Shock / Sepsis / MODS CONTENT

Early s/sx of septic shock

Tachycardia, bounding pulses, BP may be normal due to compensation, warm / flushed skin, febrile, confusion, decreased urine output

Late signs of septic shock

Tachycardia, weak/thready pulses, hypotension, cool/pale skin / necrosis, hypothermia, lethargy or coma, anuria, bleeding

Sepsis / septic shock goal

Identify and initiate txt for patients in early sepsis within 1 hour to optimize patient outcomes

Sepsis bundles

Evidence-based bundled interventions to foster early recognition and interventions in pts with sepsis

Diagnostics

Indication of infection - fever / inc WBC / Changes in BP / RR / HR

-Lung consolidation-pneumonia

-Frequent or painful urination-UTI

-Severe abdominal pain-peritonitis

-Labs: CBC BMP UA UC Blood Cultures Lactate

-CT scans / MRI

-SIRS criteria

Sepsis bundle: steps

1.Fluid resuscitation

2.Vasopressors : if fluid resuscitation didn’t achieve a MAP of 65 mm/Hg

3.Bloodwokr: serum lactation or and two sets of blood cultures ( CBC coag studies, B<P, LFTs, ABG’s)

4.Antibiotics: should be administered within 1 hour of sepsis (CULTURES SHOULD BE DONE BEFORE ABX GIVEN)

Septic shock assessments

Neuro, VS, hemodynamic monitoring (CO), RT monitoring (lung sounds, effort, rate, SAT), urinary output, skin color and temp, cap refill, signs of bleeding

Septic shock actions

Asepsis, mouth care q24h, O2 as orderedm food replacement as ordered, lactic acid monitoring, 2 blood cultures (different sites), vasoactive drips as ordered (norepi)

-Supportive care: nutrition, turning, DVT, strss ulcer prophylaxis, ROM, delirium management

Sepsis / shock complications

-Stress ulcers: PPI-pantoprazole, H2 Blockers-Famotadine, Mucosal protectants-Sucralfate

-Disseminated intravascular coagulopahty: 2 phases-clotting or thrombosis and bleeding

Anaphylaxis patho / complications

Occurs after sensitization

-Massive vasodilation that affects multiple body system

-Anaphylactic shock runs the risk of cardiovascular and respiratory failure

-High risk: asthma, chronic lung disease, medications (beta blockers / alpha adrenergic blcokers), mastocytosis

Anaphylaxis S / Sx

-Initial: rash/urticaria, SOB / wheezing, stomach pain / nausea, facial swelling, fainting

-Anaphylaxis if untreated: hypotension / hypoxia

Anaphylaxis medical management

REMOVE THE TRIGGER

-IM epi-can repeat 2-3x, IV epi if IM is ineffective, maximize oxygenation (100% nonrebreather / intubation)

-IV fluid-circulatory support

-Other meds (antihistamines, corticosteroids, inhaled bronchodilators)

Neurogenic shock: decreased CO with decreased venous and arterial vasodilation

A phenomenon that occurs after a spinal cod injury

-Vascular tone is significantly decreased (inability to vasoconstriction)-vessels are relaxed and dilated. This leads to pooling of the blood, decreasing return to the heart and decreasing CO

-Unable to compensate via tachycardia which may lead to severe bradycardia

Neurogenic shock s / sx

Warm, dry skin , flushed appearance, hypotension, bradycardia

Neurogenic shock: medical management

Cardiovascular support (while finding the cause)

-Fluid resuscitation, vasoactive IV meds (dopamine / epi / norepi / phenylephrine), bradycardia-atropine, pacing

-Intubation and mechanical ventilation

Pacing in neurogenic shock

A medical intervention used to manage severe bradycardia by delivering electrical impulses to the heart, improving heart rate and cardiac output

Hemorrhagic shock: pathophysiology

Caused by insufficient perfusion of both and oxygen to the body tissues resulting in an imbalance of oxygen supply and demand

