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1

Shock

Syndrome characterized by decreased tissue perfusion and impaired cellular metabolism.

2

4 Categories for Shock

Cardiogenic
Hypovolemic
Distributive
Obstructive

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Cardiogenic Shock

systolic or diastolic dysfunction of the heart's pumping action results in reduced CO , SV & BP.
Most common cause is MI

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Cardiogenic Shock c/m:

Tachycardia & hypotension - early manifestations
Decreased Cap refill, SV, CO, SVR, PAWP, CVP
Tachypneic & crackles
Decreased urine output, and increase Na+ and H2O retention
Pallor, cool and clammy skin
Anxiety, agitation & confusion
n/v, hypoactive bowel sounds

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Hypovolemic Shock

Inadequate volume in the intravascular space to support adequate perfusion.
Can be absolute or relative
Pts can compensate a loss of up to 15% of total volume.

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Hypovolemic Shock c/m:

Tachycardia, decreased preload, CO, CVP, PAWP, and Cap refill and Increased SVR.
Tachypnea to bradypnea (late)
Decreased urine output
Pallor, cool and clammy skin
Anxiety, agitation & confusion
Absent Bowel Sounds
Decreased Hct, Hgb & increased lactate, urine specific gravity
changes in electrolytes

7

Distributive Shock

Neurogenic
Anaphylaxis
Septic

8

Neurogenic

Hemodynamic phenomenon that can occur within 30 min of a spinal cord injury and lasts up to 6 wks.
Gen. associated with cervical or spinal cord injuries.

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Neurogenic c/m:

Bradycardia, decreased BP, CO, CVP, SVR, change in temperature
Dysfunction r/t level of injury
Bladder dysfunction
Decreased skin perfusion, cool or warm dry skin
Flaccid paralysis below the level of lesion, loss of reflex activity
Bowel dysfunction

10

Anaphylactic shock

acute life-threatening hypersensitivity reaction to a sensitizing substance
Leads to respiratory distress due to laryngeal edema, severe bronchospasm, and circulatory failure

11

Anaphylactic shock c/m:

Tachycardia, increased CO, decreased CVP, PAWP, CP, Third spacing of fluid
SOB, Edema of larynx & epiglottis, wheezing, stridor, and rhinitis
incontinence
flushing, pruritus, uticaria, angioedema
anxiety, feeling of impending doom, confusion, decreased LOC, metallic taste
cramping, abd pain, n/v, diarrhea
sudden onset, hx of allergies, exposure to contrast media.

12

Sepsis and septic shock

Sepsis: life-threatening syndrome in response to an infection.
Septic shock: subset of species characterized by persistent hypotension despite fluid resuscitation and inadequate and inadequate tissue perfusion

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Sepsis and septic shock c/m:

tachycardia, temperature changes, myocardial dysfunction, biventricular dilation, decreased EF
hyperventilation, crackles, respiratory alkalosis or acidosis, hypoxemia, respiratory failure, ARDS, pulmonary HTN
decreased urine output
warm and flushed skin to cool and mottled skin (late)
change in mental status, agitation , coma
GI bleeding, paralytic ileus
WBC changes, decreased platelets, urine na+, increased lactate, blood glucose, procalcitonin, urine specific gravity, and positive blood cultures.

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Obstructive shock

develops when a physical obstruction to blood flow occurs with decreased CO.

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Obstructive shock c/m

Tachycardia, decreased BP, preload, CO and increased SVR, CVP, JVD and pulsus paradoxus
Tachypnea to bradypnea (late), SOB
decreased urine output
Pallor, cool and clammy skin
anxiety, agitation, confusion
Decreased to absent bowel sounds
Specific to cause of obstruction

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Stages of shock

Initial
Compensatory
Progressive
Refractory

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Neurologic Compensatory Stage

Oriented to person, place, time
Restless, apprehensive, confused
Change in level of consciousness

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Cardiovascular Compensatory Stage

Sympathetic nervous system response:
• Release of epinephrine/norepinephrine (vasoconstriction)
• ↑ MVO2
• ↑ Contractility
• ↑ HR
Coronary artery dilation
Narrowed pulse pressure
↓ BP

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Respiratory Compensatory Stage

Blood flow to the lungs:
• ↑ Physiologic dead space
• ↑ Ventilation-perfusion mismatch
• Hyperventilation
• ↑ Minute ventilation (VE)
• Tachypnea

20

GI Compensatory Stage

↓ Blood supply
↓ GI motility
Hypoactive bowel sounds
↑ Risk for paralytic ileus

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Renal Compensatory Stage

↓ Renal blood flow
↑ Renin resulting in release of angiotensin (vasoconstrictor)
↑ Aldosterone resulting in Na+ and H2O reabsorption
↑ Antidiuretic hormone resulting in H2O reabsorption

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Temperature and Skin Compensatory Stage

Normal or abnormal
Pale and cool
Warm and flushed

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Neurologic Progressive Stage

↓ Cerebral perfusion pressure
↓ Cerebral blood flow
↓ Responsiveness to stimuli
Delirium

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Cardiovascular Progressive Stage

↑ Capillary permeability → systemic interstitial edema
↓ CO → ↓ BP and ↑ HR
MAP <60 mm Hg (or 40 mm Hg drop in BP from baseline)
↓ Coronary perfusion → dysrhythmias, myocardial ischemia, MI
↓ Peripheral perfusion → ischemia of distal extremities, ↓ pulses, ↓ capillary refill

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Respiratory Progressive Stage

ARDS:
• ↑ Capillary permeability
• Pulmonary vasoconstriction
• Pulmonary interstitial edema
• Alveolar edema
• Diffuse infiltrates
• Tachypnea
• ↓ Compliance
• Moist crackles

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GI Progressive Stage

Vasoconstriction and ↓ perfusion → ischemic gut (e.g., stomach, small and large intestines, gallbladder, pancreas):
• Erosive ulcers
• GI bleeding
• Translocation of GI bacteria
• Impaired absorption of nutrients

27

Renal Progressive Stage

Renal tubules become ischemic → acute tubular necrosis
↓ Urine output
↑ BUN-to-creatinine ratio
↑ Urine sodium
↓ Urine osmolality and specific gravity
↓ Urine potassium
Metabolic acidosis

28

Hepatic Progressive Stage

Failure to metabolize drugs and waste products
Cell death (↑ liver enzymes)
Jaundice (↓ clearance of bilirubin)
↑ NH3 (ammonia) and lactate

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Hematologic Progressive Stage

DIC:
• Thrombin clots in microcirculation
• Consumption of platelets and clotting factors

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Temperature and Skin Progressive

Hypothermia or hyperthermia
Cold and clammy