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MED SURG: Shock

Terms in this set (43)

shock
characterized by decreased tissue perfusion and impaired cellular metabolism
*when cells don't get O2 they need, they die and organs can't function properly
classification of shock
-cardiogenic
-hypovolemic
-distributive (neurogenic, anaphylactic, septic)
-obstructive
cardiogenic shock
LOW BLOOD FLOW
-systolic or diastolic dysfunction resulting in compromised CO
cariogenic shock precipitating causes
myocardial infarction
cardiomyopathy
blunt cardiac injury
severe systemic or pulmonary hypertension
myocardial depression from metabolic problems
cardiac tamponade
patho of cariogenic shock
EARLY:
tachycardic
hypotension
tachypneic
decreased urine output
pallor, cool and clammy
decreased cap refill
increased PAWP (fluid volume status)
hypovolemic shock
shock resulting from blood or fluid loss
absolute or relative
absolute hypovolemia
loss of intravascular-fluid volume:
-hemorrhage
-GI loss
-fistula drainage
-diabetes
-hyperglycemia
-diuresis
relative hypovolemia
-results when fluid volume moves out of the vascular space into extravascular space
-termed third spacing
-burns (burn pts d/t fluid loss)
patho of hypovolemic shock
increased anxiety and confusion
tachypneic
tachycardic
high CO then low CO
decreased PAWP
decreased urine output
pallor, cool and clammy
neurogenic shock
-hemodynamic phenomenon
-can occur within 30 min of spinal cord injury at the 5th thoracic vertebra or above
-can last up to 6 weeks
-causes: spinal cord injury or spinal anesthesia
-MASSIVE VASODILATION: pooling of blood in vessels, tissue hypo perfusion, ultimately impaired cellular metabolism
patho of neurogenic shock
hypotension
bradycardia
inability to regulate temperature
dry skin
poikilothermia
respiratory dysfunction
bladder and bowel dysfunction
end organ perfusion
change in neuro status
anaphylactic shock
-acute, life-threatening hypersensitivity (allergic) rx
-massive vasodilation (decreased CO and RR)
-release of vasoactive mediators
-increased capillary permeability
-resulting in decreased tissue perfusion
-priority= STOP GIVING IV ASAP
s/s of anaphylactic shock
-anxiety, confusion, dizziness
-sense of impending doom
-SOB, wheezing, stridor
-swelling of lips and tongue
-chest pain
-incontinence
-respiratory distress and circulatory failure
sepsis
-systemic inflammatory response to documented or suspected infection
severe sepsis
sepsis complicated by organ dysfunction
septic shock
-sepsis with HYPOTENSION despite fluid resuscitation
-inadequate tissue perfusion resulting in hypoxia
3 major pathophysiologic effects of septic shock
1. vasodilation
2. maldistribution of blood flow in extracellular spaces
3. DECREASED O2: myocardial dysfunction (ventricular dilation and decreased EF)
patho of septic shock
hypotension
tachypneic (resp. failure/ARDS)
initial high CO then decompensated to low CO
decreased urine output
warm flushed skin (b/c its an infection!)
