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Flashcards in Shock Deck (45):
1

CONCEPT

Perfusion

Ability of the cardiovascular and pulmonary systems to provide adequate oxygenated blood to the cells and organs of the body and the removal of metabolic waste

Inadequate perfusion will lead to changes that affect all body functioning

2

Terms to Know

Stroke Volume

amount of blood ejected with each ventricular contraction

3

Terms to Know

Cardiac Output

amount of blood pumped per minute (CO = HR x SV)

4

Terms to Know

Mean Arterial Pressure (MAP)

average pressure in the arterial circulation throughout the cardiac cycle

ideal 70-90

5

Terms to Know

Pulse Pressure

the difference between systolic and diastolic pressures

6

Types of Shock

Low Blood Flow

HYPOVOLEMIC
-Severe trauma with massive tissue injury
-Hemorrhage

CARDIOGENIC
-Acute MI
-Arrhythmias
-Cardiomyopathy

7

Maldistribution of Blood Flow

SEPTIC
-Pancreatitis
-Infection →Sepsis

NEUROGENIC
-Spinal Cord Injury
-Narcotic Overdose

ANAPHYLACTIC
-Multiple Transfusion
-Severe Allergic Reaction

8

Shock

Characterized by decreased tissue perfusion and decreased cellular metabolism

Imbalance in supply/demand

MAP>60 ideal
MAP<50 incompatible with life

confusion, restlessness → ↓BP

normal: 25% o2 used, 1 pass through body
shock: 80% 02 used, 1 pass through body

9

Hypovolemic Shock

Severe blood +/or fluid loss making the heart unable to pump enough blood to the body

Emergency situation
Loss of 1/5 the normal amount of intravascular volume in the body (~750ml loss)

volume problem
most common form of shock
↓BP, ↓CO

goal: maintain intravascular (fluids, fluids, more fluids)

10

HYPOVOLEMIC SHOCK
Absolute Hypovolemia

Fluid loss through:
Hemorrhage
Gastrointestinal loss
Fistula drainage
Diabetes Insipidus
Rapid diuresis
Severe dehydration
Pregnancy & Childbirth
Major Sx

11

HYPOVOLEMIC SHOCK
Relative Hypovolemia

Fluid loss through:
Movement of fluid from Intravascular to Extravascular Space
Burns
Liver disease (ascites)
“Third Spacing”
Fluid shifts

12

HYPOVOLEMIC SHOCK
(define)

Size of vascular compartment unchanged
Decreased venous return to heart
Decreased preload, SV and CO
Impaired cellular metabolism

Response to acute volume loss depends upon:
-Age
-Injury
-Health

anaerobic & anaerobic
anaerobic - gives off heat

13

HYPOVOLEMIC SHOCK
Signs & Symptoms

Anxiety, confusion
Agitation
Tachycardia
Hypotension
Pallor
Cold & clammy
Decreased capillary refill / pulses
Decreased urine output (later sign)
Decreased or absent bowel sounds (earlier sign)

14

HYPOVOLEMIC SHOCK
Immediate Treatment

Recognize A-B-C’s and LOC
High flow O2
2 large bore IV’s
Fluids / blood via warmer
Expose the patient (blankets to warm)
Medications as warranted

15

CARDIOGENIC SHOCK
Low Blood Flow Shock

Failure of the heart to act as a pump moving blood forward
Compromised CO & SV

RIGHT SIDE:
Pulmonary circulation compromised

LEFT SIDE:
Impaired ability of the ventricle to fill during diastole
Decreased Stroke Volume

clots
↓↓BP

16

CARDIOGENIC SHOCK
Causes

MI (#1 cause)
Cardiomyopathy
Severe Systemic/Pulmonary HTN
Blunt Cardiac Injury (MVA. #2)
Severe Myocardial Depression from Sepsis
Cardiac Tamponade
Dysrhythmias

17

CARDIOGENIC SHOCK
(define)

Decreased CO with resultant decreased MAP
Tachycardia compensation stresses the heart
Myocardial ischemia progresses to necrosis
Cardiac failure leads to shock and pulmonary failure

**MAP & urine output

18

CARDIOGENIC SHOCK
Signs & Symptoms

Tachycardia, thready pulse, JVD
Hypotension
Narrowed pulse pressure
Increased SVR
Increased myocardial O2 consumption (Angina)
Pale, cold, moist skin
Cyanosis

