Sepsis, Shock, SIRS, MODS

Question 1

Define shock

Answer 1

A syndrome in which there is not sufficient circulation (less oxygen being delivered than is required by tissues, switch from aerobic to anaerobic metabolism)

Question 2

What are the aerobic vs anerobic metabolic byproducts

Answer 2

Aerobic metabolism byproducts= carbon dioxide and water
Anaerobic metabolism byproducts=lactic acid

Question 3

What are the two keys things you need to successfully treat shock

Answer 3

treat early and aggressively

Question 4

What population is most at risk for shock

Answer 4

Older adults and the young are at most risk because of inadequate compensatory responses

Question 5

How do you calculate cardiac output

Answer 5

CO=Heart rate*stroke volume

Question 6

How do you calculate MAP

Answer 6

(Cardiac Output*Systemic vascular resistance)+Central Venous Pressure)

Question 7

MAP should be ___ to perfuse kidneys

Answer 7

65+

Question 8

Name some Factors that influence MAP

Answer 8

total blood volume, cardiac contractility, and systemic vascular resistance

Question 9

What are the 4 Phases of Shock

Answer 9

Initial, compensatory, progressive, refractory

Question 10

Describe the Initial Phase of Shock

Answer 10

Not visible clinically many times; shift from aerobic to anaerobic metabolism begins which starts the buildup of lactic acid in the body

Question 11

Describe the Compensatory Phase of Shock

Answer 11

blood shunted from non-vital organs to vital organs resulting in decreased BP; tachycardia and increased O2 consumption; V/Q mismatch is when part of your lung has too much or too little oxygen and blood flow; impaired GI motility; decreased UOP; cool, clammy skin

Question 12

Describe the Progressive Phase of Shock

Answer 12

compensation starts to fail; mental status changes begin; BP drops significantly; organ failure begins due to poor perfusion; difficult to find peripheral pulses; patient is more profoundly acidotic and hypoxic; issues with each organ worsen

Question 13

Describe the Refractory Phase of Shock

Answer 13

organ and system failure—body is unresponsive to therapies, ischemia and necrosis set in as well as toxins; client becomes profoundly acidotic, hypotension worsens as does mental status; multiple organs fail

Question 14

What kind of labs indicate shock

Answer 14

ABGs (lactic acidosis/metabolic acidosis)
Blood Cultures
Renal function tests
DIC Screen (coagulation alterations)
Glucose level (increased)
Serum electrolytes (abnormal dependent)
Lactate (elevated)
Liver enzymes
CBC (elevated WBC)
Cardiac enzymes (r/o cardiogenic)

Question 15

Why should you be wary of prolonged use of vasopressors

Answer 15

Long term use of (norepinephrine, phenylephrine, vasopressin, dopamine) causes peripheral ischemia and necrotic fingers/toes.

Question 16

What meds might a patient with shock be taking

Answer 16

vasopressors (increase SVR and increase BP)
positive inotropes (to help with contractility)
Bicarb (if PH gets lower than 7.1)
Sedation/paralytics (for intubation)
Isotonic Fluids (if hypovolemic)
Insulin (to tx hyperglycemia secondary effect)

Question 17

How should you give most vasopressors via

Answer 17

a central line

Question 18

What injuries can cause hypovolemic shock

Answer 18

diuresis, GI losses, blood loss, burns, DKA

Question 19

What is Third spacing

Answer 19

-fluid is still in the body, but moves to the interstitial spaces

Question 20

____ ______ are at higher risk for hypovolemic shock

Answer 20

Older adults

because of decreased fluid intake and medications that cause dehydration—do not have as much reserve

Question 21

What labs do you expect to draw for a patient with hypovolemic shock

Answer 21

Type and screen
ABGs (acidosis)
Lactate (high)
Electrolytes (may be concentrated, glucose (elevated) and renal labs
CBC: dependent on cause (blood loss vs dehydration)
Specific gravity Likely elevated

