Matching Medical Concepts in Shock Management

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Questions and Answers

Match the following blood products with their primary functions in managing hemorrhagic shock:

Red blood cells = Increases oxygen-carrying capacity Fresh frozen plasma = Provides coagulation factors and volume expansion Platelets = Promotes clot formation and prevents bleeding Fibrinogen concentrate = Increases fibrinogen levels for proper clotting

Match the following physical findings with their associated conditions:

Tachycardia and hypotension = Cardiac Tamponade Elevated jugular venous pressure (Kussmaul sign) = Cardiac Tamponade Pulsus paradoxus = Cardiac Tamponade Supine chest radiograph demonstrates an atypical right basal pneumothorax in a patient on mechanical ventilation = Tension Pneumothorax

Match the following echocardiography findings with their associated conditions:

Pericardial effusion = Cardiac Tamponade Chamber collapse = Cardiac Tamponade Diastolic collapse of the right atrium = Cardiac Tamponade Diastolic collapse of the right ventricle = Cardiac Tamponade

Match the following clinical scenarios with their associated shock types:

Compression of cardiac chambers due to increased pericardial pressure exceeding cardiac filling (diastolic) pressures = Obstructive Shock - Cardiac Tamponade A life-threatening organ dysfunction caused by a dysregulated host response to infection = Distributive Shock - Septic Shock A subset of sepsis with circulatory, cellular, and metabolic abnormalities contributing to a higher mortality risk than sepsis alone = Distributive Shock - Septic Shock Suspected or documented infection coupled with a SOFA score of more than 2 points = Distributive Shock - Septic Shock Signup and view all the answers

Match the anatomical structures with their relevant descriptions:

Right atrium = Diastolic collapse may be observed in cardiac tamponade Right ventricle = Diastolic collapse may be observed in cardiac tamponade Left-sided chambers = May collapse in cardiac tamponade Pericardium = Fluid accumulation can lead to cardiac tamponade Signup and view all the answers

Match the following medical terms with their definitions:

SOFA score = A scoring system used to assess organ dysfunction in sepsis Pulsus paradoxus = A decrease in systolic blood pressure during inspiration Kussmaul sign = Elevated jugular venous pressure Pericardiocentesis = A procedure to drain fluid from the pericardium Signup and view all the answers

Match the following diagnostic tools with their relevant application:

Echocardiography = Used to assess cardiac tamponade by detecting pericardial effusion and chamber collapse CT scan = Used to diagnose pulmonary embolism Pulmonary Index Severity index = Used to assess the severity of a pulmonary embolism Chest X-ray = Used to diagnose tension pneumothorax Signup and view all the answers

Match the following management approaches with their associated conditions:

Pericardial fluid drainage = Cardiac Tamponade Surgical approach = Cardiac Tamponade Thrombolytic therapy = Pulmonary embolism Mechanical ventilation = Tension pneumothorax Signup and view all the answers

Match the following pathophysiological changes with their associated shock types:

Total venous return falls = Obstructive Shock - Cardiac Tamponade Cardiac chambers shrink = Obstructive Shock - Cardiac Tamponade Stroke volume declines = Obstructive Shock - Cardiac Tamponade Blood pressure drops = Obstructive Shock - Cardiac Tamponade Signup and view all the answers

Match the following end-organ dysfunction criteria with their corresponding definitions:

Circulatory failure = The cardiovascular system is unable to adequately deliver blood to tissues. Hypoperfusion = The tissues are not receiving sufficient oxygen and nutrients. End organ dysfunction = The organs are not functioning properly due to inadequate blood supply. Hemometabolic = Characterized by severe lactic acidosis, reflecting impaired oxygen utilization. Signup and view all the answers

Match the following parameters with the type of assessment they reflect in cardiogenic shock:

Blood pressure = Hemodynamic assessment. ECG = Cardiac assessment. Urine output = Renal assessment. Signup and view all the answers

Match the following patient conditions with the type of cardiogenic shock they might cause:

