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shock

What is shock?

A widespread abnormal cellular metabolism that occurs when the human need for oxygenation and tissue perfusion is not met to the level needed to maintain cell function. It is the "whole-body" response that occurs when too little oxygen is delivered to the tissues.

Why is shock considered a "syndrome"?

Because the cellular, tissue, and organ events that occur in response to its presence happen in a predictable sequence.

What can start the syndrome of shock and lead to a life-threatening emergency?

Any problem that impairs oxygen delivery to tissue and organs

What is shock more often the result of?

Cardiovascular problems and changes.

What are older patients in long term care at risk for?

Sepsis and shock related to UTI's

What occurs when adaptive adjustments (compensation) or health careinterventions are not effective and shock progresses?

Severe hypoxia can lead to cell loss, multiple organ dysfunction syndrome (MODS), and dath.

How is shock usually classified?

By the functional impairment it cuases (hypovolemic shock, cardiogenic shock, distributive shock, and obtrusive shock) or by the origin of the problem (hypovolemic, cardiogenic, vasogenic and septic shock).

What do oxygenation and tissue perfusion depend on?

How much oxygen and arterial blood perfuses the tissue.

What is tissue and organ perfusion related to?

Mean arterial pressure (MAP)

Since the cardiovascular system is a closed but continuous circuit what factors influence MAP/

"• Total blood volume
• Cardiac output
• Size of the vascular bed"

Total blood volume and cardiac output are directly related to MAP so what raises MAP?

"• Increase in Total blood volume
• Increase in Cardiac output"

How is the size of the vascular bed related to MAP?

Any problem that impairs oxygen delivery to tissue and organs vasoconstriction or dialation

What is sympathetic tone?

The state of partial blood vessel constriction.

What happens when blood vessels dilate by relaxing smooth muscle in the vessel walls and total blood volume remains the same?

Blood pressure decreases and blood flow is slower. Decreases in sympathetic tone relax blood vessel smooth muscle, dilating blood vessels and lowering MAP.

What happens when blood vessels constrict and total blood volume remains the same?

Blood pressure increases and blood flow is faster. Incrases in sympathetic stimulation constrict blood vessel smooth muscle even more than normal and raise MAP.

What parts of the body can tolerate low levels of oxygenation for hours without dying or being damaged?

Some organs, such as the skin and skeletal muscles.

What parts of the body tolerate hypoxic conditions poorly?

Other organs such as the heart, brain, liver and pancreas tolerate hypoxic conditions poorly, and even just a few minutes with adquated oxygen results in serious damage and cell death.

How do we classify Hypovolemic Shock with relation to functional impairment?

"Total body fluid decreased in all compartments
• Hemorrhage
• Dehydration"

How do we classify Cardiogenic Shock by functional impairment?

"Direct pump failure, fluid volume not affected
• Myocardial Infarction
• Valvular problems such as stenosis or incompetence
• Myopathies• Dysrhythmias• Cardiac Arrest"

How do we classify Obstructive Shock by functional impairment?

"Cardiac function is decreased by noncardiac factors, total fluid volume not affected, central volume decreased.
• Pulmonary hypertension• Tension pneumothorax • Pericarditis• Thoracic tumor• Tamponade"

How do we classify Distributive Shock by functional impairment?

"Fluid shifts from central central vascular space, total body fluid volume normal or increased.
• Neural-induced loss of vascular tone (head trauma, anesthesia, opioids, sedatives)
• Chemical-induced loss of vascular tone from sepsis, anaphylaxis, capillary leak"

When does Hypovolemic Shock occur?

It occurs when too little circulating blood volume causes a MAP decrease, resulting in the body's total need for oxygen not being met.

When does Cardogenic Shock occur?

When the actual heart muscle is unhealhty and pumping is directly impaired.

What is the most common cause of direct pump failure?

Myocardial Infarction

What does any type of pump failure cause?

Decreased cardiac output and MAP

When does Distributive Shock occur?

When blood volume is not lost from the body but is distributed to the interstitial tissues where it cannot circulate and delivery oxygen.

What can cause Distributibe Shock?

A loss of sympathetic tone, blood vessel dilation, pooling of blood in venous and capilalry beds, and increased blood vessel permeability (capillary leak). All these can decrease MAP and may be started by nerve changes (neural induced) or the presence of chemicals (chemical induced).

