Sepsis, Shock, SIRS, MODS Flashcards
Define shock
A syndrome in which there is not sufficient circulation (less oxygen being delivered than is required by tissues, switch from aerobic to anaerobic metabolism)
What are the aerobic vs anerobic metabolic byproducts
Aerobic metabolism byproducts= carbon dioxide and water
Anaerobic metabolism byproducts=lactic acid
What are the two keys things you need to successfully treat shock
treat early and aggressively
What population is most at risk for shock
Older adults and the young are at most risk because of inadequate compensatory responses
How do you calculate cardiac output
CO=Heart rate*stroke volume
How do you calculate MAP
(Cardiac Output*Systemic vascular resistance)+Central Venous Pressure)
MAP should be ___ to perfuse kidneys
65+
Name some Factors that influence MAP
total blood volume, cardiac contractility, and systemic vascular resistance
What are the 4 Phases of Shock
Initial, compensatory, progressive, refractory
Describe the Initial Phase of Shock
Not visible clinically many times; shift from aerobic to anaerobic metabolism begins which starts the buildup of lactic acid in the body
Describe the Compensatory Phase of Shock
blood shunted from non-vital organs to vital organs resulting in decreased BP; tachycardia and increased O2 consumption; V/Q mismatch is when part of your lung has too much or too little oxygen and blood flow; impaired GI motility; decreased UOP; cool, clammy skin
Describe the Progressive Phase of Shock
compensation starts to fail; mental status changes begin; BP drops significantly; organ failure begins due to poor perfusion; difficult to find peripheral pulses; patient is more profoundly acidotic and hypoxic; issues with each organ worsen
Describe the Refractory Phase of Shock
organ and system failure—body is unresponsive to therapies, ischemia and necrosis set in as well as toxins; client becomes profoundly acidotic, hypotension worsens as does mental status; multiple organs fail
What kind of labs indicate shock
ABGs (lactic acidosis/metabolic acidosis)
Blood Cultures
Renal function tests
DIC Screen (coagulation alterations)
Glucose level (increased)
Serum electrolytes (abnormal dependent)
Lactate (elevated)
Liver enzymes
CBC (elevated WBC)
Cardiac enzymes (r/o cardiogenic)
Why should you be wary of prolonged use of vasopressors
Long term use of (norepinephrine, phenylephrine, vasopressin, dopamine) causes peripheral ischemia and necrotic fingers/toes.
What meds might a patient with shock be taking
vasopressors (increase SVR and increase BP)
positive inotropes (to help with contractility)
Bicarb (if PH gets lower than 7.1)
Sedation/paralytics (for intubation)
Isotonic Fluids (if hypovolemic)
Insulin (to tx hyperglycemia secondary effect)
How should you give most vasopressors via
a central line
What injuries can cause hypovolemic shock
diuresis, GI losses, blood loss, burns, DKA
What is Third spacing
-fluid is still in the body, but moves to the interstitial spaces
____ ______ are at higher risk for hypovolemic shock
Older adults
because of decreased fluid intake and medications that cause dehydration—do not have as much reserve
What labs do you expect to draw for a patient with hypovolemic shock
Type and screen
ABGs (acidosis)
Lactate (high)
Electrolytes (may be concentrated, glucose (elevated) and renal labs
CBC: dependent on cause (blood loss vs dehydration)
Specific gravity Likely elevated
Vasopressors are contraindicated for what type of shock
Hypovolemic
What is the first treatment for a patient experiencing severe hypovolemic shock
Fluids are the treatment of choice
Blood products if hemorrhaging
Increase oxygen availability-route and amount will depend on state the client is in
Find source of loss and stop it
What do you expect to do for a patient experiencing hypovolemic shock
hypovolemic shock decreased CVP
Will be on cardiac monitor
Possible arterial line
Possible CVP monitoring
Define Cardiogenic Shock
finals stage of HF
Dysfunction of the heart’s pumping action resulting in decreased CO, SV and BP (aka: decreased MAP)
Can be systolic or diastolic in nature
Fluid backs up into the pulmonary system and then eventually the periphery
This further reduces oxygenation
Decreased CO can result in less blood flow to myocardium, therefore worsening insult to cardiac muscle
Manifestations of Cardiogenic Shock
increased central venous pressure (CVP)
decreased blood flow to kidneys cause kidneys hold onto fluid causing edema, decreased urinary output
crackles in lungs
cardiogenic shock labs
Cardiac enzymes
ABGs (metabolic acidosis)
BNP (elevated) (measure of fluid volume overload )
Lactate (elevated)
Specific gravity (elevated)
Explain what diagnostic tests you would use to identify the cause of cardiogenic shock
EKG—check for MI and dysrhythmias
Echocardiogram—look for function of pump
Cardiac Cath—looking for blockage from potential MI
What drugs are the first thing given when a pt is dx w/ cardiogenic shock
Positive Inotropic agents-Dobutamine and Dopamine to make the heart contract forcefully
Vasodilators—Nitroglycerine
Diuretics (furosemide) to reduce fluid load and CVP
Bicarb is contraindicated if the pt’s fluid volume is ___.
low
What are the three ways to treat a heart with end stage heart failure
IABP (INTRA-AORTIC BALLOON PUMP)—helps to improve perfusion of the myocardium
Impella (turbine that propels blood from weak left ventricle into system)
PCI (Percutaneous Coronary Intervention) (stent in coronary arteries) to revascularize myocardium
Define Distributive Shock
Form of shock that results from systemic vasodilation (too big vasculature to push blood through)
What are the 3 types of Distributive Shock
Septic
Neurogenic
Anaphylactic
Describe the cause and effect of Septic shock
BACTERIA cause vasodilation due to cytokines (proteins we release that affect the growth of blood cells and other cells that help with the body’s immune and inflammation responses) released overstimulate the inflammatory response which causes vasodilation and increased permeability of endothelium.
