Shock

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  • 1/23 Questions

    The patient is unable to give a coherent history.  The roommate states that the patient has been feeling unwell for the past two days, with increasing lethargy, fever, intermittent "shaking" and cough productive of yellow sputum.  The patient has previously been very healthy, with the only sick contacts being her two nephews with whom she visited four days ago.  Her initial vital signs include a BP 66/32, HR 132, RR 28, temp 39.8 and O2 sat 92% on 3L nasal prongs.  Her extremities feel warm to the touch and her JVP is in the normal range.  She has bounding pulses.  Her GCS is 11.  She has not urinated in 24 hours.  Is this patient in shock?

    • Yes
    • No
    • Maybe?
    • Get me the hell out of here!?
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Shock - Quiz
About This Quiz

This quiz titled 'Shock' assesses critical emergency responses to a patient in shock due to an upper GI bleed. It evaluates skills in ABCs (Airway, Breathing, Circulation), diagnosis, and initial management, focusing on a realistic emergency scenario to enhance learner preparedness in acute care settings.

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  • 2. 

    A 53-year-old woman is brought in by ambulance to the ER.  The nurse calls you to the bedside because the patient is confused and hypertense.  The patient had felt unwell today and had told her husband that she had vomited a 'small amount' of fresh blood six times today.  After her last episode of vomiting, her husband had checked on her and found her unconscious on the bathroom floor, in a pool of blood, and called the ambulance.  The paramedics tell you that there was obvious fresh blood in the toilet bowl, as well as evidence of fresh blood oozing from her rectum.  Her initial examination reveals a BP of 70/40 mmHg, HR 140 bpm, and RR 20.  She is afebrile.  She looks very pale, and her extremities are very cold and clammy.  Her JVP and external jugular pulse are flat; she has a normal S1 and S2, and no extra heart sounds.  She has normal breath sounds bilateral.  She has decreased bowel sounds, with epigastric tenderness to palpation.  Her level of consciousness is decreased, but she does rouse to painful stimuli (GCS 12).  a Foley catheter is inserted: 15cc of concentrated urine returns.  Is this patient in shock?

    • Yes

    • No

    • Maybe?

    • Where am I?

    Correct Answer
    A. Yes
    Explanation
    inadequate tissue perfusion to meet cellular requirements of oxygen and nutrients. Manifested in this patient by hypotension, decreased LOC, hypoperfusion of skin and oliguria.

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  • 3. 

    At this point, two 14 gauge peripheral IVs are started, and she is immediately given a 2L bolus of normal saline.  Her blood is sent for a CBC, electrolytes, INR, PTT, and type and cross-match for 6 units of packed red cells.  After the bolus the patient remains somnolent.  Her BP is 76/40, HR 120 bpm (regular), RR 24 and O2 sats on 4L NP are 95%.  There is an additional 10 cc of concentrated urine in her foley catheter since it was inserted 30 minutes ago.  Her blood work has now returned and shows: ABG 7.26/30/91/13, Hb 135, WBC 8.3, platelets normal, Na 135, Cl 102, K 4.2, creatinine 162, BUN 21.3, INR 1.1, aPTT normal, lactate 4.2, ScvO2 A+.  Is this patient still in shock?

    • Yes

    • No

    • Maybe?

    • Who are you?

    Correct Answer
    A. Yes
    Explanation
    Yes - still evidence of end-organ dysfunction

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  • 4. 

    You are called urgently to the medical ward to assess a 54-year-old man who was admitted 2 days ago for investigation of recurrent abdominal pain.  Upon your arrival you are told that the blood pressure that was just taken was 114/60 mmHg.  The patient is moaning in bed, and looks unwell.  This morning he had onset of epigastric burning that got progressively worse over the next few hours, despite Maalox and ranitidine.  He has a past medical history significant for a previous gastric ulcer, tobacco use (30 pack-years), HTN, dyslipidemia and a recent diagnosis of DM type 2.  Your initial PE demonstrates cold extremities and a JVP 9cm ASA.  His blood pressure is 118/62 mm Hg, HR 102 bpm and regular, RR 30 and oxygen saturations of 93% on 10L/min by face mask.  He is working very hard to breathe, prefers sitting upright, is diaphoretic, has a new S3, equal breath sounds bilaterally, with crackles to both bases and has not made any urine for the past 4 hours.  He is able to give one to two word answers to your questions.  Is this patient in shock?

    • Yes

    • No

    • Maybe?

    • How did I get here?

    Correct Answer
    A. Yes
    Explanation
    normal blood pressure in this scenario is not reassuring, considering his history of HTN. Clinically, the patient has inadequate tissue perfusion (poor peripheral tissue perfusion and oliguria).

