What are the two characteristics of shock?
inadequate tissue perfusion and altered cellular metabolism
What can be the three causes of reduced tissue perfusion in shock?
loss of circulating blood volume, cardiac pump failure, or widespread vasodilation/capillary leaking
What happens in all types of shock re: oxygen and nutrients?
the oxygen/nutrient SUPPLY is inadequate to meet the cell/tissue/organ DEMAND
What are the three types of shock that are all distributive or vasogenic?
neurogenic, anaphylactic, septic
Cardiogenic shock results from the inability of the heart to either effectively ______ or ______ blood. It is the most extreme ______ ______.
pump or receive blood. heart failure
What lab values are increased in burn shock?
hematocrit and hemoconcentration (relative increase in number of RBCs d/t decrease in plasma volume)
What can cause fluid loss in dehydration shock?
prolonged vomiting or diarrhea, intestinal fistulas or obstruction, "third space" losses
What causes distributive or vasogenic shock?
abnormal distribution of blood in the circulatory network
The problem in distributive/vasogenic shock is alterations in the blood vessels which cause decreased ______ ______ and/or increased ______ ______.
peripheral resistance, intravascular capacity
Neurogenic, anaphylactic and septic shock all have what in common re: their effect on blood vessels?
they all cause massive vasodilation
What causes massive vasodilation in septic shock?
d/t overwhelming infection and the chemical mediators that are released as a result
What are 4 other physiologic mechanisms that result from untreated shock?
multiple organ dysfunction syndrome (MODS), acute respiratory distress syndrome, disseminated intravascular coagulopathy (DIC), acute tubular necrosis (ATN)
MODS is classified as failure of ______ or more organ systems and is a frequent complication of severe shock.
Acute respiratory distress syndrome results in acute lung ______ and diffuse ______ -______ injury.
DIC causes intravascular of coagulation, leading to consumption of ______ ______, followed by...
clotting factors, diffuse bleeding
ATN is caused by ______ that generates toxic free radicals that cause cell ______, ______ and ______.
ischemia, swelling, injury and necrosis
What can be the cause of the acute respiratory syndrome, DIC and ATN that may occur as a result of shock?
the inflammatory that is generated by shock
The story of the physiologic effects of shock
cells not receiving O2, switch to anaerobic metabolism, lack of ATP, decreased activity of Na-K-ATPase pump, Na accumulates in cell, K outside of cell, H2O follows Na into cell, disrupts cell membrane, lysosomal enzymes released. metabolic acidosis from anaerobic metabolism reduced O2 carrying capacity in blood. fat + glucose stores used up, proteins broken down through gluconeogenesis, build up of toxic wastes
Where do all 5 types of shock begin? What does this lead to next?
decreased tissue perfusion, impaired cellular metabolism
When cells switch to anaerobic metabolism, there is a decrease in ______ and an increase in ______ produced.
What is the outcome of the lactate that is produced in anaerobic metabolism during shock?
lactate makes lactic acid, which leads to metabolic acidosis which decreases oxygen's affinity for hemoglobin
Everyone who is in shock has what type of acid-base disorder?
metabolic acidosis (d/t excess lactate)
What is the effect of H2O shifting into cells during shock as the Na-K-ATPase pump fails and sodium moves in?
oncosis results in the cell and the cell dies. there is also a decrease in the circulatory volume
What happens as a result of decreased circulatory volume in shock? Why?
increased stimulation of the clotting cascade d/t increased blood viscosity
The cellular edema that occurs as a result of sodium and water moving into cells in shock leads to the release of ______ enzymes. These basically do what?
lysosomal enzymes. basically start eating their own cells
Impaired glucose use leads to an increased ______ ______ and the release of ______, ______ and ______ hormone as a result of stress.
serum glucose, catecholamines, cortisol, growth
What is the effect of catecholamines, cortisol and growth hormone in shock?
increased lypolysis, increased gluconeogenesis and increased glycogenolysis
Lipolysis leads to an increase in serum ______ and ______ ______ ______.
triglycerides, free fatty acids
Gluconeogenesis leads to a decrease in serum ______ and an increase in serum branched-chain ______ ______, which only further exacerbates the acidosis that the body is experiencing.
albumin, amino acids
An increase in serum glucose in shock leads to an increase in ______, which becomes ______ acid and only exacerbates metabolic acidosis.