19

CARDIOGENIC SHOCK
S&S of Peripheral Hypoperfusion

•Renal Blood Flow
•Decreased Urine Output
•Impaired Cerebral Blood Flow

lethargy→coma

20

CARDIOGENIC SHOCK
Treatments

Cautious use of fluids
High flow O2
Medications as indicated
Vazoactives (CO & contractility)
Beta 1 medications

Starling's Law: overstretch cardiac muscle to the point it cannot constrict

21

DISTRIBUTIVE SHOCK
(define)

vasogenic shock

An increase in the size of the vascular bed due to massive vasodilatation or peripheral pooling of blood

Normal blood volume that can not adequately fill the increased size of the capillary bed

Types:
NEUROGENIC
SEPTIC
ANAPHYLACTIC

blood vessel problem
massive vasodilation

22

NEUROGENIC SHOCK
(define)

*Occurs after spinal cord injury at T5 or above*

Results in massive vasodilatation leading to pooling of blood in vessels
Loss or suppression of -sympathetic tone- (↓ sympathetic motor function)

The rarest of all shocks

23

NEUROGENIC SHOCK
Signs & Symptoms

Hypotension
Bradycardia
--Dry, warm skin initially--
With hypothalamic dysfunction there is temperature dysregulation
Respiratory dysfunction based on level of cord injury

Can begin 30 minutes after injury & last days to weeks

bradycardia→atropine

24

NEUROGENIC SHOCK
Treatment

Treat the injury
Corticosteroids (anti-inflammatory)
Vasoactive agents (cerebral perfusion pressure = MAP-ICP)
Reduce parasympathetic stimulation

Cannot control ICP, use MAP to counteract ICP
Dopamine, Levafed(?), Epinephrine

25

ANAPHYLACTIC SHOCK
Pathophysiology

Acute, Life-Threatening Hypersensitivity Reaction
Massive Vasodilatation
Release of Mediators (Histamine, Serotonin, etc.)
Increased Capillary Permeability (capillary leakage)
Loss of Intravascular Volume
Impaired Tissue Perfusion

26

ANAPHYLACTIC SHOCK
Causes

AntigensFoodsFood AdditivesDiagnostic AgentsBiologic AgentsEnvironmental AgentsDrugsVenoms / Insects Blood reactionsIgE-mediated or non-IgE-mediated

27

ANAPHYLACTIC SHOCK
Degree of Reaction

Sudden onset of S&S

CUTANEOUS MANIFESTATIONS
Urticaria, rash, erythema, angioedema, puritis, flushing

RESPIRATORY COMPROMISE
Swelling of lips & tongue, SOB, wheezing, stridor, chest pain

NEUROLOGICAL COMPROMISE
Anxiety, confusion, impending doom, ↓ LOC

28

ANAPHYLACTIC SHOCK
Treatments

Epinephrine
Corticosteroids
High flow O2
Artificial airways

29

SEPTIC SHOCK
(define)

Systemic inflammatory response to infection
Presence of sepsis with hypotension despite fluid resuscitation with abnormal tissue perfusion
Leading cause of death in non-coronary ICU’s

PRIMARY CAUSATIVE ORGANISMS:
Gram-negative & Gram-positive bacteria [↓ outcome gram-neg]
Endotoxins stimulate inflammatory responses

body temperature
heart rate
respiration rate
leukocyte count

30

SEPTIC SHOCK
Signs & Symptoms

Early Manifestation
↓LOC

Cutaneous Manifestations
Warm, dry, flushed skin

Cardiovascular Manifestations
Hypotension, hyperthermia, ↓SVR, compensatory CO, ↑coagulation, ↓fibrinolysis, ↓urine output
Tachypnea

Fluid resuscitation does NOT work

31

SEPTIC SHOCK
"Warm" vs "Cool"

“WARM” stage
Hypotension
Tachycardia
Warm, flushed skin
Increased core temperature
Chills
Anxiousness
N/V/D

“COLD” stage
Hypotension
Tachycardia and dysrhythmias
Cool, pale edematous skin
Lethargy or Coma
Oliguria / Anuria
Decreased core temperature

longer in cold stage → harder to reverse

32

SEPTIC SHOCK
Treatments

Antibiotics and IV fluids
Possible ventilator support
Support vital functions
Cultures to identify organism

skin starts weeping d/t fluid overload

33

STAGES OF SHOCK
Initial Stage
[pt 1]

