Shock Management and Clinical Signs Quiz

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Questions and Answers

What is the expected blood pressure measurement in a patient experiencing shock?

MAP > 65 mmHg

MAP < 65 mmHg (correct)

MAP = 65 mmHg

None of the above

Which of the following is NOT a clinical sign of shock in the pulmonary system?

Dyspnea

Increased respiratory rate

Bradycardia (correct)

Tachypnea

Which of the following conditions is characterized by a warm peripheral skin temperature?

Cardiogenic shock

Septic shock (correct)

Hemorrhagic shock

Hypovolemic shock

What is the most common type of hypovolemic shock?

Hemorrhagic shock Signup and view all the answers

Which of these is NOT a determinant of shock?

Glucose availability Signup and view all the answers

Which of these is an example of a 'TANK' shock problem?

Hemorrhagic shock Signup and view all the answers

A shock index (HR/SBP) greater than 0.8 is suggestive of what?

Hemodynamic instability Signup and view all the answers

Which of these is NOT a clinical diagnostic feature of shock?

Normal blood pressure Signup and view all the answers

What is the first-line agent for managing hypotensive patients in cardiogenic shock?

Norepinephrine Signup and view all the answers

Which of the following is a sign that fluids should be administered during volume optimization?

Signs of inadequate organ perfusion Signup and view all the answers

In which condition is Nitroglycerine used as a first-line agent?

Hypertensive patients Signup and view all the answers

Which medication is considered an alternative for patients with low left ventricular ejection fraction (LVEF)?

Epinephrine Signup and view all the answers

What impact does invasive mechanical ventilation have on the body?

Decreases work of breathing Signup and view all the answers

When should volume removal be considered during cardiogenic shock management?

If pulmonary or systemic congestion is evident Signup and view all the answers

Which of the following conditions is most commonly associated with tachyarrhythmia?

Prosthetic valve dysfunction Signup and view all the answers

Which of the following medications is reserved for RV predominant cardiogenic shock?

Vasopressin Signup and view all the answers

What is the primary abnormality in obstructive shock due to cardiac tamponade?

Compression of cardiac chambers Signup and view all the answers

Which of the following is a key echocardiographic finding in diagnosing cardiac tamponade?

Pericardial effusion Signup and view all the answers

What management is required to address symptoms of cardiac tamponade?

Urgent pericardial fluid drainage Signup and view all the answers

Which physical finding is indicative of obstructive shock related to cardiac tamponade?

Hypotension Signup and view all the answers

What is the significance of a Kussmaul sign in the diagnosis of cardiac tamponade?

It reflects elevated jugular venous pressure Signup and view all the answers

In the context of obstructive shock, which condition may present with a significant risk of mortality?

Septic shock Signup and view all the answers

What does a SOFA score of more than 2 points indicate in the context of septic shock?

Documented infection Signup and view all the answers

Which imaging technique is primarily used to identify tension pneumothorax in a patient?

Supine chest radiograph Signup and view all the answers

What is the classification of blood volume loss associated with Class III hypovolemic shock?

30 – 40% Signup and view all the answers

Which of the following is NOT a cause of major hemorrhage in hypovolemic shock?

Diabetes Signup and view all the answers

Why should the use of intravenous fluids be minimized in the management of hemorrhagic shock?

They can increase the risk of coagulopathy. Signup and view all the answers

In Class II hypovolemic shock, what change is observed in urine output?

Normal Signup and view all the answers

What is the first principle in managing hypovolemic shock?

Control the source of bleeding Signup and view all the answers

What type of intravenous line is recommended for fluid resuscitation in hemorrhagic shock?

Short, large-bore (minimum 16G) Signup and view all the answers

What is the expected heart rate response in a patient experiencing Class IV hypovolemic shock?

Tachycardia Signup and view all the answers

Which of the following options best describes the capillary refill time in Class III hypovolemic shock?

Prolonged Signup and view all the answers

What is the optimal ratio for administering blood products in hemorrhagic shock?