What cause of impaired cellular metabolism during shock will only further exacerbate it?
release of lysosomal enzymes
How long does it take the impaired glucose use side of impaired cellular metabolism to run out?
compensation will only last for about 10 hours
Cardiogenic shock is ACUTE EXTREME ______ ______ and results from the heart's impaired ability to ______ or ______ blood.
heart failure, pump or receive
The etiology of cardiogenic shock can be ______ (muscle related), ______ (can't create working action potential) or ______ (e.g valvular stenosis).
myopathic, dysrhythmic, mechanical
What is an unfortunate effect of the compensatory mechanisms that occur in cardiogenic shock?
they all cause an increase in myocardial oxygen requirements
What things are released/activated in cardiogenic shock to maintain blood volume?
RAAS, ADH, aldosterone
In cardiogenic shock, the adrenal glands release ______ which cause ______ and increase heart ______ and ______.
catecholamines, vasoconstriction, contractility and rate
Clinical manifestations of cardiogenic shock may include cardiac arrhythmias. This is usually a ______ in the early stages. What can occur secondary to the ischemia created by this?
tachyarrhythmias. chest pain
A person in cardiogenic shock may have impaired ______. In other words, it may be hard to keep them awake.
The treatment of cardiogenic shock is aimed at increasing ______ ______ and ______ ______ and minimizing myocardial ______ ______.
cardiac output, tissue perfusion, oxygen demands
What classes of drugs may be given to someone with cardiogenic shock?
vasopressors/inotropic agents, phosphodiesterase enzyme inhibitors, vasodilators, analgesics, diuretics
Dopamine is a "______ agent" which stimulates ______ receptors. Which specific receptors are stimulated depends on the dose.
Low-dose dopamine (or 1-2 mcg) increases ______ and ______ vasodilation, which increases blood flow to the kidneys and abdominal organs. It also causes vasodilation of the ______ and ______ arteries.
renal and mesenteric, coronary and cerebral
2-5 mcg/kg/min of Dopamine stimulates ______ receptors and ______ and ______ adrenergic receptors.
dopaminergic, beta1 and beta2
What effects does 2-5 mcg of Dopamine have in addition to increased blood flow to the kidneys and abdominal organs?
increased cardiac output and heart rate in addition to bronchodilation
10-20 mcg/kg/min of Dopamine stimulates beta1 and beta2 receptors PLUS ______ receptors. What new effect does this cause in addition to the cardiac and pulmonary effects of beta1 and beta2?
alpha1, vasocohttp://quizlet.com/10632638/edit/nstriction to increase BP
>20 mcg/kg/min of Dopamine has purely a ______ adrenergic effect only. It causes only ______ as a effect.
Dobutamine (Dobutrex) is a sympathomimetic agent that has greater ______ than ______ effects. What makes it a better option than Dopamine for the treatment of cardiogenic shock?
beta, alpha. increases cardiac contractility with little to no increase in heart rate or blood pressure.
What drugs are phosphodiesterase enzyme inhibitors? Specifically they are PDE ______ inhibitors.
Inamrinose, Milrinone. 3.
How do phosphodiesterase enzyme inhibitors increase cardiac output with decreased afterload?
they increase cardiac contractility (positive inotropic effect) and induce peripheral vasodilation
The function of vasodilators in cardiogenic shock is to decrease ______ and/or ______, which will thus decrease myocardial oxygen demands.
______ is an example of a vasodilator. It dilates ______ more than ______ and decreases ______ and to a lesser extent ______.
Nitroglycerin. veins, arteries. preload, afterload.
Because nitroglycerin decreases preload, what does it also decrease by association?
In cardiogenic shock, ______ is the analgesic of choice. Why?
morphine. very effective for pain relief but also because it is a venodilator and thus decreases preload
Lasix causes a decrease in circulating blood volume, which decreases ______ and thus myocardial ______ ______.
preload, myocardial oxygen demands
An IABP is threaded from the ______ artery up to, but not including, the ______ of the ______.
femoral, arch of the aorta
An IABP is part of a machine that is programmed to inflate during ______ and deflate during ______.
Because an IABP inflates during diastole, it increases ______ BP and blood flow to the ______ arteries.
Why does an IABP deflate during systole?
the sudden decrease in pressure in the aorta pulls blood forward during ventricular ejection.
Because an IABP deflates during systole, ______ is decreased which decreases resistance to ventricular pumping. How does this effect the myocardium?
afterload. decreases myocardial work and oxygen consumption
The biggest issue in cardiogenic shock and the source of all other problems is...
decreased cardiac output
What is the compensation of cardiogenic shock? What causes it to stop being effective?
renin, aldosterone, ADH, and catecholamine release. it eventually increases myocardial oxygen requirements.