Acute MI = Reduced LV ejection fraction. Takotsubo cardiomyopathy = Acute reduction in LV ejection fraction. Tachymyopathy = Acute reduction in LV ejection fraction. Bradyarrhythmia = Arrhythmia. Signup and view all the answers

Match the following monitoring techniques with the specific organ system they target:

Cardiac Ultrasound = Cardiac assessment. Lung Ultrasound = Pulmonary assessment. VExUS = Venous assessment. Signup and view all the answers

Match the terms with their definitions:

Preload = The volume of blood in the ventricles at the end of diastole Afterload = The pressure the ventricles must overcome to eject blood Contractility = The strength of the heart's contraction Heart rate = The number of heartbeats per minute Signup and view all the answers

Match the determinants of contractility with their effects:

Increasing preload = Increases force of contraction Increased afterload = Increased end-systolic volume Higher heart rate = Increased intracellular calcium Decreased afterload = Decreased force against which the heart must work Signup and view all the answers

Match the components affecting the input impedance with their descriptions:

Arterial compliance = Ability of blood vessels to stretch and accommodate blood volume Inertia of the blood column = Resistance due to the mass of blood during flow changes Ventricular outflow tract resistance = Resistance faced by blood leaving the ventricle Arterial resistance = Resistance related to vessel length, viscosity, and radius Signup and view all the answers

Match the transmural pressure states with their implications:

High transmural pressure = Indicates high afterload Low transmural pressure = Indicates low afterload Negative intrathoracic pressure = Facilitates high transmural pressure Positive mechanical ventilation = Results in low transmural pressure Signup and view all the answers

Match the concepts explaining the Bowditch effect:

Increased heart rate = Reduced time for calcium expulsion Calcium accumulation = Leads to stronger contractions Shortened diastole = Insufficient time for ventricular filling Systolic performance = Enhanced by rapid heart rates Signup and view all the answers

Match the classes of blood volume loss to their corresponding percentage ranges:

Class I = < 15% Class II = 15 – 30% Class III = 30 – 40% Class IV = > 40% Signup and view all the answers

Match the physiological responses to the corresponding classification of hypovolemic shock:

Class I = Normal blood pressure Class II = Minimal changes in blood pressure Class III = Hypotension Class IV = Severe hypotension Signup and view all the answers

Match the heart rate response to the class of hypovolemic shock:

Class I = Normal Class II = Tachycardia Class III = Tachycardia Class IV = Tachycardia Signup and view all the answers

Match the capillary refill time to the class of blood volume loss:

Class I = Normal Class II = Prolonged Class III = Prolonged Class IV = Prolonged Signup and view all the answers

Match the causes of major hemorrhage to their categories:

Trauma = Physical injury Surgery = Post-operative complications Obstetric = Pregnancy-related issues Medical = Health conditions like ulcers Signup and view all the answers

Match the principle of management to its focus area:

Control source of bleeding = Hemorrhage control Minimize intravenous fluids = Coagulation preservation Transfuse blood products = Risk assessment Rapid mobilization of resources = Emergency preparedness Signup and view all the answers

Match the risks associated with excessive intravenous fluid use:

Dilution of clotting factors = Impaired coagulation Dilution of platelets = Decreased clotting capability Hypothermia = Temperature regulation issues Increased risk of coagulopathy = Altered blood function Signup and view all the answers

Match the management steps for hypovolemic shock to their descriptions:

Control source of bleeding = Immediate intervention Transfuse blood products = Quick response to need Thromboelastography = Coagulation assessment Intravenous lines = Establish necessary access Signup and view all the answers

Match the following types of shock with their associated hemodynamic characteristics:

Cardiogenic shock = ↑CVP, ↑PCWP, ↓CO, ↑SVR Obstructive shock = ↑CVP, ↑PCWP, ↓CO, ↑SVR Distributive shock = var CVP, var PCWP, var CO, ↓SVR Hypovolemic shock = ↓CVP, ↓PCWP, ↑CO, ↑SVR Signup and view all the answers

