3 Shock, Sepsis, MODS & DIC (part 1) Flashcards
Shock
-definition
-results from ?
-progresses to what 2 things?
Inadequate tissue perfusion
Imbalance between oxygen supply and demand
Results from:
-ineffective cardiac function
-inadequate blood volume/vascular tone
Progresses into SIRS and MODS
4 systems that work together to maintain homeostasis in shock
What happens if 1 fails
What happens if 2 or more fails
Blood volume
Myocardial contractility
Blood flow
Vascular resistance
When 1 fails others work to compensate
When 2 or more fail we have SHOCK
Stages of shock (4)
Initiation
Early/compensatory (reversible)
Progressive (intermediate)
Irreversible (refractory)
Stage 1 of shock
Initiation (reversible)
-decrease tissue oxygenation
Stage 2 of shock
Early/Compensatory
(Body starts to compensate)
Neural compensation by what?
Neural compensation by SNS (fight or flight):
—increased HR/contractility/vasoconstriction
—redistribution of blood flow from nonessential organs to essential organs
—bronchodilation
Stage 2 of shock
Early/Compensatory
Endocrine compensation
RAAS, ADH, glucocorticoids released
(Renin angiotensin aldosterone system):
—vasoconstriction
—renal reabsorption of Na, Cl and water
—converts glycogen to glucose for energy
Stage 2 of shock
Early/Compensatory
Chemical compensation
Chemical receptors increase rate/depth of breathing :
=hyperventilation
=alkalosis
=vasoconstriction of cerebral blood vessels
Stage 2 of shock
Early/Compensatory
Clinical manifestations
SNS:
Increased HR (except neurogenic shock)
Narrowed pulse pressure
Rapid deep resp (causes alkalosis)
Thirst
Oliguria (increased specific gravity)
Decreased bowel sounds
Hyperglycemia
Stage 3 of shock
(Failure of compensatory mechanisms)
Physiologic events:
Tissue hypoperfusion
=aerobic to anaerobic metabolism
=lactic acidosis
Resp/metabolic acidosis
(Inadequate Na/K pump)
Stage 3 of shock
(Failure of compensatory mechanisms)
Clinical manifesations
Hyper/hypoglycemia
Dysrhthmias
Anuria (increased BUN/creatinine/potassium)
Decreased BP
Lethargy to coma
Absent bowel sounds
Tachypnea
Stage 4 of shock
(Refractory)
Physiologic events
-Severe tissue hypoxia
-tissue necrosis
-worsening acidosis
(SIRS/MODS)
Stage 4 of shock
(Refractory) (NONREVERSIBLE)
Clinical manifestations (everything starts to fail)
-dysrhuthmias
-severe HOTN despite pressors
-acidosis
-acute resp failure
-DIC/liver failure
-AKI
-MI
-cerebral ischemia/infarction
4 classifications of shock
Hypovolemic (inadequate volume)
Cardiogenic (inadequate contractility)
Obstructive (obstruction of blood flow)
Distributive (inadequate vascular tone)
-anaphylactic/neurogenic/septic
Hypovolemic shock
Clinical manifestation:
What happens to HR/RR/BP/CVP/PAOP/SVR
Management: 3 things to look at
Increased HR/RR/SVR
Decreased BP/CVP/PAOP
Management:
-UOP 30ml/hr
-CVP 2-6
-SBP over 90/ MAP over 65
Hypovolemic shock causes (basic level)
Loss of fluids (blood/burns/v/d/diuresis)
Hypovolemic shock
Lab findings
Serum lactate (1.2) increased
= lactic acidosis (decreased perfusion)
—ABG/electrolytes
—H&H
—Decreased SvO2 (<60%)
-all shock is low SvO2 d/t decreased perfusion
Hypovolemic shock tx
-IV needed
(Do what with what solutions)
Fluid resuscitation
-multiple large bore IVs
Crystalloid solution (isotonic)
Blood products
Other colloid solutions (albumin/ volume expanders)
Hypovolemic shock tx
How fast to replace fluids
-what type of line to measure what?
Worries about giving large amounts of blood
Continuous resp assessment to watch for what 2 things?
1-2L (crystalloid solutions) over 10-15mins
Central line w/ CVP capability
Worries: hypocalcemia from citrated plasma
Continuous resp assessment:
-pulmonary congestion
-resp distress thru inadequate oxygenatioln
Cardiogenic shock
Causes
Clinical manifestations
-what happens to HR/RR/BP/SvO2/CVP/PAOP
(What does it look like)
-other 1 symptom
All heart issues (HF/MI/cardiomyopathy)
Symptoms (look like a active MI)
Increased HR/RR
Opposite of hypovolemic (increased CVP/PAOP)
Decreased SvO2, BP
Chest pain
Difference between hypovolemic shock and cardiogenic shock
hypovolemic (decreased CVP/PAOP)
Cardiogenic (increased CVP/PAOP)
—Cardiogenic is heart issue but not a volume issue like hypovolemia
Cardiogenic shock management
Goal:
3 things to do/give
2 machines we can put them on
1 procedure we can do
Goal: improve contractility:
-inotropic agents (dopamine, dobutamine)
-keep MAP >65
-reduce preload and afterload (CVP/PAOP)
Put on:
Ventilator
IABP
Procedure:
Cath lab (improve blood flow)
Cardiogenic shock labs
Increased in MI:
—CPK-MB
—Troponin
Increased if increased myocardial pressure:
—BNP
Cardiogenic shock tx:
Goal:
Decrease myocardial workload
Increase myocardial oxygen delivery
Cardiogenic shock meds
5
ACE inhibitors
ARBs
Diuretics
Digoxin
Dobutamine:
-B1 and B2 agonist
-Increases CO and decreases PAWP