An increase in myocardial oxygen requirements in cardiogenic shock leads to a decrease in cardiac ______, ______ ______ and ______ ______.
output, blood pressure, ejection fraction
Hypovolemic shock is the only time that there is a shift of fluid from the ______ to the ______.
interstitium to the vessels
What is the compensation in hypovolemic shock?
shift of interstitial fluid, aldosterone/ADH release, splenic discharge, catecholamine release (increase in SVR)
Because there is a decrease in circulating blood volume in hypovolemic shock, there is a decrease in ______ return of blood to the heart. This leads to a decreased ______ of the ventricles and thus a decreased ______ ______ and ______ ______.
venous, filling, stroke volume, cardiac output
The ______ ______ of hypovolemia are probably more effective than any other type of shock.
compensatory mechanisms/adaptive responses
The compensatory mechanisms of hypovolemic shock kick in early and are effective in maintaining adequate ______ ______ and ______ ______ in the early stages.
blood pressure and cardiac output
What receptors sense a decreased blood pressure/volume? Where are they located? What do they stimulate?
baroreceptors. aorta and carotid artery. SNS
The SNS stimulation caused by baroreceptors during decreased BP results in...
increased HR and contractility, increased vasoconstriction, increased sodium and water retention secondary to RAAS and ADH
S/S of early hypovolemic shock: ______ heart rate, decreased ______ blood pressure (slightly), increased ______ blood pressure, increased respiratory ______ and ______, decreased ______ output, skin that ______, ______ and ______.
increased, systolic, diastolic, rate and depth, urine, cool, pale and diaphoretic
The slightly lowered systolic BP and increased diastolic BP in hypovolemic shock leads to a narrowed...
What 3 things are leading to a decrease in urine output in hypovolemic shock?
decreased blood volume, increased aldosterone and ADH
2 broad goals of the treatment of hypovolemic shock
replace intravascular volume, repair "leak" (underlying cause)
What are the two sources to replace intravascular volume in hypovolemic shock?
isotonic crystalloids and colloids
Isotonic crystalloids are "standard" IV fluids and are distributed in both the ______ and ______ spaces. The are concerns though with interstitial ______.
intravascular and interstitial, edema
Colloids are fluids that have ______ active substances in them, such as ______, that will expand the intravascular volume and pull fluid from the ______ and ______ spaces.
oncotically, proteins, interstitial, intracellular
Colloids reduce the tendency towards ______ and/or ______ edema but they more also more ______ and less accessible.
pulmonary and cerebral edema, expensive
Synthetic colloids are an alternative to natural colloids. They have a higher ______ ______ than natural colloids so a greater percent remains in the intravascular space and leads to less interstitial edema.
Removal of the underlying cause of hypovolemia: ______ as warranted, other hemostatic therapies, such as ______ or ______.
surgery, tourniquets, clamps
Neurogenic shock is inadequate tissue perfusion due to a loss of ______ ______. It is relatively ______ compared to the other types of shock.
sympathetic tone. rare.
What is the difference between the terms "spinal shock" and "neurogenic shock?"
spinal shock refers to ALL manifestations of loss of nervous system input below the area below the SCI. neurogenic shock refers specifically to the cardiovascular changes associated with a loss of sympathetic tone
What are some possible causes of neurogenic shock?
most common cause is spinal cord injury, also can occur secondary to other trauma such epidural anesthesia
Neurogenic shock is most common in what type of SCI? What is the underlying problem?
those at occur at T6 or above. loss of sympathetic outflow from injured spinal cord
What makes neurogenic shock different from all other types?
there is no compensation because the SNS is the problem
Neurogenic shock occurs within __-__ minutes following an SCI. How long does it last?
30-60 minutes. however long it takes for sympathetic reflexes to take over.
What is the range of time for sympathetic reflexes to take over in neurogenic shock? What is the average?
anywhere from a few hours to months. average is 1-6 weeks
Neurogenic shock involves complete or nearly complete suppression of all ______ activity below the level of injury. What system then dominates?
What happens physiologically in neurogenic shock?
there is a loss of vasomotor tone without the SNS and thus a decrease in BP. the heart has lost its ability to respond to the decreased BP and decreased venous return.
The massive vasodilation in neurogenic shock leads to a decrease in ______. These two factors combined make for an inadequate ______ ______. This is what leads to the decreased tissue perfusion and later impaired cellular metabolism.
SVR. cardiac output
What are some signs and symptoms of neurogenic shock?
orthostatic hypotension, bradycardia, decreased sweat, decreased temperature, decreased cardiac output
Why does orthostatic hypotension occur in neurogenic shock?
due to vasodilation below the area of injury
Why does someone in neurogenic shock have decreased sweat?
due to lack of SNS stimulation of alpha adrenergic receptors in sweat glands
Why does someone in neurogenic shock have a decrease in temperature?
due to break in connection between SNS and hypothalamus. also due to passive heat loss from vasodilation.