What is neural-induced distrbutive shock?

It is a loss of MAP that occurs when sympathetic nerve impulses controlling blood vessel smooth muscle are decreased and the smooth muscles of blood vessels relax, causing vasodilation. This blood vessel dilatin can be a normal local response to injury, but shock results when the vasoldilation is widespread or systemic.

What are the three common origins of chemical-induced shock?

"• Anaphylaxis
• Sepsis
• Capillary leak syndrome"

What is the result of Anaphylaxis?

Widespread loss of blood vessel tone and decreased cardiac output.

What is the result of Sepsis?

Sepsis is a widespread infection that triggers a whole-body inflammation response which leads to distributive shock when infectious microorganisms are present in the blood.

What is capillary leak syndrome?

It is the response of capillaries to the presenc of biologic chemical (mediators) that change blood vessel integrity and allow fluid to shift from the blood in the vascular space into the interstitial tissues. Once in the interstitial tissue, these fluids are stagnant and cannot deliver oxygen or remove tissue waste products.

What does the fluid shift in capillary leak syndrome result from?

They result from increased size of capillary pores, loss of plasma osmolarity, and increased hydrostatic pressure in the blood.

What problems cause fluid shifts?

"• Severe burns
• Liver disorders, Ascites
• Peritonitis, Paralytic ileus
• Severe malnutrition, • Trauma
• Large wounds, Hyperglycemia
• Kidney disease, Hypoproteinemia

What is obstructive shock caused by?

Problems that impair the ability of the normal heart muscle to pump efectively. The heart itself remains normal but conditions outside the heart prevent either adequate filling of the heart or adequate contraction of the healthy heart muscle.

What are the cardiovascular manifestations of shock?

"• Decreased cardiac output
• Increased pulse rate,Thready pulse
• Decreased blood pressure, Narrowed pulse pressure
• Postural hypotension, Low CVP
• Flat neck and hand veins in dependent positions
• Slow cap refill, Diminished peripheral pulses

What are the most common causes of obstructive shock?

"• Pericarditis
• Cardiac tamponade"

What are the respiratory manifestations of shock?

"• Increased respiratory rate
• Shallow depth of respirations
• Decreased Paco2
• Decreased Pao2
• Cyanosis, especially around lips and nail beds

What are the neuromuscular manifestations of shock?

"Early= Anxiety• Restlessness• Increased thirst
Late=• Decreased CSN activity (lethargy to coma)• Generalized muscle weakness• Diminished or absent deep tendon reflexes• Sluggish pupillary response to light

What are the renal manifestations of shock?

"• Decreased urine output
• Increased specific gravity
• Sugar and acetone present in urine"

What are the integumentary manifestations of shock?

"• Cool to cold
• Pale to mottled cyanotic
• Moist, clammy
• Mouth dry; pastelike coating present"

What are the gastrointestinal manifestations of shock?

"• Decreased motility
• Diminished or absent bowel sounds
• Nausea and vomiting
• Constipation"

What is the basic problem with hypovolemic shock?

A loss of blood volume from the vascular space, resulting in a decreased MAP, and a loss of oxygen-carrying capacity from the loss of circulating red blood cells.

What does the reduced MAP with Hypovolemic Shock result in?

Decreased tissue pefusion. The loss of RBCs decreases the ability of the blood oxygenate the tissue it does reach.

What do the oxygenation and tissue perfusion problems lead to ?

Cellular anaerobic (without oxygen) conditions and abnormal cellular metabolism.

What is the main trigger leading to hypovolemic shock?

A sustained decreased in MAP that results from decreased circulating blood volume. A decrease in MAP of 5 to 10 mm Hg below the patient's normal baseline value is detected by pressure-sensitive nerve receptors (baroreceptors in the aortic arch and carotid sinus. )

What happens when the baroreceptors sense a decrease in MAP of 65 to 10 mm Hg below the baseline n hypovolemic shock?

The information is transmitted to the brain centers, which stimulate adjustment (adaptive or compensatory mechanisms).

What do the adaptive or compensatory mechanisms do in hypovolemic shock?

They ensure continued blood flow and oxygen delivery to vital organs while limiting blood flow to less vital areas.

What causes the manifestations of hypovolemic shock?