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  • 5. 

    You are called urgently to the medical ward to assess a 54-year-old man who was admitted 2 days ago for investigation of recurrent abdominal pain.  Upon your arrival you are told that the blood pressure that was just taken was 114/60 mmHg.  The patient is moaning in bed, and looks unwell.  This morning he had onset of epigastric burning that got progressively worse over the next few hours, despite Maalox and ranitidine.  He has a past medical history significant for a previous gastric ulcer, tobacco use (30 pack-years), HTN, dyslipidemia and a recent diagnosis of DM type 2.  Your initial PE demonstrates cold extremities and a JVP 9cm ASA.  His blood pressure is 118/62 mm Hg, HR 102 bpm and regular, RR 30 and oxygen saturations of 93% on 10L/min by face mask.  He is working very hard to breathe, prefers sitting upright, is diaphoretic, has a new S3, equal breath sounds bilaterally, with crackles to both bases and has not made any urine for the past 4 hours.  He is able to give one to two word answers to your questions.  How will you manage this patient?

    • Identification of the underlying etiology of the shock state

    • Immediate resuscitation of the shock state

    • Initiation of specific therapies related to the underlying etiology

    • Identification and treatment of any complications related to the shock state

    • All of the above

    Correct Answer
    A. All of the above
    Explanation
    Given the ECG findings (that you haven't seen because I am too lazy), this patient is having an acute MI. He needs definitive therapy as quickly as possible.
    Dependingo n what resources are available in the centre you are practicing, thrombolysis or percutaneous coronary intervention (PCI) should be arranged urgently. In the meantime, the usual therapy for an ACS should be undertaken: 160 mg ASA chew, nitro spray or SL nitro, heparin IV, beta-blocker if pulmonary edema, ACE inhibitors and statin (later). Once the underlying etiology has been addressed, potentially modifiable variables (content, contractility, rate, rhythm, afterload, preload) must be addressed; then complications (pulmonary edema, acute renal failure)

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  • 6. 

    Chest x-ray shows a right upper-lobe infiltrate.  How would you initially manage this patient?

    • Crystalloids 500-1000mL boluses every 15-30 minutes

    • Broad spectrum antibiotics

    • Find the source of infection

    • Draw cultures as soon as possible to maximize chances of isolating an organism

    • All of the above

    Correct Answer
    A. All of the above
    Explanation
    The correct answer is "all of the above" because when a patient presents with a right upper-lobe infiltrate on a chest x-ray, it indicates a possible lung infection. In order to manage this patient, it is important to administer crystalloids in boluses to maintain fluid balance, initiate broad-spectrum antibiotics to target the infection, find the source of the infection to prevent further spread, and draw cultures as soon as possible to identify the causative organism and guide targeted treatment. Therefore, all of the mentioned actions are necessary for the initial management of this patient.

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  • 7. 

    A 53-year-old woman is brought in by ambulance to the ER.  The nurse calls you to the bedside because the patient is confused and hypertense. Which of the following would you do first?

    • Get a basic history

    • Basic clinical examination - vital signs

    • ABCs

    • Placement of foley catheter

    Correct Answer
    A. ABCs
    Explanation
    You would do all of the above, but you would do the ABCs (Airway, Breathing, Circulation) first.

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  • 8. 

    Which of the four broad categories of shock is this patient's clinical presentation most in keeping with?

    • Cardiogenic

    • Hypovolemic

    • Distributive

    • Obstructive

    Correct Answer
    A. Hypovolemic
    Explanation
    low JVP, cool extremities, history of blood loss, lack of history suggestive of decompensated distributive shock - suggest that this is most likely hypovolemic shock.

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  • 9. 

    You are completing a rotation in a rural hospital, and as the clinical clerk, you are first call to the ER.  One night when you are on call, a 23 year old woman is brought in by her roommate because of a high fever.  The nurse asks you to see the patient right away because she believes the patient is very ill.  What would you do first?

    • Get a basic history

    • Basic clinical examination - vital signs

    • ABCs

    • Placement of foley catheter

    Correct Answer
    A. ABCs
    Explanation
    You would do all of the above, but you would do the ABCs (Airway, Breathing, Circulation) first.

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  • 10. 

    The patient is unable to give a coherent history.  The roommate states that the patient has been feeling unwell for the past two days, with increasing lethargy, fever, intermittent "shaking" and cough productive of yellow sputum.  The patient has previously been very healthy, with the only sick contacts being her two nephews with whom she visited four days ago.  Her initial vital signs include a BP 66/32, HR 132, RR 28, temp 39.8 and O2 sat 92% on 3L nasal prongs.  Her extremities feel warm to the touch and her JVP is in the normal range.  She has bounding pulses.  Her GCS is 11.  She has not urinated in 24 hours. Which type of distributive shock is the most likely possibility in this case?

