Shock and Multisystem Failure

Cardiovascular Health Maintenance

* Maintained by interaction of 3 components :


1. Heart (pump)
2. Blood vessels
3. Blood volume

Shock Definition

* A state of inadequate tissue performed that impairs maintenance of normal cellular metabolism
* ANY condition that compromises oxygen delivery to tissues and organs can cause SHOCK!
* Decreased O2 tissue oxygenation = acidotic state
* Loss of O2 perfusion in the body
* Anaerobic metabolism
* Lactic Acid > 4 - anaerobic metabolism

Lactic Acid Level

* > 4 = anaerobic metabolism

Shock

* Is an ACUTE process of hemodynamic and metabolic derangements, resulting from the disruption of one or more factors in the triad below :


1. Blood vessels
2. Heart
3. Blood volume

Shock - Types

* Classified by its underlying cause :

→ Cardiogenic

→ Hypovolemic

→ Circulatory/Distributive
* Neurogenic, Anaphylactic, Septic

→ Obstructive

Cardiogenic Shock Classification

* Pump failure/heart failure
* Left or right ventricles are NOT pumping effectively

Hypovolemic Shock Classification

* Marked decrease in intravascular volume
* Volume depletion inside VESSELS
* Hemorrhage out or MOVING out of vessels into INTERSTITIAL space

Circulatory/Distributive Shock

* WIDESPREAD vasoDILATION and increased capillary permeability ;3 types


1. neurogenic
2. anaphylactic
3. septic
* Systemic VASCULAR resistance is LOW

Obstructive Shock Classification

* Mechanical blockage in the heart or great vessels
* Cardiogenic shock = ex ; obstructive cause such as Cardiac tamponade

Pathophysiology

* Hypoperfusion of the tissues
* Not getting good oxygenation
* Hypermetabolism
* Leads to anaerobic metabolism
* Not using oxygen, increased use of CO2 → lactic acidosis production
* Activation of inflammatory response
* Compensation
* Heart will attempt to compensate → Tachycardia
* Activation of the sympathetic nervous system
* INC. HR, BP
* Activate other key factors - RAAS
* Release of hormones to get compensation back
* Hypermetabolic and inflammatory response

Hypermetabolism

* Anaerobic due to LACK of O2 perfusion
* Not using O2 = inc. CO2 → inc. lactic acidosis production

Compensation - Pathophysiology

* Heart will attempt to compensate → leading to Tachycardia

Activation of the Sympathetic Nervous System

* INC. HR, BP
* Activate other key factors - RAAS\*
* Release of hormones to get compensation back

4 Stages of Shock

* Initial
* Compensatory
* Progressive
* Irreversible/Refractory

Stage 1 : Initial

* No visible changes in the patient’s parameters
* Only changes on the cellular level

Stage 2 : Compensatory

* BP often remains NORMAL and helps maintain adequate CO and SVR
* “fight-or-flight” response (Sympathetic)
* Vasoconstriction, Inc. HR, Increased contractility of heart
* Cool clammy skin

Nurse’s Role - Compensatory

* Role of nurse at this stage is to monitor the patient’s hemodynamic status, administer medications and fluids, and assess level of consciousness, vital signs, urinary output (problems with kidney perfusion), skin, and laboratory values

shock

Early intervention at the compensatory stage can prevent progression to _______

Compensatory Mechanisms that Maintain Homeostasis

* Increase Heart Rate
* INC. HR
* Vasoconstriction
* To help keep BP up
* Fluid shift from tissues to the Vascular Bed
* Increased RR
* BLOW off acid
* Decreased UOP
* Body is worried about heart and brain
* LESS worried about other organs

Best Way to Assess If Organs Are Getting Perfused?

* The body’s natural compensation will always perfuse the brain and heart but will not perfuse other organs is their priority such as the kidneys
* There will be a decrease in UO if the kidneys (other organs) are not getting good perfusion

Stage 3 : Progressive

* Compensatory mechanisms are NOT working
* Hypotension and declining mental status
* Kusmual’s
* Systolic blood pressure < 90 mmHg
* Mottling Skin
* Cool to touch

Stage 4 : Irreversible/Refractory

* Metabolic Acidosis → OVERWHELMING
* Organ damage
* Total body failure
* Not responding to treatment
* Multiorgan dysfunction syndrome (MODS)

Metabolic Acidosis

What acid base balance disturbance does Stage 4 of shock result in?

Shock : Initial Management

* Recognition of Shock IS CRUCIAL
* Intervene within FIRST 6 hours = better survival rate for patient
* Identifiable of the PROBABLE cause
* Goal → to maximize O2 delivery to meet cellular O2 requirements in an ongoing effort to prevent tissue and cell death AND maintain end-organ perfusion

6 hours

Intervene within what time frame for a better survival rate for a patient with shock?