Moving oxygenated blood into slected areas while bypassing others causes the manifestations of shock.

With hypovolemic shock what occurs if the events that caused the initial decrease in MAP are halted at this point?

The adaptive (compensatory) mehcanisms can return the body tissues to a normal perfused and oxygenated state.

What happens if the initiating events continue and MAP decreases further?

Some tissues function under anaerboic conditions which increases lactic acid levels and other harmful metabolites which lead to electrolyte and acid-base imbalances with tissue-damaging effects and depressed heart muscle activity.

Are these effects temporary and reversible?

Yes, if the cause of shock is corrected within 1 to 2 hours after onset.

What happens if the hypovolemic shock continues for longer periods without help?

The resulting acid-base imbalance, electrolyte imbalances, and increased metabolites cause so much cell damage in vital organs that multiple organ dysfuncton syndrome (MODS) occurs and full recovery from shock is no longer possible.

What are the stages of hypovolemic shock?

"• Initial Stage
• Nonprogressive Stage
• Progressive Stage
• Refractory Stage"

In the initial stage of hypovolemic shock what occurs?

"A decrease in baseline MAP of 5-10mmHg results in increased sympathetic stimulation
• Mild vasoconstriction
• Increase in heart rate"

In the nonprogressive stage of hypovolemic shock what occurs?

"A decrease in MAP of 10-15mm Hg from the patient's baseline value causes continued sympathetic stimulation.
• Moderate vasoconstriction
• Increased heart rate, Decreased pulse pressure
-chemical compensation RAAS, mild acidosis and hyperkalemia

And chemical compensation occurs, causing secretion of renin aldosterone, and ADH secretion resulting in:

• Increased vasoconstriction
• Decreased urine output
• Stimulation of the thirst reflex

Some anaerobic metabolism in nonvital organs lead to:

• Mild acidosis
• Mild hyperkalemia"

In the progressive stage of shock what occurs?

"A decrease in MAP of > 20mm Hg from the patients' baseline value causes the anoxia of nonvital organs, hypoxia of vital organs and overall metabolism is anaerobic resulting in:
• Moderate acidosis
• Moderate hyperkalemia
• Tissue ischemia"

In the refractory stage of shock what occurs?

"• Severe tissue hypoxia and ischemia and necrosis
• Release of myocardial depressant factor from the pancreas
• Buildup of toxic metabolites
• Multiple organ dysfunction syndrome (MODS)
• Death"

In the initial stage of hypovolemic shock what do the compensatory mechanisms do?

They are very effective at returning MAP to normal lvels that oxygenated blood flow to all vital organs is maintained.

What is the cellular change during the initial stage of hypovolemic shock.

The change is increased anaerobic metabolism with production of lactic acid, although overall cellular metabolism is still aerobic. The adaptive responses of vascular cconstriction and increased heart rate are effective, and both cardiac output and MAP are maintained within the normal range.

Why is shock so difficult to detect in the initial stage of hypovolemic shock?

Because vital organ function is not disrupted.

What may be the only manifestations of the initial stage of hypovolemic shock.

A heart and respiratory rate increase from the patient's baseline level or a slight increase in diastolic blood pressure .

What occurs during the nonprogressive state of hypovolemic shock when the MAP decreases by 10 to 15 mm Hg from baseline?

Kidney and hormonal adaptive (compensatory) mechanisms are activated because cardiovascular adjustments alone are not enough to maintain MAP and supply needed oxygen to the vital organs.

In the nonprogressive stage of hypovolemic shock what occurs when the baroreceptors in the kidney sense an ongoing decrease in MAP?

The kidneys begin to compensate by releasing of renin, AdH, aldosterone, epinephrine, norepinephrine is triggered.

In the nonprogressive stage of hypovolemic shock what oocurs when renin is secreted from the kidney?

Renin starts the reactions to decrease urine ouptut, increase sodium reabosorption and cause widespread blood vessel constriction.

In the nonprogressive state of hypovolemic shock what occurs when ADH is secreted by the posterior pituitary gland.

ADH incereases wter reabsorption in the kidney, further reducing urine output, and also causes blood vessel constriction in the skin and other less vital tissue areas.

What occurs in the skin, GI tract and kidney during the nonprogressive stage of hypovolemic shock?

