CMS Shock

Shock

Widespread abnormal cellular metabolism that occurs when OXYGENATION and tissue PERFUSION needs are NOT MET

• Patho is the same for all types of shock except cause is different

1. Pump (cardiogenic)

2. Pipes (distributive)

3. Plasma (hypovolemic)

Each P has a different associated shock

What are the three P’s of perfusion?

• Adequate VOLUME of blood for the heart to pump (preload)

• Effective PUMPING by the heart (CO)

• Constriction and dilation of the VASCULATURE (SVR)

• Unobstructed pathway for blood flow

What does adequate perfusion depend on (hemodynamics)?

• CO = HR x SV

• HR

• SV = volume/beat

• Preload = volume of blood available to be pumped

• Afterload (SVR) = how much resistance the heart is beating against

• Contractility = how strong each beat is

• Control of peripheral circulation = dilation/constriction

• MAP = indicator of perfusion of capillary beds

What are the hemodynamic terms?

((systolic + (2)diastolic))/3

How do you calculate MAP?

• Blood FLOW (CO)

• AMOUNT of hemoglobin available to carry oxygen (ex., anemia)

• Percentage of arterial oxygen hemoglobin saturation (SpO2) (blood from ABG)

What does O2 delivery depend on?

O2 consumption

Represents the body’s demand for oxygen and is a reflection of the body’s metabolism

• DECREASED in shock; magnitude of O2 consumption deficit has been correlated with mortality rates

• Reduction in blood flow (hypovolemic, cardiogenic, obstructive)

• Uneven distribution of blood (septic, anaphylactic, neurogenic)

Why does the body show decreased O2 consumption during shock?

The body normally provides 3-4 times more oxygen than needed for normal metabolism

• Start CAB NOT ABC

Why is there some wiggle room before you give O2?

• Volume

  • Not enough volume perfusing (ex. hemorrhage, dehydration, third spacing)

  • Wrong type of volume perfusing (ex. NS/LR)

• Pump ineffective

• Vasculature ineffective

  • Volume isn’t where it needs to be

• Obstruction in the blood’s pathway

What are the possible causes of hypo-perfusion and hypoxia?

• Hypovolemic (inadequate volume)

• Cardiogenic (inadequate pump)

• Distributive (ineffective vasculature)

  • Neurogenic

  • Chemical (anaphylaxis, sepsis, capillary leak)

(burns are a mix of distributive/hypovolemic)

What are the types of shock?

1. Initial

2. Nonprogressive/compensatory

3. Progressive

4. Refractory (irreversible)

What are the stages of shock?

• MAP/SBP: Mild vasoconstriction

• HR: Tachycardia (first sign something is wrong)

• Respiratory status: Slight increase to retain more O2 (Kussmaul’s)

• Skin: Pallor

• UOP: Normal

• Mentation: Normal, slight anxiety

• Acid-base: Normal (still compensating)

What are the S/S of INITIAL shock?

• MAP/SBP: Decreased 10-15 mmHg from baseline, hypotension

• HR: Tachycardia (SNS stimulation)

• Respiratory status: Increased RR, O2 sat decreased 2-5% from baseline

• Skin: Cool, pale (vasoconstriction; body pulling blood away from vital organs)

• UOP: Decreased; THIRST

• Mentation: Anxious, restless

• Acid-base: Mild acidosis, mild hyperkalemia

What do each of the body systems look like in NONPROGRESSIVE/COMPENSATORY shock?

• MAP/SBP: Decreased >20 mmHg from baseline, hypotension

• HR: Tachycardia

• Respiratory status: Increased RR, O2 sat decreased 5-20% from baseline

• Skin: Cool, cold, pale, DIAPHORETIC; anoxia to nonvital organs

• UOP: Decreased to anuria

• Mentation: altered, confused

• Acid-base: metabolic acidosis, lactic acid production

What do each of the body systems look like in PROGRESSIVE shock?

• MAP/SBP: SEVERE hypotension, MAP <65

• HR: Blood is so acidotic and heart damaged that it could be any rate

• Respiratory status: Respiratory FAILURE (intubation), pulse ox fails or is INACCURATE due to vasoconstriction

• Skin: MOTTLED, dark, dusky (gray); very COLD to touch (no blood flow)

• UOP: ANURIA, INCREASED BUN/Cr (kidney not filtering)

• Mentation: COMA, loss of consciousness, SEIZURES

• Acid-base: MIXED acidosis; hyperkalemia, lactic acid

CAN’T REVIVE

What do each of the body systems look like in REFRACTORY/IRREVERSIBLE shock?