    • Anaphylaxis

    • Fulminant hepatic failure

    • Adrenal insufficiency

    • Septic shock

    • Neurogenic

    Correct Answer
    A. Septic shock
    Explanation
    The patient's symptoms, such as fever, lethargy, productive cough, and yellow sputum, along with her vital signs, including high heart rate, low blood pressure, and low oxygen saturation, suggest an infection. The fact that she has not urinated in 24 hours indicates possible kidney dysfunction. These findings are consistent with septic shock, which is a type of distributive shock caused by a severe infection leading to systemic inflammation and organ dysfunction.

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  • 11. 

    Which of the following would you do during the CIRCULATION) portion of ABC?

    • Check for evidence of end-organ function

    • Check for adequate level of consciousness

    • Check for adequate cough

    • Check for adequate O2 saturation

    • Apply oxygen to the patient

    • Obtain IV access

    • Check for adequate gag reflex

    Correct Answer(s)
    A. Check for evidence of end-organ function
    A. Obtain IV access
    Explanation
    During the CIRCULATION portion of ABC, checking for evidence of end-organ function is important to assess the overall perfusion and function of vital organs. This helps in determining if the circulation is adequate or if there are any signs of organ dysfunction. Obtaining IV access is also crucial during this phase as it allows for the administration of fluids and medications to support circulation and maintain blood pressure.

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  • 12. 

    What is the significance of a mild elevation in lactate in this patient?

    • Impending respiratory failure

    • Previous MI

    • End-organ hypoperfusion

    • Anaerobic metabolism

    • C and D

    Correct Answer
    A. C and D
    Explanation
    A mild elevation in lactate in this patient signifies both end-organ hypoperfusion and anaerobic metabolism. End-organ hypoperfusion refers to inadequate blood flow to organs, which can be caused by various conditions such as shock or heart failure. Anaerobic metabolism occurs when there is insufficient oxygen supply to tissues, leading to the production of lactate. Therefore, a mild elevation in lactate suggests that the patient may be experiencing both inadequate blood flow to organs and anaerobic metabolism, which can be indicative of impending respiratory failure.

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  • 13. 

    The patient is unable to give a coherent history.  The roommate states that the patient has been feeling unwell for the past two days, with increasing lethargy, fever, intermittent "shaking" and cough productive of yellow sputum.  The patient has previously been very healthy, with the only sick contacts being her two nephews with whom she visited four days ago.  Her initial vital signs include a BP 66/32, HR 132, RR 28, temp 39.8 and O2 sat 92% on 3L nasal prongs.  Her extremities feel warm to the touch and her JVP is in the normal range.  She has bounding pulses.  Her GCS is 11.  She has not urinated in 24 hours.  With which broad category of shock is this patient's presentation most in keeping?

    • Hypovolemic

    • Obstructive

    • Distributive

    • Cardiogenic

    Correct Answer
    A. Distributive
    Explanation
    Given the warm extremities, the hypotension and the end-organ dysfunction, this is distributive shock.

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  • 14. 

    A 53-year-old woman is brought in by ambulance to the ER.  The nurse calls you to the bedside because the patient is confused and hypertense. The patient had felt unwell today and had told her husband that she had vomited a 'small amount' of fresh blood six times today.  After her last episode of vomiting, her husband had checked on her and found her unconscious on the bathroom floor, in a pool of blood, and called the ambulance. The paramedics tell you that there was obvious fresh blood in the toilet bowl, as well as evidence of fresh blood oozing from her rectum.  Based on this history, what is the most likely diagnosis?

    • Upper GI bleed

    • Lower GI bleed

    • Bleeding from lungs

    • Aortic aneurism

    Correct Answer
    A. Upper GI bleed
    Explanation
    The most likely source is from the GI tract, but a coagulopathy with hemoptysis and bleeding from hemorrhoids is also a remote possibility. From this information, we can begin to narrow the DDx for the etiology of her shock state.

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  • 15. 

