Shock

Shock

It is more than decreased blood pressure.

It is inadequate tissue perfusion and impaired cellular metabolism where the body must compensate!

What will you see in shock?

We will often see early changes in heart rate, mental status before blood pressure actually starts to drop

If we don’t restore perfusion then

our organs begin to fail if they are not being oxygenated and that’s going to make shock a life threatening condiiton regardless of the underlying cause

SHOCK DOESN’T ALWAYS LOOK _____

dramatic as first

It is can happen slowly

Regardless of cause of shock, certain physiologic responses are common such as

Hypoperfusion of tissues (blood being shunted away from those nonessential tissues to protect the heart and brain)

Hypermetabolism: our body will increase it’s energy use in order to compensate so it will raise it’s glucose and oxygen demand

Activation of the inflammatory response: Edema

Aerobic metabolism

Normal condiiton

Efficient production of ATP

ATP maintains cellular metabolic function

That energy keeps cellular processes and organ function running normally

Anaerobic metabolism

What happens when our body is in shock

The oxygen delivery is going to shift into anaerobic metabolism

Cells can’t get enough oxygen = Less ATP

Lactic acid

Lactic acid leads to metabolic acidosis = cellular dysfunction

We want our MAP above what?

65

What is the first stage of shock?

Compensatory

It is subtle, easy to miss

(The body is trying to hide it)

The body recognizes there is decreased perfusion and it responds by increasing HR, vasoconstriction, blood shunting to maintain BP and protect the heart and brain

Vital signs seem okay but tissues are already becoming hypoxia

Assessment findings in first stage of shock?

Assessment:

• RR increase due to acidosis

• Confusion, anxiety, restlessness (oxygen being shunted to the brain stem)

• Tachycardia with bounding pulse

• Hypoactive bowel sounds

• Decreased Urine Output

• Cool/clammy skin

YOU DO NOT SEE HYPOTENSION IN THIS STAGE

What is the second stage of shock?

Progressive

It is worsening profusion with some obvious declines

BP AND MAP decreased with narrowed pulse prressure

Tachycardia; weak, thready pulses

Cool/calmy skin

Mental status worsen

Serum lactate > 2

Worsening liver/GI dysfunction

Risk for DIC

WIDESPREAD HYPOPERFUSION

What is the last stage of shock?

Irreversibile

Comatose or unresponsive

Severe hypotension

Bradycardia; dysrhythmias

Profound metabolic acidosis

Coagulopathy (petechiae, purpura, bleeding)

Widespread organ failure with no response to interventions

Hypovolemic shock

Severe blood or fluid loss

The gasoline is running out, leaving the car (body) unable to run

Obstructive shock

A blockage prevents blood flow

A gas line blockage prevents fuel from reaching the engine

Cardiogenic shock

The heart is failing to pump effectively

The gas pump (heart) is broken so fuel isn’t reaching the body

Distributive Shock

Blood vessles are too leaky or dilated

It isn’t going where it is supposed to

Hypovolemic shock treatment

Restore intravascular volume

Fill it up! IV fluids, blood transfusions, volume expanders)

Cardiogenic shock

Improve the heart’s pumping ability

Inotropes, mechanical support like an intra-aortic ballon pump

Obstructive shock

Remove obstruction and restore blood flow (treat tension pneumothorax, remove clots, or relieve pericardial tamponade)

Distributive shock

Improve vascular tone and maintain perfusion

Vasopressors, fluids, treating the underlying cause

Hypovolemic shock: Assessment (Subjective cues)

Reports dizziness, weakness, thirst

Abdominal pain, flank pain, back pain

It is not always massive blood loss: it can be trauma, vomititng, diarrhea, bleeding (any sort of fluid that is leaving the body)

Hypovolemic shock: Assessment (Objective cues)

Loss of circulating volume (blood or fluids/decreae preload)

Hypotension/Tachycardia (attempt to maintain perfusion)

Cool/Clammy Skin

Decreased Urine Output (<30mL)

AMS

Evidence of bleeding or fluid loss

H & H trending down (possible hemorrhage)

GI losses: fluid/electrolyte imbalance)

Hypovolemic Shock: Prioritizing hypothese

Critical volume loss (Replace those fluids)

Ongoing bleeding (stop the bleed)

Risk for organ dysfunctions (MODS) Prevent the patient from getting to there!

Hypovolemic Shock: Generating Solutions

Rapid fluids

Blood products if needed

Stop the source of loss

Provide oxygen, monitor perfusion (2L nasal cannula)

Perfusion: Peeing, mental status is improving

Our patients who are hypovolemic needs 2 Large-Bore IVs

We want large to get the fluid through really quickly

What type of fluids will we give to a hypovolemic shock patient?

Isotonic fluid: Normal saline, Lactate ringer’s

Make sure to trend what

Trend vital signs

Check urine output

HR go down

BP go up

Fluid overload

Be careful giving patients too many fluids

Make sure to look for signs of fluid overload

Swelling, JVD, crackles lung sounds

When would you administer blood products?

If hemoglobic is <7

Administered through a 16,18,20 gauge

What is a s/s of a vasopressor?

Make sure the vasoconstriction is not a problem.

TRY FLUIDS FIRST THEN A VASOPRESSOR

Cardiogenic shock

Lack its ability to pump. It can’t contract or push blood out to the vital organs or body

OFTEN MI

Cardiogenic Shock Subjective Cues

Chest pain or pressure

Dyspnea “I can’t breathe”

Feeling faint, anxious

Cardiogenic Shock Objective Cues

Hypotension (SBP <90; MAP <65)

Tachycardia or bradycardia

Cool, clammy skin

Crackles/Dyspnea/JVD

ECG/EKG Changes

Cardiogenic Shock Hypotheses

Acute pump failure (MI)

Hypoxia from pulmonary congestion

Risk for lethal arrhythmias

Cardiogenic Shock Solutions

Oxygen therapy; respiratory support

Inotropes/vasopressors

Limit fluids

Prepare for PCI or rhythm management (cath lab)

Oxygen and position upright

2 large-bore IVs

Obstructive shock

Blockage of blood flow

JVD/Dyspnea

Muffled heart sounds

Tracheal deviation

Sudden hypoxia

Anaphylactic shock

Severe allergic

Vasodilation + capillary leak + airway edema

ACE inhibiotrs can cause angioedema

Anaphylactic shock solutions

AIRWAY FIRST

IM epineephrine = first line treatment

We always have respiratory team.

Supine with legs elevated

S/S: vomiting so order some Zofran

Septic shock can could from a

Viral, bacteral, or fungal