Shock Flashcards
Define “shock”
When the body’s tissues do not receive enough oxygen nor is their removal of waste products
T/F
Shock is a disease
False. Shock is a syndrome.
What does shock usually result from? (3)
- Ineffective pumping
- Insufficient volume
- Massive vasodilation
When the body is not able to perfuse the tissues with oxygen, what happens to the blood glucose levels?
Blood glucose will sky rocket
When there is shock, what does response does that activate?
What med could you give?
What would you use to counteract it?
Inflammatory response
- you could give a steroid as an BUT understand that it can raise blood glucose even higher
- You would need to hang an _insulin dri_p then.
What is MODS?
Multi-organ failure (death). Shock can cause it & if it gets to this point, its over.
What is common to all shock states?
Inadequate O2 delivery to meet cellular oxygen demand
- not “decreased”.
Explain the pathophysiology of shock with this:
Not enough o2 > Anaerobic metabolism > Acidotic body > Na-K malfunction > call structures damaged > cell death
Not enough 02 tissue perfusion is occurring. This causes the cells to go through necrosis which causes acidosis. At this point, it is reversible if we intervene. The body will try to support a dropping BP by vasoconstriction. If this goes on, you will have MODS due to hypoxemia and metabolic acidosis.
Common occurrences with shock/MODS
Respiratory failure
Renal failure
Decreased Cerebral perfusion
Disseminated Intravascular Coagulation (blood clotting)
What causes the vasodilation/vasoconstriction changes in the body on the cellular level?
List some…
Cytokines - they do this based off the body’s needs for compensation due to the body’s neural, chemical, and hormonal aspects working together to keep the body perfused
- interferon, interleukin, growth factors
Three classifications of shock states
- Cardiogenic shock of the heart
- Hypovolemic shock rt third spacing
- Distributive-abnormal placement
Most common form of cardiogenic shock?
Left ventricular failure shock rt myocardial infarction
What is hypovolemic shock?
Decreased tissue perfusion due to a lack of intravascular volume (state of being hypovolemic or dry)
What does hypovolemic shock result from? (2)
- A decrease of fluid in your circulation (maybe you lost blood from trauma)
- Internal fluid shifts are going on (dehydration, edema, ascites)
Explain the hypovolemic shock relationship with the heart affects blood pressure?
Due to a decrease of volume of some sort, the right atrium is not perfused which affects the whole heart and reduces CO and therefore reduces the BP.
Hypovolemia related to Fluid Shift example
Hemorrhage
Burns (due to 3rd spacing & drainage)
Ascites
Peritonitis (inflamed peritoneal)
Dehydration
Hypovolemia related to Fluid Losses examples
Trauma
Surgery
Vomiting
Diarrhea
Diuresis
Diabetes insipidus
How is diabetes inspidus fluid loss able to cause hypovolemic shock?
Due to the ADH hormone. Diabetes insipidus = less ADH = more peeing so fluid is lost
How exactly does less blood volume in hypovolemic shock cause less oxygen to be transported?
What will we be checking?
Less blood means less hemoglobin for oxygen to hope on to to get to the tissue!
We will be checking H&H labs, RBC, and O2 sats.
How can hypovolemic shock lead to carbon monoxide toxicity (transport shock state)?
Due to not being able to bring oxygen to the tissue, the tissue is unable to get rid of the CO2 waste as well
(this process is gas exchange)
How can hypovolemic shock lead to anemia (transport shock state)?
What about hemorrhage?
The decrease in H&H and MCV - size of rbcs.
Hemorrhage results in a loss of fluid from the body completely
What is cardiogenic shock?
Impaired oxygen delivery to the rest of your body due to the cardiac dysfunction
- don’t confuse this with hypovolemic shock simply causing the heart to lower BP. It is different
How does MI cause cariogenic shock?
If you have an MI, anterior especially, your heart stops working and the rest of your body experience shock
What mechanical complications of the heart can lead to cariogenic shock?
valve stenosis and regurgitation
Again, these issues cause the rest of your body to go into shock
How can cardiomyopathy cause cardiogenic shock?
