Shock

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Ohio State University Nursing 385.02

What are the two characteristics of shock?

inadequate tissue perfusion and altered cellular metabolism

What can be the three causes of reduced tissue perfusion in shock?

loss of circulating blood volume, cardiac pump failure, or widespread vasodilation/capillary leaking

What happens in all types of shock re: oxygen and nutrients?

the oxygen/nutrient SUPPLY is inadequate to meet the cell/tissue/organ DEMAND

What are the three major groups of shock?

cardiogenic, hypovolemic, distributive/vasogenic

What are the four types of hypovolemic shock?

hemorrhagic, traumatic, burn, dehydration

What are the three types of shock that are all distributive or vasogenic?

neurogenic, anaphylactic, septic

Cardiogenic shock results from the inability of the heart to either effectively ______ or ______ blood. It is the most extreme ______ ______.

pump or receive blood. heart failure

Most common cause of hypovolemic shock

hemorrhagic

Hemorrhagic shock is the loss of blood from the ______ space.

intravascular

Traumatic shock results from blood loss PLUS...

major tissue injury

What is plasma lost as in burn shock?

burn exudates

What lab values are increased in burn shock?

hematocrit and hemoconcentration (relative increase in number of RBCs d/t decrease in plasma volume)

What can cause fluid loss in dehydration shock?

prolonged vomiting or diarrhea, intestinal fistulas or obstruction, "third space" losses

Slowest form of shock

dehydration shock

What causes distributive or vasogenic shock?

abnormal distribution of blood in the circulatory network

The problem in distributive/vasogenic shock is alterations in the blood vessels which cause decreased ______ ______ and/or increased ______ ______.

peripheral resistance, intravascular capacity

Neurogenic, anaphylactic and septic shock all have what in common re: their effect on blood vessels?

they all cause massive vasodilation

What causes massive vasodilation in neurogenic shock?

loss of sympathetic tone

What causes massive vasodilation in anaphylactic shock?

antigen-antibody reaction

What causes massive vasodilation in septic shock?

d/t overwhelming infection and the chemical mediators that are released as a result

What are 4 other physiologic mechanisms that result from untreated shock?

multiple organ dysfunction syndrome (MODS), acute respiratory distress syndrome, disseminated intravascular coagulopathy (DIC), acute tubular necrosis (ATN)

MODS is classified as failure of ______ or more organ systems and is a frequent complication of severe shock.

two

Acute respiratory distress syndrome results in acute lung ______ and diffuse ______ -______ injury.

inflammation, alveolar-capillary

DIC causes intravascular of coagulation, leading to consumption of ______ ______, followed by...

clotting factors, diffuse bleeding

ATN is caused by ______ that generates toxic free radicals that cause cell ______, ______ and ______.

ischemia, swelling, injury and necrosis

What can be the cause of the acute respiratory syndrome, DIC and ATN that may occur as a result of shock?

the inflammatory that is generated by shock

The story of the physiologic effects of shock

cells not receiving O2, switch to anaerobic metabolism, lack of ATP, decreased activity of Na-K-ATPase pump, Na accumulates in cell, K outside of cell, H2O follows Na into cell, disrupts cell membrane, lysosomal enzymes released. metabolic acidosis from anaerobic metabolism reduced O2 carrying capacity in blood. fat + glucose stores used up, proteins broken down through gluconeogenesis, build up of toxic wastes

Where do all 5 types of shock begin? What does this lead to next?

decreased tissue perfusion, impaired cellular metabolism

Impaired cellular metabolism leads to impaired ______ and ______ use.

oxygen, glucose

When cells switch to anaerobic metabolism, there is a decrease in ______ and an increase in ______ produced.