1:1:1 Signup and view all the answers

What is the target hemoglobin concentration for transfusion during hypovolemic shock?

<blockquote> 7 – 9 g/dl </blockquote> Signup and view all the answers

What volume of fresh frozen plasma should be administered per kilogram of body weight?

15 – 20 ml/kg Signup and view all the answers

What is the initial dose of tranexamic acid administered intravenously for hemorrhagic shock?

1 g Signup and view all the answers

Which of the following factors is essential in monitoring during the treatment of hypocalcemia?

Ionized calcium levels Signup and view all the answers

What is the target fibrinogen concentration for patients with obstetric hemorrhage?

Above 200 mg/dl Signup and view all the answers

Which condition can lead to coagulopathy as a result of hypothermia?

Reduced enzymatic activity of coagulation factors Signup and view all the answers

What should be the primary consideration when using group O Rhesus negative blood?

It is reserved for pregnant patients only. Signup and view all the answers

Which of the following factors can directly impact preload by influencing venous return?

Resistance to venous return Signup and view all the answers

Which of the following factors can contribute to decreased cardiac output by reducing preload?

Increased intrathoracic pressure Signup and view all the answers

Which of the following scenarios BEST illustrates the concept of afterload as it relates to cardiac output?

A patient with hypertension, requiring the heart to pump against increased resistance. Signup and view all the answers

Which of the following factors can increase oxygen consumption ( VO2) by the heart?

Increased contractility Signup and view all the answers

Which of the following factors can lead to decreased cardiac output by directly affecting contractility?

Myocardial infarction Signup and view all the answers

Which of the following is NOT a factor that contributes to inadequate rate/rhythm as a cause of decreased cardiac output?

Hyperthyroidism Signup and view all the answers

Which of the following factors can directly contribute to increased afterload?

Increased peripheral vascular resistance Signup and view all the answers

Which of the following situations can lead to a decrease in cardiac output by directly influencing preload?

Aortic valve regurgitation 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. It results in cellular and tissue hypoxia.
Shock is defined as a state of cellular and tissue hypoxia caused by reduced oxygen delivery, increased oxygen consumption, or inadequate oxygen utilization. It commonly presents as hypotension (reduced tissue perfusion), but can also present as hypertensive or normotensive.
Shock is initially reversible, but must be recognized and treated immediately to prevent irreversible organ damage.
"Undifferentiated shock" is when the cause of shock is unknown.

Relevant Physiology

Cardiac output (CO) is calculated as stroke volume (SV) multiplied by heart rate (HR).
Preload is the myocardial sarcomere length just before contraction.
Afterload is the resistance to ventricular ejection, the load the heart must eject blood against.
Contractility is the change in peak isometric force at a given initial fiber length (end-diastolic volume).

Determinants of Preload

Factors affecting ventricular filling include intrathoracic pressure, atrial pressure, right atrial pressure, mean systemic filling pressure, total venous blood volume, resistance to venous return, and venous vascular compliance.

Determinants of Afterload

Wall stress is defined by Laplace's Law (P × r/T), where P is ventricular transmural pressure, r is ventricular radius, and T is ventricular wall thickness.
Input impedance, during systole, depends on arterial compliance, blood column inertia, and ventricular outflow resistance and the length of the arterial tree, blood viscosity, and vessel radius.

Determinants of Contractility

Increased preload increases the force of contraction.
Increased afterload - increases end-systolic volume and sarcomere length = increased force of contraction.
Heart rate affects contractility (Bowditch effect). Higher heart rates reduce intracellular calcium, leading to increased force of contraction.
Other determinants include catecholamines, ATP availability, temperature, and hormones (e.g., thyroid, glucagon). Calcium plays a crucial role.

