PAT 401-011 WEEK TWELVE (12): SHOCK AND MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS)

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

Cardiac Output is low meaning

tissues are not being perfused properly and getting the oxygen they need

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

BP formula

CO X SVR

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

CO formula

CO = HR X SV (stroke volume)

Cardiac output formula

heart rate x stroke volume

stroke volume

The amount of blood ejected from the heart in one contraction.

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock: SVR causes vessels to be

smaller

low svr

vasodilation

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

impaired cell metabolism due to

due to a lack of oxygen to tissues

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

low blood perfusion = low 02 = low atp meaning what metabolic processes must occur now

anaerobic processes = uptake of gluconeogenesis, lipolysis, and glyconeogenssi, protein breakdown, and lactic acidosis

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

protein metabolism is impaired why?

glucongoegenesis occurs to feed the tissue in response to no atp for glucose = bad bc protein buildup like ammonia and urea is toxic in the body!

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

protein metabolism is bad for the body because

it affects cell functioning = builds ammonia and urea

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

the go to protein the body breaks down first is?

albumin

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

protein content in the ______ is broken down before the ______

blood before the muscles

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

the body turns to albumin in the blood for energy which in turn causes what

albumin is a huge protein = breakdown reduces circulatory volume - increases shock more

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

breakdown of muscle causes?

muscle wasting

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

anerobic metabolism causes what acid base imbalance

metabolic acidosis = disrupts electrolyte imbalances

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

impaired na-k pump d/t no atp causes what cellular ionic change for these ions

na increase inside the cell

k loss

water goes into the cell = further causes shock

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

does the blood become thinner or thicker

thicker bc losing more water so it acc becomes thicker with plasms and lots of rbc

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

compensatory mechansisms the body relies on what two cardiovascular techniques

1. tries to increase blod volume

2. increases blood pressure

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock: shock involves a deep working with the SNS system = the go-to catecholamines are?

NE and EPI and Dopamine

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock: SNS catecholamines will do what?

increase in growth hormones just like in burns = massive increase in constriction increasing SVR and HR

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

dopamine and NE acts on what receptors?

alpha and beta receptors

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

what renal chemical is released

renin

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

renin does what (1 + 2) linear things

increased aldosterone release --> increases svr and increases na retention

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

besides ne/epi/da and renin what else contributes to increase in SVR and BP

vasopressin

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

chemicals such as NE that cause vasconstriction can cause clots. why?

vasoconstriction = turbulent flow = favor clot formation

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

NE drug does acts on what 2 cdv processes

increasing BP

increasing CO via increasing contractility

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

how does NE increase CO

increases contracility

positive inotrope

a drug that increases the FORCE of heart contractions

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

shock is classified as a shift in?

shift in volume

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

shift in volume is aka

distributive shock = in which shift in volume causes low perfusion d/t vessels dilation

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

septic shock think ifx will present with

capillary permeability/leakage

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

anaphylactic shock leads to massive....

vasodilation

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

neurogenic shock is an issue of ____ and _____ of the CNS

neurogenic shock = issue of tone and dysregulation of the CNS

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

for septic shock = 3 main tx

abx for ifx

vasopressor for fluid

fluids for fluids

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

anaphylactic shock = 5 main tx

remove antigen

EPI pen

fluids

antihistamine

steroids

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

neurogenic shock: 4 main tx

position upright for venous return,

fluids

vasopressor

temp regulation

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

hypovolemic shock - losing...

losing volume

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

hemorrhgaic shock -losing

losing blood

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

nonhemmorhagic shock -

losing fluids and plasma

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

main 3 symptoms

cool extremitiries

oliguria

decrease in turgor

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

shock can also be r/t output

cardiogenic shock - r/t to what 3 issues

myocardial MI

arrhytmias

valves

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

obstructive output shocks = is d/t what 2 main things

poor outflor

poor inflow

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

obstructive outflow shock example

cardiac tamponade = cardiac effusion = lots of fluid closing on heart causing heart to not move this impedes diastolic filling

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

what is reperfusion injury?

poor perfusion, give fluids, causes injury, xanthine oxidase combines combines with oxygen to become free 02 radicals leading to destruction of tissue and can also lead to MODS

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock: Primary MODS caused by?

lack of perfusion causes an increase in catecholamines - neutrophils and macrophages are primed

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

primary mods what wbc are primed (2)

neutrophils

macrophages

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

primary MODS is not clinically testable but?

