Shock/MODS

shock

A condition in which the circulatory system fails to provide sufficient circulation to enable every body part to perform its function; also called hypoperfusion.

types of shock

Hypovolemic

Distributive: septic, neurogenic, anaphylactic

Cardiogenic

distributive shock

+fluid leaks from the vascular/intracellular space into interstitial space; usually takes longer than other types

stages of shock

Initial/Compensatory

Progressive

Refractory/Irreversible

changes during shock (to monitor during all stages)

BP, HR, RR, lungs, GI, kidneys, pH, liver, LOC, glucose, temp, O2, coagulation studies

compensatory stage

+CO increases/O2 decreases, tachycardia first

+Lactic Acid increases: pulling oxygen from smooth muscle

+RR increase

+Fluid retention & shift: reabsorption of water and sodium

+GI changes: decrease of peristalsis

+Mental status: lethargy, mild confusion

+Cold, clammy skin

+Glucose increases: problem for diabetic pts

+Temperature changes: can go up or down

+Significance of changes depends on the timing/severity of issue

progressive stage

+Deterioration worsens dramatically

+Hypotension

+Tachycardia increases

+Systemic hypoxia

+Lungs fail; atelectasis

+Kidneys fail

+GI tract; one of the first ones; constipation/issues with metabolism

+Lactic Acid increases, acidosis ensues (both; metabolic/respiratory usually first)

+pH drops, PaCO2 up, Bicarb down

+Liver failure: rapid decreases chance of survival

+Coagulation problems

+(DIC) possible

+Know Coagulation Studies (PTT, PT/INR, Fibrinogen); increases and raises hemorrhage risk

+Thrombocytopenia

coagulation studies

PTT: 25-30 sec

PT: 10-13.5 seconds

INR: 0.8-1.1

fibrinogen: 200-400mg/dL

thrombocytopenia

low platelet count

PT/INR

prothrombin time/international normalized ratio

irreversible stage

+Severe organ damage

+Hypotension worsens

+Acidosis worsens

+MODS progresses (multiorgan disfunction syndrome)

+Death

monitoring needed for shock treatment

central venous: may need multiple; also for CVP

dialysis catheter or CRRT

peripheral access: 16/18G IV or IO

arterial line

swan-ganz

TPN

urinary catheter

continuous ekg

treatment of shock

fluids

vasopressors

vasodilators: initially, esp for cardiogenic

inotropic

monitoring

nutrition

positioning

oxygen

blood cultures; esp for septic

fluids for shock tx

crystalloids: LR (first), or NS

colloids: albumin; pulls water into intravascular

blood products:

-plasma: decreases hemorrhage risk

-RBC: tx anemia

-platelets: tx thrombocytopenia

vasopressors

drugs used to increase blood pressure

norepinephrine (levophed): first line for septic

epinephrine: good for anaphylactic shock

vasopressin: adjunct for septic

phenylephrine

dopamine: good for cardiogenic; mixed effects

assessments for vasopressors

extremities because of peripheral vasoconstriction

check for extravasation: can lead to tissue necrosis

vasodilators

can be used in initial phases; esp in cardiogenic shock

Isorbid dinitrate (Iso-Bid, Isotrate, Sorbitrate)

Isorbid mononitrate (IMDUR)

Hydralazine (Apresoline)

inotropic agents

drugs that stimulate the heart to increase the force of contractions

ex: dobutamine

CRRT

continuous renal replacement therapy

aka very slow dialysis

sequence of pressors

for sepsis, no benefit to starting in a particular sequence, though

NE VASO EPI PHENYL DA is common.

CVP normal

2-6 mmHg

usually low; tx with crystalloids, albumin, vasodilators

nutrition and shock

+Increased protein & calories

+Enteral vs IV: may need TPN; but leads to hyperglycemia and needs IV insulin drip

+GI motility: risk of obstruction or paralytic ileus

+GI prophylaxis: decrease risk of gastritis

hypovolemic shock

shock resulting from blood or fluid loss; Most common type of shock; can coincide with other forms

+Intracellular vs Interstitial fluid vs Intravascular fluid

+Can be internal &/or external

+Careful with your cardiac patients; fluid overload

cardiogenic shock

Shock caused by inadequate function of the heart, or pump failure.

can be coronary or non-coronary

•BP falls, CO & venous return decrease

coronary cardiogenic shock

Most common in those with an acute MI, resulting in damage to the left ventricular myocardium

non coronary cardiogenic shock

Caused by factors that stress the myocardium

Severe hypoxemia, acidosis, hypoglycemia, hypocalcemia, tension pneumothorax, cardiomyopathies, valvular damage, cardiac tamponade, and dysrhythmias

tx specific to cardiogenic shock

•Cardiac Enzymes

•Emphasis on ^ output (inotropic agents, vasopressors)

•Antiarrhythmics

•Cardizem (CCB/atrial issue), Amiodarone (ventricular issue)

•Intra-Aortic balloon pumps

IABP

intra-aortic balloon pump; used to support patients in cardiogenic shock

septic shock

+Caused by infection, or response to infection

+Most common distributive form of shock

+Highest level of death from shocks

causes of septic shock

+MRSA

+C-Diff

+Inflammatory Response Syndrome

+Pneumonia

+UTI: urosepsis

+Immunosuppression

inflammatory response syndrome

•Sepsis dx must have 2 of the 4 s/s of Inflammatory Response Syndrome:

1. Fever (>100.4 F) or Hypothermia (<96.8 F)

2. Tachycardia

3. Tachypnea (CO2 < 32 or mechanical ventilation)

4. Leukocytosis (WBC > 12000) or Leukopenia (WBC < 4000)

tx specific to septic shock

+Same as others, to a degree: vasopressors, crystalloids

+Blood cultures

+Antibiotics: esp gram neg ones that are very strong

+CRRT (as with other shocks)

neurogenic shock

+Vasodilation due to imbalances / miscommunication of PNS & SNS

As a results:

+Bradycardia, not tachycardia; BP varies

+Dry / warm skin

+Poikilothermia: poor thermoregulation

anaphylactic shock

+Severe allergic reaction due to antigen-antibody reaction

+IgE; histamine response

+Mass vasodilation occurs due to excessive histamine release

S/S of anaphylactic shock

hives, itching, bronchoconstriction, angioedema, stridor, wheezing, and hypotension

Tx of anaphylactic shock

Epinephrine

diphenhydramine

prednisone

albuterol