    You are called urgently to the medical ward to assess a 54-year-old man who was admitted 2 days ago for investigation of recurrent abdominal pain.  Upon your arrival you are told that the blood pressure that was just taken was 114/60 mmHg.  The patient is moaning in bed, and looks unwell.  This morning he had onset of epigastric burning that got progressively worse over the next few hours, despite Maalox and ranitidine.  He has a past medical history significant for a previous gastric ulcer, tobacco use (30 pack-years), HTN, dyslipidemia and a recent diagnosis of DM type 2.  Your initial PE demonstrates cold extremities and a JVP 9cm ASA.  His blood pressure is 118/62 mm Hg, HR 102 bpm and regular, RR 30 and oxygen saturations of 93% on 10L/min by face mask.  He is working very hard to breathe, prefers sitting upright, is diaphoretic, has a new S3, equal breath sounds bilaterally, with crackles to both bases and has not made any urine for the past 4 hours.  He is able to give one to two word answers to your questions.  With which broad categories of shock is this patient's presentation most in keeping?

    • Distributive

    • Cardiogenic

    • Obstructive

    • Hypovolemic

    Correct Answer
    A. Cardiogenic
    Explanation
    The highest considerations on the DDx are cardiogenic and obstructive shock. Given his history, his cardiac risk factors and his physical exam (cool extremities, high JVP, S3, crackles), this is most likely cardiogenic shock. Although the initial presentation of abdominal pain may make some students consider hypovolemic shock initially, the elevated JVP makes this unlikely.

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  • 16. 

    At this point, two 14 gauge peripheral IVs are started, and she is immediately given a 2L bolus of normal saline.  Her blood is sent for a CBC, electrolytes, INR, PTT, and type and cross-match for 6 units of packed red cells.  After the bolus the patient remains somnolent.  Her BP is 76/40, HR 120 bpm (regular), RR 24 and O2 sats on 4L NP are 95%.  There is an additional 10 cc of concentrated urine in her foley catheter since it was inserted 30 minutes ago.  Her blood work has now returned and shows: ABG 7.26/30/91/13, Hb 135, WBC 8.3, platelets normal, Na 135, Cl 102, K 4.2, creatinine 162, BUN 21.3, INR 1.1, aPTT normal, lactate 4.2, ScvO2 A+.  Interpret the ABG

    • Wide anion gap metabolic acidosis with resp compensation

    • Normal anion gap metabolic acidosis with resp compensation

    • Wide anion gap resp acidosis with metabolic compensation

    • Normal anion gap resp acidosis with metabolic compensation

    Correct Answer
    A. Wide anion gap metabolic acidosis with resp compensation
    Explanation
    The ABG results indicate a low pH (7.26) and low bicarbonate (HCO3-) level (13), which suggests metabolic acidosis. The anion gap is elevated (30), indicating the presence of unmeasured anions in the blood. The respiratory compensation is evident by the low partial pressure of carbon dioxide (PCO2) of 30, which is in the expected direction to compensate for the metabolic acidosis. Therefore, the correct answer is "wide anion gap metabolic acidosis with resp compensation." This suggests that there is an underlying metabolic acidosis with an elevated anion gap, and the respiratory system is compensating by decreasing the PCO2 levels.

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  • 17. 

    Which of the following would you do during the BREATHING portion of ABC?

    • Check for evidence of end-organ function

    • Check for adequate level of consciousness

    • Check for adequate cough

    • Check for adequate O2 saturation

    • Apply oxygen to the patient

    • Obtain IV access

    • Check for adequate gag reflex

    Correct Answer(s)
    A. Check for adequate O2 saturation
    A. Apply oxygen to the patient
    Explanation
    During the BREATHING portion of ABC, it is important to check for adequate O2 saturation and apply oxygen to the patient. This is because ensuring the patient has sufficient oxygen levels is crucial for their respiratory function and overall well-being. By checking the O2 saturation and providing oxygen if necessary, you can help support the patient's breathing and prevent further complications.

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  • 18. 

    At this point, two 14 gauge peripheral IVs are started, and she is immediately given a 2L bolus of normal saline.  Her blood is sent for a CBC, electrolytes, INR, PTT, and type and cross-match for 6 units of packed red cells.  After the bolus the patient remains somnolent.  Her BP is 76/40, HR 120 bpm (regular), RR 24 and O2 sats on 4L NP are 95%.  There is an additional 10 cc of concentrated urine in her foley catheter since it was inserted 30 minutes ago.  Her blood work has now returned and shows: ABG 7.26/30/91/13, Hb 135, WBC 8.3, platelets normal, Na 135, Cl 102, K 4.2, creatinine 162, BUN 21.3, INR 1.1, aPTT normal, lactate 4.2, ScvO2 A+.  What is the significance of the patient's Hb?

