(15) Shock and Resuscitation

Shock

a critical condition that results in the inadequate perfusion of cells, tissue, and organs, leading to cellular and organ dysfunction

• leads to cell injury, organ dysfunction, multisystem organ failure, and even death

• hypoperfusion

Resuscitation

the emergency care process that attempts to restore lost vital functions

• focuses on managing the:

  • airway

  • oxygenation

  • ventilation

  • circulation

perfusion

oxygen and glucose delivery

increase

To make more oxygen available in the alveoli for gas exchange, you should (increase/decrease) the oxygen concentration of inhaled air.

HR (Heart Rate); SV (Stroke Volume)

Cardiac Output equation:

CO = ___ x _____

decrease

If the pump fails, regardless of thdece blood volume, the delivery of oxygen and glucose to cells will (increase/decrease).

decreases; decrease

If the vessel size increases because of massive vasodilation, the resistance (increases/decreases) and the blood pressure and perfusion also (increase/decrease).

hypovolemic shock

shock that is caused from blood loss or loss of some sort of other body fluid.

• most common

• can be due to blood loss or loss of some other body fluid

  • hemorrhage (loss of blood)

  • dehydration

Distributive shock

decrease in intravascular volume caused by massive systemic vasodilation and an increase in capillary permeability

• relative reduction in volume

  • volume that has become inadequate to fill the increased size and capacity of the vessels

• reduces systolic blood pressure

• decrease in tissue perfusion

Cardiogenic shock

caused by ineffective pump function of the heart

• adequate blood volume and vessel tone

• hypoperfusion

reduction; poor

When the left ventricle fails to generate enough force to eject sufficient blood from the chamber into the systemic circulation, the result is a(n):

(increase/reduction) in stroke volume, cardiac output, and systolic blood pressure, leading to (strong/poor) tissue perfusion.

Obstructive shock

results from a condition that obstructs forward blood flow

• adequate volume & resistance

metabolic shock (respiratory shock)

a dysfunction in the ability of oxygen to diffuse into the blood, be carried by hemoglobin, offload at the cell, or be used effectively by the cell for metabolism

Hemorrhagic hypovolemic shock

results from the loss of whole blood from the intravascular space

• Medical causes:

  • gastrointestinal bleeding

  • uterine bleeding

  • aortic disease

  • ectopic pregnancy

  • esophageal disease

• decrease in perfusion

• decrease in pressure

• management: stopping the bleeding; immediate transport

Nonhemorrhagic Hypovolemic Shock

caused by the shift of fluid out of the intravascular space; R.B.C. and hemoglobin remain within the vessels

• Oxygen-carrying capability is preserved

• reduction in blood volume, pressure, and perfusion

• administration of intravenous fluids may be beneficial

• water, plasma proteins, and electrolytes are lost

Burn shock

specific form of nonhemorrhagic hypovolemic shock resulting from a burn injury

• burns may disrupt the body’s fluid balance

• a result of inadequate intravascular volume

• collection of fluid leaking out of capillary and in the edema leads to this

capillaries; vassels

In burn shock, burns can interrupt the integrity of what two structures?

Anaphylactic shock

distributive shock (hypoperfusion) state that results from dilated and leaking blood vessels related to severe allergic reaction

• Chemical mediators that are released cause massive and systemic vasodilation

• reduction in systemic vascular resistance

Epinephrine

What is the medication of choice in the anaphylactic shock patient?

Septic shock

a type of distributive shock that results from sepsis, which is an exaggerated inflammatory response to an infection that causes the vessels throughout the body to dilate and become permeable

• created by vasodilation

  • Reduced systemic vascular resistance

  • blood pressure

  • perfusion

Sepsis

the body’s exaggerated inflammatory response to an infection that causes the vessels throughout the body to dilate and become permeable

• typically fungal, viral, or bacterial,

• causes a disruption in cell and organ function

<90

Severe sepsis with hypotension has a systolic blood pressure of __________ mm Hg.

Sepsis

Key physical exam findings of __________:

• Tachycardia

• Tachypnea

• Hyperthermia or hypothermia

• Hypotension

• Flushed, warm skin (early)

• Mottled and cyanotic skin (late)

• Altered mental state

respiratory infection

Sepsis thought to be from a _______ ______:

• Productive cough

• Fever

• Chills

• Upper respiratory symptoms (runny or stuffy nose, sneezing)

• Throat or ear pain

• Crackles upon auscultation (may indicate pneumonia)

Neurogenic shock (vasogenic shock)

Results from a spinal cord injury, which may damage sympathetic nerve fibers that control vessel tone below the level of injury

• vessels dilate

• no fluid loss from intravascular space

• Care:

  • Call for ALS

  • give medication to constrict vessels

  • spine motion restriction

  • management of airway, ventilation, and oxygenation

Cardiogenic shock

most often due to:

• an acute myocardial infarction (heart attack)

• congestive heart failure

• abnormal cardiac rhythm

• valvular disease

• infection

• overdose on drugs that depress the pumping function of the heart such as beta blockers or calcium channel blockers

sympathetic nervous system

When shock occurs, which nervous system is activated?