Question 22

Vasopressors are contraindicated for what type of shock

Answer 22

Hypovolemic

Question 23

What is the first treatment for a patient experiencing severe hypovolemic shock

Answer 23

Fluids are the treatment of choice
Blood products if hemorrhaging
Increase oxygen availability-route and amount will depend on state the client is in
Find source of loss and stop it

Question 24

What do you expect to do for a patient experiencing hypovolemic shock

Answer 24

hypovolemic shock decreased CVP
Will be on cardiac monitor
Possible arterial line
Possible CVP monitoring

Question 25

Define Cardiogenic Shock

Answer 25

finals stage of HF Dysfunction of the heart’s pumping action resulting in decreased CO, SV and BP (aka: decreased MAP) Can be systolic or diastolic in nature Fluid backs up into the pulmonary system and then eventually the periphery This further reduces oxygenation Decreased CO can result in less blood flow to myocardium, therefore worsening insult to cardiac muscle

Question 26

Manifestations of Cardiogenic Shock

Answer 26

**increased central venous pressure (CVP)** decreased blood flow to kidneys cause kidneys hold onto fluid causing edema, decreased urinary output crackles in lungs

Question 27

cardiogenic shock labs

Answer 27

Cardiac enzymes ABGs (metabolic acidosis) BNP (elevated) (measure of fluid volume overload ) Lactate (elevated) Specific gravity (elevated)

Question 28

Explain what diagnostic tests you would use to identify the cause of cardiogenic shock

Answer 28

EKG—check for MI and dysrhythmias Echocardiogram—look for function of pump Cardiac Cath—looking for blockage from potential MI

Question 29

What drugs are the first thing given when a pt is dx w/ cardiogenic shock

Answer 29

Positive Inotropic agents-Dobutamine and Dopamine to make the heart contract forcefully Vasodilators—Nitroglycerine Diuretics (furosemide) to reduce fluid load and CVP

Question 30

Bicarb is contraindicated if the pt's fluid volume is ___.

Answer 30

low

Question 31

What are the three ways to treat a heart with end stage heart failure

Answer 31

IABP (INTRA-AORTIC BALLOON PUMP)—helps to improve perfusion of the myocardium Impella (turbine that propels blood from weak left ventricle into system) PCI (Percutaneous Coronary Intervention) (stent in coronary arteries) to revascularize myocardium

Question 32

Define Distributive Shock

Answer 32

Form of shock that results from systemic vasodilation (too big vasculature to push blood through)

Question 33

What are the 3 types of Distributive Shock

Answer 33

Septic Neurogenic Anaphylactic

Question 34

Describe the cause and effect of Septic shock

Answer 34

BACTERIA cause vasodilation due to cytokines (proteins we release that affect the growth of blood cells and other cells that help with the body's immune and inflammation responses) released overstimulate the inflammatory response which causes vasodilation and increased permeability of endothelium. Results in HYPOTENSION AND HYPOPERFUSION TO FINGERS/TOES

Question 35

Describe the cause and effect of Neurogenic shock

Answer 35

INJURY ABOVE THE MID-THORACIC REGION causes impairment in conduction of nervous system, vessels in periphery can no longer constrict Results in HYPOTENSION AND BRADYCARDIA

Question 36

Describe the cause and effect of Anaphylactic shock

Answer 36

HISTAMINE causes vasodilation and increased permeability Results in HYPOTENSION AND DECREASED O2 TO ORGANS

Question 37

What pathogen most commonly causes sepsis

Answer 37

gram negative bacteria

Question 38

Neurogenic shock occurs with injury...

Answer 38

above the T6 region

Question 39

What type of hypersensitivity cause anaphylactic reactions?

Answer 39

Type I Hypersensitivity

Question 40

What shock manifestation is specific to neurogenic shock?

Answer 40

bradycardia, flushed skin

Question 41

What shock manifestation is specific to anaphylactic shock?

Answer 41

angioedema, wheezing

Question 42

You might see a rash with what type of shock?