change in LOC
paralytic ileus
obstructive shock
-develops when physical obstruction to blood flow occurs with decreased CO:
pulmonary embolism
abdominal compartment syndrome
cardiac tamponade
tension pneumothorax
SVC syndrome
patho of obstructive shock
hypotension
low preload
low bowel sounds
tachypneic to bradypneic
decreased urine output
skin pale, cool and clammy
anxiety
*organ perfusion is impaired because not enough O2 is getting to the tissues
stages of shock
initial
compensatory
progressive
refractory
*4 overlapping stages*
Disseminated Intravascular Coagulation (DIC)
abnormal activation of the proteins involved in blood coagulation, causing small blood clots to form in vessels and cutting off the supply of oxygen to distal tissues
-noticed in PROGRESSIVE STAGE OF SHOCK when liver fails to metabolize drugs and waste
anasarca
severe generalized edema
-fluid leakage affects solid organs and peripheral tissues
-decreased blood flow to pulmonary capillaries
-fluid is leaking resulting in decreased blood flow and can develop ARDS
diagnostic studies
-thorough H and P (hx of recent events)
-no single study to determine shock
-blood work= increased lactate
-12 lead ECG with continuous monitoring
-chest x ray
-hemodynamic monitoring
successful management
-identify patients at risk
-establish a diagnosis
-control/eliminate cause of decreased tissue perfusion
-protect organs from dysfunction
-multisystem supportive care
general management
1. ensure patient is responsive (ABCs)
2. ensure a patent airway
3. maximize O2 delivery
*always draw blood cultures to target antibiotic for a specific bacteria*
O2 and ventilation management
*increase supply!*
-optimize CO
-fluid replacement or drug therapy
-increase Hgb----transfusion
-increase arterial oxygen (like supplemental O2 or mechanical ventilation)
Sepsis, hypovolemia and anaphylaxis management
VOLUME EXPANSION--FLUID RESUSCITATION
-1 or 2 large bore IV cats, intraosseous access device or central venous catheters
-isotonic crystalloids(normal saline or Lactated Ringers)
-colloids (albumin!)
-blood products
clinical assessment to determine fluid responsiveness:
-vital signs (decreased HR)
-cerebral and abdominal pressure (BP low to normal)
-cap refill
-skin temperature
-urine output
-hypothermia (too much fluid)
-coagulopathy (too much fluid)
hypotension management
-vasopressors (squeeze blood vessels to get O2 to the tissues) ex: norepinephrine and dopamine
-goal of drug therapy: correct tissue perfusion!
-give inotrope: dobutamine
-MAP: 60-65
nutrition management
-start enteral nutrition within first 24 hours
-trophic feeding= slow drip of small amounts of enteral nutrition
-parenteral nutrition only used if enteral feedings is contraindicated (use TPN instead)
-monitor weight, protein, albumin, pre-albumin, BUN, glucose and electrolytes!
cardiogenic shock care
restore blood flow to myocardium by restoring balance between 02 supply and demand
-prevent shock: angioplasty, emergency revascularization and valve replacement
-hemodynamic monitoring
-drug therapy (diuretics and vasodilators)
-circulatory assist devices
-heart transplantation
hypovolemic shock care
stop loss of fluid
-restore circulating volume (burns!!)
-fluid resuscitation is calculated using a 3:1 rule (3mL of isotonic crystalloid for every 1mL of estimated blood loss)
septic shock care
-fluid resuscitation to restore perfusion
-vasopressor drug therapy: norepinephrine is first choice then exogenous vasopressin
-obtain cultures
-start antibiotics within 1st hour
-glucose levels less than 180
-stress ulcer prophylaxis (protonix)
-VTE prophylaxis (heparin)
neurogenic shock care
SCI: spinal stability!!
-tx of hypotension and bradycardia (give vasopressors and atropine)
-cautious with fluids
-monitor for hypothermia
how to treat hypotension and bradycardia
vasopressors and atropine
used for neurogenic shock care
anaphylactic shock care
-epinephrine, diphenhydramine, ranitidine
-maintain patent airway
-aggressive fluid replacement (usually crystalloids)
-IV corticosteroids if significant HYPOTENSION persists after 1-2 hours of aggressive therapy
*first tx is IM epinephrine!*
Crystalloids
normal saline
Lactated Ringers
Colloids
albumin and other proteins in the blood
obstructive shock care
-early recognition and tx to relieve obstruction
-mechanical decompression
-thrombolytic therapy (heparin)
-radiation, debunking or removal of mass
-decompressive laparotomy: open up abdomen if abdominal compartment syndrome
patients at risk for shock
1. older patients
2. those who are immunocomprised
3. those with chronic illnesses
4. surgery or trauma patients
how to prevent shock
-hand washing to prevent spread of infection
-monitoring fluid balance to prevent hypovolemia
shock evaluation
-adequate tissue perfusion with restoration of normal or baseline BP
-normal organ function with no complications from hypoperfusion
-decreased fear and anxiety and increased psychologic comfort
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