Adult Health II - Shock Week 6

Shock

Decrease in blood flow and O2 to organs (no tissue perfusion)

Builds up waste and acid

Distributive shock

Excessive vasodilation

Impaired blood flow distribution

Kinds of Distributive Shock

Neurogenic

Septic

Anaphylactic

Neurogenic Shock

Can occur within 30 minutes of a spinal cord injury or in response to spinal anesthesia

Bradycardia

Warm, dry

Injury at T5 or higher

Unable to regulate

Meds for Neurogenic Shock

Phenylephrine

Atropine

Neurogenic Shock Impact on Hemodynamics

Decreased CVP & SVR

Anaphylactic Shock

System wide histamine releases which leads to leaky capillaries causing massive edema

Anaphylactic Tx

Low dose epi

Anaphylactic Shock Impact on Hemodynamics

Decreased CVP & PAWP

Kinds of Hypovolemic Shock

Absolute: Fluid loss to outside (ex: bleeding out)

Relative: Fluid shift, loss to another area (ex: edema, ascites)

Direct: Blood

Indirect: Any other bodily fluid

Causes of Hypovolemic Shock

Hemorrhage

Extensive burns

Diabetes Insipidus

Hypovolemic Shock Impact on Hemodynamics

Decreased PAWP & CVP

Cardiogenic Shock

Problem with the heart, not pumping effectively

Causes of Cardiogenic Shock

Cardiac dysrhythmias

MI (#1 Cause)

Valvular stenosis/regurgitation

Cardiogenic Shock s/s

EKG change

Crackles

Drugs for Cardiogenic Shock

inotropes

Dopamine (gold standard)

Dobutamine

If SVR is high, give vasodilator (sodium nitro)

Cardiogenic Shock Impact on Hemodynamics

May see increase in CVP, PVR, PAWP, & SVR because blood is backing up

Obstructive Shock

Physical blockage

Causes of Obstructive Shock

PE

Tension Pneumothorax

Cardiac Tamponade

CAD

Obstructive Impact on Hemodynamics if cause is Pneumo/Cardiac Tamponade

Increased CVP, PAWP, PVR, and SVR

Obstructive Impact on Hemodynamics if cause is PE

Increased PVR & CVP

Decreased PAWP

Shock Process

1. Decreased tissue and cellular perfusion

2. Hypoxia

3. If uncorrected: tissue and cellular death

4. Organ dysfunction

5. Organ failure

6. Organ death

7. Death

Shock Stages

1. Early signs

2. Compensatory Signs

3. Progressive Signs

4. Refractory Signs

Early signs of shock

MAP 10 below baseline

Effective compensation

O2 going to vital organs

Slight tachycardia

Compensatory Signs of Shock

MAP 10-15 below baseline

RAAS (Renin) compensation

ADH Compensation

Vasoconstriction

Decreased pulse pressure

Tachycardia

Decreased pH

Restless

Apprehensiveness

Increased K+

Progressive Signs of Shock

MAP > 20 below baseline

Tissue organ/hypoxia

Oliguria

Weak rapid pulse

Decreased pH

Sensorineural changes

Refractory Signs of Shock

Excessive cell/organ damage

Multisystem organ failure

Decreased pH

*at this point, death is expected

Shock Progressive NC

Progresses quickly, must catch while still able to compensate

Tx Shock in this order:

1. ABCs

2. Fluids

3. pressors

4. Tx cause

Sepsis Steps

1. SIRS

2. Sepsis

3. Severe Sepsis

4. Septic Shock

SIRS

Systemic Inflammatory Response Syndrome

Step 1: SIRS Criteria (must have 2 or more of the following)

T: >100.4 or <96.8

RR: >20

HR: >90

WBC: >12000 or <4000 or >10% BANDS (leukocytosis)

PCO2: <32

Step 2: Sepsis Criteria

SIRS + confirmed or suspected infection

Step 3: Severe Sepsis

Sepsis + Signs of end organ damage, or Hypotension (SBP < 90), or lactate >4

Step 4: Septic Shock

Severe Sepsis + persistent signs of end organ damage, or Hypotension (SBP < 90), or Lactate >4

Septic Shock

Life threatening syndrome in response to an infection

Sepsis is body's overwhelming immune response to severe infection that can result in damaged tissues and organs

Septic Shock s/s

Hypotension despite adequate fluid resuscitation

Increased capillary permeability

If Sepsis is suspected

1. Call MET code

2. Draw STAT lactate

- If >2, start protocol

- Get 2 cultures from 2 places

3. Notify HCP & get abx order

4. CBC & another lactate

- Low prealbumin, high procalcitonin (indicates inflammation & bacterial infection), high C reactive protein (indicates inflammation)

Septic Shock Risk Factors

S: Suppressed Immune System

E: Extreme age

P: Post-Op

T: Transplant recipients

I: Indwelling devices

C: Chronic Disease

Septic Shock NI

S: Start abx (w/in 1st hr)