Goal → Shock

To MAXIMIZE O2 delivery to meet CELLULAR O2 requirements in an ongoing effort to prevent tissue and cell death and MAINTAIN end-organ perfusion

Adequate Tissue Perfusion Requires :

1. Functioning PUMP (Heart)
2. Adequate Volume of Fluid
3. Adequate Gas Exchange


1. Between alveoli and capillaries
4. Intact Vascular System-blood vessels


1. No hemorrhage causing them to lose blood
5. Adequate Extraction

Cardiogenic Shock

* Inability of the Heart Muscle to Pump Adequately
* Pump problem most commonly caused by :
* Coronary - acute MI with damage to the left ventricular myocardium
* Non-coronary - any condition that STRESSES the myocardium or conditions causing ineffective myocardial function

Coronary Pump Problem

* Acute MI with damage to the LEFT ventricular myocardium (inability to problem with heart pumping blood to the rest of the body)

Non-coronary Pump Problem

* Any condition that stresses the myocardium or conditions causing ineffective myocardial function

Pump Failure

* Results in DECREASED CO and MAP (Mean Arterial Pressure - 65-65)
* Less than 65 → probably NOT perfusing

Cardiogenic Shock S/S

* Tachycardia
* Hypotension
* Urine < 30 mL/hr
* Cool, clammy, diaphoretic skin
* Pulmonary Edema
* Tachypnea
* Inc. RR
* Blow of excess CO2
* Chest pain/discomfort
* Dysrhythmias

Management of Cardiogenic Shock - Priority

* Correction of UNDERLYING problem
* # 1 priority is oxygen to heart muscle

Coronary Cardiogenic Shock Treatment

* Thrombolytic Therapy
* Percutaneous Coronary Interventions
* CABG
* Intra-aortic Balloon Pump
* Augment or help filling of heart

Non-coronary Cardiogenic Shock

* Valve replacement
* Corrections of dysrhythmias, acidosis, and electrolytes
* Treatment of tension pneumothorax
* Oxygen Therapy → O2 needs of the heart muscle are PRIORITY
* Educate the patient ways to reduce the MI risk

Treatment - Cardiogenic Shock

* Vasopressors and Positive Inotropes if SEVERE multi-organ failure
* Intra-aortic Balloon Pump (IABP)
* Left Ventricular Assist Device (LVAD)
* Possible intubation and mechanical ventilation
* Antiarrhythmics

Intra-aortic balloon pump (IABP)

* Reduces preload (filling pressure), afterload (heart can beat past resistance), and facilities LV ejection (better EF)
* Inflates during diastole…help perfuse
* Pushes the fluid forward
* Deflates before systole..reduces afterload
* Deflates during squeeze (don’t want to increase resistance)
* Helps when the heart is not pumping correctly

Reduction of Preload

* Reduces filling

Reduces Afterload

* Decreased resistance to pump to the body

Principles of IABP

* A flexible catheter is inserted into the __**FEMORAL**__ artery and passed into the __**descending aorta**__
* Correct positioning is CRITICAL in order to avoid blocking off the subclavian, carotid, or renal arteries
* Do __**NOT**__ want to __***BLOCK***__ perfusion
* When inflated, the balloon blocks __**85-90% of the aorta**__
* __**Complete occlusion**__ would damage the walls of the aorta, red blood cells, and platelets
* __**Inflated**__ during **diastolic**, **deflates** during **systole**

Complications of IABP - Pulmonary Edema

* Nursing Actions
* High Fowler’s
* Never put them up full 90 degrees
* Will occlude the balloon
* No HIGHER than 45 degrees
* 30-45 degrees
* Give O2
* Diuretics to take off fluid
* Possible intubation

Left Ventricular Assist Device (LVAD)

* Functions outside the body
* Device a patient wears
* Assists with cardiac output and peripheral perfusion

Medications - Cardiogenic Shock Treatment

* Nitroglycerin
* Dopamine
* Dobutamine

Nitroglycerin

* Venous Vasodilator
* Decreases workload and resistance
* Given IV, SL, intrabuccal, paste
* S/S → hypotension, headache
* IV
* Glass bottle
* Will absorb into plastic
* Special vented tubing
* Given at LOW DOSES

Dopamine

* Central line ONLY
* Adrenergic agonist
* Vasoconstrictor
* NEVER GIVEN ORALLY
* Digestive enzymes would destroy it
* Targets alpha and beta receptors
* INC. HR, inc. contractility
* Dose Dependent
* MC/KG/MIN
* < 5 MC - kidneys
* 5-10 MC - heart
* Over 10 - peripheral

Dobutamine

* Inotrope → inc. contractility
* High doses
* INC. afterload
* INC. contractility
* Low doses
* DEC. preload
* Need to ween off medications, CAN’T abruptly stop
* MUST be ran on a PUMP

