Overview Different Types of Shock Shock Type Skin Wedge Pressure (PCWP) (Preload) Systemic Vascular Resistance (SVR) (Afterload) Cardiac Output Hyovolemic Cold and clammy skin ↓↓ ↑ ↓ Cardiogenic ↑ or ↓ ↑ ↓↓ Obstructive Distributive Warm or dry skin ↓ ↓↓ ↓ (dry)↑ (warm) Introduction Clinical definition decreased oxygen delivery, increased oxygen consumption, or impaired oxygen utilization that results in cellular and tissue hypoxia this occurs in cases of reduced tissue perfusion (e.g., hemorrhage) there are 4 types of shock cardiogenic hypovolemic distributive obstructive Cardiogenic Clinical definition shock secondary to intracardiac causes results in a decreased cardiac output self-perpetuating since hypotension will result in decreased perfusion to the coronary vessels thus worsening ischemia decreased stroke volume will in turn increase the amount of blood in the left ventricle (LV) which increases LV size and thus myocardial oxygen demand Etiology causes of cardiogenic shock can be divided into three categories cardiomyopic myocardial infarction (e.g., > 40% of the LV mass is infarcted) heart failure exacerbations (e.g., dilated cardiomyopathy) myocarditis stunned myocardium in the setting of prolonged ischemia drug induced (e.g., β-blockers) arrhythmic tachyarrhythmias (e.g., atrial fibrillation) bradyarrhythmias (e.g., Mobitz type II second degree heart block) mechanical valvular pathology (e.g., valvular rupture, insufficiency, and severe stenosis) atrial myxoma Clinical findings cold and clammy skin Treatment intravenous inotropes (e.g., dobutamine) intra-aortic balloon pump in certain cases percutaneous left ventricular assist device (LVAD) in cases where more extensive and prolonged support is needed to achieve hemodynamic stability Hypovolemic Clinical definition shock secondary to reduced intravascular volume the reduced preload results in a decreased cardiac output Etiology causes of hypovolemic shock can be divided into hemorrhagic (e.g., trauma and gastrointestinal bleeding) non-hemorrhagic decreased intravascular volume not due to loss of blood gastrointestinal losses (e.g., diarrhea) skin loss (e.g., heat stroke and burns) Clinical findings cold and clammy skin Treatment intravenous fluids Distributive Clinical definition shock secondary to severe peripheral vasodilation Etiology septic shock non-septic causes include systemic inflammatory response syndrome (SIRS) neurogenic shock (e.g., traumatic brain and spinal cord injury and neuro-axial anesthesia) anaphylaxis Clinical findings warm or dry skin Treatment intravenous fluids and vasopressors Obstructive Clinical definition shock secondary to extracardiac causes of pump failure (most common) typically is associated with impaired right ventricular output Etiology causes of obstructive shock can be divided into pulmonary vascular (e.g., severe pulmonary embolism and pulmonary hypertension) mechanical (e.g., tension pneumothorax, pericardial tamponade, and constrictive pericarditis Clinical findings cold and clammy skin Treatment manage the obstruction
QUESTIONS 1 of 4 1 2 3 4 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.PA.36) A 73-year-old male is brought into the ED unconscious with cold, clammy skin. His blood pressure is 65 over palpable. There is no signs of blood loss. You recognize the patient is in acute shock and blood is drawn for investigation as resuscitation is initiated. Which of the following might you expect in your laboratory investigation for this patient? Review Topic QID: 100101 1 Increased arterial pH 6% (14/231) 2 Increased serum bicarbonate 6% (13/231) 3 Increased serum ketones 15% (34/231) 4 Decreased hemoglobin 7% (16/231) 5 Increased blood lactate 66% (152/231) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 5
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