below 50 compensation efforts have failed and lactic acidosis will start

What vital signs are diagnostic of shock?

A. No single vital sign is diagnostic of shock because they do not accurately reflect tissue hypoperfusion.

Q. If you suspect shock what are the lab tests that are indicated?

A. ABG Lactate D-Dimer, Fibrinogen LFT’s CT head LP Cortisol Cbc Cmp Pt, INR UA CXR ECG Blood cultures Sputum cultures Wound cultures ABG Lactate D-Dimer, Fibrinogen LFT’s CT head LP Cortisol

Q. What is important to remember when preparing to intubate a patient in shock?

A. Sedatives will lower BP by causing vasodilatation Positive pressure ventilation will reduce preload and therefore cardiac output Prepare for this by using fluids and starting a pressure support before attempting endotracheal intubation.

What is the main benefit to intubation in a patient in shock?

A. It decreases the work of breathing

Q. What are the goal directed end points of resuscitation ? Probably the most important question of the chapter.

A. Urine output > 0.5 ml/kg /hr CVP 8 –12 MAP 65-90 Scvo2 > 70%

Q. If a patient had an acute blood loss of 0. 5 L Q. If a patient had an acute blood loss of 0.5 L. How much crystalloid solution is indicated to restore hemodynamic status?

A. 1.5 Liters For every amount of blood loss three times that amount of isotonic crystalloid is required. This is because 30% of the infused fluid will stay intravascular.

Q. At what point in the fluid resuscitation is blood transfusion indicated?

A. If the patient has not improved after 2-3 L of crystalloid solution. You know that the patient suffered a profound blood loss and is on the verge of cardiovascular collapse

Q. What class of Hemorrhage (stage of shock) will blood pressure start to drop?

A. Class 3 Hemorrhage

At what class of shock is tachycardia first apparent ?

A. Class 2 Hemorrhage

Q. How is CVP used to monitor response to Resuscitation?

A. It is used to assess volume status. If there is no response to a crystalloid infusion then the vascular system is still compliant and the patient will benefit from more fluids.

Q. What is the overall mortality of Sepsis?

A. Overall 45 % Ranging from 20-80% depending on host age and comorbidities.

Q. Which of the following is true regarding SIRS? It confirms Sepsis It is a final diagnosis It is a good indicator of prognosis All of the above None of the above

A. E. SIRS does not confirm sepsis, it is not considered a final diagnosis and is not an accurate reflection of overall prognosis

Q. What are the beneficial and negative effects of nitric oxide release in sepsis? (SORRY)

A. BENEFITS NEGATIVE EFFECTS Inhibits platelet aggregation Vasodilator Which counters the vasoconstrictive effects of inflammation mediator Antimicrobial effect Antitumor effect Free radical scavenger NEGATIVE EFFECTS Potential for hypotension Increased permeability seen in septic shock

Q. What is the most frequent mental status change in sepsis?

A. Mental Obtundation

Q. A person in septic shock will have vasodilatation causing extremities to have what physical exam findings?

A. Shock with warm and flushed extremities.

Q. A person originally admitted with a diagnosis of urosepsis was boarded he has new CXR findings of bilateral infiltrates and a wedge pressure >18. His FiO2/ Pao2 ratio is greater than ?

A. 200, He has developed ARDS

What is most common cause of ARDS ?

Septic shock from Gm – organisms

What are the renal manifestations of ARDS? Acute renal failure Azotemia Oliguria

Q. What is the most common hepatic abnormality seen with septic shock?

A. Cholestatic jaundice

What will the CBC show in septic shock?

A. Thrombocytopenia Neutropenia/ Neutrophilia

A patient in septic shock secondary to pneumonia is acutely worsening, She is bleeding from various orifices. Repeat lab work shows thrombocytopenia, prolonged PT with high normal PTT and a D-dimer > 7,000. What branch of the clotting cascade has been activated?

A. The patient is in DIC releasing tissue type plasminogen activator causing activation of the EXTRINSIC clotting cascade.

What is the management/treatment for the above patient?

A. FFP- to replace clotting factors Platelet transfusion to maintain > 50k

A patient has not responded to an initial fluid bolus of 1 liter of NS A patient has not responded to an initial fluid bolus of 1 liter of NS. What is the amount of fluid patients in septic shock can receive ? (usual)

A. 4-6 L

What is the urine output to be used as a guideline for adequate fluid resuscitation ?

A. 1ml/ kg/ hr 30ml/ hr

He didn’t respond to the (usual) 5 L of NS and now he has worsening breath sounds and a wedge pressure of > 15. What is the next step in management?

A. Start Dopamine

What is the initial dose? 5 micrograms/ Kg/ min

You have now increased the dose up to 20 micrograms/Kg/min and the patient is still not responding. What can you do now?

A. Start norepinephrine

A patient is obviously septic and the source is believed to be N A patient is obviously septic and the source is believed to be N. meningitidis. What medication is indicated because of this bacteria’s association with adrenal insufficiency?

A. Steroids - Hydrocortisone 50mg IV q 6 hrs

What is the appropriate blood glucose range for tight glycemic control?

A. 80 – 100 Intensive insulin therapy should be started in the ED. There has been a reduction in mortality in patients with septic shock regardless of past history of diabetes.

EMPIRIC ANTIBIOTICS Rapid Review

Neonate and infants up to 3 months

Ampicillin and Cefotaxime

Infant >3 months GBS, E. coli, Listeria

Ceftriaxone

Adult (no source)

Piperacillin/tazobactam and cefotaxime

Neutropenic patients (children or adults)

Imipenem, Merropenem or gent + piperacillin/ tazobactam

History of IVDA

Vancomycin

Potential anaerobic source

Metronidazole or Clindamycin

Indwelling catheter

Vancomycin

Legionella

Macrolide

Asplenic patient

Ceftriaxone