WBC are primed

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

secondary mods = d/t

casacde of issues stemming from inflammation

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

secondary mods = what 2 wbc components are involved

neutrophils and platelets

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

Secondary MODS neutrophils and plts are injuring what?

injuring the endothelium leading to MODS

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

secondary MODS activation of what 2 processes

endothelial activation and neuroendocrine activation

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

what causes endothelial activation in secondary MODS

arachinodic acid metabolism and ros = increase during endothelial activation

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

neuroendocrine activation = causes what 2 things

hypermetabolic state

catabolism

r/t catecholamine release

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

secondary shock = flow phase is hypermtabolic which leads to an increase in what 4 things

increase in 02 consumption

increase in glucagon

increase in cortisol

increase in growth hormone

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

tx for shock centered (6)

mechanical ventilation

enternal feeding for calories, nutrients, glucose control

dialysis

inotropic drugs

vasopressors

dvt prophylaxis

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

shock in children assessment -->

head to toe

check cap refill

peripheral pulse

breathing - accessory muscles retraction

skin mottled cool cold clammy

mottled skin

is patchy discoloration indicating primary or secondary changes of the deep, middle, or superficial dermal blood vessels

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

what shock pts are flushed and pink d/t vasodilation (4)

septic shock

anaphylactic shock

neurogenic shock

disruptive shock

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

for children we use what lab value

lactate = indicative of acidosis

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

fluid replacement via what 2 medications usually

colloids or crystalloids

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

(Overview) of Shock:

anaphylactic shock = given them

h1 receptor anagonist diphenhydramine

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Introduction to Shock:

Shock is characterized

circulatory dysfunctioning that is both _____ and ______

acute and progressive

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Introduction to Shock

shock is not only poor 02 to tissues but also

poor 02 + nutrients to tissues

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Introduction to Shock

Normally the cdv system is able to maintain blood flow, in shock the CV system fails to maintain and thus there is general and widespread impairment of?

cellular metabolism

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Introduction to Shock: 3 main common pathways in all types of shock are

1. no 02/nutrients = cellular metabolism impairment

2. cells demanding and consuming more 02 and nutrients from other places

3. decreased removal of cellular wastes (normal part of metabolism)

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Introduction to Shock: Understanding Shock

3 main linear arrow pathways briefly explain

failure of normal regulatory mechansism can lead to rapid and profound shock

--> decreased tissue perfusion

--> impaired cellular metabolism

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Impairment of Cellular Metabolism: Impaired Oxygen Delivery & Use

the body will shift from aerobic metabolism to?

anaerobic metabolism

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Impairment of Cellular Metabolism: Impaired Oxygen Delivery & Use

Lack of 02 disrupts ATP na/k synthase pump creating a loss of ability to maintain what inside the cell

loss of ability to maintain an electrochemical gradient

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Impairment of Cellular Metabolism: Impaired Oxygen Delivery & Use

poor 02 = no atp = poor na/k pump

meaning what is high inside the cell and what is low inside the cell

na, cl, and water high in cell (reducing ecf volume)

k leaves the cell

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Impairment of Cellular Metabolism: Impaired Oxygen Delivery & Use

activation of which pathway and release of which enzymes

activation of coagulation pathway and release of lysososomal enzymes

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Impairment of Cellular Metabolism: Impaired Oxygen Delivery & Use

lysosomal enzymes are enzymes which break down material = contribute to

damage of the cell tissues organs

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Impairment of Cellular Metabolism: Impaired Oxygen Delivery & Use

Glycogenolysis

breakdown of glycogen to glucose

lipolysis

the breakdown of fats and other lipids by hydrolysis to release fatty acids

gluconeogenesis

formation of glucose from noncarbohydrate sources

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Impairment of Cellular Metabolism: Impaired Nutrient Delivery (Glucose):

Impaired nutrient delivery of glucose leads the cells to shift into what 3 metabolic processes to

glycogenolysis

gluconeogeneosis

lipolysis

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Impairment of Cellular Metabolism: Impaired Nutrient Delivery (Glucose):

Glucongeogenesis uses what for fuel?

uses proteins for fuel

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Impairment of Cellular Metabolism: Impaired Nutrient Delivery (Glucose)