Match the following causes with their associated findings:

Hepatic insufficiency = Evidence of infection (cholecystitis, endocarditis) Burns = Gastro-intestinal losses High spinal anesthesia = Flat neck veins Intrinsis depression (SIRS related) = Variable IVC Signup and view all the answers

Match the following physical exam findings with their respective shock types:

Cardiogenic shock = Weak pulses (narrow pulse pressure) Obstructive shock = Plethoric IVC, reversal of flow in HV Distributive shock = Warm, flushed, Brisk cap refill Hypovolemic shock = Small/collapsing IVC Signup and view all the answers

Match the following lung findings with the associated condition:

B-line pattern + pleural effusions = Cardiogenic shock Lack of lung sliding ± lung point = Obstructive shock A line pattern = Hypovolemic shock Signup and view all the answers

Match the following skin findings with their respective shock types:

Cardiogenic shock = Usually cool, Delayed cap refill Obstructive shock = Usually cool, Delayed cap refill Distributive shock = Warm, flushed, Brisk cap refill Hypovolemic shock = Usually cool, Delayed cap refill Signup and view all the answers

Match the following neck findings with the appropriate type of shock:

Cardiogenic shock = Increased JVP Obstructive shock = Increased JVP Distributive shock = Variable Hypovolemic shock = Flat neck veins Signup and view all the answers

Match the following conditions with their associated physical exam findings:

Cardiogenic shock = Pericardial effusion, RA collapse Obstructive shock = DVT or clot in transit (PE) Distributive shock = Lung and heart sounds are unreliable Hypovolemic shock = Blood or fluid in abdomen (FAST) Signup and view all the answers

Match the following hemodynamic parameters with the relevant shock type:

Cardiogenic shock = Reduced contractility ± RV dilation Obstructive shock = RV dilation ± septal D sign Distributive shock = Hyperdynamic (hypodynamic in late sepsis) Hypovolemic shock = Weak pulses (narrow pulse pressure) Signup and view all the answers

Study Notes

Shock

Shock is a life-threatening condition of circulatory failure, causing inadequate oxygen delivery to meet cellular metabolic needs and oxygen consumption requirements, producing cellular and tissue hypoxia.
It's defined as a state of cellular and tissue hypoxia due to reduced oxygen delivery, increased oxygen consumption, inadequate oxygen utilization, or a combination of these processes.
Most commonly, it occurs when there is circulatory failure, manifested as hypotension. However, a patient in shock can present as hypertensive, normotensive, or hypotensive.
Shock is initially reversible but must be recognized and treated immediately to prevent progression to irreversible organ dysfunction.
"Undifferentiated shock" refers to a situation where shock is recognized, but the cause is unclear.

Relevant Physiology

$CO\ x\ [(1.39\ x\ Hb\ x\ SaO_2)\ +\ (PaO_2\ x\ 0.003)]$ - calculation for arterial content of $O_2$
$VO_2\ = CO\ x\ (CaO_2 – ((SvO_2\ x\ 1.36\ x\ Hb)\ +\ (0.0031\ x\ PvO_2))$) - calculation for venous content of $O_2$
$O_2ER = VO_2 / DO_2$ (normally around 25%)
$VO_2\ aprox.\ 250\ ml/min$
$DO_2\ aprox.\ 1000\ ml/min$
Critical $DO_2$ point = the point where maximum O₂ER is reached; beyond this, any increase in $VO_2$ or decrease in $DO_2$ leads to tissue hypoxia and anaerobic metabolism.