ATP, lactate

What is the outcome of the lactate that is produced in anaerobic metabolism during shock?

lactate makes lactic acid, which leads to metabolic acidosis which decreases oxygen's affinity for hemoglobin

Everyone who is in shock has what type of acid-base disorder?

metabolic acidosis (d/t excess lactate)

What is the effect of H2O shifting into cells during shock as the Na-K-ATPase pump fails and sodium moves in?

oncosis results in the cell and the cell dies. there is also a decrease in the circulatory volume

What happens as a result of decreased circulatory volume in shock? Why?

increased stimulation of the clotting cascade d/t increased blood viscosity

The cellular edema that occurs as a result of sodium and water moving into cells in shock leads to the release of ______ enzymes. These basically do what?

lysosomal enzymes. basically start eating their own cells

Impaired glucose use leads to an increased ______ ______ and the release of ______, ______ and ______ hormone as a result of stress.

serum glucose, catecholamines, cortisol, growth

What is the effect of catecholamines, cortisol and growth hormone in shock?

increased lypolysis, increased gluconeogenesis and increased glycogenolysis

In glycogenolysis, the body takes glycogen from the ______ and the ______.

liver, muscles

Glycogenolysis leads to diminished ______ stores.

energy

Lipolysis leads to an increase in serum ______ and ______ ______ ______.

triglycerides, free fatty acids

Gluconeogenesis leads to a decrease in serum ______ and an increase in serum branched-chain ______ ______, which only further exacerbates the acidosis that the body is experiencing.

albumin, amino acids

An increase in serum glucose in shock leads to an increase in ______, which becomes ______ acid and only exacerbates metabolic acidosis.

pyruvate, pyruvic

What cause of impaired cellular metabolism during shock will only further exacerbate it?

release of lysosomal enzymes

How long does it take the impaired glucose use side of impaired cellular metabolism to run out?

compensation will only last for about 10 hours

What has a person had prior to developing cardiogenic shock?

heart failure

Cardiogenic shock is ACUTE EXTREME ______ ______ and results from the heart's impaired ability to ______ or ______ blood.

heart failure, pump or receive

The etiology of cardiogenic shock can be ______ (muscle related), ______ (can't create working action potential) or ______ (e.g valvular stenosis).

myopathic, dysrhythmic, mechanical

What is an unfortunate effect of the compensatory mechanisms that occur in cardiogenic shock?

they all cause an increase in myocardial oxygen requirements

What things are released/activated in cardiogenic shock to maintain blood volume?

RAAS, ADH, aldosterone

In cardiogenic shock, the adrenal glands release ______ which cause ______ and increase heart ______ and ______.

catecholamines, vasoconstriction, contractility and rate

Clinical manifestations of cardiogenic shock may include cardiac arrhythmias. This is usually a ______ in the early stages. What can occur secondary to the ischemia created by this?

tachyarrhythmias. chest pain

What will the lung sounds and arterial blood gases indicate in cardiogenic shock?

pulmonary edema

Respiratory manifestations of cardiogenic shock

orthopnea, dyspnea, shortness of breath

What extra heart sound(s) may be heard in cardiogenic shock?

S3 and S4

Would a person in cardiogenic shock be hyper- or hypotensive?

hypo

A person in cardiogenic shock may have impaired ______. In other words, it may be hard to keep them awake.

mentation

The treatment of cardiogenic shock is aimed at increasing ______ ______ and ______ ______ and minimizing myocardial ______ ______.

cardiac output, tissue perfusion, oxygen demands

Drugs given in shock are almost always given by what route?

IV

What does a vasopressor do?

cause contraction of the smooth muscle of arteries and arterioles

Inotropic agents do what?

increase the force of myocardial contraction

What classes of drugs may be given to someone with cardiogenic shock?

vasopressors/inotropic agents, phosphodiesterase enzyme inhibitors, vasodilators, analgesics, diuretics

Dopamine is also called....

Inotropin

Dopamine is a "______ agent" which stimulates ______ receptors. Which specific receptors are stimulated depends on the dose.

sympathomimetic, adrenergic

What does of Dopamine is inotropic?