HYPERKALEMIA AND HYPONATREMIA

What is the MAIN electrolyte imbalance that happens in shock?

Hypovolemic shock

Caused by a loss of whole blood, plasma, or interstitial fluids in such quantities that the body’s metabolic needs can no longer be met; low preload = low CO

• Ex., dehydration, vomit/diarrhea, third-spacing, hemorrhage, diabetes (insipidus), burns

1. Decreased blood volume or plasma loss = decreased venous return (PRELOAD) = decreased STROKE VOLUME = decreased CO = decreased tissue PERFUSION

   1. Decreased CO = ANAEROBIC metabolism and LACTIC ACID production = MYOCARDIAL DEPRESSION

   2. Decreased CO = decreased CORONARY ARTERY perfusion

   3. Decreased CO = inadequate cellular perfusion, which leads to an increased susceptibility to INFECTION and HEMORRHAGE = ORGAN DAMAGE

What is the PATHO for hypovolemic shock?

STAGE DEPENDENT (same as S/S shock)

• Skin (least reliable indicator)

  • Cool, pale skin due to vasoconstriction

  • Decreased cap refill (>3)

  • Clammy, moist skin due to release of epinephrine and norepinephrine

• Thirst

  • Activated due to increased serum osmolality

• UOP

  • Decreased due to vasoconstriction and decreased GFR

    • ADH released to retain fluid

• LOC

  • Hyper-alert initially, then decreased

• TACHYCARDIA

  • Very early sign

  • SV decreases and HR increases to maintain CO

• Increased RR (rate and depth)

  • Improve blood oxygenation levels

  • Blow off CO2 (Kussmaul’s)

  • Compensate for impending acidosis

• Labs

What are the S/S hypovolemic shock?

• H/H (depends on underlying cause)

• Electrolytes (Hyperkalemia, Hyponatremia)

What do the LABS look like in hypovolemic shock?

• CVP (preload)

  • 2-6 mmHg

• MAP

  • 65-110 mmHg

  • SBP + (DBP x 2)/3

What are the hemodynamic parameters for hypovolemic shock?

• Airway = assess and establish

• Breathing = assess, assist

• C = circulation

CAB for emergency pt.

What are the interventions for hypovolemic shock?

• STOP THE LOSS

  • Restore circulating blood volume (most important intervention)

• Replace what was lost (ex. fluid, blood, plasma, etc.)

• Fluid replacement; ADMINISTER ENOUGH to correct problems (improve BP, UOP)

• Secondary interventions

What is the intervention for circulation in hypovolemic shock?

• Crystalloid solutions (LR, 0.9% NS)

• Albumin

• Hespan (hetastarch)

• Plasma (FFP)

• Blood

REPLACE WHAT WAS LOST

What is the fluid selection for hypovolemic shock?

• ISOTONIC SOLUTION

• Provides intravascular expansion

• May or may not be all that is needed (depends on what is lost); not all that is needed in blood loss

• DO NOT USE D5W

How do crystalloid solutions (LR, 0.9% NS) help in hypovolemic shock?

• Glucose is metabolized, leaving behind water

• Hypotonic fluid; leaves the blood vessels and is not in the circulating volume

• Only causes edema

Why is D5W NOT used in hypovolemic shock?

• Give if fluid loss is due to plasma (ex. BURNS)

• Also given for clotting DO

How does plasma (FFP) help in hypovolemic shock?

Major blood losses should be replaced with blood products (ex. whole blood (trauma), packaged RBC (ED ICU), etc.)

How does blood help in hypovolemic shock?

Foot of bed elevated, may not be appropriate for all patients depending on oxygenation status and patient acuity

• Increase blood flow back to heart

• NOT in cardiogenic shock

What is the early positioning for hypotension?

• CARDIOVASCULAR SUPPORT (if pump problem)

  • Contractility (LV function):

    • INOTROPIC agents (increase contractility)

      • DOBUTAMINE, MILRINONE, DIGOXIN

  • Preload:

    • Vasoconstrictors

      • NOREPINEPHRINE (LEVOPHED), NEO-SYNEPHRINE

  • Both:

    • DOPAMINE (Intropin) (EFFECTS ARE BASED ON DOSE)

What are the pharmacological interventions for hypovolemic shock?

