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PMS: SHOCK
from book
64
Anatomy
2nd Grade
07/30/2010

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Cards

Term

Shock from any  cause can progress to....

 

(2)

Definition

organ failure

 

death

Term
What is multiple organ dysfunction syndrome?
Definition

progressive

 

often involves the ultimate failure of 2 or more organ systems after a severe illness or injury.

Term
How can shock be classified? (3)
Definition

type

prinicipal pathophys process

clinical manifestations

Term

What causes the following:

cardiogenic: 

neurogenic or vasogenic: 

anaphylactic: 

septic: 

hypovolemic:

traumatic shock: 

Definition

cardiogenic: caused by heart failure

neurogenic or vasogenic: caused by alterations in vascular smooth muscle tone

anaphylactic: caused by hypersensitivity

septic: caused by infection

hypovolemic: caused by insufficient intravascular fluid volume

traumatic shock: components of hypovolemic and septic shock

Term
What are common signs of symptoms of pt experiencing shock?
Definition

feel sick

weak

cold

hot

neauseated

dizzy

confused

afraid

thirsty 

SOB

Term
What is the common pathway in all types of shock?
Definition
impairment of cellular metabolism
Term

Explain the impairment of oxygen use in:

 

cardiogenic shock

hypovolemic shock

neurogenic, anaphylactic and septic shock

Definition

cardiogenic shock: CO is too low to deliver adequate oxygen to the cell

 

hypovolemic shock: O2 delivery is impaired by inadequate numbers of red cells or inadeq volume of intrvascular fluid.

 

Neurogenic, anaphylactic, septic shock: systemic vascular resistance is too low and perfusion pressure in the capillaries is inadequate to drive O2 across cell membranes

 

Septic shock: hypoxia is made worse by fever, which increases the cell's oxygen consumption rate and by endotoxic and inflammatory chemical disruption of cell metabolism, which impairs the cells' ability to use oxygen

Term
What happens when a cell doesn't have oxygen?
Definition

it shifts from aerobic to anaerobic metabolism

 

anaerobic metabolism is less efficient method of extracting energy from carbon bonds and cell begins to use adenosine triphosphate faster than it can be replaced

Term
What happens when a cell doesn't have ATP?
Definition
without ATP, cell loses its ability to maintain an electrochemical gradient across its selectively permeable membrane (ie. can't work the Na/K pump)
Term
What happens if the Na and K pump doesn't work bc of lack of O2?
Definition
sodium and chloride builds up in the cell and K exits
Term
How do you get decreased circulatory volume when there is impairment of oxygen use?
Definition
As sodium moves into the cell, water follows. Throughout the body, the water drawn from the interstitium into the cells is "replaced" by water that is in turn drawn out of the vascular space, often called "third spacing" of fluid
Term
What 3 positive feedback loops further impair oxygen use:
Definition

1. activation of the clotting cascade

2. decreased circulatory volume

3. lysosomal enzyme release

Term

What activates the clotting cascade in the positive feedback loop?

 

What are complications of clotting cascade in shock?

Definition

sluggish capillary flow decreases tissue perfusion further and activates the clotting cascade.

 

Complications: acute tubular necrosis, ARDS, DIC

Term
What amplifies intravascular fluid loss?
Definition
when serum protein and other plasma proteins are consumed for fuel which results in decreased intravascular osmotic pressure, shift of fluid to the interstitial or extracellular spaces and decreased circulation volume
Term
Impair oxygen use causes lysosomal enzymes to be released from cells...what is the impact?
Definition

the enzymes not only damage the cell that released them but also injures adjacent cells.

 

By damaging the mechanisms of surrounding cells, lysosomal enzymes extend areas of impaired metabolism and cellular injury.

Term
WHen you don't have oxygen for cells, the cells go into anaerobic metabolism. This has an effect on the pH. Explain.
Definition

it causes metabolic acidosis

 

cardiac and skeletal muscle use lactic acid as fuel sources, but only for a limited time

Term
What are consequences of decreasing pH of a cell?
Definition

Enzymes necessary for cellular function dissociate under acid conditions.

 

Enzyme dissociation stops cell function, repair and division.

 

As lactic acid is released systemically- blood pH drops, reducing the oxygen-carrying capacity of the blood; THEREFORE LESS OXYGEN IS DELIVERED TO THE CELLS!