Why is metabolic acidosis compensatory mechanism inititiated

allows cardiac and skeletal muscle to use lactic acid as a fuel source but only for a limited time

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Impairment of Cellular Metabolism: Impaired Nutrient Delivery (Glucose)

What 2 compensatory metabolic processes contribute to cellular failure when *sustained*

glycogenolysis

lipolysis

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Impairment of Cellular Metabolism: Impaired Nutrient Delivery (Protein):

What metabolic pathway causes proteins to be used for fuel

gluconeogenesis

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Impairment of Cellular Metabolism: Impaired Nutrient Delivery (Protein)

Why is sustained gluconeogenesis problematic from a protein structural pov

protein breakdown for energy means those proteins are no longer available to maintain normal functionings: cellular structure, function, repair, replication --> causes cellular/tissue/organ failure

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Impairment of Cellular Metabolism: Impaired Nutrient Delivery (Protein)

Why is sustained gluconeogenesis problematic from a protein byproduct pov?

ammonia and urea produced

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Impairment of Cellular Metabolism: Impaired Nutrient Delivery (Protein)

Protein breakdown for secondary metabolism is preferential; what does this mean?

serum albumin and other plasma proteins are consumed for fuel first

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Impairment of Cellular Metabolism: Impaired Nutrient Delivery (Protein)

Serum protein consumption during protein breakdown = contributes what intravascular change

loss of serum protein = decreases capillary osmotic pressure = leading to edema

albumin draws water inside the BV = loss of it means less water entering BV = edema development! -> contributes to a decrease in circulatory volume

capillary osmotic pressure

inward pulling force of particles in vascular fluid

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Impairment of Cellular Metabolism: Impaired Nutrient Delivery (Protein)

Muscle wasting by protein breakdown affects what 2 tissue types

skeletal muscle

cardiac muscle

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Impairment of Cellular Metabolism: Impaired Nutrient Delivery (Protein)

protein breakdown = metabolic wastes accumulate in cell and interstitial spaces and contribute to?

toxic to cells and further disrupt cellular function and membrane integrity

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Impairment of Cellular Metabolism: Impaired Nutrient Delivery (Protein)

T or F Decrease of circulatory volume when albumin is consumed

True

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Clinical Manifestations of Shock:

Each type of shock involves numerous clinical manifestations & s/s.

if there are overlapping shock states that occur simultaneously then it becomes difficult to?

determine the cause based only on CM

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Clinical Manifestations of Shock

what can help determine etiology of shock

clients history risk and situation are correlated with suspected or anticipated shock state

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Bodily Compensation for Shock:

3 main aspects

1. SNS alpha and beta receptors adrenergic receptors to increase bp and bv

2. renin

3. other clotting factors

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Bodily Compensation for Shock

Compensatory mechanisms try to maintain SATA

a. bp

b. cxn

c. co

d. HR

blood pressure and cardiac output

A AND C

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Bodily Compensation for Shock

condition not tx promptly then compensatory mechansims will....

decompensate into various shock states = decompensated

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Bodily Compensation for Shock

compensatory mechansism are not effective over long term --> they become

uncompensated and detrimental

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Shock #1: Neurogenic/Vasogenic Shock: Compensatory Mechanisms:

What is it caused by?

loss of sympathetic tone prevents compensatory tachycardia

meaning the person is no longer able to compensate via higher hr --> there is a disconnect with the SNS no increase in BP or CO because no increase in HR (which is in both of these formulas)

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Shock #2: Cardiogenic Shock: Compensatory Mechanisms

Main compensatory method here is?

renin-angiotension compensatory method

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Shock #2: Cardiogenic Shock

Compensatory responses: renin-angiotension, neurohormonal, and SNS cause what 4 cdv changes

1) fluid retention via aldosterone

2) vasoconstriction via ace enzyme

3) tachycardia

4) catechoalmines increase contractility and heart rate

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Shock #2: Cardiogenic Shock

what is wrong with cardiogenic shock compensatory mechansims?

tachycardia and systemic arterial constriction actually increase o2 consumption in a time where 02 consumption is already strained = so dysfunctioning can lead to CO and BP falling again

PAT 401-011 WK 12: Shock + Multiple Organ Dysfunction Mods (MODS)

Shock #2: Cardiogenic Shock

what may result from persistant and severe organ failure

MODS