Improve LV function, increase contractility of heart

What do inotropic agents do for cardiovascular support in hypovolemic shock?

Improve preload (after volume replaced)

What do vasoconstrictors/pressors or fluids do for cardiovascular support in hypovolemic shock?

Anaphylactic

What type of shock is Norepinephrine or Neo-synephrine NOT used?

Arterial line; continous ABG, BP, and MAP

What is important to monitor with vasopressors?

mcg/kg/min

How is dopamine titrated?

0.5-2 mcg/kg/min (low dose)

How much is dopamine given for renal and mesenteric (gut) dilation (increase blood flow)?

No

Does a patient with low UOP get dopamine?

2-10 mcg/kg/min

How much dopamine is given for inotropic effects (act on beta receptors in heart, increase contractility) to increase CO?

>10 mcg/kg/min

• NOT GIVEN ABOVE 20 mcg/kg/min (severe)

How much is dopamine given for vasoconstriction (alpha receptors on blood vessels)?

• Correct acid-base balance

• Monitor for FVO; Rebound (over tx)

• Meet nutritional needs

• Provide emotional support

What are the secondary interventions for hypovolemic shock?

Cardiogenic shock

Caused whenever the heart’s pumping ability becomes impaired, resulting in decreased CO

• S/S like HF but not about volume

Any condition that causes dysfunction of the LV, the RV or both due to ischemia, structural problems or dysrhythmias

What are the CAUSES of cardiogenic shock?

1. Decreased cardiac contractility

2. Decreased SV and CO leads to:

   1. Pulmonary congestion

   2. Decreased systemic tissue perfusion

   3. Decreased coronary artery perfusion

3. Decreased coronary artery perfusion leads to a further decrease in cardiac contractility

What is the PATHO of cardiogenic shock?

Shock:

• Acute issue

• It is more about no oxygenation and perfusion, which causes the heart to reduce its contractility and ischemia to the heart.

HF:

• More of a long-term issue and a pressure/congestion issue. Perfusion can be adequate.

Similarities:

• S/S is are the same

How is cardiogenic shock different than HF?

• CO/CI: Low

  • BP: Low (hypotension)

  • Peripheral pulses: Weak, decreased cap refill

  • Skin: cool, clammy

  • UOP: Low; not getting O2 to work correctly

  • LOC: impaired (alert → anxious → coma)

  • Heart failure S/S

    • Crackles

    • Tachypnea

    • Fatigue, confusion

    • Tachycardia

    • Systemic vascular congestion and peripheral edema

What are the S/S cardiogenic shock?

• Initial cause: PUMP issue not plasma issue

• S/S: Same except s/s HF

• Collaborative interventions:

  • Hypovolemic: fluids

  • Cardiogenic: DIURETICS, INOTROPES

• Expected outcome: better for hypovolemic

• How do you differentiate when a patient arrives with a BP 76/30?

  • LISTEN TO LUNGS

    • Fluid overload = cardiogenic

    • Hypovol = Low CVP, preload, bleeding

How is cardiogenic shock different from hypovolemic shock?

• Oxygenation

• Increased CO (preload (CVP), afterload, contractility (SVR))

• Decrease LV workload (diuretics)

• Devices

What are the interventions for cardiogenic shock?

• Correct any dysrhythmias

• Correct any hypovolemia (or hypervolemia); monitor f/e

• Meds: inotrope, vasopressor, and vasodilator (not at the same time as other)

How do you increase CO in cardiogenic shock?

• Vasodilators to decrease AFTERLOAD (decreased workload on heart)

  • NITROGLYCERIN, NITROPRUSSIDE

• Correct FLUIDS balance (hypo or hypervolemia); DIURETICS

How do you decrease LV workload in cardiogenic shock?

SBP >110

When do you use a VASODILATOR in cardiogenic shock?

Vasculature (circulatory) problem; pipes

What type of problem is distributive/circulatory shock?

1. Event (trigger)

2. Vasodilation (capillary beds)

3. Inflammatory response (leaky)

4. Misdistribution (everywhere else)

5. Decreased preload (doesn’t return to heart)

6. Decreased CO

7. Inadequate perfusion

What is the PATHO for distributive/circulatory shock?