May not be clinically apparent
May be restless or anxious
Metabolism changes from aerobic to anaerobic (leads to lactic acid accumulation)
Lactic Acid accumulates (sodium bicarb tx)
Must be removed by blood & broken down by the liver
This requires unavailable O2

34

STAGES OF SHOCK
Initial Stage
[pt 2]

Baroreceptors detect a sustained decrease in the MAP (<10 mmHg)
Decreased circulating blood flow
Natural physiologic responses are activated
Vasoconstriction
Increased cardiac contractions & HR

Reversible at this point

35

STAGES OF SHOCK
Compensatory Stage
[pt 2]

Attempted homeostasis
MAP < 10-15 mmHg & 25-35% volume loss
Renin-Angiotensin system activated
Impaired GI motility
Cool, clammy skin
Except septic shock where skin is warm & flushed

"fight or flight" activity

still reversible

36

STAGES OF SHOCK
Compensatory Stage
[pt 2]

Shunting blood from lungs = physiologic dead space
SNS stimulation increases myocardial O2 demand
Decreased blood to kidneys
Reabsorb Na+/H2O, ↓K+

If the deficit is not corrected, the patient enters the PROGRESSIVE STAGE

37

STAGES OF SHOCK
Progressive Stage
[pt 1]

MAP < 20 mmHg
Begins when compensatory mechanisms fail
Lactic acid accumulation
Requires aggressive interventions to prevent multi-organ dysfunction syndrome (MODS) and death

38

STAGES OF SHOCK
Progressive Stage
[pt 2]

Decreased cellular perfusion and altered capillary permeability
Movement of fluid from intravasculature to interstitium
Hyperkalemia due to cellular destruction

39

STAGES OF SHOCK
Progressive Stage
[pt 3]

Fluid movement into alveoli
CO begins to fall
Myocardial Dysfunction
GI system becomes ischemic
Liver fails to metabolize drugs & wastes
Failure of one organ system affects others

cardiac muscle affected by lactic acid

40

STAGES OF SHOCK
Refractory Stage

Exacerbation of anaerobic metabolism
Accumulation of lactic acid (sodium bicarb drips tx)
Increased capillary permeability
Hypotension & tachycardia worsen
Decreased coronary blood flow
Cerebral ischemia
Hypoxemia

RECOVERY UNLIKELY

41

COMPARISON OF SHOCK STATES

SHOCKSTATE CVP PWP CO SVR BP Hypovolemic ↓↓↓↓ ↓↓↓↓ ↓↓↓↓ ↑↑↑↑ ↓↓↓↓
Cardiogenic ↓↓↓↓ ↑↑↑↑ ↓↓↓↓ ↑↑↑↑ ↓↓↓↓
Septic ↓↓↓↓ ↓↓↓↓ ↓↓↓↓ ↓↓↓↓ ↓↓↓↓

42

MEDICAL MANAGEMENT

SUPPORTIVE CARE
Ventilation & Oxygenation

ADEQUATE INTRAVASCULAR VOLUME
Positioning
Volume Replacement

CIRCULATORY SUPPORT
Vasopressors & Positive Inotropes
Vasodilators
Circulatory Assist Devices

**NO Ringer's Lactate**

43

NURSING DIAGNOSES

DECREASED CARDIAC OUTPUT
IMPAIRED GAS EXCHANGE
FLUID VOLUME DEFICIT
ALTERED TISSUE PERFUSION: Cerebral, Renal, GI, Peripheral
HYPERTHERMIA / HYPOTHERMIA
FEAR / ANXIETY
KNOWLEDGE DEFICIT: Patient / Family

[pulse pressure & urinary output - best indicator of tissue perfusion]

44

COMPLICATIONS

Multiple Organ Dysfunction Syndrome (MODS)
Myocardial Failure
ARDS
Disseminated Intravascular Coagulation (DIC)
GI Bleeding
Hepatic Failure
Death

45

In which shock state is the client warm, flushed, bradycardia and hypotension?

1. Cardiogenic shock
2. Septic shock
3. Hypovolemic shock
4. Neurogenic shock

4