Interpretation of O₂ER

High O₂ER suggests:
Inadequate oxygen delivery:
Hypoxia (low FiO2, high altitude, lung disease).
Anemia.
Altered cardiac contractility.
Inadequate heart rate/rhythm.
Shock/hypoperfusion due to other problems.
Increased oxygen consumption (VO₂):
Fever/inflammatory states (sepsis, burns, trauma, surgery).
Increased metabolic rate (hyperthyroidism, adrenergic drugs, hyperthermia, burns).
Increased muscular activity (exercise, shivering, seizures, agitation, anxiety, pain or increased respiratory efforts).
Low O₂ER suggests:
Increased oxygen delivery:
Hyperoxia (high FiO2, hyperbaric oxygen or ECMO)
Decreased oxygen consumption:
Decreased metabolic rate (hypothyroidism, sedatives, hypnotics, hypothermia).
Decreased muscular activity (sedation, muscle paralysis, ventilatory support).
Antipyretics.
Starvation/malnutrition.
Sepsis causes shunting and histotoxic hypoxia.
Histotoxic hypoxia (cyanide poisoning).

Common Point - Cardiac Output

$CO = SV \ x\ HR$
Preload: Myocardial sarcomere length just before contraction.
Afterload: Resistance to ventricular ejection; the "load" the heart must overcome to eject blood.
Contractility: Change in peak isometric force (isovolumic pressure) at a given initial fiber length (end diastolic volume).

Determinants of Preload

Pressure filling the ventricle:
Intrathoracic pressure.
Atrial pressure (atrial contractility and rhythm, atrioventricular valve competence, ventricular end-systolic volume).
Right atrial pressure.
Mean systemic filling pressure.
Total venous blood volume.
Resistance to venous return.
Venous vascular compliance.
Compliance of the ventricle:
Pericardial compliance and wall compliance.
Ventricular wall compliance.
Duration of ventricular diastole.
Wall thickness.
Relaxation proprieties of the muscle.
End-systolic volume of the ventricle.

Determinants of Afterload

Wall stress (defined by the law of Laplace): $P\times r / T$.
$P$ = ventricular transmural pressure (difference between intrathoracic pressure and ventricular cavity pressure).
$r$ = radius of the ventricle.
$T$ = thickness of the ventricular wall.
Input impedance (describes ventricular cavity pressure during systole, depends on):
Arterial compliance.
Inertia of the blood column
Ventricular outflow tract resistance.
Arterial resistance (length of the arterial tree, blood viscosity, vessel radius).

Determinants of Contractility

Preload: Increasing preload increases the force of contraction.
Afterload: Increased afterload increases end-systolic volume, = increased sarcomere length, = increased force of contraction.
Heart rate: At higher rates, the heart doesn't have time to fully expel intracellular calcium, accumulating to increase the force of contraction.
Other factors: Catecholamines, ATP availability, temperature. Hormones (glucagon, thyroid). Calcium.

Clinical Diagnosis of Shock

Neurologic: Altered mental status (agitation, bradypsychic, bradylalia, coma).
Pulmonary: Tachypnea.
Cardiac: Hypotension (MAP < 65 mmHg or significant drop from baseline values). Bradycardia. Tachycardia (> 120 bpm).
Renal: Shock index (HR/BPs) > 0.8. Low urine output (< 0.5 ml/kg/h).
Peripheral perfusion/temperature: Temperature decreased in shock. Warm peripheral skin temperature predicts high output shock (high positive and negative predictive value). Skin mottling negatively correlated with urine output and positively correlated with lactate level and organ hypoperfusion.
Capillary refill time: Prolonged. Brisk capillary refill time predicts high output shock.

Types of Shock

Cardiogenic shock: Pump problem (myocardial infarction, cardiomyopathy, arrhythmias).
Obstructive shock: Obstructive problem, pipes problem, tank problem(pulmonary hypertension, tension pneumothorax, pulmonary/air embolism, cardiac tamponade, positive pressure ventilation, mediastinal tumors, tamponade, dissection aneurysm.)
Distributive shock: Pipes problem, tank problem (sepsis, anaphylaxis, septic shock)
Hypovolemic shock: Tank Problem (Hemorrhagic, non-hemorrhagic)

Cardiogenic Shock - Definition

Cardiogenic shock represents the final common pathway in which cardiovascular disease causes circulatory failure, hypoperfusion, and end organ dysfunction.

