Shock

condition in which vital tissues and organs are not recieving enough blood flow to function properly

shock

what are the two main outcomes of shock

tissue hypoxia

cellular dysfunction

what are the 3 causes of shock

cardiogenic

distributive

hypovolemic

decreased cardiac output

cardiogenic shock

maldistribution of blood flow

distributive shock

reduced blood oxygen content

hypovolemic shock

what are the 3 components needed for BP and tissue perfusion

blood volume

cardiac pump

effective vasculature tone

MAP must exceed what number for cells to have enough nutrients and oxygen

65

the window of opportunity that increases the likelihood of patient survival occurs when aggressive therapy begins within

3 hours of identifying shock

SNS and RAAS are active in what stage of shock

compensatory stage of shock

in what stage of shock are:

homeostatic mechanisms sufficient to maintain adequate tissue perfusion, despite a reduction in CO

SNS activation attempts to maintain BP

compensatory stage of shock

what is the role of baroreceptors in the compensatory stage of shock

increase HR and contractility to increase CO

what is the role of the RAAS in the compensatory stage of shock

vasoconstriction and volume expansion to increase preload and systemic vascular resistance

S/S:

initially patient looks good

Apprehension/restless/confusion

BP normal, SNS stimulation so INC HR RR

blood shunt from organs to vital

skin cool/clammy/pale

hypoactive bowel sounds

decreased UO

inc glucose and sodium

compensatory stage of shock

what are the early signs of compensatory shock

narrow pulse pressure

low systolic

low map

what test is used to determine whether patients will or will not respond to IV fluid bolus challenges

passive leg raise

if the blood pressure improves when the patients leg is raised 30-45 degrees, the patient will

respond well to fluids

S/S:

Patient looks sick-decompensation begins

◦Hypotension

◦Signs of declining mental status/lethargy

◦Ischemia, HF, arrhythmias

mottled skin, petechia, jaundice

◦Capillary leakage-interstitial edema, reduced venous return to heart

◦Crackles, rapid, shallow respirations

◦PaO2<80, PaCo2>45-Metabolic acidosis

◦GI=Stress ulcers->GI bleed

◦ARF-when MAP falls below 65

◦DIC

progressive shock

what are the goals of care for a patient in compensatory shock

maintain adequate BP

reestablish and maintain adqeuate tissue perfusion

how do we treat compensated shock

fluids

o2

pressors

what are the treatment goals for a patient in progressive shock

supporting resp. system and pumping action of the heart

optimizing intravascular volume

improving the competence of the vascular system

Organ damage is so severe that the patient does not respond to treatment and cannot survive.

irreversible shock

 Profound hypotension

 Severe hypoxemia-despite vent

 MAP inadequate for tissue perfusion

 Anuria-renal shutdown

 Liver failure

 Overwhelming metabolic acidosis

 Progression to Multiple organ system failure (MODS)

 BP = Requires mechanical/pharmacologic support

 Heart Rate = erratic

 RR = > requires intubation, ventilation, and oxygenation

 Skin = Jaundice

 Urinary Output = Anuria

 Mental Status = Unconscious

 Acid-Base balance = Profound Acidosis

irreversible shock

Dysfunction of one organ system is associated with

20% mortality

if more than four organs fail, the mortality is at least

60%

remains the top priority in managing MODS

prevention

decreased intravascular volume

Hypovolemic shock

impaired pumping

cardiogenic shock

infectious cause

septic shock

nervous system damage or associated with meds

neurogenic shock

hypersensitivity

anaphylactic shock

cardiac tamponade and tension pneumothorax is an example of

obstructive shock

blunt cardiac injury, dysrythmias, and MIs are examples of

cardiogenic shock

anaphylaxis, sepsis, and spinal cord injuries are examples of

distributive shock

hemorrhage or hypovolemia are examples of

hypovolemic shock

decreased intravascular volume from blood loss and/or fluid shifts

hypovolemic shock

what are the goals of care for hypovolemic shock

restore intravascular volume

correct cause

restore and redistribute volume

what is the fluid and blood replacement standard

3ml of crystalloid solution for each ml of EBL

how do we treat hypovolemic shock

fluid/blood replacement

two large gage IV

patient positioning

monitor for hypovolemia, TRALI

monitor cardiac and resp function

supplement O2

cardiac output is impaired by an obstruction that prevents the heart from filling properly or emptying (ex PE, tamponade, tension pneumo)

obstructive shock

S/S:

tachypnea

  hypotension

  tachycardia

  altered ms

  decreased c.o., u.o.

