distributive shocks Flashcards
distributive shocks are characterized by…
massive vasodilation
3 types of distributive shocks
- neurogenic
- anaphylactic
- septic
describe neurogenic shock
Rare and usually transitory
Massive dilation of blood vessels as a result of the loss of sympathetic tone
causes of neurogenic shock
Injury to spinal cord
Spinal anesthesia
Emotional stress, severe pain or drug overdose
clinical manifestations of neurogenic shock
Hypotension
Bradycardia
Hypothermia
treatment of neurogenic shock
Treat or remove cause
Volume replacement
Vasopressors
descrieb anaphylactic shock
Characterized by massive dilation and increased capillary permeability
“Antigen-Antibody” reaction
Release of vasoactive substances
what does histamine do in anaphylactic shock
Causes vasodilation
Decreased vascular resistance
Decreased BP
what does serotonin do in anaphylactic shock
Increased capillary permeability
Decreased circulating blood volume
Decreased BP
what are some causes of anaphylactic shock
Drugs
Contrast media
Blood and blood products
Insect bites or stings
Foods
signs and symptoms of anaphylactic shock
Pruritis
Erythema
Urticaria
Angioedema
Laryngeal edema
Hypotension
treatment of anaphylactic shock
PREVENTION!
Remove antigen
Reverse effects of vasoactive substances
Maintain airway – intubation
Corticosteroids
Fluid resuscitation
May need + inotropes and/or vasopressors
what is sepsis
Life-threatening organ dysfunction due to a dysregulated host response to infection
what is septic shock
sis plus hypotension not responsive to fluid resuscitation, along with perfusion abnormalities
clinical signs of sepsis
Change in mental status (GCS < 15)
Tachypnea (RR > 22)
Hypotension (SBP < 100)
Tachycardia
Fever (or hypothermia)
Fatigue, malaise, chills
Nausea and/or vomiting
Increased WBC with left shift (or decreased)
early recognition of sepsis
Vitals
- SIRS criteria v. qSOFA
Labs
- Lactate
- Coags
- Liver function
- Renal function
- Procalcitonin
QSOFA utilizes 3 criteria, what are they
Identifies patients with suspected infections
1 point low BP (<100 mmHg)
1 point altered mentation (GCS<15)
1 point high respiratory rate (>22 bpm)
SIRS criteria
Temp > 38 degrees C
Heart rate > 90 beats/min
RR > 20 or PaCO2 < 32
WBC > 12,000 or >10% bands (immature)
2 or more = SIRS
describe SIRS
Systemic inflammatory response syndrome
Complex system in place throughout the body to localize inflammation
Inflammation, thrombosis & fibrinolysis
Can occur for other reasons (other types of shock, trauma, surgery)
whos at risk for sepsis
Although everyone is at risk for developing sepsis from minor infections, it is more likely to develop in people who:
are very young or old
have a weakened immune system
have wounds/injuries from burns/trauma
have addictive habits
have IV’s, foleys, wound drainage, etc.
name some HAIs
Central line associated bloodstream infections (CLABSI)
Catheter-associated UTIs (CAUTI)
Surgical site infections (SSI)
Ventilator-associated pneumonia (VAP)
central line bundle
Proper hand hygiene
Maximum barrier precautions upon insertion
Chlorhexidine skin antisepsis
Avoidance of the femoral vein
Daily review of line necessity with prompt removal of unnecessary lines
describe diagnosing the source of sepsis
Appropriate cultures
- Urine, sputum, wound
Blood cultures
- Minimum 2 cultures
- 1 percutaneous
- 1 from each vascular access > 48 hrs.
when should blood cultures be obtained?
After administering the antibiotic
After obtaining the urine culture
After giving the patient prn Tylenol
Before administering the antibiotic
Before administering the antibiotic
1hr resuscitation bundle for sepsis and septic shock
Measure lactate level
Obtain blood cultures prior to administration of antibiotics
Administer broad spectrum antibiotics
Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L
Apply vasopressors if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure ≥ 65 mm Hg
Remeasure lactate if initial lactate elevated (>2mmol/L)
clinical manifestations of early septic shock
Skin is pink, warm and dry
CO is normal or elevated
- Due to catecholamine release (epi and norepi)
Decreased afterload
Increased respiratory rate
Changes in Mental status
As shock progresses, fluid leaks from vascular compartment and patient develops hypovolemia.
hemodynamic profile of a patient in early septic shock
Preload is decreased
- CVP is low
- PCWP (PAOP) is low
Afterload is decreased
- SVR is low
- BP is decreased
HR is increased
- Contractility appears normal or increased
- CO/CI is normal or increased
treatment of early septic shock
Continue fluid administration and antimicrobial agents
Corticosteroids
Supportive care
- DVT & Stress ulcer prophylaxis
- Managing hemodynamics
- Mechanical ventilation if needed
- Electrolyte & glycemic control
describe progression of septic shock
Capillary walls have increased permeability
- Fluid leaves vascular space enters interstitial and intra-cellular space
Decreased circulating blood volume
Increased blood viscosity
Interstitial and intra-cellular edema
Compensatory mechanisms are failing
Tissue perfusion is decreased
Mitochondrial damage – cells can’t use oxygen
SIRS leads to MODS
what is MODS
Multiple Organ Dysfunction Syndrome
Progressive physiologic failure of 2 or more separate organ systems
Homeostasis cannot be maintained without intervention.
clinical manifestations of late septic shock
Cold, clammy skin
Edema (total body) – Anasarca
Low cardiac output
Severe hypotension
hemodynamic profile of a patient in late septic shock
Preload is increased
- CVP is higher than previously
- PCWP (PAOP) is higher than previously
Afterload is increased
- SVR is high
Contractility is decreased
- BP and CO/CI are very low
treatment of late septic shock
Continue supportive care
Vasopressors
Inotropes
Corticosteroids
Consider limitation of support
