Shock Priority concepts Objectives • Perfusion • Blood Volume • Cardiac Output • Systemic Vascular Resistance Interrelated Concepts • Clotting • Gas Exchange • Immunity Pathophysiology of Shock Cause of Shock Relative to Perfusion Inadequate blood volume • Total volume vs. Relative Inadequate cardiac output Inadequate tissue function Increased peripheral vasodilation Cardiac output and Stroke Volume Factors that Affect Blood Flow • Contractility • Preload and Afterload Vital Organ Perfusion • MAP > 60 mmHg • Pulse Pressure 40mmHg • Size and integrity of the vascular bed Inadequate perfusion Effects of shock are the same regardless of the cause Some effects are due to lack of oxygen / nutrients Other effects are due to compensation The Problem with Shock Unknown; it is a response not a disease Recognize signs Continued assessment Patient Teaching Incidence and Prevalence | Health Promotion and Maintenance Compensatory Mechanisms Hypovolemic* Types of Shock Cardiogenic* Distributive* • Septic* • Neurogenic • Anaphylactic Hypovolemic Shock Drop in MAP – 5/10 mmHg from baseline Initial Stage Increased sympathetic stimulation Mild vasoconstriction/increased HR Compensatory Stage MAP drops further 15 mmHg from baseline Decreasing pulse pressure Renin, aldosterone, ADH hormone secretion Increased vasoconstriction Urine output decreases Client may express thirst and anxiety Mild acidosis/hyperkalemia Progressive stage Sustained drop in MAP of >20 mmHg or fluid loss of 35-50% Compensatory mechanisms still in play but not effective Body switches from aerobic to anaerobic metabolism creating a further acidotic state Na+/K+ pump fails causing a shift in fluid into the cell Acid byproducts cause fluid shift back to interstitial spaces Refractory Shock Class EBL Treatment Classification of Hypovolemic Shock I <15% (<750ml) Fluids II 15-30% (750-1.5L) Fluids III + Blood 30-40% (1.5L-2.0L) IV >40% (>2.0L) Fluids + Blood Fluids History • Risk factors • Illness, trauma, procedures, chronic health problems • Urine output Recognizing Cues… Physical Assessment Signs & Symptoms • Cardiovascular, respiratory, kidney and urinary, skin, CNS, and skeletal muscle changes Psychosocial Assessment • Determine if behavior and cognition are the same or different from baseline Clinical Picture: Early Hypovolemic Shock All signs of early shock Oliguria Clinical Picture: Late Hypovolemic Shock Rapid, thready pulse – may need a doppler to assess Hypotension; MAP begins to drop Restlessness / agitation Poor capillary refill Ischemia / cyanosis 3rd spacing Metabolic acidosis / Lactic acid production Weakness; DTRs become absent Laboratory Assessments Decreased pH Decreased PaO2 Increased PaCO2 Increased lactic acid Increased or decreased hematocrit Increased or decreased hemoglobin Increased potassium Planning and Implementation: Generate Solutions – Take Action! Sensorium HR Determining Circulatory Competence…. BP Urine output Skin color Invasive monitoring • CVP (Normal 2-6 mmHg) • PAWP (normal 4-12 mmHg) • Arterial BP Cardiogenic Shock Clinical Picture: Cardiogenic Shock Distended neck veins Hypotension Peripheral edema Hepatomegaly Dyspnea / Rales ECG signs of ischemia Cardiomegaly on chest x-ray Cardiogenic Shock Management Oxygen Laboratory testing/ECG monitoring Opioids - relieve pain, provide sedation Diuretics - decrease afterload, alleviate peripheral and pulmonary edema Inotropic agents - improve cardiac contractility Pacing Mechanical support (IABP / LVAD) may be needed Also known as vasogenic shock Result is widespread vasodilation and decreased peripheral vascular resistance Distributive Shock There is no change in blood volume • hypovolemia occurs from fluid shifts from intravascular space to interstitial space Septic, neurogenic, and anaphylactic shock are forms of distributive shock Septic Shock Definitions of Sepsis and Septic Shock Septic Shock Early phase Increased O2 consumption Tachycardia Hyperdynamic – Warm phase Flushed, warm skin Low-grade fever (some patients have high fever) WBCs increasing Tachypnea Decreasing urine output Decreased cardiac output Massive vasodilation Hypotension, narrow pulse pressure Cold clammy skin Hypodynamic - Cold Phase Altered LOC Hypoperfusion/hypoventilation poor gas exchange Oliguria Microthrombi development • Progression to DIC (Disseminated Intravascular Coagulopathy) Early Detection is essential!! Health Promotion and Maintenance • • • • • CAUTI Bundles CLABSI Bundles VAP bundles Wound prevention Sequential Organ Failure assessment/qSOFA assessment • Modified Early Warning System: MEWS Prevention is BEST! History • Age and risk factors; drugs taken Physical Assessment: Signs and Symptoms Recognize Cues.. • • • • Cardiovascular Respiratory Skin Kidney/urinary Psychosocial assessment • Decreased patience; restless, fidgety Nonspecific during early phase Laboratory Testing Then… • • • • Rising serum procalcitonin level Increasing serum lactate level Normal or low total white blood cell (WBC) count Decreasing segmented neutrophil level with a rising band neutrophil level 1 hour sepsis bundle O2 therapy Antibiotic therapy Septic Shock: Management Low-dose corticosteroids Unfractionated heparin therapy Blood replacement therapy: FFP; PRBCs Antibiotic therapy
