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types of shock
- cardiogenic
- hypovolemic
- distributive
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shock presentations
- systemic inflm response syndrome
- SBP < 90 or a decrease > 60 from baseline
- oliguria (incr BUN, Scr, urine <0.5ml/kg/hr)
- metabolic acidosis
- cutaneous vasoconstriction
- mental confusion (agitation, stupor, or coma)
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SIRS presentations include
- HR > 90 (tachycardia)
- RR > 20 bpm or PaCO2 < 32 mmgHg
- WBC > 12,000, <4,000 or bands > 10%
- Temp < 36(96.8) or > 38(100.4)
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the most common type of shock
hypovolemic shock
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hypovolemic shock manifestation and compensation
- decrease IV volume, venous return, CO
- increase contractility, HR, SVR
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1000 ml of NS infused leads to how much expansion
250 ml
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1000 ml of LR infused leads to how much expansion
250 ml
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1000 mL D5W infused leads to how much expansion
100 mL
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500 ml of albumin 5% infused leads to how much expansion
500 mL
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100 ml of albumin 25% infused leads to how much expansion
500 mL
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500 ml of hetastarch 6% infused leads to how much expansion
500 mL
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manifestations of cardiogenic shock
- decreased CO and BP
- increased SVR
- increased HR
- cold extremeties
- pulmonary congestion
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what is distributive shock
peripheral vascular dilation causes fall in SVR which leads to a normal or increased CO and low BP
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causes of distributive shock
- septic shock
- anaphylactic shock
- neurogenic shock
- acute adrenal insufficiency
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b1 agonism
increase HR, CO, and contractility
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a1 agonism
increase SVR and MAP
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dopamine agonism
increase urine output
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vasopressin hemodynamic effect
increase SVR, MAP, urine output
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renal dose of dopamine
low dose (< or = 3 mcg/kg/min)
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intermediate dose of dopamine
3-10 mcg stimulates B receptors in the heart
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high dose of DA
> 10 mcg/kg/min stimulates alpha receptors in the systemic and pulmonary system
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indications for DA
cardiogenic and septic shock
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DA is an alternative to NE in which pts
ONLY in pts with low risk for tachycardia or pts with bradycardia
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AE of DA
- tachyarrhythmia
- ischemic limb necrosis
- decrease gastric emptying
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pressor of choice for septic shock
NE
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IND for NE
hypotension refractory to fluid resuscitation
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AE of NE
- tachyarrhythmia (less compared to DA)
- myocardial ischemia
- tissue necrosis and sloughing
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what is the first line alt to NE in septic shock
Epinephrine (can be added or sub)
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AE of Epinephrine
- tachyarrhythmia
- hyperlactemia
- decrease splanchnic blood flow
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what drug is the second alt to NE in refractory septic shock
phenylephrine (especially in pts who cant tolerate tachycardia)
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AE of Phenylephrine
- HTN
- palpitations
- paresthesia
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Vasopressin MOA
- acts on Vasopressin 1 and 2 receptors
- direct peripheral vasoconstriction
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indication of vasopressin
add on agent to vasopressors in refractory septic shock
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which vasopressor is not indicated as a monotherapy
vasopressin
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AE of vasopressin
- drowsiness
- confusion
- water intoxication
- splanchnic ischemia
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Dobutamine MOA
- binds to B1-increase CO, SV and decrease SVR
- weakly binds to B2- slight peripheral vasodilation
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indications of dobutamine
- cardiogenic shock
- septic shock
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AE of dobutamine
- tachycardia (less compared to DA)
- myocardial ischemia
- tachyphylaxis
- hypokalemia
- hypotension
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Milrinone brand name
primacor
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milrinone MOA
inhibits cAMP breakdown in the hear to increase CO and in vascular smooth muscle to decrease SVR
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indication for primacor
- acute decompensated HF -- cardiogenic shock
- preferred to dobutamine in pts on chronic B-blocker therapy
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if a pt presents with acute decompensated HF and is on b-blockers which drug is preferred to tx
milrinone
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AE of Milrinone
- hypotension
- thrombocytopenia
- tachycardia
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indication for vasodilators (Nipride, NTG)
acute decompensated HF -- cardiogenic shock
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AE of sodium nitroprusside
- hypotension
- cyanide
- thiocyanate toxicity
- reflex tachycardia
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AE of NTG
- hypotension
- HA
- tachyphylaxis
- reflex tachycardia
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