N380 SHOCK, SEPSIS, MODS Flashcards
Chacterizations of shock include
decreased tissue perfusion and impaired cellular metabolism
Imbalance of O2 supply and demand
-Continuous demand for O2 and nutrient supply at cellular level
Low supply of O2 and nutrition leads to cell necrosis, organ damage, and failure.
Metabolic and hemodynamic instability
Drop in blood pressure!
Four classifications of shock
cardiogenic
hypovolemic
distribution
obstructive
Name common types of cardiogenic shock
MI, cardiomyopathy, dysrhythmias
Name a type of hypovolemic shock
hemorrhage, GI bleed, vomiting, diarrhea
Name some types of distribution shock; there’s three
- neurogenic- spinal cord injury
- anaphylactic- insect bites, anesthetics, vaccines, contrast media, snake venom
- septic- PNA, Peritonitis, Cholangitis
Name three types of obstructive shock
cardiac tamponade, pneumothorax, SVC syndrome
define systolic dysfunction and some examples
inability of the heart to pump blood forward and affects primarily the left ventricle
cardial infarction, cardiomyopathy, blunt cardiac injury, severe systemic or pulmonary
hypertension, myocardial depression from metabolic problems
most common cause of systolic dysfunction= acute MI
What are the three major pathophysiologic effects of septic shock
-vasodilation, maldistribution of blood flow, and myocardial depression
Causes of SIRS include?
Burns, crush injuries, surgical procedures
Abscess formation
Ischemic or necrotic tissue: Pancreatitis, vascular disease,
Microbial invasion: Bacteria, viruses, fungi, parasites
Name two reasons why the increased cytokine levels seen in SIRS cause a drop in BP?
- vasodilation
2. increase cellular permeability
term for infection in the blood and BP didn’t drop
sepsis
infection in the blood, BP is dangerously low, and organ failure
septic shock
Stages of shock
- Initial
- Compensatory
- Progressive
- Refractory
s/sx of initial shock
- Mild tachycardia
- Mild tachypnea
- Normal BP, may trend downward a little
- Normal urine output
- Slightly cool extremities (hands/feet)
- Pt may be anxious
stage of shock
When the metabolism changes at cellular level from aerobic to anaerobic, causing lactic acid buildup
initial
stage of shock:
Body activates neural, hormonal, and biochemical compensatory mechanisms to overcome the increasing consequences of anaerobic metabolism and to maintain homeostasis and Classic sign of shock: drop in BP
compensatory stage
stage of shock
Pulmonary system is often the first system to display signs of critical dysfunction
GI system is also affected by prolonged decreased tissue perfusion
Effect of prolonged hypoperfusion on the kidneys is renal tubular ischemia
progressive stage
stage of shock
Decreased perfusion from peripheral vasoconstriction and decreased CO exacerbate anaerobic metabolism
Patient demonstrates profound hypotension and hypoxemia
refractory stage
drugs that cause peripheral vasoconstriction and examples
vasopressors
norepinephrine, epinephrine, dobutamine, dopamine
effective volume expanders because the size of their molecules keeps them in the vascular space for a longer time
colloids
stage in septic shock when decreased tissue oxygenation with barely any observable clinical indications
initiation
stage of septic shock body is trying to compensate by activating neural, hormonal, biochemical mechanisms and maintain homeostasis; if unsuccessful this is where the BP drops starts
compensatory
stage of septic shock when the tissue hypoperfusion progresses leading to lactic acidosis; failure Na+ and K- pump and cellular edema occurs and the patient needs to be moved to the ICU
progressive
stage in septic shock
Severe tissue hypoxia with ischemia and necrosis while acidosis continues to worsen; MODS comes into play; life threatening dysrhythmias, extreme hypotension is not responding to vasopressors, ARF, ARDS, DIC, MI
refractory
Name some symptoms of sepsis
confusion/disorientation, SOB, tachycardia, fever/shivering, extreme pain or discomfort, clammy/sweaty skin
Name signs of cardiogenic shock
hypotension, tachycardia, tachypnea, crackles, high PVR, weak pulses, low cap refill, clammy skin
Cardiac interventions
- dobutamine and dopamine are the pressors usually used
- patients will most likely need VADs due to increased use of pressor
reaction that quickly causes massive vasodilation, release of vasoactive mediators, and increase in capillary permeability is called…
anaphylactic shock
anaphylactic shock can lead to
respiratory distress due to
laryngeal edema or severe bronchospasm and circulatory failure from the massive vasodilation
immediate treatment for anaphylactic shock are
- GIVE IM EPINEPHRINE (so it can cause peripheral vasoconstriction and bronchodilation)
- Diphenhydramine and ranitidine (Zantac) are given as adjunctive therapies to block the ongoing release of histamine from the allergic reaction
- maintain patent airway (w/bronchodilators)
If a patient presents with anaphylactic shock and has multiple layers of clothing on, how do you proceed with giving the emergent IM dose of epinephrine?
