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Shock

Terms in this set (71)

whats the big deal with shock
-shock can progress very rapidly
- life threatening w/a high mortality rate
- one hour window (possible 3 hour window for survival)
-ER departments across the country see over 1 million cases per year
WHat is shock
- a state of reduced systemic tissue perfusion
- decreased delivery of oxygen to the tissues
- decreased ability to remove metabolic waste products
- leading to tissue injury

Overall, decreased tissue perfusion
What do we need to prevent shock
- a properly beating heart
- adequate transportation system
- intact functioning vessel system
- functioning respiratory system
what are the types of shock
cardiogenic
obstructive
hypovolemic
distributive
- septic
- neurogenic
- anaphylactic
common bond between shocks (except cardiogenic shock)
Patho of all classification of shock is decreased venous return
- if a guy suffers amputation, can blood return? NO!
neurogenic shock
severed spinal cord from a gunshot wound or a fall allows blood to pool, nerves have been cut
Septic shock
overwhelming infection
- dilation of blood vessels=DVR
Stages of shock
initial stage- no visible changes in client parameters. changes at the cellular level . compensation is cascular constriction and increased HR

compensatory or non progressive- body is mounting measures to increased CO to restore tissue perfusion and oxygenation. B/P is WNL, vasoconstriction, increased HR, stimulation of SNS, release of epi and norepi. maintaining BP w/tachycardia

progressive or decompensated- compensatory mechanisms begin to fail, skin is cool and clammy, bowel sounds hypoactive, UO is decreased in response to aldosterone and ADH, RR increases in response to metabolic acidosis

refractory or irreversible- compensatory mechanisms are gone
Shock compensation
increased HR
increased RR
constriction peripheral circulation
pale cool skin
decompensated shock
low blood volume
lack of perfusion
falling bp
First thing you will see when pt starts to go into shock
Altered LOC
MOS, multi organ shock
can be any organ except reproductive
has to be more than 1
what is cardiogenic shock
- decreased ability of the heart to contract and pump blood
- supply of oxygen is inadequate for the heart and tissues
- coronary or noncoronary
- high mortality rate
pathophysiology of cardiogenic shock
cardiac output is compromised
blood supply is inadequate
impaired tissue perfusion
fluid accumulation on the lungs
what is the most common cause of cardiogenic shock
MI
causes of cardiogenic shock
MI is the most common
left ventricular failure
diastolic failure, caused by left ventricular stiffness
endocarditis
dangerous heart rhythm
s/s of cardiogenic shock
- dependent on the underlying cause
- chest pain
- SOB
- tachycardia
- ALOC!!!!!!!!!!!!!!!!!!!!!!!!
Due to cardiogenic
- weak/faint pulse
- decreased UO
Obstructive shock
type of cardiogenic shock
- d/t mechanical obstruction of blood flow
- obstruction of venous return and/or arterial blood outflow from the heart
causes of obstructive shock
pulmonary embolism
tension pneumothroax
cardiac tamponade
aortic stenosis
s/s obstructive shock (KNOW FOR TEST!!!)
MUFFLED OR DISTANT HEART SOUND!!!!! (due to obstructive shock)
- due to fluid accumulation
hypotension
narrowing pulse pressure
mental status
skin cchanges
chest pain
LUNG SOUNDS MAY BE CLEAR
goal medical management shock (KNOW)
improve cardiac function by increasing CO