Answer 42

septic, anaphylactic

Question 43

What do you expect the ABG to be for Distributive Shocks

Answer 43

*METABOLIC ACIDOSIS*

Question 44

When should you check a patient's inflammatory markers during an episode of Distributive Shock?

Answer 44

Check CRP, ESR IF IMMUNOSUPRESSED

Question 45

How do you treat septic shock

Answer 45

Blood cultures before administration of antibiotics FLUIDS BEFORE VASOPRESSORS Fluids to get MAP to at least 70 Give 2L of fluid then move on to vasopressors Mechanical ventilation Control glucose levels-insulin Sodium Bicarb if acidotic Possible FFP (fresh frozen plasma) Possible antipyretics to maintain normal temperature

Question 46

How do you treat Neurogenic shock

Answer 46

Stabilize the spine Mechanical ventilation Support with fluids Maintain normal temperature Possible vasopressors Possible atropine if severely bradycardic

Question 47

How do you treat Anaphylactic shock

Answer 47

Mechanical ventilation Administration of epinephrine Administration of isotonic fluids if orthostatic or have incomplete response to epinephrine Possible Corticosteroids

Question 48

What do you expect to do for a patient experiencing distributive shock

Answer 48

Administer fluids Oxygen Monitor patient VS Will be on cardiac monitor Possible arterial line

Question 49

Define Obstructive Shock

Answer 49

Physical obstruction to blood flow occurs (Ex: Cardiac tamponade, PE, Tension pneumothorax)

Question 50

Describe Sx of Obstructive Shock

Answer 50

chest pain, muffled and distant heart sounds dyspnea, uneven lung expansion

Question 51

Describe Tx of Obstructive Shock

Answer 51

Fix Cause Decompression of pneumothorax Pericardial drain for cardiac tamponade Anticoagulation/Thrombolytic for PE

Question 52

What do you expect to do for a patient experiencing Obstructive shock

Answer 52

Oxygen Monitor patient VS Will be on cardiac monitor Possible arterial line

Question 53

What is SIRS and MODS stand for

Answer 53

Systemic Inflammatory Response Syndrome (SIRS), and Multiple Organ Dysfunction Syndrome (MODS)

Question 54

Describe SIRS

Answer 54

SIRS is a clinical response to a variety of severe clinical insults such as infection, trauma, pancreatitis, or burns. It is characterized by an exaggerated, widespread inflammatory reaction in the body. To diagnose SIRS, at least two of the following four criteria must be met: Fever (temperature >38°C or <36°C) Tachycardia (heart rate >90 beats per minute) Tachypnea (respiratory rate >20 breaths per minute or PaCO2 <32 mm Hg) Abnormal white blood cell count (either >12,000 or <4,000 cells/μL, or >10% immature bands)

Question 55

Describe MODS

Answer 55

MODS refers to the progressive failure of two or more organ systems due to an overwhelming inflammatory response. SIRS can be seen as an early stage or precursor to MODS. The excessive and sustained inflammatory response that characterizes SIRS can lead to widespread tissue damage, impaired organ function, and ultimately, the development of MODS if not managed effectively. Cannot maintain homeostasis without intervention

Question 56

What meds do you expect to administer a patient diagnosed with SIDS or MODS

Answer 56

Diuretics Stress ulcer prophylaxis (PPI) Vasopressors Antibiotics Isotonic fluids Electrolyte replacement Possible glucocorticoids

Question 57

What nutritional needs do you expect for a patient diagnosed with SIDS or MODS

Answer 57

Hypermetabolic state results in caloric expenditure of 1.5-2 times normal Will need calories to replace to reduce mortality Enteral is preferred, but can use PN if needed Monitor glucose carefully

Question 58

What complications can you expect from a patient diagnosed with SIDS or MODS

Answer 58

Pulmonary edema AKI Ischemic bowel injury Hypoglycemia Liver dysfunction DIC Cardiac arrest Death

Question 59

T/F: SIRS/MODS causes hypoglycemia and tachycardia/pnea whereas sepsis causes hyperglycemia and bradycardia

Answer 59

True