1. Neural (neurogenic) (spinal cord)

2. Chemically

   1. SEPSIS (infection)

   2. ANAPHYLAXIS (allergy, antigen)

   3. CAPILLARY LEAK (burns)

What are the two ways distributive/circulatory shock can be induced?

Neurogenic shock

Occurs due to massive VASODILATION as a result of loss of sympathetic tone

• Spinal cord injury (T6 and above)

• Spinal anesthesia

What are the CAUSES of neurogenic shock?

• BP: Drops rapidly

• HR: DECREASED; No sympathetic tone from severed spinal cord, so parasympathetic nervous system kicks in instead

• Extremities: Warm/red initially (vasodilation); vessels will not send blood back to heart and eventully become cool/pale

• Difficult thermoregulation

Compare and contrast neurogenic vs. hypovolemic shock S/S

• Fluids (still hypovolemic and low CVP)

• O2 (for all shock)

• Vasoconstricting drugs

  • Norepinephrine (Levophed), Epinephrine

• HIGHER MAP GOAL: 85-90 for the first 7 days after spinal cord injury

  • Increase perfusion to spinal cord

What are the interventions for neurogenic shock?

Acts as SNS, sending blood back to heart (preload) and increasing BP/MAP to improve perfusion

Why is vasoconstricting drugs used in treatment of neurogenic shock?

Anaphylactic shock

Sudden life-threatening hypersensitivity reaction to an antigen

• Characterized by massive VASODILATION and INCREASED CAPILLARY PERMEABILITY

• Not perfusing or oxygenating

Chemical mediators cause profound vasodilation, capillary permeability, bronchoconstriction, increased coronary permeability

What is the PATHO for anaphylaxis?

SEVERE HYPOEXMIA secondary to bronchoconstriction or from cardiovascular collapse

How does death result from anaphylaxis?

• Rapid onset

• Angioedema (airway edema)

• Difficult breathing, dyspnea

• Tachycardia

• Hypotension

• Dizziness or syncope (faint)

• Anxiety

What are the S/S anaphylaxis?

• Epi-pen (epinephrine)

• O2, fluids

• Benedryl

• Steroids

• Bronchodilators (albuterol)

• Can give Epinephrine IV drip (vasoconstriction, increases BP, tx allergic reaction)

What is the TX for anaphylaxis?

1. Anaerobic metabolism

2. Brain: seizures, cerebral infarction, decreased LOC, coma, etc.

3. Kidneys: ACUTE TUBULAR NECROSIS, oliguria, BUN/Cr

4. Myocardium: dysrhythmias; place on EKG, tele, auscultate

5. Fluid shifts: distributive (edema)

6. Peripheral circulation: vasoconstriction; assess skin, cap refill, touch, turgor

7. GI: stress ULCERS, bowel infarction, ILEUS; assess septic shock, BOWEL SOUNDS

8. Hepatic system: JAUNDICE, DIC; assess ALT/AST, neuro

9. Glucose metabolism: HYPERGLYCEMIA (stress)

10. Lungs: ARDS

What are the body systems that are affected in all types of shock?

1. Inappropriate inflammation

2. Global inappropriate microcirculatory clotting (body uses up large amounts of platelets and clotting factors; loses ability to clot normally)

3. Paradoxical bleeding (excessive clotting and bleeding at the same time, seen everywhere in the body)

4. Lead to MODS

What is disseminated intravascular coagulation (DIC)?

• Trauma

• Shock

• Sepsis

• Toxin

• Allergies

• Cancer

(Don’t memorize, just know there are alot)

What are the CAUSES of DIC?

• Check skin and others for bleeding

• Check labs

• Assess for clotting

• Assess for organ dysfunction

How do you assess for DIC?

• Platelets: low (all used up)

• D-dimer: high (waste product of clotting)

• PT: high (clotting factors used up)

• PTT: high (clotting factors used up)

• TT (thrombin time): high (clotting factors used up)

• Fibrin: low (used up for inappropriate clotting)

• FDP: high (waste product from clotting)

• H/H: low with bleeding

JUST KNOW TRENDS

What are the LAB values in DIC?

• Underlying cause

• Correct secondary effects

• Replace what’s missing

  • Volume

  • RBC

  • FFP

  • Clotting factors

• HEPARIN therapy; stop clot, but STOP when bleeding

• Monitor for bleed

What is the TX for DIC?:

Multiple organ dysfunction syndrome (MODS)

When 2 OR MORE organs separate from initial organ damaged after initial insult