Clinical Diagnosis of Shock

Neurologic: altered mental status (agitation, bradypsychic, bradylalia, coma).
Pulmonary: tachypnea.
Cardiac: hypotension (MAP < 65 mmHg or significant drop from baseline), bradycardia, tachycardia (>120 bpm associated with profound bleeding in hemorrhagic shock).
Renal: shock index (HR / BP) > 0.8 is suggestive of hemodynamic instability, low urine output (<0.5 ml/kg/h).
Peripheral perfusion/temperature: decreased temperature in shock; warm peripheral skin temperature predicts septic shock. Skin mottling is a poor prognostic sign; capillary refill time is prolonged in shock

Types of Shock

Cardiogenic shock: pump problem, including myocardial infarction, cardiomyopathy arrhythmias, myocarditis, valvular dysfunction, post-cardiopulmonary bypass, intrinsic depression (SIRS related).
Obstructive shock: pipes problem: pulmonary hypertension, pulmonary/air embolism, tension pneumothorax, cardiac tamponade, positive pressure ventilation, mediastinal tumors, high spinal anesthesia.
Distributive shock: tank problem. Hypovolemic: hemorrhage, trauma, surgery, obstetric. Examples: traumatic, gastric ulcers, post-partum bleedings, non-hemorrhagic (e.g., intestinal losses, renal losses, burns). Septic (including anaphylactic): sepsis, sepsis coupled with high mean arterial pressure and blood lactate level > 2 mm/L.

Cardiogenic Shock: Definition

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

Cardiogenic Shock: Classification

SCAI Shock classification stages (E, D, C, B, A) outline the severity of cardiogenic shock based on hypoperfusion and hemodynamic instability.

Cardiogenic Shock: Phenotypes & Severity

Different patterns of ventricular function, filling pressures, peripheral vascular tone, and congestion are important to consider.
The end stage of cardiogenic shock includes severe lactic acidosis, RV congestion, greater shock severity, and multiple organ failure.
Hemodynamic profiles, laboratory biomarkers, and clustering of "omics" data help evaluate the severity and phenotype of cardiogenic shock.

Cardiogenic Shock: Monitoring

Vital signs (blood pressure, heart rate, respiratory rate, pulse oximetry), urine output, laboratory values (ureaa, creatinine, liver function tests, lactate), and basic echocardiography are essential
Advanced monitoring, including cardiac ultrasound (e.g., using apical 4-chamber, 2-chamber, 5-chamber, and long-axis views), pulmonary capillary wedge pressure (PCWP), central venous pressure (CVP), and superior vena cava (SVC) and inferior vena cava (IVC) assessment are crucial.

Cardiogenic Shock: Management

Treat the underlying cause of the shock acutely, including oxygen supplementation, using high-flow oxygen therapy, non-invasive or invasive mechanical ventilation, inotropic support (e.g., dobutamine, Milrinone, Levosimendan), volume optimization (administration, reduction).
Consider mechanical circulatory support (e.g., intra-aortic balloon pump [IABP], venoarterial ECMO [VA-ECMO]) as a bridge to recovery, heart transplant, or other definitive treatment.

Obstructive Shock: Cardiac Tamponade

Cardiac tamponade results from pericardial pressure exceeding cardiac filling pressures, leading to reduced venous return, cardiac chamber shrinkage, stroke volume decrease, and blood pressure drop.
Causes include idiopathic (viral inflammation), infectious (viral, bacterial, fungal, parasitic), non-infectious (autoimmune or autoinflammatory, neoplasms (metastatic, or primary), cardiac (early infarction pericarditis, myocarditis, dissecting aortic aneurysm), trauma, iatrogenic complications.
Diagnosis relies on physical examination (tachycardia, hypotension, elevated jugular venous pressure, pulsus paradoxus), together with echocardiography, which typically displays pericardial effusion and chamber collapse.
Management involves urgent pericardial fluid drainage, commonly through percutaneous pericardiocentesis, and/or surgical drainage if percutaneous access is not possible.