  SQ air (pneumo)

  Tracheal deviation (tension pneumo)

obstructive shock

how do we treat obstructive shock

identify and treat the cause

how do we treat a pneumo/tension pneumo

needle decompression

chest tube

how do we treat a PE

TPA

clot retrieval

how do we treat tamponade

pericardiocentesis

pericardial drain

ability of heart to pump/contract/supply oxygen is impaired

cardiogenic shock

S/S:

 Angina

 Arrhythmias

 Fatigue

 Feelings of doom

 ECG changes

 Increased cardiac enzyme levels and cardiac biomarkers

cardiogenic shock

what are the goals of care for cardiogenic shock

correct cause

limit further myocardial damage

improve cardiac function by inc contractility and dec afterload

how do we treat cardiogenic shock

pain control

judicious fluid and blood replacement - monitor hemodynamics

monitor cardiac and resp - O2, Alines, Tele

monitor response to med

can be caused by either a loss of sympathetic tone or a release of biochemical mediators from cells that causes vasodilation

distributive shock

what are the 3 types of distributive shock

septic

neurogenic

anaphylactic

what is the leading cause of death in noncoronary ICU patients

septic shock

what are the risk factors for shock

§Hospital aquired infections

§Bacteremia

§Pneumonia

§Urosepsis

§Wound infections

§Intravascular/urinary catheters

§Increased number of antibiotic-resistant microorganisms,

§Aging population

Initial S/S:

◦Hyperthermia

◦Tachycardia

◦Bounding pulses

◦Hypotension with decreased urine output

◦Nausea, vomiting, decreased GI motility

◦Subtle changes in mental status

Later S/S:

BP drop

cool, mottled skin

multiple organ dysfunction with no response to tx

septic shock

what are the goals of treatment for a patient experiencing septic shock

recognize and treat promptly

rapid and effective restoration of tissue perfusion

evaluation and treatment of immune response

treatment of the dysregulation of the coag system

when a patient is in septic shock, when is nutritional supplementation initiated?

24-48 hrs

how to treat septic shock

monitor cardiac/resp

cultures + sensitivity

lactate, labs, abg, bnp

aggressive fluids and antibiotics

imbalance between parasympathetic and sympathetic stimulation that can be caused by spinal cord injury, spinal anesthesia, or nervous system damage

neurogenic shock

S/S:

 Hypotension

 Bradycardia

 Syncope, fainting

 Dry, warm skin

neurogenic shock

what are the goals of care when treating neurogenic shock

prevention

restore sympathetic tone through stabilizing spinal injury

treat underlying cause

support cardiac and neuro functioning

how do we treat neurogenic shock

elevate HOB 30 degrees after anesthesia

monitor for VTE

monitor for internal bleeding

support cardio and neuro functioning

caused by a severe allergic reaction, most common triggers are foods, medication, and insect bites and stings

anaphylactic shock

what are the 3 defining characteristics of anaphylactic shock

acute onset

presence of 2 or more : resp distress, hypotension, GI distress, skin or mucosal irritation

cardiovascular compromise

how long after exposure to antigens do signs occur

2-30 minutes

S/S:

headache

lightheadedness

nausea

vomiting

puritis

generalized flushing

dyspnea

bronchospasm

cardiac arrythmias

hypotension

mild anaphylaxis

S/S:

rapid hypotension

decreased LOC

respiratory distress

cardiac arrest

severe anaphylaxis

what are the goals of care when treating anaphylactic shock

remove antigen if possible

provide emergency support of basic life functions

how do we treat anaphylactic shock

meds: epi, diphenhydramine, albuterol

CPR

prevent/recognize

assess

provide education

NS 0.09% and LRs are

crystalloids

albumin, blood, and dextran are

colloids used for volume resuscitation

when giving colloids what do you monitor for

fluid overload

pulm edema

abdominal compartment syndrome

anaphylaxis

dobutamine, dopamine, epi. and milrinone are

inotropes used to increase cardiac output

nitroglycerin and nitroprusside are

vasodilators used to decrease preload and afterload in shock management.

norepinephrine, dopamine, phenylephrine, vasopressin, epi, and angiotensin II are

vasopressors utilized to increase blood pressure in shock management.

improve contractility, increase stroke volume, and increase cardiac output

inotropic agents

what are the disadvantages of inotropic agents

increase oxygen demand of the heart

Reduce preload and afterload, reduce oxygen demand of the heart

vasodilators

what are the disadvantages of vasodilators

cause hypotension

Increase blood pressure by vasoconstriction

vasopressors

what are the disadvantages of vasopressors

increase afterload, thus increasing cardiac workload

compromise perfusion to skin, kidneys, lungs, and GI tract

what is used to prevent a stress ulcer in a patient experiencing shock

H2 blockers

antacids

PPIs