- limit further damage to myocardial tissue
- preserve healthy myocardium
- improve cardiac function
- decreasing ventricular afterload
How to treat shock (order of symptoms)
Rate, rhythm, BP
- BP is the last to go
What drug prescribed to improve contractility
dobutamine, dopamine
Collaborative care cardiogenic shock
O2
Pain control (morphine)
- helps with pain but also vasodilates
- decreases preload and helps afterload
Hemodynamic monitoring
- assess pt. response to treatment
pulmonary artery catheter
- assess myocardial pressure (cardiac output),
laboratory marker monitoring
- cReactive protein, BnP
Fluid therapy
- monitor for fluid volume overload
Drug therapy (to restore and maintain CO by reducing afterload, etc)
- dobutamine, nitroglycerine, dopamine
Mechanical assist devices
Dilated blood vessels are associated with what kind of shock
distributive shock
Collaborative care of obstructive shock
DETERMINED BY UNDERLYING CAUSE
- removing the obstruction
- surgical repair
- chest tube
- clot dissolving medication
- needle aspiration of fluid
Nursing interventions of obstructive shock
- promoting adequate supply of 02 to the myocardium
- limiting myocardial consumption of 02
- monitoring the pts response to treatment
- monitoring vs
- monitoring lab results
- monitoring mental status
Hypovolemic shock
- decreased preload (decreased venous return)
- decreased CO
- SVR is increased to compensate
- empty tank
direct vs indirect hypovolemic shock
direct- bleeding, hemorrhage, burn (3rd spacing, plasma loss)
indirect- vomiting, diaeresis
Stages of hypovolemic shock
Stages 1-4
1- compensatory stage to maintain CO (body lost very little blood... maybe 15% or 750mL. BP is normal, RR is normal, possible anxiety
2- slightly more critical. blood loss doubles to 30% (1500ml ish) BP still normal but little decrease from baseline. decrease in UO.
3- acidosis. Pt lost 30-40% of fluid. (1500-2000). HR increases, RR increase, Pt is anxious/agitated. Skin pale and diaphoretic
4- Game over... blood loss great then 2000mL >40%. rapid pulse, poor perfusion.
Hypovolemic shock outcome KNOW THIS!!!
Symptoms and Outcome bary depending on...
- amount of blood volume loss
- age of the patient
- rate of blood loss
- illness on injury causing the loss
Causes of hypovolemic shock
hemorrhage
dehydration
trauma
burns
diuretic therapy
third spacing
it is a blood volume problem
what is the saying for blood loss and where it goes
blood you see and blood you do not see

"on the floor and 4 more"
- various internal cavities
how much blood can be lost in a femur fx
1000-1500
Hypovolemic shock decreases
decreases in
blood volume
preload
stroke vlume
CO

produces a syndrome of hypotension with a narrowing pulse pressure
clinical presentation of hypovolemic shock
Mental status changes
skin cool and clammy
decreased BP
decreased O2 sat
tachycardia and tachypena
decreased UO
- Strong urine odor due to concentration

Prolonged
- waxy look
- cyanotic
- increased cap refill time
Collaborative care of hypovolemic shock
Stop the bleeding
stop the fluid loss
replace fluids (dependent on type of fluid being lost)
low dose inotropic
assess response
What do we need for MAP
up to 80
CBC 12-15
fluid replacement rule of loss
for every 100 lost 300 added

for every bleed, 3 to 1 you will need
Why do we use crystaloids
blood is a crystaloids
they can move back and forth and everywhere
D5,LR, NS, blood

NS replaces plasma- when no loss of RBCs
- careful cuz bicarb is lost due to high chloride in NS
Best clinical indicator of fluid loss
UO
When do we use drugs
When fluid reces is not working.
- CAN NOT USE NOREPI IF VOLUME DEFICIENT
THINKING ON YOUR FEET (SEE HANDOUT)
see handout
critical tissue perfusion time limits
--------mins
Brain
heart
lungs
-------- mins
kidney
liver
GI
2-3h
Skin
Muscles
Distributive shock
Excessive vasodilation in the peripheral vascular system
- cardiac function is normal
--------------------------------------
- Characterized by loss of blood vessel tone
- enlargement of the vascular compartment
- displacement of the vascular volume from systemi circulation
- venous return is decreased
- there is decreased CO but NOT a decrease in total volume
what are the three types of distributive shock
Septic
anaphylactic
neurogenic
is there a change in blood volume in distributive shock? KNOW THISSSSSSSSSSSSSSSSS
NO CHANGE IN BLOOD VOLUME