• stimulates primarily the vessels and the heart to restore the blood pressure in the arteries

increase

An increase in heart rate and stroke volume causes a(n) (increase/decrease) in cardiac outpit.

Recall:
CO = HR x SV

adrenal medulla

stimulated by the nervous system to release the hormones epinephrine and norepinephrine

Epinephrine

Effects on body:

• increased heart rate (beta 1)

• increased contractility (beta 1)

• vasoconstriction (alpha 1)

• sweat gland stimulation (alpha 1)

• Decreased insulin secretion (alpha 2)

• Conversion of stored glucose in liver to blood glucose

• Conversion of noncarbohydrates into sugar

• Iris muscle contraction (alpha 1)

Norepinephrine

Stimulates alpha 1 and beta 1 receptors

Effects on body:

• vasoconstriction (alpha 1)

• increased heart rate (beta 1)

alpha receptors

receptors located primarily in vessel smooth muscle

• stimulation causes vasoconstriction

• increases systematic vascular resistance & blood pressure

• stimulation of sweat glands

Beta 1

receptors that stimulate the heart

• increases heart rate & force of contraction

Aldosterone

Sodium reabsorption in the kidney

Compensatory shock

the stage of shock in which a cascade of organ and gland stimulation and hormones occurs to:

• increase the blood pressure

• restore arterial wall tension

• maintain a near normal blood pressure and perfusion of the vital organs.

increase

Reduction in urine excretion causes retention of waste products, which could (increase/decrease) the acidity of the blood.

Decompensatory shock (progressive shock)

the body’s compensatory mechanisms are no longer able to maintain a blood pressure and perfusion of the vital organs

• advanced stage of shock

• compensatory mechanisms become overwhelmed or exhausted

  • leads to a failure in maintaining pressure inside the vessels and perfusion of vital organs

Multiple organ dysfunction syndrome (MODS)

the stage in which multiple organs begin to fail throughout the body from extreme and prolonged hypoxia, altered metabolism, and elevated carbon dioxide and acid levels

• irreversible shock

• a continuous process

perfusion

Common signs of poor ________ for shock:

• Altered mental status

• Pale, cool, clammy skin

• Delayed capillary refill

• Decreased urine output

• Weak or absent peripheral pulses

supine

To manage a pt in shock, keep them in what position?

body heat

Newborns have been known to go into shock from loss of:

Shock

Signs of what?

• Weak or absent peripheral pulse

• Adequate, weak or absent central pulse

• Delayed (2-4 seconds) capillary refill

• Absent (> 4 seconds) capillary refill

cardiac arrest

the cessation of cardiac function with the patient displaying no pulse, no breathing, and unresponsiveness.

• ventricles of the heart aren’t contracting

sudden death

death of a patient within 1 hour of the onset of the signs and symptoms

Downtime

This time starts when the patient goes into cardiac arrest until CPR is effectively being performed

Total downtime

This is the total time from when the patient goes into cardiac arrest until you deliver the patient to the emergency department or there is a return of spontaneous circulation (ROSC)

Defibrillation

electrical shock or current delivered to the heart through the patient’s chest wall or internally from an implanted device to help the heart restore a normal rhythm.

F

T or F?

Pulse checks are performed immediately after defibrillation

T

T or F?

Following defibrillation, immediately resume CPR with chest compressions without a pulse check to reduce the interruption in the delivery of chest compressions.

Ventricular fibrillation (VF or V-Fib)

a continuous, uncoordinated, chaotic rhythm that does not produce pulses

• commonly associated with advanced coronary artery disease

Ventricular tachycardia (VT or V-Tach)

a very fast heart rhythm that is generated in the ventricle instead of the sinoatrial node in the atrium

• pumping is rapid

  • heart does not refill properly

  • CO is sharply reduced

Asystole

the absence of electrical activity and pumping action in the heart

• “flatline”

Pulseless electrical activity (PEA)

a condition in which the heart generates relatively normal electrical rhythms but fails to perfuse the body adequately because of a decreased or absent cardiac output from cardiac muscle failure or blood loss

F

T or F?

The AED is intended for trauma patients.

hypoxia

In maternal cardiac arrest, pregnant pt are more prone to what?

• oxygenation and ventilation should be prioritized during resuscitation