Cardiomyopathy is a hereditary disease of the heart which affects the hearts ability to pump out blood to the body - which can lead to shock.
How can a myocardial contusion cause cariogenic shock?
Contusion is bruising of the heart so it affects perfusion to the rest of the body
How can pericardial tamponade cause cardiogenic shock?
What will you notice on assessment?
Fluid surrounds the heart so there’s a decrease in room for it to contract & therefore less perfusion
heart sounds will sound distant and muffled
How can ventricular rupture cause cardiogenic shock?
Ventricular rupture means blood is being lost through the ventricles and without the ventricles, you can’t perfuse the body
How can arrhthymias cause cardiogenic shock
A.fib and A. flutter decrease the amount of blood being perfused to the rest of the body
How can end stage HF cause cardiogenic shock?
The ejection fraction could be so low it can’t perfuse the body. (norm is 50-70%).
Populations that are most vulnerable to cardiogenic shock?
Elderly
Diabetics - their vascular is brittle and stenosed
Anterior MI - descending coronary artery
History of MI
T/F
Ventilated patients are safe from cardiogenic shock
False!
The ventilation settings affect heart contractility - which can in turn cause the cardiogenic shock.
What might lung sounds be like for patients with heart issues?
What type of shock might you find this in?
Lungs sounds will be crackled due to it affecting the hearts ability to perfuse
Definitely find it in cardiogenic shock since blood is backed up into the pulmonary
If you have a cardiogenic shock patient with muffled/crackled lung sounds, what do you anticipate?
Anticipate diuretics to get rid of the fluids.
But, consider that your patient is already dealing with a perfusion issue so diuretics can make it worse - so, they will need to be on a pressor.
What is the difference between left ventricle and right ventricle infarction as far as its effects?
Left ventricle - backs up into pulmonary, and less stroke volume
Right ventricle - doesn’t eject enough blood into left side of the heart , so there’s less stroke volume
What are obstructive shock states?
This happens when something is physically blocking O2 blood from being delivered to the body
What are examples of obstructive shock states?
Pulmonary embolism
Tension pneumothorax - need chest tube
Cardiac tamponade
Athersclerosis of the vessels
Explain pulmonary embolism causing obstructive shock
The pulmonary artery is obstructed, causes alveolar dead space, and impaired gas exchange.
Right ventricular after load has to work harder to push
Explain tension pneumothorax causing obstructive shock
Air enters pleural space during inspiration and is trapped.
Explain cardiac tamponade causing obstructive shock
Bleeding into pericardial sac around the heart puts too much pressure on the ventricles and stops it from filling
Why do compensatory mechanisms exist
To prevent us from deteriorating and to restore homeostasis
What is distributive circulatory shock?
Blood volumes start to pool in the peripheral blood vessels
What is distributive circulatory shock the result of?
- Loss of sympathetic tone (fight or flight)
- Release of biochemicals in mediators
What can the dilation from distributive circulatory shock cause? (3 categories)
Septic shock
Neurogenic shock
Anaphylactic shock
(Distributive Circulatory Shock)
Septic shock is caused by what?
Caused by widespread infection
- foleys, central lines, arts, etc
(Distributive Circulatory Shock)
Septic shock clinical presentation?
Increase in HR
Fever
Flushed skin
Bounding pulses
Tachypnea
Later on, UO changes & GI dysfunction
What hyper metabolism signs can you see in septic shock?
Increased blood sugar and insulin resistance (will have to try to bring down slowly too)
Mental changes that occur in septic shock?
Confusion and agitation
- more of a late sign as well
Labs to check for septic chock
WBC will be increased
C reactive protein increase
- measure of inflammation in the body. If its high, sign of infection and long term disease
How does septic shock progress as perfusion and acidosis worsen?
Blood pressure drops
Cool, pale, mottled skin
Temperature can be normal or low
Anuria (no UO)
MODS
Death
Rapid Heart rate and rapid breathing still present
What is Neurogenic shock from?
