Shock And Resuscitation (1 - 6 Of 13 MCQs)

Explanation
This patient is in cardiogenic shock from decreased cardiac output producing inadequate tissue perfusion. Support for this diagnosis includes an older patient with a history of coronary artery disease, new mental status changes, dyspnea, edema and basal crepitations. Common causes of cardiogenic shock include acute MI, pulmonary embolism, COPD exacerbation, and pneumonia. A rapid workup including ECG, chest x-ray, laboratory tests, echocardiogram, and hemodynamic monitoring should confirm the etiology.
 

Hypovolemic shock occurs when there is inadequate volume in the circulatory system, resulting in poor oxygen delivery to the tissues. Neurogenic shock occurs after an acute spinal cord injury, which disrupts sympathetic innervation resulting in hypotension and bradycardia. Anaphylactic shock is a severe systemic hypersensitivity reaction resulting in hypotension and airway compromise. Septic shock is a clinical syndrome of hypoperfusion and multiorgan dysfunction caused by infection.

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Explanation
The ECG shows a narrow complex, regular tachycardia typical of supraventricular tachycardia. It is caused by a re-entry or an ectopic pacemaker in areas of the heart above the bundle of His, usually the atria. Regular P waves will be present, but may be difficult to discern owing to the very fast rate.

The patient in this case has normal vital signs and examination, and is therefore stable. First-line treatment for a patient with stable SVT is vagal maneuvers to slow conduction and prolong the refractory period in the AV node. Other vagal maneuvers include carotid sinus massage (after auscultating for carotid bruits) and facial immersion in cold water.

If vagal maneuvers fail, the next step is adenosine, a very short-acting AV nodal blocking medication. Initially, adenosine 6 mg is rapidly pushed through the IV in a site as close to the heart as possible. Patients may experience a few seconds of discomfort, including chest pain and facial flushing on receiving the adenosine. If the patient remains in SVT 2 minutes after receiving adenosine, a second dose of adenosine at 12 mg is administered. If the second dose of adenosine fails and the patient remains stable, short-acting calcium channel blockers (eg, verapamil), beta-blockers, or digoxin can be administered. If at any time the patient is considered unstable (hypotension, pulmonary edema, severe chest pain, altered mental status, or other life-threatening concerns), synchronized cardioversion should be performed immediately.

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Explanation
This patient is in hypovolemic shock secondary to blood loss from a femoral fracture. Hypovolemic shock occurs when there is inadequate volume in the circulatory system, resulting in poor oxygen delivery to the tissues. Hemorrhage, GI losses, burns, and environmental exposures can all be responsible for hypovolemic shock. In trauma, hemorrhage is the most common cause of hypovolemic shock. This patient fractured his femur, disrupting the nearby vascular supply, resulting in significant blood collection in the soft tissue.

 

Other areas of life-threatening hemorrhage in trauma include the chest, abdomen, retroperitoneum, and pelvis. It is also important to keep in mind that significant blood loss could have occurred at the scene despite no obvious active bleeding in the emergency.

 

Neurogenic shock Occurs after an acute spinal cord injury, which disrupts sympathetic innervation resulting in hypotension and bradycardia. Cardiogenic shock is caused by decreased cardiac output producing inadequate tissue perfusion. Anaphylactic shock is a severe systemic hypersensitivity reaction resulting in hypotension and airway compromise. Septic shock is a clinical syndrome of hypoperfusion and multiorgan dysfunction caused by infection.

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Explanation
Septic shock is a clinical syndrome of hypoperfusion, hypotension, and multiorgan dysfunction caused by infection. This patient is clearly in shock with hypotension, tachycardia, tachypnea, and acute mental status changes. He also has fever and pus in his urine, making a urine infection the likely source of infection. Elderly patients with comorbid conditions, such as diabetes are more prone to developing sepsis. In addition, patients with indwelling lines, such as Foley catheters, are at an even higher risk for infection.

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Explanation
The rhythm shown is VF. The earlier a "shock" is administered in cardiac arrest, the more likely the patient will return to spontaneous circulation. If there is a delay to defibrillation (> 4 minutes), CPR should be administered for 60 to 90 seconds before defibrillation. If after defibrillation, the patient rhythm is still VF or pulseless VT, then assisted ventilation and chest compressions should be started. Intubation should be performed and IV access obtained for the administration of epinephrine or vasopressin. If the rhythm is unchanged after administration of vasopressor therapy, then another attempt at defibrillation with subsequent administration of amiodarone is recommended.

 

There is no role for observation with VF. Successful return of a perfusing rhythm is most likely to result with immediate defibrillation. Synchronized cardioversion is energy delivered to match the QRS complex. This reduces the chance that a shock will induce VF.

Synchronization is used to treat tachyarrhythmias (eg, rapid atrial fibrillation) in hemodynamically unstable patients. It should not be used in VF or pulseless VT.

 

Amiodarone is used in patients with VF or pulse less VT after appropriate defibrillation and administration of vasopressor therapy.

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Explanation
This patient is in anaphylactic shock from a food allergy while dining. Anaphylaxis is a severe systemic hypersensitivity reaction leading to shock from hypotension and respiratory compromise. The diagnosis is made clinically: This patient's reaction began classically with urticarial symptoms of pruritus and flushing. She then progressed to shock with hypotension and respiratory edema. She should be treated immediately with oxygen, intramuscular or IV epinephrine, corticosteroids, diphenhydramine, and IV fluids.
 

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