Proceed with giving the injection directly through the clothing
What are some causes of SIRS
Burns, crush injuries, surgical procedures
Abscess formation
Ischemic or necrotic tissue: Pancreatitis, vascular disease,
Microbial invasion: Bacteria, viruses, fungi, parasites
s/sx of SIRS
tachycardia, tachypnea, hyperthermia
s/sx of sepsis
leukocytosis, leukopenia
s/sx of septic shock
severe hypotension despite adequate fluid resuscitation with impaired organ perfusion
Initial management for hypotension should be ?
0.9% NS using the formula of 30 cc per kg of body weight
What is the ratio for fluid resuscitation when a patient is in hypovolemic shock
3:1
Give 3mL of fluid for every 1mL of blood loss
Give examples of sympathomimetic drugs
- norepinephrine (Levophed)
- Phenylephrine (Neosynephrine)
- Vasopressin
- Hydrocortisone
What are the advantages of central venous access device
Reduce need for multiple venipuncture
Infusion of fluids and medications
Administration of vesicant drugs, blood products, total parenteral nutrition, hemodynamic monitoring, etc.
What is one major disadvantage of a central venous access device
Central Line Associated Bacterial Systemic Infection (CLABSI)
Where can central venous catheters be inserted
Rests in SVC if inserted through subclavian or jugular vein
Femoral vein sometime accessed
Peripheral inserted central catheter
Rests in SVC inserted into a vein (cephalic, median, brachial vein) in the arm
For patients who needs vascular access for 1 week to 6 months (sometimes longer)
Hypoxemia frequently occurs in patients with ….
SIRS and MODS
Interventions that decrease O2 demand and increase O2 delivery are essential
Sedation, mechanical ventilation, analgesia and rest may decrease O2 demand
If fluid bolus is not helping to raise the BP, the patient most likely needs to be started on…
sympathomimetic drugs such as vasopressors via IV drip
If your patient is presenting with shock what is the first and most immediate intervention for your patient?
Give fluids/ fluid resuscitation
Shock is a clinical syndrome that is characterized by ….
inadequate tissue perfusion
What is the purpose of intra aortic balloon pump (IABP)?
- reduces afterload and augments aortic diastolic pressure
- increase coronary blood flow!
- separate set of cardiac leads are applied to the patient and the machine syncs with the cardiac cycle
What happens when the IABP is inflated on diastole?
-when the aortic valve is closed
What happens when the IABP is deflated on systole?
-just before left ventricular ejection
ECG is the trigger used to…
start deflation on the upstroke of the R wave (of the QRS) and inflation on the T wave
Known ascounterpulsationbecause the timing of balloon inflation is opposite to ventricular contraction.
Complications of IABP
- thromboembolism caused by trauma, balloon obstruction of blood flow distal to catheter
- thrombocytopenia
- hemorrhage from the insertion site
- balloon leak or rupture
A hemodynamic phenomenon that can occur within 30 minutes of a spinal cord injury and can last up to 6 weeks is known as
neurogenic shock
Clinical manifestations of neurogenic shock
Hypotension
Bradycardia
Patient may not be able to regulate body temperature
Skin is warm due to massive vasodilation
seen in patients with spinal anesthesia, spinal cord injury (cervical or high thoracic injuries)
What is the treatment for neurogenic shock
- Treatment involves the use of vasopressors (e.g. phenylephrine) to maintain BP and organ perfusion
- Bradycardia may be treated with atropine
- monitor for hypothermia
Why should you infuse fluids slowly for a patient with neurogenic shock
Infuse fluids cautiously as the cause of the hypotension is not related to fluid loss
The patient with a spinal cord injury also needs to be monitored for hypothermia caused by hypothalamic dysfunction
How do we treat the hypotension seen in an anaphylactic shock patients?
IV fluid adminstration
fluid volume that moves out of the vascular space into the extravascular space is called?
relative hypovolemic shock
fluid lost through hemorrhage, GI such as vomiting and diarrhea, fistula drainage, diabetes insipidus, diuresis
absolute hypovolemic shock
Management of hypovolemic shock focuses on
- stopping the loss of fluid and restoring the circulating volume
- give IV crystalloids such as NS or lactated ringers
this type of shock develops when a physical obstruction to blood flow occurs with a decreased cardiac output
obstructive shock
where excess fluid in the pericardium causes increase pressure on the heart and restricts diastolic filling
pericardial effusion/cardiac tamponade
What is seen in abdominal compartment syndrome and SVC syndrome
excess pressure is placed on the vena cava causing a decrease in blood returning to the heart from the body
Low BP, low CO, JVD, pulsus paradoxus
What are the interventions for the following issues that can lead to obstructive shock?
a. Pericardial effusion/cardiac tamponade
b. Abdominal compartment syndrome
c. SVC syndrome
d. Pulmonary embolism
e. Tension/Hemo Pneumothorax
a. mechanical decompression
b. radiation, debulking, removal of the mass or cause
c. radiation, debulking removal of the mass or cause
d. thrombolytic therapy
e. mechanical decompression done by needle or tube insertion