Results in HYPOTENSION AND HYPOPERFUSION TO FINGERS/TOES
Describe the cause and effect of Neurogenic shock
INJURY ABOVE THE MID-THORACIC REGION causes impairment in conduction of nervous system, vessels in periphery can no longer constrict
Results in HYPOTENSION AND BRADYCARDIA
Describe the cause and effect of Anaphylactic shock
HISTAMINE causes vasodilation and increased permeability
Results in HYPOTENSION AND DECREASED O2 TO ORGANS
What pathogen most commonly causes sepsis
gram negative bacteria
Neurogenic shock occurs with injury…
above the T6 region
What type of hypersensitivity cause anaphylactic reactions?
Type I Hypersensitivity
What shock manifestation is specific to neurogenic shock?
bradycardia, flushed skin
What shock manifestation is specific to anaphylactic shock?
angioedema, wheezing
You might see a rash with what type of shock?
septic, anaphylactic
What do you expect the ABG to be for Distributive Shocks
METABOLIC ACIDOSIS
When should you check a patient’s inflammatory markers during an episode of Distributive Shock?
Check CRP, ESR IF IMMUNOSUPRESSED
How do you treat septic shock
Blood cultures before administration of antibiotics
FLUIDS BEFORE VASOPRESSORS
Fluids to get MAP to at least 70
Give 2L of fluid then move on to vasopressors
Mechanical ventilation
Control glucose levels-insulin
Sodium Bicarb if acidotic
Possible FFP (fresh frozen plasma)
Possible antipyretics to maintain normal temperature
How do you treat Neurogenic shock
Stabilize the spine
Mechanical ventilation
Support with fluids
Maintain normal temperature
Possible vasopressors
Possible atropine if severely bradycardic
How do you treat Anaphylactic shock
Mechanical ventilation
Administration of epinephrine
Administration of isotonic fluids if orthostatic or have incomplete response to epinephrine
Possible Corticosteroids
What do you expect to do for a patient experiencing distributive shock
Administer fluids
Oxygen
Monitor patient VS
Will be on cardiac monitor
Possible arterial line
Define Obstructive Shock
Physical obstruction to blood flow occurs (Ex: Cardiac tamponade, PE, Tension pneumothorax)
Describe Sx of Obstructive Shock
chest pain, muffled and distant heart sounds
dyspnea, uneven lung expansion
Describe Tx of Obstructive Shock
Fix Cause
Decompression of pneumothorax
Pericardial drain for cardiac tamponade
Anticoagulation/Thrombolytic for PE
What do you expect to do for a patient experiencing Obstructive shock
Oxygen
Monitor patient VS
Will be on cardiac monitor
Possible arterial line
What is SIRS and MODS stand for
Systemic Inflammatory Response Syndrome (SIRS), and Multiple Organ Dysfunction Syndrome (MODS)
Describe SIRS
SIRS is a clinical response to a variety of severe clinical insults such as infection, trauma, pancreatitis, or burns. It is characterized by an exaggerated, widespread inflammatory reaction in the body. To diagnose SIRS, at least two of the following four criteria must be met:
Fever (temperature >38°C or <36°C)
Tachycardia (heart rate >90 beats per minute)
Tachypnea (respiratory rate >20 breaths per minute or PaCO2 <32 mm Hg)
Abnormal white blood cell count (either >12,000 or <4,000 cells/μL, or >10% immature bands)
Describe MODS
MODS refers to the progressive failure of two or more organ systems due to an overwhelming inflammatory response.
SIRS can be seen as an early stage or precursor to MODS. The excessive and sustained inflammatory response that characterizes SIRS can lead to widespread tissue damage, impaired organ function, and ultimately, the development of MODS if not managed effectively.
Cannot maintain homeostasis without intervention
What meds do you expect to administer a patient diagnosed with SIDS or MODS
Diuretics
Stress ulcer prophylaxis (PPI)
Vasopressors
Antibiotics
Isotonic fluids
Electrolyte replacement
Possible glucocorticoids
What nutritional needs do you expect for a patient diagnosed with SIDS or MODS
Hypermetabolic state results in caloric expenditure of 1.5-2 times normal
Will need calories to replace to reduce mortality
Enteral is preferred, but can use PN if needed
Monitor glucose carefully
What complications can you expect from a patient diagnosed with SIDS or MODS
Pulmonary edema
AKI
Ischemic bowel injury
Hypoglycemia
Liver dysfunction
DIC
Cardiac arrest
Death
T/F: SIRS/MODS causes hypoglycemia and tachycardia/pnea whereas sepsis causes hyperglycemia and bradycardia
True