- it is a decrease in vascular tone
IT IS A BLOOD VOLUME PROBLEM
Septic shock "overwhelming bacterial infection
the most commonly encountered form of distributive shock
- it is the most common cause of non cardiac deaths in ICE
- there are approximately 750000 cases of severe sepsis/yr
what are the predisposing factors of septic shock
1. access to the vascular compartment by an infectious agent
2. a susceptible host
Predisposing factors of septic shock
Drugs- steroids/chemo (suppress immune system)
elderly
extensive trauma
burns
neoplastic disease
diabetes
presence of indwelling catheters or IVs
penetrating injuries
Clinical presentation of septic shock
VS are extremely important in these patients
assessment of ABCs
Mental status
appear acutely ill
observe for signs of hypoperfusion
look for evidence of infection
pt. presents w/typical s/s
the septic pt is going to have a wide pulse pressure
pt is going to look volume depleted
what to look for in septic shock
wide pulse pressure
gerontological considerations shock
- indicence of sepsis and septic shock is increasing in our older adults
- predisposed to sepsis d/t comorbidities
- repeated and prolonged hospitalizations
- compromised immune systems
- functional limitations
- increased risk of colonization of fram negative organisms
- changes in organ systems
- decreased cardiac output
- increased BP
- arteriosclerosis develops
- impaired gas exchange
- decreased vital capacity
- slower expiratory flow rates

THE ONLY SIGN OF SHOCK IN A OLDER ADULT MAY BE ALTERED MENTAL STATUS OF TACHYPNEA
FAVORITE QUESTION
SEPSIS CLASSIFICATION
SIRES (2 or more)
T> 38 or <36
HR>90
RR>20 or PCO2 <32
WBC>12 or <4 or bands >10%
SEPSIS
SIRS with infection
SEVERE SEPSIS
sepsis with organ dysfunction, hypoperfusion or hypotension
SEPTIC SHOCK
severe sepsis plus hypotension unresponsive to fluids
KNOW NORMAL LACTATE LEVEL
if greater than 2. considered severe sepsis
if greater than 4 considered septic shock
Diagnostic tests of sepsis
LACTATE
c-reactive protein is increased
blood cultures (prior to abx treatment)
C&S
antibiotics
procalcitonin
Collaborative care of sepsis
Kill the bugs
fluids
vasopressors
tube feeding
insulin therapy
foley
ventilator
know your BUNDLE (1 hour)
IV fluids
Maintain CVP between 8-12mgHg (Lucky 7)

Low CVP means DVR or fluid deficit
High CVP means fluid overload
Low reading spells T-R-O-U-B-L-E
Maintain Scvo2>=70%

NEED TO BE DONE IN FIRST 6 HOURS
SEPSIS SIX
give high flow exygen
obtain blood cultures
IV antibiotics
fluid challenge
measure lactate
monitor urinary output

These 6 simple interventions in the first hour foubles a pt chance of survival
what is your bedside assessment of potentioal sepsis
S- Shivering fever
E- extreme pain/discomfort
P- Pale of discolored skin
S- sleepy, difficult to wake up
I- i feel like im going to die
S- Short of breath
Path of anaphylactic shock
- antigen-antibody reaction
- widespread vasodilation
- capillaries become more permeable
- shift of fluid causing hypotension
- fluid shift from the vasculature into the interstitial space
- blood pools in the tissues
causes of anaphylactic shock
- food
- antibiotics
- insects
clinical presentation anaphylactic shock
- sudden onset
- sudden swelling of lips and tongue
- stridor
- chest pain
- skin symptoms
- metallic taste
- flushing, itching, hives
- life threatening laryngeal airway obstruction
Defining characteristic with anaphylactic
metallic taste
hives, flushing, itching
laryngeal airway obstruction
collaborative care anaphylactic shock
prevention!!!
AIRWAY MAINTENANCE and SUPPORT
First line defense
- 1:1000
Second line defense
- corticosteroids
- H1 and H2 blockers

Bronchodilators
antihistamines
oxygen
fluids
Neurogenic shock
uncontrolled dilation of blood vessels due to nerve paralysis
Neurogenic shock s/s
HYPOTENSIVE
BRADYCARDIAC
Pokliothermic
vasodilation
decrease venous return
decrease CO= decrease HR
decrease tissue perfusion
Patient presentation neurogenic shock
hypotension
bradycardia
poiklothermia
flaccid paralysis below the level of the lesion
clinical comparison shock patient
SEE HANDOUT
causes of neurogenic shock
MVA
GSW
Drugs
epidurals
hypoglycemia
severe pain
shell chock
problems diagnosing neurogenic shock KNOW THISSSSSSSSSSSSSSSS
Age of the casualty
athletes
hypothermic causalities
Pts w/pacemaker
Pts. on beta blockers
Collaborative care neurogenic shock
treatment depends on the cause
prevent cardiovascular decline
promote optimal tissue perfusion
treatment of hypotension and bradycardia
fluids PRN
maintain body temp
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