Someone in neurogenic shock has decreased cardiac output due to a decreased ______ ______ and also due to decreased ______ ______ due to vasodilation.
heart rate, filling pressures
For the treatment of neurogenic shock, it is necessary to replace SNS function until sympathetic reflexes return. What two drugs are used for this?
epinephrine (Adrenaline) and norepinephrine (Levophed)
What are two non-pharmacologic treatments of neurogenic shock?
1. fluids to increase blood volume and venous return to the heart. 2. compression to augment venous return
Compression for a patient with neurogenic shock would come in the form of...
thigh high TED hose, abdominal binder
Anaphylactic shock results from the interaction of an ______ with ______ on sensitized body tissue.
Anaphylaxis involves the attachment of a sensitized ______ antibody to a ______ cell. This causes the release of chemical ______ from inside the ______ cell.
IgE, mast, mediators, mast
What is the actual cause of neurogenic shock?
the chemical mediators, not the antigen-antibody reaction
A hypersensitivity reaction is an ______ tissue-damaging response of the immune system. The antigen precipitating the response is called an ______.
What are common biologic agents that cause an anaphylactic reaction?
semen, food additives, pesticides, gluten
Manifestations of anaphylaxis: ______, increased ______ leaking, ______ muscle contraction, ______ formation, and increased ______ ______ secretions.
vasodilation, capillary, smooth, microthrombi, gastric acid
Increased capillary leaking in anaphylaxis leads to the formation of ______, swelling of the ______, ______, ______ and ______, ______ edema and ______ edema.
urticaria, lips, tongue, feet, hands, periorbital, pulmonary
Smooth muscle contraction in anaphylaxis that occurs in the lungs causes ______, ______, ______, ______ ______ and ______ edema.
wheezes, dyspnea, stridor, air hunger, pulmonary edema
Smooth muscle contraction in anaphylaxis that occurs in the GI tract causes what symptoms?
nausea, vomiting, diarrhea, cramping/abdominal pain
Smooth muscle contraction in anaphylaxis that occurs in the GU tract may cause...
urinary incontinence and vaginal bleeding
In anaphylaxis there is altered ______ and ______ (clot-dissolving). This may lead to...
coagulation, fibrinolysis, DIC
The priorities in the treatment of anaphylaxis are to ______ and ______ the cause and to maintain a ______ airway, and give ______ if necessary.
determine, eliminate, patent, oxygen
What 5 types of drugs may be given in anaphylaxis?
epinephrine, inhaled B2 agonists, antihistamines, corticosteroids, volume expanders
Epinephrine works in the treatment of anaphylaxis by counteracting ______ ______ by acting on what adrenergic receptors?
chemical mediators, A1, B1 and B2
What effect does epi have on: A1 receptors, B1 receptors and B2 receptors?
A1--vasoconstriction (increase BP), B1-- increase heart rate and contractility (increase BP), B2-- bronchodilation
Inhaled B2 agonists cause ______, which counteracts the bronchospasm associated with anaphylaxis.
Antihistamines in anaphylaxis work primarily against ______. They inhibit the ______ and ______ ______ ______ associated with anaphylaxis.
urticaria, vasodilation, smooth muscle contraction
Antihistamines given in anaphylaxis result in decreased ______ and decreased ______ narrowing, but increased ______ ______.
bronchospasm, airway, blood pressure
Corticosteroids in anaphylaxis: reverse histamine-induced ______, histamine-induced ______ by decreasing the release of chemical mediators from ______ cells.
Are are volume expanders needed in anaphylaxis?
volume resuscitation needed--can lose up to 1/3 of total blood volume in a few minutes
What might be given as volume expanders in anaphylaxis?
isotonic crystalloids and repeated doses of epi or epi IV
What are some of the chemical mediators in anaphylaxis?
complement, histamine, kinins, prostaglandins
What causes the relative hypovolemia that occurs in anaphylaxis?
the extravasation of intravascular fluids (edema), decreased SVR (d/t peripheral vasodilation)
Steps to septic shock: ______, ______, ______, ______, ______ ______, and finally septic shock.
infection, bacteremia, SIRS, sepsis, severe sepsis, septic shock
An infection is an ______ response to the presence of microorganisms or the invasion of normally sterile host tissue by microorganisms.