2-20 mcg

1-2 mcg/kg/min of Dopamine only stimulates ______ receptors.

dopaminergic

Low-dose dopamine (or 1-2 mcg) increases ______ and ______ vasodilation, which increases blood flow to the kidneys and abdominal organs. It also causes vasodilation of the ______ and ______ arteries.

renal and mesenteric, coronary and cerebral

2-5 mcg/kg/min of Dopamine stimulates ______ receptors and ______ and ______ adrenergic receptors.

dopaminergic, beta1 and beta2

What effects does 2-5 mcg of Dopamine have in addition to increased blood flow to the kidneys and abdominal organs?

increased cardiac output and heart rate in addition to bronchodilation

2-5 mcg of Dopamine affects the ______, ______ and ______. (organs)

heart, lungs and kidneys

5-10 mcg/kg/min of Dopamine stimulates what receptors?

only beta1 and beta2

10-20 mcg/kg/min of Dopamine stimulates beta1 and beta2 receptors PLUS ______ receptors. What new effect does this cause in addition to the cardiac and pulmonary effects of beta1 and beta2?

alpha1, vasocohttp://quizlet.com/10632638/edit/nstriction to increase BP

10-20 mcg/kg/min of Dopamine is used for low ______ ______ in cardiogenic shock.

blood pressure

>20 mcg/kg/min of Dopamine has purely a ______ adrenergic effect only. It causes only ______ as a effect.

alpha, vasoconstriction

What effects does >20 mcg/kg/min of Dopamine have?

ice cold skin, goosebumps, mottled coloring

Dobutamine (Dobutrex) is a sympathomimetic agent that has greater ______ than ______ effects. What makes it a better option than Dopamine for the treatment of cardiogenic shock?

beta, alpha. increases cardiac contractility with little to no increase in heart rate or blood pressure.

What drugs are phosphodiesterase enzyme inhibitors? Specifically they are PDE ______ inhibitors.

Inamrinose, Milrinone. 3.

How do phosphodiesterase enzyme inhibitors increase cardiac output with decreased afterload?

they increase cardiac contractility (positive inotropic effect) and induce peripheral vasodilation

The function of vasodilators in cardiogenic shock is to decrease ______ and/or ______, which will thus decrease myocardial oxygen demands.

preload, afterload

______ is an example of a vasodilator. It dilates ______ more than ______ and decreases ______ and to a lesser extent ______.

Nitroglycerin. veins, arteries. preload, afterload.

Because nitroglycerin decreases preload, what does it also decrease by association?

pulmonary congestion/edema

In cardiogenic shock, ______ is the analgesic of choice. Why?

morphine. very effective for pain relief but also because it is a venodilator and thus decreases preload

What is the diuretic of choice in cardiogenic shock? Why?

Lasix. rapid effect

Lasix causes a decrease in circulating blood volume, which decreases ______ and thus myocardial ______ ______.

preload, myocardial oxygen demands

What may be used as mechanical support in cardiogenic shock?

Intra-aortic Balloon Pump (IABP)

An IABP is threaded from the ______ artery up to, but not including, the ______ of the ______.

femoral, arch of the aorta

An IABP is part of a machine that is programmed to inflate during ______ and deflate during ______.

diastole, systole

Because an IABP inflates during diastole, it increases ______ BP and blood flow to the ______ arteries.

diastolic, coronary

Why does an IABP deflate during systole?

the sudden decrease in pressure in the aorta pulls blood forward during ventricular ejection.

Because an IABP deflates during systole, ______ is decreased which decreases resistance to ventricular pumping. How does this effect the myocardium?

afterload. decreases myocardial work and oxygen consumption

The biggest issue in cardiogenic shock and the source of all other problems is...

decreased cardiac output

What is the compensation of cardiogenic shock? What causes it to stop being effective?

renin, aldosterone, ADH, and catecholamine release. it eventually increases myocardial oxygen requirements.