-Causes: blood loss (trauma / internal bleeding / aneurysms), fluid loss (vomiting, diarrhea, excessive urination or burns), third spacing

-A subunit of hypovolemic shock that directly refers to blood loss

Hypovolemic shock: s / sx

-Compensatory: normal BP, tachy, restless/confusion, pale / cool / clammy, weak pulses, hyperventilation, hypoactive bowel sounds

-Progressive: Lethargy, hypotension, anuria, cool / cyanotic skin, weak / absent pulses, dysrhythmias

-Refractory: coma, severe hypotension, ischemic and necrotic cold extremities, renal / hepatic failure

Hypovolemic shock: medical management

Assess and stabilize airway

-Rapid fluid resuscitation: non-hemorrhagic: warm crystalloids (NS/LR), hemorrhagic: packed red blood cells or fresh frozen plasma / platelets

-Identify cause of bleeding and control / stop

Hypovolemic shock: nursing management

Assessments

-ActionsL 100% nonrebreather mask, prepare for intubation, insert large-bore IV line, fluid replacement as ordered

Pathophysiology: cardiogenic shock

Circulatory failure and hypoperfuson caused by cardiac dysfunction leading to myocardial ischemia

-inadequate pumping ability of the heart / decreased cardiac output and poor tissue perfusion

-Pump failure

Compensation of cardioghenic shock

Decreased blood pressure, elevated HR to compensate

-Increase in catecholamines causing vasoconstriction

-Activation of RAAS system causing retention of Na and free fluid (trying to correct decreased CO)

-Blood shunting to brain and vital organs, causing increase in myocardial wok and increased O2 demand

Potential causes of cardiogenic shock

MI , severe valvular dysfunction, severe HF, cardiac tamponade, ventricular hypertrophy, cardiomyopathy, dysrhythmias, tension pneumothorax, blunt cardiac injury, pulmonary HTN

Cardiogenic shock: s/sx

Chest pain, diaphoresis, N / V, hypotension, decreased LOC / urine output, weal pulses, pale / cool skin, decreased bowel sounds, SOB / crackles

-As it worsens: profound hypotension and brady / organ failure

Cardiogenic shock medical management

12-lead EKG & cardiac enzymes (rules out MI)

-CX-r/o tension pneumothorax, tamponade, confirm presence of PE

-Stabilize oxygenation: 100% O2 non-rebreather, intubation and ventilation

-Drug therapy- increase CO / BP:

Vasopressors (BP)-dopamine/norepinephrine

Inotropes (contractility)-subtractive / dopamine

Intra-aortic Baltic (drug heart pump-temp) / ventricular assist device (helps heart pump-perm)

Obstructive shock pathophysiology

Occurs when blood flow is blocked and circulation to the major organs is disrupted

-PE, pulmonary htn, tension pneumothorax, mechanical ventilation with high PEEP, aortic dissection, pericardial tamponade, pericardial effusion, cardiac mass

Initial stage of shock

Too little oxygen in the blood to feed organs, body switches from aerobic to americium metabolism

-Increased lactic acid

Compensatory stage of shock

Aldosterone released to maintain BP

-Vasoconstriction to shunt blood to vital organs

-Increased HR

-Sympathetic nervous system releases catecholamines to compensate for low oxygen

(Step two)

Progressive stage of shock

Oliguria, altered LOC, pallor / cool clammy skin, electrolyte imbalance, hypotension

(Stage three)

Refractory stage of shock

Irreversible cellular and organ failure

-Impending death

Overall basics of shock txt and therapies

Txt is focused supportive care

-IV fluids, ventilation, hemodynamic monitoring, IV antibiotics, norepinephrine IV for MAP, blood and blood products, mechanical circulatory support, nutrition, hemodynamic monitoring

Cardiogenic shock on the kidneys relation

Heart’s inability → kidneys taking it as a sign that there’s low BP → kidneys release renin to start the cascade

-This backfires because this leads to fluid overload since the heart cannot handle more fluid / increases workload