Tissue hypoxia occurs, but it is not great enough to cause permanent damage.

What occurs due to anaerobic metabolism during the nonprogressive stage of hypovolemic shock?

Acid-base and electolyte changes occur in response to the buildup of metabolites. Changes include acidosis (low blood pH) and hyperkalemia (increased blood potassium level).

What are the manifestations of the nonprogressive stage of hypvolemic shock resulting from decreased tissue perfusion?

"Subjective changes include:
• Thirst sensation, Anxiety
Objective changes include:
• Restlessness,Tachycardia, Increased respiratory rate, Decreased urine output, Falling systolic blood pressure, Rising diastolic blood pressure, Narrowing pulse pressure, Cool extremities, 2% to 5% decrease in oxygen saturation"

How long can a person remain in the nonprogressive stage of hypovolemic shock?

They can remain in ths nonprogressive stage for hours without having permanent damage.

What can prevent hypovolemic shock from progressing beyond the nonprogressive stage?

Stopping the conditons that started the shock at this stage and providing supportive interventions can prevent it from progressing.

When does the progressive stage of shock occur?

When there is a sustained decrease in MAP of more than 20mm HG from baseline.

What occurse in the progressive stage of hypovolemic shock?

Adaptive or compensatory mechanisms are functioning but can no longer deliver sufficent oxygen, even to the vital organs.

What worsens the problem?

The fact that the adaptive mechanisms require large amounts of oxygen in some tissues (e.g., the heart).

What happens to vital organs during the progressive stage of hypovolemic shock?

They develop hypoxia, and less vital organs become anoxic (no oxygen) and ischemic (cell dysfunction or death from lack of oxygen. As the result of poor oxygenation and a buildup of toxic metabolites some tissue have severe cell damage and die.

What do the manifestations of the progressive stage of hypovolemic shock include?

"It includes a worsening of subjective changes:
• Severe thirst sensation, Severe anxiety
• A sense of impending doom
Worsening objective changes include:
• Rapid, weak pulse, Low blood pressure
• Pallor to Cyanosis of oral mucous membranes and nail beds
• Cool and moist skin, Anuria
• 5% to 20% decrease in oxygen saturation"

What may lab values show during the progressive stage of hypovolemic shock?

"• Low pH
• Rising lactic acid level
• Rising potassium level."

How long can vital organs tolerate the progressive stage of hypovolemic shock?

Only a short time before they are damaged permanently. The patient's life usually can be saved if the conditions causing shock are corrected within 1 hour or less of onset of the progressive stage.

When does the refractory stage of hypovolemic shock occur?

When too much cell death and tissue damage result from too little oxygen reaching the tissues. Vital organs have overwhelming damage.

Why is this stage of hypovolemic shock termed refractory?

Because the body can no longer respond effectively to interventions and shock continues. The remaining cells metabolize anaerobically.

Is therapy effective during the refractory stage of hypovolemic shock?

Therapy is not effective in saving the patient's life, even if the cause of shock is corrected and MAP temporarily returns to normal. So much tissue damage has ocurred with widespread release of toxic metabolites and detructive enzymes that cell damage to vital organs continues despite agrressive interventions.

What re the manifestations of the refractory stage of hypovolemic shock?

• Rapid loss of consciousness
• Nonpalpable pulse
• Cold, mottled or dusky extremities
• Slow, shallow respirations
• Unmeasurable oxygen saturation

What is multiple organ dysfunction syndrome?

The sequence of cell damdage caused by the massive release of tox metabolites and enzymes.

What occurrs with MODS?

Once the damage has started, the sequence bcomes a vicious cycle as more dead cells break open and release harmful metabolites..

What do the metabolites trigger?

They trigger small clots (microthrombi) to form

What do the microthrombi do?

They block tissue oxygenation and damage more cells, thus continuing the devastating cycle.

Where does MODS occur first?

First in the liver, heart, brain, and kidney.

What is the most profound change with MODS?

It is damdage to the heart muscle.

What is one cause of this damage to the the heart muscle?

The release of myocardial depressant factor (MdF) form the ischemic pancreas.

What type of shock is more common in younger adults?

Hypovolemic shock from trauma

Where are signs of shock first evident?

Changes in the cardiovascular function.

What changes do we see as shock progresses?