 

further acidosis triggers the release of more lysosomal enzymes because the low pH disrupts lysosomal membrane integrity

Term
What prevents glucose uptake?
Definition
vasoactive toxins, endotoxins, histamine and kinins
Term
What can influence glucose metabolism to be increased or disrupted? (2)
Definition
fever or bacteria
Term

What are the effects of high serum levels of cortisol, growth hormone, and catecholmines?

 

5

Definition

cause hyperglycemia and insulin resistance

tachycardia

increased SVR

increased cardiac contractility

Term
When cells are not getting the glucose that they need, for example, due to a shock state- how do they compensate?
Definition
glycogenolysis, gluconeogenesis and lipolysis
Term

True or False:

 

The depletion of fat and glycogen stores is the cause of organ failure.

Definition

False

 

The energy costs of glycogenolysis and lipolysis are considerable and contribute to the cells' failure.

Term

What is a cause of organ failure in shock?

 

why?

Definition

depletion of protein is a cause

 

why? Gluconeogensis causes proteins to be used for fuel soo these proteins are no longer available to maintain cellular structure, function, repair and replication.

Term

During anaeorobic metabolism,

 

protein breakdown liberates ____, which is converted to ___ acid. IN sepsis this ____ acid is changed into lactic acid and positive feedback loop is formed.

Definition

During anaeorobic metabolism,

 

protein breakdown liberates alanine, which is converted to pyruvic acid. IN sepsis this pyruvic acid is changed into lactic acid and positive feedback loop is formed.

Term

what is the byproduct of proteins broken down during anaerobic metabolism--aka what is produced?

 

2

Definition
urea and ammonia
Term
In septic shock plasma protein breakdown includes ____, thereby impairing immune system function when it is most needed.
Definition
immunoglobulins
Term
what is considered a final outcome of impaired cellular metabolism?
Definition

build up of metabolic end products in the cell and interstitial spaces. 

 

Waste products are toxic to the cells and further disrupt cellular function and membrane integrity.

 

Ex. in septic shock- a deficiency isn cellular metabolism and the buildup of toxins may precede and cause decreased tissue perfusion.

Term

The inability of the heart of pump adequate blood to tissues and end organs from any cause, the most common being within hours of an acute MI or severe epidsode of myocardial ischemia.

 

What is this called?

Definition
cardiogenic shock
Term
Name 3 things that can lead to cardiogenic shock.
Definition

 pathologic conditions that:

 

1. reduce contractility: AMI, cardiomyopathy, sepsis,  myocarditis, dysarrythmias, metabolic abnormalities, papillary muscle reputure

 

2. impair diastrolic filling: related to arrythmias

 

3. cause obstruction: due to PE, cardiac tamponade, valvular disorders and wall rupture or defects

Term
What are some compensatory mechanisms that kick in when CO decreases?
Definition

RAA system

neurohormoanal and sympathetic nervous system

 

BP mainted through vasoconstriction in response to catecholmine release from adrenals; catecholmines also increase HR and contractility

 

Increases in blood volume and vascular resistance normalize blood pressure and increase cardiac performance

Term
What progressively deteriorates the mycocardium?
Definition

increased coronary, tissue and cellular ischemia

 

pg. 1700

Term

Tachycardia

tachypnea

hypotension

JVD

low measured CO

Definition
hallmarks of cardiogenic shock
Term
What are signs of end organ failure in cardiogenic shock?
Definition
cyanosis, skin mottling, rapid, faint or irregular pulses, low urine output and occasional peripheral edema 
Term
Name causes of hypovolemic shock.
Definition

whole blood (hemorrhage)

plasma (burns)

interstitial fluid (diaphoresis, DM, diabetes insipidus, emesis or diuresis)

 

Term
How do the liver and spleen try to assist in hypovolemic shock?
Definition
add to blood volume by disgorging stored red blood cells and plasma
Term
How do the kidneys assist in hypovolemic shock?
Definition
renin stimulates aldosterone relase and retention of sodium (and hence water), whereas ADH, or vasopressin, from the posterior pituitary gland increases water retention
Term

high SVR

poor skin turgor

thirst

oliguria

low systemic and pulmonary preloads and rapid heart rate

Definition
hypovolemic shock
Term

Widespread and massive vasodilation that results from an imbalance between parasympathetic and sympathetic stimulation of vascular smooth muscle.

 

what is this describing?

