Shock Flashcard 4

D. Rationale: Vasopressors and vasodilators are the medications of choice to optimize the afterload (systemic vascular resistance). Intravenous fluid therapy optimizes preload. Inotropes and inodilators optimize contractility, and chronotropes such as epinephrine optimize the heart rate.

A. Rationale: Cardiogenic or obstructive shock will require less fluid given at a slower rate due to the unwanted effect of increased preload when treating cardiogenic shock. The amount recommended is a bolus of 5–10 mL/kg IV over 10-20 minutes, and the patient is reassessed after each bolus for impending respiratory distress, rales, or signs of hepatomegaly and pulmonary edema. If pulmonary edema ensues, the team must provide immediate respiratory support by maintaining an airway, giving oxygen, and assisting ventilation with positive end-expiratory pressure.

B. Rationale: Isotonic crystalloid solutions are given as a bolus of 10-20 mL/kg IV over 5–20 minutes. It is repeated as needed to reach the desired effect. Fluid overload during treatment for septic shock increases morbidity rates. Providers should use their best clinical judgment to determine if fluid boluses should be 10 mL/kg or 20 mL/kg. Some children with septic shock may need fluids of 60 mL/kg in the first hour of therapy or even as much as 200 mL/kg over the first 8 hours.

C. Rationale: Sodium bicarbonate is a buffer that can temporarily correct profound metabolic acidosis secondary to shock early in the disease. Metabolic acidosis is caused by lactic acid production secondary to inadequate tissue perfusion resulting in anaerobic metabolism. Sodium bicarbonate should not be routinely used during a resuscitation. Its indicated only for hyperkalemia and severe metabolic acidosis not resolved with other interventions.

B. Rationale: A 10 to 20 mL/kg bolus of isotonic crystalloid solution should be given to patients with hypotension due to intravascular fluid volume loss.

B. Rationale: The primary goals of managing shock are to increase oxygen delivery to the tissues, balance tissue perfusion and metabolic demand, reverse perfusion abnormalities, maintain organ function, and ultimately prevent the deterioration of shock to cardiac arrest. The immediate application of vasopressors and correcting arrhythmias are specific treatments that may be used in one form of shock but not another.

A. Rationale: To compensate for the effects of shock, the body increases venous smooth muscle tone, heart rate, systemic vascular resistance, and myocardial contractility. Initially, tachycardia is the body’s attempt to increase cardiac output in children. The body then tries to divert blood flow to vital organs. Thus, it selectively increases vascular resistance to nonessential tissues. In the clinical setting, the provider will notice that the patient has cool extremities and weak peripheral pulses. As the body further directs blood flow to the heart and brain, there is reduced perfusion to the kidneys, which decreases urine output.

D. Rationale: The goal of improving shock is to improve tissue perfusion and oxygen delivery to tissues by increasing heart rate, systemic vascular resistance, and increase in the strength of myocardial contractility and venous muscle tone.

D. Rationale: Pediatric patients in shock are critically ill and their tissues have an increased oxygen demand. Pain, anxiety, fever, and increased breathing effort further increase oxygen demand. Sedatives, neuromuscular blockade, and anti-pyretics are useful adjuncts to offload oxygen demand created by these signs and symptoms. Clinicians should obtain expert consultation when using neuromuscular blockade and sedative medications.

D. Rationale: Reducing oxygen demand in a pediatric patient in shock is achieved by mitigating pain, anxiety, and fever and improving ventilation and oxygenation. The clinician can administer sedatives and analgesics to decrease pain and anxiety. The patient may also need mechanical ventilation to address respiratory insufficiency. Neuromuscular blockade in an intubated patient reduces metabolic demands on the muscles.