Changes in the renal, respiratory, integumentary, musculoskeletal, and central nervous systems becom evident.

What oxygen saturation level is considered a life-threatening emergency?

Any value below 70% and may signal the reftractory stage of shock.

What happens when anoxia or hypoxia persists beyond one hour?

Patients are at risk for acute tubular necrosis and kidney failure.

What skeletal muscle changes occur in hypovolemic shock?

Cahnge inlcude muscle weakness and pain response to tissue hypoxia and anaerobic metabolism (later manifestations). Weakness is generalized and has no specific pattern.

What do nursing interventions for hypovolemic shock focus on?

They focus on reversing the shock, restoring fluid volume to the normal range, and preventing complications through supportive and drug therapies.

What are the two types of fluids used to increase fluid volume?

Crystaolloids and colloids

What do crystalloids contain?

Nonprotein substances (e.g., minerals, salts, sugars)

What do colloid solutions contain?

Large molecules, ususually starches.

Why are crystalloid fluids given?

To help maintain an adequate fluid and electrolyte balance.

What are two common crystalloids?

Normal saline and Ringer's lactate.

What is the fluid replacement solution of choice to increase plasma volume?

Normal saline, it can also be given with blood

What does Ringer's contain?

"• Sodium
• Chloride
• Calcium
• Potassium
• Lactate
All dissolved in water

Why should you not hang Ringer's with blood?

The calcium induces clotting of the infusing blood

What helps restore osmotic pressure and fluid volume?

Protein containing colloids such as blood and blood products when shock is caused by blood loss.

What do whole blood and prbc's do?

They increase hematocrit and hemoglobing along with fluid volume.

Why is whole blood used?

To replace large columes of blood loss because it increase colume and imporves the oxygen-carrying capacity of the blood.

Why are PRBC's used?

They are given for moderate blood loss because they resotre the red blood cell deficit and improve oxygen carrying capacity without adding excessive fluid colume.

Why is plasma given?

To restore osmotic pressure when hematocrit and hemoglobin levels are within normal ranges.

What do plasma protein factors and synthetic plasma do?

They increase plasma volume and are used as early treatment for hypovolemic shock before a cause can be established.

Why might drug therapy be used?

If the volume deficit is sever and the patient does not respond sufficiently to the replacement of fluid volume and blood products.

What are the actions for drugs for shock?

They increase venous return, improve cardiac contractility, or improve cardiac perfusion by dilating the coronary vessels.

How do vasoconstricing drugs stimulate venous return?

By constricing the blood vessels and decreasing venous pooling of blood thereby increasing cardiac output and MAP, which help improve tissue perfusion and oxygenation.

What vasoconstricting drugs are used?

Dopamine and norepinephrine

What do inotropic drugs directly stimulate?

Adrenergic receptor sites on the heart muscle and improve heart muscle cell contraction resuling in greater recolil and more blood leving the left ventricle during contraction.

What inotropic drugs are used?

Dobutamine and milrinone

What do the drugs enhancing myocardial perfusion ensure?

That the heart is well perfused, especially when giving drugs to impprove cardiac contraction, so that aerobic metabolisms is maintained in the heart cells and maximum contractility occurs.

What drugs are used to enhance myocardial perfusion?

Drugs that dilate coronary blood vessels while minimally dilating systemic vessels such as sodium nitroprusside.

Why must care be taken when we administer drugs that enchance myocardial perfusion?

Because they can cause systemic vasodilation and increase shock if the patient is volume depleted.

How often should you assess vital signs in a patient with shock?

Every 15 minutes until the shock is controlled and the patient's conditon improves.

What do changes in CVP reflect?

Hypovolemic shock.

What surgical interventions may be need to correct the cause of shock after a cause has been established?

"• Vascular repair or revision
• Surgical hemostasis of major wounds
• Closure of bleeding ulcers, and chemical scarring (chemosclerosis) of varicosities

What is sepsis or septic shock?

It is a complex type of distrbutive shock that usually begins as a bacterial or fungal infection and progresses to a dangerous condition over a period of days. It is widespread and couple with a more general inflammatory response known as systemic inflammatory response syndrome.

Whem is SIRS triggered?