E: Enteral nutrition

P: Pressors (keep MAP>65)

T: Trend VS, labs, Is&Os

I: Inotropes (dobutamine)

C: Crystalloids or Colloid solutions

S: Steroids

H: Hemodynamic monitoring

O: O2 (Keep >95%)

C: Cultures (b4 abx)

K: Keep glucose <180

DIC

Clotting & hemorrhage simultaneously

Always due to underlying cause

Organ ischemia due to bleeding

Steps of how Septic Shock leads to DIC

1. Recruiting WBCs which causes vasodilation

2. Decreased SVR & BP

3. Increased vascular permeability

4. Deceased O2 to tissues

5. Damage to blood vessels

6. Clotting to fix damage

7. Decreased clotting factors

8. Hemorrhaging & clotting simultaneously = DIC

Intrinsic Causes of DIC

Damage to Blood

Transfusion reaction

Sepsis

Sickle Cell disease

ARDS

Malignant hyperthermia

Extrinsic Causes of DIC

Damage to physical tissue

Endotoxins

Crush injuries

Malignancies

Neurologic damage

Extensive surgery

Obstetrical conditions

What lab values would you expect to see in a patient with DIC?

a. increased fibrinogen, increases plts

b. decreased fibrinogen, no change in plts

c. decreased fibrinogen, decrease plts

d. no change in fibrinogen, decrease plts

c. decreased fibrinogen, decrease plts

DIC expected lab values

Decreased plts & fibrinogen

Prolonged PT, PTT

Increased D-Dimer

Decreased Hgb & Hct

DIC Clinical manifestation of decreased plts

Petechiae

Ecchymosis

DIC Clinical manifestation of Hemorrhage

Tachycardia/pnea

Hypotension

Blood in all mucosal surfaces (RR, vaginal bleeding, hematuria, hematemesis, melena)

DIC Tx

1. Eliminate underlying disorder

2. Correct hypovolemia, hypotension, hypoxia, and acidosis

3. Stop microclotting to maintain perfusion & protect vital organs with heparin

4. Stop the bleeding:

- direct pressure

- replace with blood products

Blood products

1. FFP

2. Cryoprecipitate

3. Plts

4. PRBCs

Plt tranfusion NC

Only give if px has 20,000 or less, or is symptomatic

#1 Drug for septic shock

Norepi

Neurogenic shock s/s

Warm, pink & dry skin

Septic Shock Body Temp NC

Temp initially increases, but after prolonged time, it deceases - this is ominous sign

Vitamin K

Need for prothrombin formation in the liver

Helps form clotting factors in liver

How quickly does transfusion need to begin after receiving PRBCs?

within 30 mins

How splenomegaly affects blood cell counts

normal filtering capacity increases, thus decreasing amount of filtering blood

Autonomic dysreflexia S/S

HTN

Pounding HA

Profuse sweating

Nasal congestion

Bradycardia

Flushed & clammy skin

Goosebumps

The nurses recognizes that which patient would be most likely to develop hypovolemic shock? A patient with:

a. decreased CO secondary to EKG changes

b. severe constipation causing watery diarrhea

c. ascites

d. Syndrome of Inappropriate ADH

c. ascites

Third spacing shift fluids

3rd Spacing

Fluid shifts, drop in circulating blood volume

Commonly caused by burns and ascites

Often leads to hypovolemic shock

Position tx for hypovolemic shock

Lay down, feet elevated above head

Trendelenburg positioning

Hypovolemic shock s/s

restlessness

orthostatic hypoTN

decreased skin perfusion

Life-threatening complications of hypovolemic shock

Renal insufficiency

Cerebral ischemia

The nurse is concerned that a patient is at risk for developing obstructive shock because of which assessment findings? SATA

a. Age 80

b. Hx of a fib

c. bacteremia

d. T3 spinal cord injury

e. latex allergy

a. Age 80 (increased risk of PE development)

b. Hx of a fib (increased risk of PE development)

Anaphylactic Shock Steps

1. Release of histamine

2. vasodilation

3. plasma leakage

4. profound HypoTN, hypovolemia, reduced preload, and reduced CO

A px with cardiomyopathy is demonstrating signs of cardiogenic shock. The nurse realizes that this type of shock is d/t:

a. reduced CO

b. increased SV

c. reduced blood flow

d. blood flow blacked in the pulmonary circulation

a. reduced CO

Rationale: in cardiogenic shock, stroke volume and CO are reduced leading to poor tissue perfusion

A px being treated for cardiogenic shock is being hemodynamically monitored. Which findings are consistent with the patient's dx? SATA

a. abnormal PAWP

b. abnormal SVR

c. elevated MAP

d. elevated SV

a. abnormal PAWP

b. abnormal SVR