Four criteria for SIRS--plus how many must be met in order for it be considered such
temp greater than 38 or less than 36, HR greater than 90, resp rate greater than 20 or PACO2 less than 32, WBC count greater than 12,000 or less than 400 or less than 10% bands (NEED TWO OR MORE OF CRITERIA)
Why would someone with SIRS have a PACO2 less than 32?
indicating respiratory alkalosis to compensate for metabolic acidosis
Sepsis is the ______ response to infection, characterized by ______ and ______ ______.
systemic, SIRS, positive cultures
Severe sepsis is associated with ______, ______ and particularly ______ dysfunction.
hypoperfusion, hypotension, organ
What are some signs of hypoperfusion in severe sepsis?
lactic acidosis, oliguria, mental status changes, hypoxemia
Signs of hepatobiliary dysfunction in severe sepsis
elevation in liver function enzymes and serum bilirubin
Signs of dysfunctional coagulation in severe sepsis
decreased plt count, increased bleeding time, increased fibrin degradation product (FDP)
Septic shock is sepsis, but with ______ despite aggressive fluid resuscitation, along with signs of ______ abnormalities.
Septic shock is caused by the destructive effects of the ______ ______ and the ______ ______. The host releases huge amounts of ______ ______ that can be even more destructive than the infectious pathogen.
infectious pathogen, host response, chemical mediators
What causes the difference between early and late septic shock?
different mediators are predominant at different phases
What are the two phases of septic shock called?
1. EARLY "warm shock" (hyperdermic phase)
2. LATE "cold shock" (hypodermic phase)
Warm shock is characterized by massive ______ and active ______ mechanisms (neuro, hormonal, chemical).
Patients in warm septic shock--what will their cardiac output be like? What will their skin be like? What about their BP?
normal or high. pink, warm and dry. low.
The massive vasodilation that occurs in "warm" septic shock causes decreased ______ ______ and ______ ______.
venous return, peripheral resistance
In late shock, the ______ mechanisms are overwhelmed. This leads to the release of ______ ______ ______. The body is then no longer able to maintain an adequate ______ ______. This results in pathophysiology similar to ______ shock.
compensatory, myocardial depressant factor, cardiac output, cardiogenic
Capillary leaking occurs in late shock due to chemical mediators. This leads to a loss of ______ ______, which promotes SNS-induced ______. This is similar to ______ shock.
blood volume, vasoconstriction, hypovolemic
In septic shock, myocardial depressant factor is secreted from ______ in response to ______.
Late septic shock: decreased ______ ______, decreased ______ ______, skin _____ and ______, widespread ______ and ______ edema and severe ______ ______ (acid-base d/o).
tissue perfusion, organ function, cold and mottled, peripheral and pulmonary, metabolic acidosis
Treatment during septic shock focuses on ______ therapy, ______ therapy and ______ support.
fluid, antibiotic, cardiovascular
Why is fluid therapy used during septic shock?
to increase circulating blood volume to compensate for massive vasodilation
Antiobiotic therapy in septic shock: start ______ spectrum or ______ antibiotics to do what?
broad, multiple, cover as many organisms as possible and as early as possible (cannot not for C and S)
Cardiovascular support during septic shock might include ______ ______ ______ and "pure" ______.
positive inotropic agents, vasoconstrictors
Positive inotropic agents given in septic shock might include ______, ______ and ______ (or Levophed).
dopamine, dobutamine, and norepinephrine
Levophed is a ______ drug that stimulates adrenergic receptors. Which ones?
sympathomimetic, A1 and B1
When Levophed stimulates A1 receptors it causes ______ and increased ______ ______.
vasoconstriction, blood pressure
What do "pure" vasoconstrictors do?
act only on A1 receptors. this causes vasoconstriction which increases BP without increasing C.O.
Is the bactermia that causes septic shock more commonly caused by gram-negative organisms or gram-positive?
Gram-negative organisms cause the release of ______ whereas gram-positive cause the release of ______.
Either the endotoxins or exotoxins released in bacteremia result in the triggering of the ______ system, ______ cascade, ______ system or ______, ______ and ______-______ cell activity. THESE are the sources of chemical mediators.
complement, coagulation, kinin, neutrophil, endothelial, monocyte-macrophage
In warm septic shock, ______ ______ has been released during endothelial damage. The ______ is effective at keeping control.
nitric oxide, SNS
Cold septic shock: patient is cold like ______ shock, the ______ is ineffective like neurogenic shock, there is ______ dysfunction like cardiogenic shock and ______ like anaphylactic shock. It is usually IRREVERSIBLE.
hypovolemic, SNS, cardiac, leaking
Circulating blood volume in the different types of shock
decreased in late septic shock, anaphylactic and hypovolemic shocks. no change in cardiogenic, neurogenic and early septic shock.
Preload in the different types of shock
increased in cardiogenic and late septic. decreased in all others