When an infection escapes local control. The organisms and the toxins or endotoxins in the bloodstream enter other body areas and the inflammatory response becomes an enemy leading to extensive tissue and vascular changes that furtehr impair oxygenaton and tissue perfusion.

What occurs at the tissue level with sepsis?

The WBCs are producing many pro-inflammatory cytokines and as a result, there is a widespread vasodilation and pooling of blood in some tissues.

What are some of the signs of sepsis?

• Mild hypotension
• Increased respiratory rate
• These actions result in a hypodynamic state with decreased cardiac output.
• Temperature can vary (low, low-grade or high)
• Reduced urine output
• Elevated WBC's

What symptoms result directly from SIRS?

Fever and hypotension

What symptoms are a result of the adaptive mechanisms?

"• Reduced urine output
• Increased respiratory rate

What causes cell hypoxia and reduced organ function with sepsis?

Microthrombi begin to form within the capillaries of some organs.

Is the damage at this point reversible?

Yes, if if it is stopped at this point but it is very hard to detect.

What do the microthrombi do?

They increase the number of cells that are operating under anaerobic conditions, which results in the generation of more toxic metabolites. These cause more cell damage and increase the production of pro-inflammatory cytokines, leading to an intensifying or amplification of the SIRS and a vicious repeating cycle of poor oxygenation and tissue perfusion.

What is severe sepsis?

It is the progression of sepsis with an amplified inflammatory response. All tissues are involved and all have some degree of hypoxia, although some organs are experienceing cell death and dysfunction at this time. Microthrombi formation is widespread using much of the available platelets and clotting factors (DIC)

In additon what does the amplified sirys and cytokine release result in?

Capillary leakiness, injured cells, and increased metabolism.

What does damage to the endothelial cells do?

It reduces anticlotting actions and triggers the formation of even more small clots.

What does the continued anaerobic metabolism result in?

Poor oxygen uptake and the continued stress response triggers the continued release of glucose form the liver and the patient also has hyperglycemia. The more severe the response the higher the blood sugar.

Why is the sepsis often missed in the second stage?

Because cardiac function is hyperdynamic in this phase. The pooling of blood and the widespread capillary leaking stimulatse the heart, and cardiac output is increasee with a more rapid heart rare and an elevated systolic blood pressure.

What may the patient's extremities feel like at this time?

They may feel warm and there is little or no cyanosis.

By this time what changes are occuring at the cellular level?

WBC count may no longer be elevated. Oxygen sats are lower, respiratory rate is rapid, urine output is decreased or absent and there is a change in the patient's cognition and affect.

What is septic shock?

It is the stage of sepsis and SIRS when multiple organ failure is evident and uncontrolled bleeding occurs.

Even with intervention what is the death rate of patients in this stage of sepsis?

60^

What is present in this stage of septic shock?

Hypovolemic shock is present with hypodynamic cardiac function. This is the result of an inability of the blood to clot because the platelets and clotting factors were consumed eariler, capillary laek continus as a resulf ofo the presense of pro-inflammatory cyotkines and cardiat contractility is poor from cellurlar ischemia and the presence of myocardial depressant factor. This resembles the late stages of hypovolemic shock.

What is the major cuase of sepsis?

Bacterial infection that escapes local control, although inimmunocompromised patients, fungal infections can also lead to sepsis.

What are some common organisms that cause sepsis?

Escherichia coli and Klebsiella pneumoniae as well as Staph and Strep.

What is the hallmark of sepsis?

An increasing serum lactate level, a normal or low total WBC count, and a decreasing segmented neuthrophil level with a rising band neutrophil level. (left shift)

How does sepsis and septic shock differ form other tpes of shock?

• Then entire syndrome may occur over many hours to days
• Manifestations usually are less obvious
• The chance for recover is good when sepsis is caught early and appropriate interventions are started.
• The cause of sepsis is often less obvious than for other types of shock.

What are the normal levels in the healthy patient?

"• Cardiac output - 3 to 5 L/min
• Stroke volume - 60 to 80 mL
• Serum lactate - < 2 mmol/L
• Blood glucose - < 110
• Oxygen saturation - 95%-100%

What are the parameters for early sepsis?

"• Cardiac Output - decreased
• Stroke Volume - decreased
• Serum lactate - normal to slightly increased
• Blood glucose - 110- 120 mg/dL
• Oxygen Saturation - < 95%

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