Cardiogenic Shock - SCAI Shock Classification

Stages (based on patient's condition): E (extremis), D (deterioration), C (classic), B (beginning), A (at risk)

Cardiogenic Shock – Phenotypes & Severity

Cardiogenic shock involves different patterns of ventricular dysfunction, filling pressures, vascular tone, and congestion.
End-stage of cardiogenic shock:
Severe lactic acidosis.
RV congestion.
Greater shock severity.
Multiple organ failure.
Hemometabolic/cardiometabolic cardiogenic shock occurs.

Cardiogenic Shock - What are we monitoring?

Basics: Clinical examination, ECG, Pulse oximetry, Blood pressure, Urine output, Labs (urea, creatinine, liver function tests (AST, ALT), acid-base status: lactate)
Reassuring: Warm extremities, Normal capillary refill. Normal pulse pressure. HR/SBP < 0.8, adequate urine output, baseline/normal creatinine, no shock liver, normal lactate, normal mentation, normal blood pressure, no dyspnea, POCUS (A-lines), clear CXR/CT, no peripheral edema. stable weight, normal JVP, normal IVC.
Worrisome: Cool extremities, slow capillary refill (mottling), narrow pulse pressure. HR/SBP > 0.8. Oliguria. Elevated creatinine (or shock liver). Lactate elevation. Late signs of severe shock: hypotension/delirium, dyspnea, POCUS (B-lines), pulmonary edema (CXR/CT), peripheral edema, weight gain, elevated JVP and distended IVC.
Cardiac ultrasound: (various views)

Lung Ultrasound

VEXUS

Arterial Line

A continuous column of fluid is used between the catheter and a pressure transducer in the arterial line allowing for arterial pressure measurement.

Central Venous Line

The central venous line's principle is a continuous fluid column between a catheter and a transducer, enabling pressure measurements in the central circulation.

CI (l/min/m²)

Values in context of GEDI, ELWI, etc. to determine appropriate action

Hypovolemic Shock – Hemorrhagic Shock

Early mortality due to major hemorrhage.
Classification (based on percentage of blood loss): I ( <15%), II (15-30%), III (30-40%), IV ( >40%).
Causes : Trauma, Surgery, Obstetric (antepartum and postpartum), medical conditions (GI bleeds)

Hypovolemic Shock – Hemorrhagic Shock. Management

Principles: Control bleeding and minimize intravenous fluid use; rapidly mobilize resources (surgery, anaesthetics, blood bank). Thromboelastography (TEG/ROTEM) to guide trauma resuscitation.
IV fluids: Minimise, due to risk of coagulopathy.
Blood products: Important for rapid restoration of blood volume and target hemoglobin (7-9 g/dL); plasma to platelets ratio (1:1:1).

Hypovolemic Shock – Hemorrhagic Shock. Management - Other

Fibrinogen supplementation: Target fibrinogen level of at least 150 mg/dl.
Prothrombin complex concentrate: Used for vitamin K-dependent coagulation factors (II, VII, IX, X).
Tranexamic acid: Antifibrinolytic, initial dose 1 g IV immediately, followed by 1 g infused over 8 hours.
Calcium: Essential cofactor for activation of factors II, VII, IX and X, with protein C. Hypocalcemia, from citrate chelation, should be monitored and treated (target ≥ 0.9 mmol/l).

Distributive Shock - Septic Shock

Sepsis is a life-threatening organ dysfunction induced by a dysregulated response to an infection; septic shock is a subgroup of sepsis where the circulatory, cellular, and metabolic abnormalities contribute to higher risk of mortality.
Definition
- Sepsis (suspected infection and SOFA score > 2)
- Septic shock (sepsis with vasopressor requirement to maintain MAP ≥ 65 mmHg AND/OR blood lactate > 2 mmol/l, in the absence of hypovolemia).
SOFA Scores (for organ dysfunction assessment).
Management
- Fluid administration (if appropriate)
- Vasopressors (Norepinephrine first choice), potentially add vasopressin or epinephrine if necessary.
- Antimicrobial or antibiotic therapy. Early (within 1 hour) and appropriate.