    • Rules out massive bleed

    • Rules out hemorrhagic shock

    • Neither of the above

    Correct Answer
    A. Neither of the above
    Explanation
    When a patient is acutely bleeding and no fluid resuscitation has been undertaken, the hematocrit (and measure Hb levels) will remain relatively unchanged. It is only after fluid resuscitation is underway, or there is time for equilibration of extravascular fluid to the intravascular space, that a drop in Hb will become manifest on a CBC. The important point ot stress is that a normal Hb level cannot be used to rule out hemorrhagic shock.

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  • 19. 

    Based on the formula for oxygen delivery, what are the two factors that can be modified to optimize the amount of oxygen carried in the blood?

    • SaO2

    • PaO2

    • Hb

    • Hct

    Correct Answer(s)
    A. SaO2
    A. Hb
    Explanation
    DO2 = CO x [(1.34 x Hb x SaO2) + (0.003 x PaO2)]

    Hb: an "adequate" Hb level is needed to carry oxygen to the tissues.
    SaO2: maximize oxygen saturations in the short-term (increase FiO2, intubate if necessary)
    PaO2: does not make a significant contribution given the very small value.

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  • 20. 

    After 2L of normal saline, the patient's BP rises to 72/50 mmHg.  However, she continues to be somnolent, have no urine output and have a ScvO2 of 55%.  Her JVP is 1cm ASA, and her SaO2 is 98% on a non-rebreather mask.  All the following measures can be undertaken to help resuscitate this patient EXCEPT:

    • Increase the SaO2 by increasing FiO2 or intubation with mechanical ventilation

    • Give a vascoconstricting agent to increase afterload

    • Crystalloid administered to target a CVP of 8-12 mmHg

    • Agent to increase contractility

    Correct Answer
    A. Agent to increase contractility
    Explanation
    Currently, contractility is maintained in this patient (high cardiac output state - warm extremities). However, the patient is inappropriately vasodilated leading to the hypotension. If this patient progresses to decompensated septic shock, then an agent to increase contractility may be needed.

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  • 21. 

    What signs and symptoms suggest that a patient is in shock?

    • Confusion

    • Asterixis

    • Tachycardia

    • Decreased capillary refill

    • Decreased breath sounds

    • Decreased bowel sounds

    • Decreased urinary output

    Correct Answer(s)
    A. Confusion
    A. Tachycardia
    A. Decreased capillary refill
    A. Decreased bowel sounds
    A. Decreased urinary output
    Explanation
    Evidence of end-organ dysfunction: confusion, decreased level of consciousness (CNS); hypotension, tachycardia, poor pulses, poor peripheral perfusion, decreased capillary refill (CV); tachypnea (resp); decreased bowel sounds, hepatic dysfunction (GI); decreased urinary output, anuria (GU); decreased perfusion, livedo reticularis (skin). Evidence of an underlying etiology for the shock state.

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  • 22. 

    Which of the following would you do during the AIRWAY portion of ABC?

    • Check for evidence of end-organ function

    • Check for adequate level of consciousness

    • Check for adequate cough

    • Check for adequate O2 saturation

    • Apply oxygen to the patient

    • Obtain IV access

    • Check for adequate gag reflex

    Correct Answer(s)
    A. Check for adequate level of consciousness
    A. Check for adequate cough
    A. Check for adequate gag reflex
    Explanation
    During the AIRWAY portion of ABC, you would check for adequate level of consciousness, cough, and gag reflex. These assessments are important to determine if the patient's airway is patent and if they are able to protect their airway. If the level of consciousness is decreased, it may indicate a compromised airway. Adequate cough and gag reflex are signs that the patient can effectively clear their airway and protect against aspiration. These assessments help ensure that the patient's airway is open and functioning properly.

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  • 23. 

    What are the potentially modifiable variables for every patient in shock?

    • Blood content

    • Cardiac contractility

    • Heart rate

    • Heart rhythm

    • Afterload

    • Preload

    • Temperature

    Correct Answer(s)
    A. Blood content
    A. Cardiac contractility
    A. Heart rate
    A. Heart rhythm
    A. Afterload
    A. Preload
    Explanation
    The potentially modifiable variables for every patient in shock include blood content, cardiac contractility, heart rate, heart rhythm, afterload, and preload. These variables can be adjusted or manipulated to improve the patient's condition and stabilize their vital signs. By addressing issues such as low blood volume, poor cardiac contractility, abnormal heart rate or rhythm, increased afterload, and inadequate preload, healthcare providers can work towards restoring the patient's hemodynamic stability and improving their overall prognosis.

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Quiz Review Timeline (Updated): Mar 22, 2023 +

Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.

  • Current Version
  • Mar 22, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Mar 02, 2011
    Quiz Created by
    Cimanim
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