Hemodynamics : Summary → Cardiogenic Shock

* Decreases
* Afterload (resistance)
* Myocardial Oxygen demand
* Increases
* Coronary flow
* Cardiac output

Diagnostic Tools Used for Cardiogenic Shock

* Hemodynamic monitoring
* CVP → Right Atrial Pressure
* fluid status
* 2-6 mmHg
* Wedge → Left Atrial Presure
* EKG
* Heart Rhythm
* ECHO
* Ejection Fraction
* 50-70%
* Percentage of blood EJECTED from left ventricle with each contraction
* CT
* Aortic dissection, fluid accumulation
* Cardiac Cath
* Chest X-ray
* Endoscopy
* All ways to diagnose a patient for shock

Management Strategies in Cardiogenic Shock

* Fluid Replacement
* Vasoactive Medications
* Nutritional Support
* Respiratory Support

Fluid Replacement - Cardiogenic Shock

* Crystalloids (NS 0.9%, LR → to volume expand)
* Colloids (Dextram, Albumin)
* Blood Components

Vasoactive Medications

* Used to INCREASE myocardial contractility, regulate HR, reduce myocardial resistance, and initiate vasoconstriction
* Hallmark
* 1. Should be ON pump
* 2. Check VS every 15 minutes
* Look at MAP for perfusion
* At least 65\*
* 3. Not put in peripheral IV
* Central access\*
* Costic to vein
* Extravasate - blow the vein causing tissue necrosis

Nutritional Support

* Compensates for increased metabolic rate

Respiratory Support

* To decrease work of breathing
* Not getting good perfusion through body and and good gas exchange through lungs

Hypovolemic Shock

* Characterized by a decreased intravascular volume 15-30%
* Most COMMON type of shock
* Usually from SEVERE
* Blood or fluid loss
* Burns, ascites, hemorrhage
* Related to dehydration, MASSIVE vomiting, diarrhea

Goal - Hypovolemic Shock

Restore intravascular volume, reverse the events leading to inadequate tissue perfusion, and correct the CAUSE of fluid LOSS

* Increase Volume and Cardiac Output

Nursing Priorities

CLOSE monitoring and administration of necessary fluid and medications

Causes - Hypovolemic Shock

* Fluid shifts
* Ascites (third spacing - fluid sitting in adipose tissue)
* Fluid loss
* Hemorrhage, burns, maceration

decrease

Hypovolemic Shock patients are at high risk for a _______ in cardiac output

Management

* Treat UNDERLYING cause!
* Fluid Replacement
* Modified Trendelenburg
* Prevention

Fluid Replacement - Hypovolemic Shock

* Fluid Replacement (2 large bore IVs - 18-gauge)
* Crystalloids/Colloids/Blood (18-gauge\*)
* Monitor for fluid overload
* Listen to lungs → NOT hearing crackles
* Transfusion reaction
* Monitor temperature

Modified Trendelenberg

* Promotes VENOUS return
* Feet UP, head is kind of UP
* Do NOT want to cause too much of their blood volume to be moved
* Don’t want TOO many fluid shifts
* Will AFFECT cardiac output\*

Shock (Hypovolemic) Nursing Diagnosis

1. Impaired Gas Exchange
2. Fluid Volume Deficit
3. Decreased Cardiac Output
4. Altered Tissue Perfusion
5. Potential for Hypothermia

Distributive Shock

* Abnormal Placement of Intravascular Volume
* Intravascular Volume shifts to PERIPHERAL blood vessels
* Caused by LOSS of sympathetic tone and widespread VASODILATION
* DEC. SVR → vessels are WIDE OPEN

sympathetic, vasodilation

In Distributive Shock there is a LOSS of ______ tone leading to widespread _______

3 Major Types - Distributive Shock

* Septic
* Neurogenic
* Anaphylactic

Septic Shock

* Most severe form of SEPSIS
* Cause : Widespread infection or sepsis (gram negative bacteria - MOST common)
* # 1 cause of NON-coronary patients in the ICU

Health-Care Associated Infections - Septic Shock

* Bacteremia - originated in bloodstream
* Pneumonia - originates in the lungs
* Urosepsis - originates in the urinary tract

Septic Shock Pathophysiology

* Widspread systemic response to sepsis
* Organisms enter the VASCULAR system and promote the release of endotoxins → interstitial fluid leak
* leads to INC. vascular permeability and vasodilation
* Peripheral pooling and 3rd spacing → inadequate tissue perfusion

Septic Shock Pathophysiology - Order

1. Third spacing of fluid (into interstitial space)
2. Fluid will leak out of vessels
3. Widespread vasodilation and increased vascular permeability
4. Inadequate tissue perfusion

