AH III Exam 3 - Shock & Sepsis

What is shock?

Circulatory system unable to supply enough O2 to tissues to meet metabolic demand

What occurs to BP in the compensatory stage?

BP stays normal

What occurs to BP in the progressive stage?

• SBP <90

• MAP <65

• Hemodynamic compromise

What occurs to BP in the refractory stage?

Severe hypotension → requires vasopressor, does not respond to fluids

What happens to HR in the compensatory stage?

Increased - elevated from baseline

What happens to HR in the progressive stage?

Dysrhythmias

What happens to HR in the refractory stage?

Erratic/asystole

What happens to resp in the compensatory stage? (2)

• RR >20

• PaCO <35 (blowing off CO2)

What happens to resp in the progressive stage? (3)

• Rapid, shallow

• PaO2 <80

• PaCO2 >45

What happens to resp in the refractory stage?

Requires mech vent!!!

What happens to skin in the compensatory, progressive & refractory stage?

• Compensatory: Cold, clammy

• Progressive: Cold extremities

• Refractory: Jaundice, peripheral tissue necrosis

What happens to urinary output in the compensatory, progressive & refractory stage?

• Compensatory: Decreased urine

• Progressive: Further decreased or Anuric

• Refractory: Anuric

What happens to LOC in the compensatory, progressive & refractory stage?

• Compensatory: confused/agitated

• Progressive: lethargy or coma

• Refractory: coma

What happens to ABG in compensatory, progressive & refractory stage?

• Compensatory: Resp alk

• Progressive: Metabolic & resp acidosis (no comp)

• Refractory: Profound acidosis

What is hypovolemic shock?

A volume problem → fluid or blood

• Blood loss → trauma, GI bleed

• Rapid fluid loss → V, D, burns

Tx for hypovolemic shock

• Treat the underlying cause → think abt the root cause

  • Blood transfusion

  • Fluids (V, D)

What is modified trendelenburg used for? (hypovolemic shock)

Increase blood return to the RS of ❤ ; recheck BP, if it goes up, giving fluids will help pt

What is cardiogenic shock?

A pump problem → impairment of ventricular contraction, the pt HAS volume, just can’t pump it

Cardiogenic shock causes

Has to do w the ❤ (duh)

• MI

• Cardiomyopathy

• Heart failure

Tx for cardiogenic shock (2)

• Correct underlying cause

• Initiate first-line tx → think of ABCs

What is Intra-Aortic Balloon Counterpulsation (balloon pump)? (3)

• Inserted through fem artery to aorta

• Inflates at diastole; deflates prior to systole

  • Perfuses coronary arteries during DIASTOLE

• Need an A-line!!!!

Intra-Aortic Balloon Counterpulsation (balloon pump) contraindications (2)

• Aortic insuff

• Aortic aneursym

What is Intra-Aortic Balloon Counterpulsation (balloon pump) used for?

For pts awaiting CABG → bridge therapy, temp. care

Benefits of IABP (4)

• Increased coronary artery perfusion

• Decreased O2 demand

• Increased O2 supply

• Decreased afterload

What is dobutamine used for w cardiogenic shock? (2)

• Strengthens myocardial contraction

• Increase CO

What is nitro used for w cardiogenic shock?

• Decrease preload → don’t want to overload pt

What is dopamine used for w cardiogenic shock? (2)

• Help w the squeeze of the ❤

• Increase CO

What are the 3 types of distributive shock?

• Septic

• Neurogenic

• Anaphylactic

What is SIRS (sepsis) (3)

• Very broad, not specific to sepsis

• Early indicator - is there source of infx?

• HR >90, RR >20, Temp >38 or <36, WBC >12k or <4k

What is septic shock?

Severe sepsis + MAP <65 or lactate >4 after fluids

What is sepsis?

SIRS + infx

• 2+ SIRS

What is severe sepsis?

Sepsis + organ dysfun

1st 3 hrs of sepsis bundle (3)

• Measure lactate level → anaerobic metabolism; if lactate goes up, pt not getting better

• Obtain blood cultures prior to abx

  • If can’t get blood, do NOT delay abx

  • Admin broad spect abx within 1 hr!!!!!

• Admin 30ml/kg NS/LR for hypoten or lactate >4

Critical care for sepsis - 1st 6 hrs (3)

• If pt NOT responsive to fluids, vasopressors for hypoten!!

• Maintain MAP >65

  • **Norepinephrine → first-line; titratable

  • **Vasopressin → 2nd line; NOT titratable

• Monitor lactate level & reevaul need for more fluids

What is MODS? (3)

• Organs fail in 1+ organs; complication of sepsis

• High mortality rate

• Think abt what caused this

2 phases of DIC

• Clotting

• Bleeding

  • Clot a lot then bleed a lot

• Complication of sepsis

What is neurogenic shock?

Parasympathetic nervous system overdrives → massive vasodilation

Common cause of neurogenic shock

Spinal cord injury!!!

Key s/s of neurogenic shock (2)

• Bradycardia

• Hypoten

Management of neurogenic shock (ABCs) (3)

• A/B → if resp compromise (diaphragm can be injured); mech vent to support resp function

• C → Stabilize BP & CO: vasopressors (first-line!!), IVF

• Manage bradycardia → Atropine (1 mg up to 3x)

What is anaphylactic shock?

Severe allergic reaction → causes widespread vasodilation

Tx of anaphylactic shock (5)

1. STOP the exposure

2. Admin epinephrine; IM lateral thigh

3. Ensure airway patency → emergency trach if hella upper airway swelling

4. Admin antihistamines, corticosteroids

5. IVF & vasopressors IF unstable af

What is obstructive shock?

Mechanical problem!! → pressure on ❤ & ❤ can’t mechanically do what it should

Causes + tx of obstructive shock (2)

Relieve the pressure!!!

• Cardiac tamponade → pericardiocentesis

• Tension pneumo → chest tube or needle decomp

Nutritional management of ALL types of shock

Pt is in a hypermetabolic state → needs tube feeds!!!; can dev tissue necrosis