An increase in myocardial oxygen requirements in cardiogenic shock leads to a decrease in cardiac ______, ______ ______ and ______ ______.

output, blood pressure, ejection fraction

Hypovolemic shock is a decrease in ______ volume.

intravascular

Hypovolemic shock is the only time that there is a shift of fluid from the ______ to the ______.

interstitium to the vessels

What is the compensation in hypovolemic shock?

shift of interstitial fluid, aldosterone/ADH release, splenic discharge, catecholamine release (increase in SVR)

Because there is a decrease in circulating blood volume in hypovolemic shock, there is a decrease in ______ return of blood to the heart. This leads to a decreased ______ of the ventricles and thus a decreased ______ ______ and ______ ______.

venous, filling, stroke volume, cardiac output

The ______ ______ of hypovolemia are probably more effective than any other type of shock.

compensatory mechanisms/adaptive responses

The compensatory mechanisms of hypovolemic shock kick in early and are effective in maintaining adequate ______ ______ and ______ ______ in the early stages.

blood pressure and cardiac output

What receptors sense a decreased blood pressure/volume? Where are they located? What do they stimulate?

baroreceptors. aorta and carotid artery. SNS

The SNS stimulation caused by baroreceptors during decreased BP results in...

increased HR and contractility, increased vasoconstriction, increased sodium and water retention secondary to RAAS and ADH

What are the early signs and symptoms of hypovolemic shock related to?

SNS stimulation

S/S of early hypovolemic shock: ______ heart rate, decreased ______ blood pressure (slightly), increased ______ blood pressure, increased respiratory ______ and ______, decreased ______ output, skin that ______, ______ and ______.

increased, systolic, diastolic, rate and depth, urine, cool, pale and diaphoretic

The slightly lowered systolic BP and increased diastolic BP in hypovolemic shock leads to a narrowed...

pulse pressure

Breathing patterns of hypovolemic shock: ______ and ______.

tachypnea and hyperventilation

What 3 things are leading to a decrease in urine output in hypovolemic shock?

decreased blood volume, increased aldosterone and ADH

2 broad goals of the treatment of hypovolemic shock

replace intravascular volume, repair "leak" (underlying cause)

What are the two sources to replace intravascular volume in hypovolemic shock?

isotonic crystalloids and colloids

Isotonic crystalloids are "standard" IV fluids and are distributed in both the ______ and ______ spaces. The are concerns though with interstitial ______.

intravascular and interstitial, edema

What are the two common isotonic crystalloids?

lactated ringers and normal saline

Colloids are fluids that have ______ active substances in them, such as ______, that will expand the intravascular volume and pull fluid from the ______ and ______ spaces.

oncotically, proteins, interstitial, intracellular

Colloids reduce the tendency towards ______ and/or ______ edema but they more also more ______ and less accessible.

pulmonary and cerebral edema, expensive

What are two natural colloids?

albumin and packed red blood cells

Synthetic colloids are an alternative to natural colloids. They have a higher ______ ______ than natural colloids so a greater percent remains in the intravascular space and leads to less interstitial edema.

molecular weight

What are three common synthetic colloids?

hetastarch, pentastarch, dextran 70

Removal of the underlying cause of hypovolemia: ______ as warranted, other hemostatic therapies, such as ______ or ______.

surgery, tourniquets, clamps

Neurogenic shock is inadequate tissue perfusion due to a loss of ______ ______. It is relatively ______ compared to the other types of shock.

sympathetic tone. rare.

What is the difference between the terms "spinal shock" and "neurogenic shock?"

spinal shock refers to ALL manifestations of loss of nervous system input below the area below the SCI. neurogenic shock refers specifically to the cardiovascular changes associated with a loss of sympathetic tone

Spinal shock most importantly includes the loss of ______ activity.

motor

What are some possible causes of neurogenic shock?

most common cause is spinal cord injury, also can occur secondary to other trauma such epidural anesthesia

Neurogenic shock is most common in what type of SCI? What is the underlying problem?

those at occur at T6 or above. loss of sympathetic outflow from injured spinal cord

Preganglionic neurons from the SNS emerge from the spinal cord at __ and at __.