Common Organism - Septic Shock

* Gram-negative Enteric Bacillus


1. E. Coli
2. Pseudomonas
3. Staph

Early S/S - Septic Shock

* Normal BP or Hypotensive
* Tachycardia
* Bounding pulses
* Febrile
* Tachypnea
* INC. in RR
* Hyperglycemia - hypermetabolism
* Confusion/agitation

Late S/S - Septic Shock

* Hypotension
* Acidosis → Comatose state
* Poor perfusion
* Organ failure
* Skin → cool, pale
* Urine output ceases → dec. urine output
* Hypotension → < 90 mmHg
* Tachypnea
* Tachycardia → weak, thready pulse
* HIGH HR, RR, AND LOW BP

Phases - Septic Shock

* Hyperdynamic
* Hypodynamic

Mortality Rate - Septic Shock

60%

Hyperdynamic

* Warm
* Systemic Vascular Resistance FALLS (dec. SVR)
* High CO (inc. CO)

Hypodynamic

* Cold
* DEC. CO
* Extreme VasoCONSTRICTION
* Classic SHOCK picture\*

Management - Septic Shock

* PRIORITY is identification and elimination of INFECTION
* Within 6 hours it needs to be TREATED
* Cultures on EVERYTHING
* Blood, Sputum, Wound, Invasive, Catheters
* Broad Spectrum Antibiotics
* After C&S
* Fluid Challenge - fluid admin.
* Vasopressors
* Prevention strategies

Priority - Septic Shock Treatment

Identification and Elimination of Infection

6

Within __ hours Septic Shock needs to be promptly treated

Vasopressors

* Norepinephrine
* Dopamine
* MAP > 65
* INCREASE VASOCONSTRICTION to INC. BP

Neurogenic Shock

* Loss of balance between SYMPATHETIC/PARASYMPATHETIC stimulation (vasoconstriction) causing massive vasodilation
* ONLY shock you won’t see compensation in
* Trauma
* Spinal cord injury
* Spinal anesthesia
* Lack of glucose (insulin reaction)

Neurogenic Shock S/S

* Hypotension
* Loss of Temperature Regulation → Hypothermia
* Dependent edema
* Dry, warm skin
* Bradycardia

Neurogenic Shock Management

* HOB 30 degree for spinal/epidural
* Stabilization of spinal cord in acute injury (immobilization)
* Assessment for venous thromboembolism → HIGHER incidence with neurogenic shock
* Especially with spinal cord injury

Anaphylactic Shock

* Antigen-antibody reaction causing massive vasodilation
* Severe allergic reaction in patients
* Massive vasodilation and capillary leakage
* Peanuts
* Medications
* Insects
* Present minutes after antigen exposure
* Potential trouble breathing

Goal - Anaphylactic Shock

Epinephrine is our ONLY goal

Assessment - Anaphylactic Shock

* Assess for allergies!
* Monitor for
* HA
* Acute abdominal pain
* Pruritus
* Feeling in impending doom
* Erythema/flushing
* Difficulty breathing (Laryngeal edema)
* Bronchospasm
* Stridor
* Hypotension
* Cardiac Dysrhythmias

Management - Anaphylactic Shock

* Eliminate the CAUSE
* Fluid __**resuscitation**__
* Medications to restore vascular tone to normal (not low where everything is WIDE)
* Education

Medications - Anaphylactic Shock

* Goal - restore vascular TONE to normal (not LOW where everything is wide → vasodilation)
* Sympathomimetic IV Epinephrine
* Antihistamine - IV Benadryl
* Bronchodilator - Albuterol
* Corticosteroids

Sympathomimetic - IV Epinephrine

* Every 3-5 mintues if given outside the hospital

Antihistamin - IV Benadryl

Decrease the release of histamine

Bronchodilator - Albuterol

* Rescue inhaler
* Helps open the airway
* Helps with the patient’s stridor

Corticosteroids

* Decrease edema and swelling

Education - Anaphylactic Shock

* Medical alert bracelet
* Avoid allergies
* EPI pen

Obstructive Shock Defintion

Blockage of great vessles

Causes of Obstructive Shock

* Tension Pneumothorax
* Valvular Disease
* Cardiac Tamponade
* Pulmonary Embolism
* Thoracic Tumors

Tension Pneumothorax

* Air pressure pushing against heart
* Squeezing heart
* Chest tube

Valvular Disease

* Problems in vessels of heart

Cardiac Tamponade

* Fluid building up around sac of heart causing pressure buildup
* Pericardiocentesis

Pulmonary Embolism

* Problems with gas exchange and perfusion of lungs
* Anticoagulant

Treatment - Obstructive Shock

* SYMPTOM management
* Focus on RELIEVING OBSTRUCTION\*