Distributive Shock - Anaphylactic Shock

Characterized by profound reductions in venous tone, fluid extravasation, reduced venous return and depressed myocardial function.
Criteria: Acute onset of illness (minutes to hours), with simultaneous skin/mucosal involvement plus respiratory/circulatory compromise, or severe gastrointestinal symptoms.
Triggers range from insect stings to medication.
Pathophysiology:
Cardiac effects: myocardial ischemia (coronary vasospasm), conduction defects, possible stress cardiomyopathy.
Respiratory effects: upper airway (sneezing, rhinorrhea, dysphonia, laryngeal edema, laryngeal obstruction, oropharyngeal angioedema); lower airway (cough, wheeze, pulmonary hyperinflation, edema, hemorrhage, respiratory arrest).
Fluid shifts: massive shifts due to increased vascular permeability, initial volume shift into extravascular space, compensatory responses (catecholamines, angiotensin II, endothelins).

Hypovolemic shock - Hemorrhagic Shock

Early death consequence from significant blood loss (hemorrhage).
Classification (based on blood loss):
Class I (<15%),
Class II (15-30%),
Class III (30-40%),
Class IV (>40%).
Causes: Trauma, surgery, obstetric complications (antepartum, postpartum), medical conditions.
Management
Control bleeding.
Minimize IV fluids (due to coagulopathy risk).
Rapid mobilisation of resources.
Thromboelastography (TEG/ROTEM).
Access solutions for massive transfusion (dialysis catheter, multilumen access catheter).
Avoidance (coagulopathy, hypothermia, acidosis).

Obstructive Shock – Cardiac Tamponade

The primary abnormality is compression of cardiac chambers due to increased pericardial pressure exceeding cardiac filling (diastolic) pressures.
Causes: Idiopathic (viral, immune-mediated, infectious), post-cardiac injury, neoplastic & non-neoplastic inflammation.
Diagnosis: Physical findings (tachycardia, hypotension, elevated jugular venous pressure (Kussmaul sign), pulsus paradoxus). echocardiography findings (pericardial effusion, chamber collapse [right atrium, right ventricle and left side]).
Management: Urgent pericardial fluid drainage (percutaneous pericardiocentesis or surgical drainage).

Obstructive Shock – Pulmonary Embolism

Pathophysiology: Increased RV afterload, RV dilatation, TV insufficiency, neurohormonal activation, RV O2 demand (and ischemia).
Echocardiography:
Enlarged right ventricle in parasternal long-axis view.
Dilated RV with basal RV/LV ratio >1.0 and McConnell sign (four-chamber view).
Flattened intraventricular septum (parasternal short-axis view).
Distended inferior vena cava with diminished inspiratory collapse (subcostal view).
60/60 sign: Acceleration time of pulmonary ejection (<60 ms) and midsystolic notch with elevated peak systolic gradient (<60 mmHg).
CT scan: Multifocal filling defects.
Management. Anticoagulation (UFH). Systemic thrombolytic therapy. Surgical pulmonary embolectomy. Percutaneous catheter-directed therapy.

Obstructive Shock - Tension Pneumothorax

A life-threatening accumulation of air in the pleural space, creating pressure that compresses the lung and pushes the mediastinum.
Chest X-ray/ultrasound diagnosis is required.
Urgent decompression (needle or tube thoracostomy)

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Description

This quiz challenges you to match various medical concepts related to shock management, including blood products, physical findings, and echocardiography results. Test your understanding of how different conditions and diagnostic tools interact in the context of hemorrhagic shock and cardiogenic shock. Perfect for medical students and professionals looking to refine their knowledge in this crucial area.