1. Book Review CH 30-32

2. Q. What is the definition of shock?

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

4. Q. What are the four classifications of shock?

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

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

7. 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

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

9. 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

10. Q. What are the SIRS criteria?

11. 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

12. Q. Define central venous/ mixed venous oxygen saturation?

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

14. What vital signs are diagnostic of shock?

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

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

17. 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

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

19. 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.

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

21. A.
It decreases the work of breathing

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

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

24. 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?

25. 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.

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

27. 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

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

29. A.
Class 3 Hemorrhage

30. At what class of shock is tachycardia first apparent ?

31. A.
Class 2 Hemorrhage

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

33. 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.

34. Q. What is the overall mortality of Sepsis?

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

36. 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

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

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

39. 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

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

41. A.
Mental Obtundation

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

43. A.
Shock with warm and flushed extremities.

44. 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 ?

45. A.
200, He has developed ARDS

46. What is most common cause of ARDS ?

47. Septic shock from Gm – organisms

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

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

50. A.
Cholestatic jaundice

51. What will the CBC show in septic shock?

52. A.
Thrombocytopenia
Neutropenia/ Neutrophilia

53. 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?

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

55. What is the management/treatment for the above patient?

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

57. 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)

58. A.
4-6 L

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

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

61. 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?

62. A.
Start Dopamine

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

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

65. A.
Start norepinephrine

66. 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?

67. A.
Steroids - Hydrocortisone 50mg IV q 6 hrs

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

69. 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.

70. EMPIRIC ANTIBIOTICS
Rapid Review

71. Neonate and infants up to 3 months

72. Ampicillin and Cefotaxime

73. Infant >3 months
GBS, E. coli, Listeria

74. Ceftriaxone

75. Adult (no source)

76. Piperacillin/tazobactam and cefotaxime

77. Neutropenic patients (children or adults)

78. Imipenem, Merropenem or gent + piperacillin/ tazobactam

79. History of IVDA

80. Vancomycin

81. Potential anaerobic source

82. Metronidazole or Clindamycin

83. Indwelling catheter

84. Vancomycin

85. Legionella

86. Macrolide

87. Asplenic patient

88. Ceftriaxone