T1 and L2

What makes neurogenic shock different from all other types?

there is no compensation because the SNS is the problem

Neurogenic shock occurs within __-__ minutes following an SCI. How long does it last?

30-60 minutes. however long it takes for sympathetic reflexes to take over.

What is the range of time for sympathetic reflexes to take over in neurogenic shock? What is the average?

anywhere from a few hours to months. average is 1-6 weeks

Neurogenic shock involves complete or nearly complete suppression of all ______ activity below the level of injury. What system then dominates?

SNS, PSNS

What happens physiologically in neurogenic shock?

there is a loss of vasomotor tone without the SNS and thus a decrease in BP. the heart has lost its ability to respond to the decreased BP and decreased venous return.

The massive vasodilation in neurogenic shock leads to a decrease in ______. These two factors combined make for an inadequate ______ ______. This is what leads to the decreased tissue perfusion and later impaired cellular metabolism.

SVR. cardiac output

What are some signs and symptoms of neurogenic shock?

orthostatic hypotension, bradycardia, decreased sweat, decreased temperature, decreased cardiac output

Why does orthostatic hypotension occur in neurogenic shock?

due to vasodilation below the area of injury

Why does bradycardia occur in neurogenic shock?

due to a decrease in cardioacceleratory stimulation

Why does someone in neurogenic shock have decreased sweat?

due to lack of SNS stimulation of alpha adrenergic receptors in sweat glands

Why does someone in neurogenic shock have a decrease in temperature?

due to break in connection between SNS and hypothalamus. also due to passive heat loss from vasodilation.

Someone in neurogenic shock has decreased cardiac output due to a decreased ______ ______ and also due to decreased ______ ______ due to vasodilation.

heart rate, filling pressures

For the treatment of neurogenic shock, it is necessary to replace SNS function until sympathetic reflexes return. What two drugs are used for this?

epinephrine (Adrenaline) and norepinephrine (Levophed)

What are two non-pharmacologic treatments of neurogenic shock?

1. fluids to increase blood volume and venous return to the heart. 2. compression to augment venous return

Compression for a patient with neurogenic shock would come in the form of...

thigh high TED hose, abdominal binder

Anaphylactic shock results from the interaction of an ______ with ______ on sensitized body tissue.

antigen, antibody

Anaphylaxis is what type of hypersensitivity?

type I

Anaphylaxis involves the attachment of a sensitized ______ antibody to a ______ cell. This causes the release of chemical ______ from inside the ______ cell.

IgE, mast, mediators, mast

What is the actual cause of neurogenic shock?

the chemical mediators, not the antigen-antibody reaction

A hypersensitivity reaction is an ______ tissue-damaging response of the immune system. The antigen precipitating the response is called an ______.

exaggerated, allergen

What drugs most commonly cause an anaphylactic reaction?

penicillins, cephalosporins

What are common biologic agents that cause an anaphylactic reaction?

semen, food additives, pesticides, gluten

What is a common chemical allergen in anaphylactic reactions?

latex

Manifestations of anaphylaxis: ______, increased ______ leaking, ______ muscle contraction, ______ formation, and increased ______ ______ secretions.

vasodilation, capillary, smooth, microthrombi, gastric acid

The vasodilation that occurs in anaphylaxis causes ______.

hypotension

Increased capillary leaking in anaphylaxis leads to the formation of ______, swelling of the ______, ______, ______ and ______, ______ edema and ______ edema.

urticaria, lips, tongue, feet, hands, periorbital, pulmonary

Smooth muscle contraction in anaphylaxis that occurs in the lungs causes ______, ______, ______, ______ ______ and ______ edema.

wheezes, dyspnea, stridor, air hunger, pulmonary edema

Smooth muscle contraction in anaphylaxis that occurs in the GI tract causes what symptoms?

nausea, vomiting, diarrhea, cramping/abdominal pain

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