Definition
neurogenic or vasogenic shock
Term
Explain the process of impaired cellular metabolism as it related to neurogenic shock
Definition
blood volume has not changed, but the amt of space containing the blood has increased, so the SVR decreases drastically; thus pressure in the vessels is inadequate to drive nutrients across capillary membranes, and nutrient delivery to the cells is impaired.
Term
parasympathetic stimulation automatically ___ sympathetic activity and vice versa
Definition
inhibits
Term

Normally, sympathetic stimulation maintain ____.

 

If the stimulation is interrupted or inhibited- this causes...

Definition

muscle tone

 

causes vasodilation

Term
WHat are ways to interrupt sympathetic activity causing neurogenic shock?
Definition

trauma to the spinal cord or medulla

 

conditions that interrupt the supply of oxygen to the medulla, or conditions that deprive the medulla of glucose

 

Other: depressive drugs, anesthetic agents, severe emotional stress and pain

Term

low SVR

bradycardia

ejection fraction remains high (indicates healthy myocardium)

fainting

Definition
neurogenic shock
Term

True or False

 

Most  episodes of fainting are NOT shock

Definition
true
Term
widespread hypersensitivity reaction
Definition
anaphylactic shock
Term
What is the inflammatory response to allergen in anaphylactic shock?
Definition

vasodilation and increased vascular permeability, resulting in peripheral pooling and tissue edema

 

Extravascular effects: constriction of extravascular smooth muscle--often causes respiratory difficulty bc it tends to affect smooth muscle layers in the airways walls

Term
What is often the first manifestation of anaphylactic shock?
Definition
anxiety, difficulty in breathing, GI cramps, edema, hives, and sensations of burning or iteching of the skin
Term
Why do you give EPI in anaphylactic shock?
Definition
decrease mast cell and basophil degranulation, cause vasoconstriction and reverse airway constriction
Term
How does septic shock happen? (ie progression)
Definition

begins with systemic inflammation response syndrome (SIRS)

Sepsis

severe sepsis

septic shock

 

Term
What are the most common infection sites associated with sepsis in the ICU?
Definition

pneumonia

bloodstream

intravascular catheter

intra-abdominal

urosepsis

surgical wound infection

Term
What is the leading cause of sepsis?
Definition

gram pos bacteria

 

(used to be gram neg but abx have helped lower)

Term

How does bacteria enter the blood to form bacteremia?

 

2

Definition

1. directly from the stie of infection

 

2. from toxic substances released by the bacteria directly into the blood stream

Term
What are the toxic substances released that lead to septic shock?
Definition

gram neg: endotoxins

gram pos: lipoteichoic acids and peptidoglycan

Term

What are the proinflammatory cells released during septic shock?

 

what are proinflammatory mediators?

Definition

cells:

polymorphonuclear leukocytes

macrophages

monocytes

platelets

 

mediators:

cytokines

TNF

kinin

 

pg. 1704

Term
Proinflammatory cytokines enhance tissue factors which initiates ______.
Definition
coagulation
Term
What is the end result of septic shock?
Definition
mixed antagonistic response syndrome as proinflammatory and anti-flammatory mediators respond, intensify and lead the host into MODS
Term

Septic shock and states of proglonged shock cause.....

 

Definition

tissue hypoxia with lactic acidosis increase NO synthesis, activate ATP sensitive and calcium regulated K channels in vascular smoothmuscle and lead to depletion of ADH.

 

tachycardia causes cardiac output to remain normal or become elevated, although myocardial contractility is reduced.

 

Pt could be hyperthermic or hypothermic

Term
What can help prevent evolution of severe sepsis and shock?
Definition
ABX and identifiying sepsis in early stages
Term
What should be included in initial resuscitation in septic shock?
Definition

initial resuscitation within the first 6 hrs to include fluids, (crystalloids or colloids)

ABX

Term
What are the most common causes of multiple organ dysfunction syndrome?
Definition
sepsis and septic shock
Term
Who is at the greatest risk for developing MODS?
Definition
older adults and persons with significant tissue injury or preexisting disease
Term
What causes secondary MODS?
Definition
the result of an excessive inflammatory reaction, after a latent period following the initial injury, in organs distant from the site of the original injury
Term
What organs are most severely affected by MODS?
Definition
lungs, splanchnic bed, liver and kidneys
Term
What is an early indicator of progression of sepsis to MODS?
Definition

shunting caused by loss of autoregulation in some organs

 

 

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