Obstructive Shock: Pulmonary Embolism

Increased RV afterload results from pulmonary artery obstruction, leading to RV dilation, TV insufficiency, RV wall tension, neurohormonal activation, myocardial inflammation, and intrapulmonary A-V shunting; and RV ischemia and hypoxic injury.
Diagnosis relies on physical examination (tachycardia, hypotension, low respiratory rate, respiratory distress, or cyanosis) alongside echocardiography assessment (e.g., enlarged right ventricle, dilated RV with basal RV/LV ratio > 1.0, flattened intraventricular septum, distended inferior vena cava with diminished inspiratory collapsibility, and abnormal tricuspid annular plane systolic excursion).
Management includes anticoagulation, thrombolytic therapy, surgical embolectomy, and possibly catheter-directed treatment.

Obstructive Shock: Tension Pneumothorax

Tension pneumothorax results from the increased pressure within the pleural cavity when air continuously enters but cannot escape. It causes the lung to collapse; the mediastinum shifts from the affected side; and subsequently, blood flow is negatively compromised, cardiac output is reduced, and blood pressure falls.
Diagnosis involves detection of a tracheal deviation in an upright chest radiograph. Treatment involves insertion of a needle or thoracostomy tube to release the air from the pleural space.

Distributive Shock: Septic Shock

Sepsis is defined as widespread host inflammatory responses to infection. Septic shock is a subset of sepsis with abnormalities in cellular and metabolic function that increases mortality risk.
Sepsis involves suspected or documented infection coupled with a SOFA score >2. Septic shock involves this along with vasopressor requirement to maintain MAP of 65 mm Hg, and blood lactate > 2 mmol/L without hypovolemia.

Distributive Shock: Anaphylactic Shock

It is characterized by profound reduction in venous tone, with features of hypovolemic shock (including fluid extravasation), causing depressed myocardial function. It also typically involves rapid onset of the illness (minutes to hours), and simultaneous involvement of the skin (hives, flushing, urticaria) and mucosal tissues, or both (lips, tongue, and uvula swelling) alongside respiratory compromise (dyspnea, wheeze, stridor, reduced peak flow, and hypoxia). Circulatory compromise comprises reduced blood pressure with associated end-organ dysfunction (e.g., hypotension, collapse, syncope, incontinence) or gastrointestinal symptoms (severe crampy abdominal pain, severe repetitive vomiting).
Cardiac effects can include myocardial ischemia (often due to coronary vasospasm) which can lead to myocardial infarction. Additionally, conduction defects can arise and include atrial and ventricular arrhythmias. Post-menopausal women are particularly vulnerable to stress cardiomyopathy (Takotsubo syndrome) during anaphylaxis. Also, there are pulmonary effects, including upper airway symptoms (sneezing, rhinorrhea, dysphonia, laryngeal edema, laryngeal obstruction, and oropharyngeal angioedema) and lower airway symptoms (cough, wheeze, pulmonary hyperinflation, edema, hemorrhage, respiratory failure, respiratory arrest).

Hypovolemic Shock (Hemorrhagic Shock)

A person dies from injury approximately every 3 minutes, and 40% of these deaths are due to major hemorrhage or consequences. Death from hemorrhage is early, with 60% of deaths occurring within the first 3 hours.
Classified into four classes (I, II, III, and IV) based on blood loss percentage and clinical presentation (e.g., varying degrees of hypotension, tachycardia, decreased capillary refill time).
Causes include trauma, surgery, obstetrical issues (antepartum, postpartum), and medical issues (e.g., bleeding peptic ulcer disease, gastritis, esophagitis, esophageal varices, and anticoagulants).
Management prioritizes controlling bleeding and quickly mobilizing resources to address hypovolemia rapidly (e.g., surgery, anesthesia, blood bank, and transfer to a trauma center). It is essential to avoid coagulopathy and hypothermia.
Management includes using intravenous fluids judiciously, and if necessary, promptly administering blood products (red blood cells, plasma, and platelets) in a 1:1:1 ratio, using thromboelastography or similar testing to guide resuscitation.

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Test your knowledge on the clinical features and management of shock. This quiz covers various types of shock, diagnostic indicators, and treatment protocols. Prepare to enhance your understanding of this critical medical condition.