There becomes a loss of balance between the sympathetic and parasympathetic systems due to spinal injury, medication, or glucose.
Due to the parasympathetic system, there’s vasodilation (so low CO).
What else can cause neurogenic shock?
Damage to the nervous system
- spinal injury
- spinal anesthesia epidurals
First clinical presentation of neurogenic shock?
Bradycardia
Hypotension
Dry and warm skin
What is Anaphylactic Shock ?
What is the patho?
Allergic rxn where mast cells like histamine and bradykinin are realeased and cause widespread vasodilation and permeability
What is the clinical presentation of anaphylactic shock?
Rapid onset of hypotension
Neuro compromise
Respiratory distress(SOA and flushed)
Cardiac arrest
Your patient is receiving morphine and their cheeks turn red. What do you do?
You assure them this is common response. It is not an allergy
The four main progressive categories of shock
Initial
Compensation
Progressive
Refractory
Initial stage of shock
No signs and symptoms at all yet
Compensatory stage of shock
When the neural, hormonal, and chemical response kicks in and your body is trying to compensate for the decrease in CO and O2
Progressive shock stage
Beginning of the end of organ failure from the cytokines.
GI>renal>cardiac>liver>neuro
Refractory stage
Irreversible stage of shock- should probably be talking to family
Neural response
pressoreceptors in aorta and carotid arteries activate vasomotor center of medulla
Hormonal reponse
increased catecholamines and ACTH.
RAAS and AHD hormone form pituitary
How does the SNS act when trying to compensate for shock?
It will try to vasoconstrict
- to increase HR and contractility
in order to maintain the BP and CO
Where does the body steal blood from or shunt from in order to compensate for shock?
How can you tell?
Steals from skin, kidneys, and GI tract
The skin is cool and clammy
Hypoactive bowels
Decrease UO
Why does acidosis occur in shock again?
Anaerobic metabolism = creating energy through combustion of carbs instead of o2
What can develop in response to the acidosis?
What stage of shock is this?
respiratory alkalosis in order to fix it
compensation
What happens to BP when it can no longer compensate in the progressive stage?
BP and Map decrease
- causing organs to suffer and not be perfused HOWEVER
- vasoconstriction will still try to occur and it makes it worse
What happens to mental status in the progressive stage
it further deteriorates as a result of decreased CPP occurring
What happens to the pulmonary system in progressive stage?
Lungs start to fail since alveoli collapse
Pulmonary edema occurs
Decreased pulmonary blood flow causes hypoxemia in the blood
CO2 levels increase
What starts to develop cardiac wise in the progressive stage
PAC
PVC
tachy/Brady (depending on which shock)
Sign of pulmonary edema
pink froth
What stage doe acute renal failure occur in for shcsok?
Typically the progressive stage due to the decrease in map below 70 which affects GFR
When will DIC probably develop in the shock stage?
Disseminated Intravascular Coagulation will occur probably in the progressive stage of shock
- if these form, do not move the patient
Refractory period of shock
No tretmetn is going to fix it at this point. Consider palliative/hospice care.
Bp stays low, renal and liver fail, anaerobic metabolism worsens , MODS becomes complete
Initial chart
HR
BP
RR
UO
Skin
Cap refill
HR below or equal to 100
Normal BP
Normal respiratory rate
Urine output greater than 30 ml/hr
Skin is cool, pink, dry
Capillary refill is normal
Compensation chart
HR
BP
RR
UO
Skin
Cap refill
HR above 100
BP normal or high
RR 20-30
UO- 20-30 ml/hr
Skin- cold, pale, drymoistr
Cap refill - slight delay
progressive chart
HR
BP
RR
UO
Skin
Cap refill
HR - above 120
BP - 70-90
RR- 30-40
UO - 5 to 20 ml/hr
Skin - cold pale moist
Cap refill - delay
Refractory chart
HR
BP
RR
UO
Skin
Cap refill
HR greater than 140
Bp is 50-60
RR greater than 40
UO none
SKin cold, mottled, cyanotic, dry
Cap refill is not noted
c
