Shock Flashcards
SHOCK (MCH is in shock)
is defined as a syndrome characterized by decreased tissue perfusion , resulting in cellular, metabolic and hemodynamic instability.
All shock results in ineffective tissue perfusion and acute circulatory failure
Shock is initiated by a Drop in MAP (mean arterial Pressure) - how to calculate MAP?
Leads to impaired tissue perfusion
MAP = SBP + 2(DBP)/3
how does shock start?
Shock begins with an inciting event:
focus of infection: abscess, UTI
Injury: gun shot wound, burn…
This event produces a systemic circulatory abnormality that may progress through several stages :
SVR - Systemic Vascular Resistance - SVR is the same as afterload
(sever the afterload)
The resistance that the left ventricle must pump against to eject bld. (Afterload)
Afterload (after the force) (same as SVR)
Force Left ventricle pumps against to eject blood into body. (SVR)
Preload- when does it start?
Filling pressure of left ventricle Amount of blood in left ventricle at the end of diastole
Left ventricular end diastolic pressure (pre - end in the lungs)
= Preload = pressure in the lungs or in the right side of the heart
Chronotrope med (rate chron news)
Affects heart RATE
Inotrope med (I NO I contract)
Affects contractility of heart
Stroke Volume- normal amount- (stroke it for 60 min)
Amt of blood ejected from ventricle with each contraction (60—130ml)
Sympathetic Receptors: (the alpha is not sympathetic)
alpha, beta 1 and beta 2
Alpha
(the alpha is smooth and constricts)
(vascular smooth muscle) Vasoconstriction
beta 1
(beta take care of my one heart)
(1 heart) (Cardiac tissue)
beta 2 (2 lungs) - and drug ex? YOU know this
(2 lungs)
Relaxes vascular smooth muscle, vasodilation of lung tissue = bronchodilators (albuterol)
PCWP or PAWP: (Swanz Ganz Catheter)
(P for preload)
Pulmonary cap wedge pressure = Left ventricular end diastolic pressure
Same as preload pressure in the lungs or in the right side of the heart
normal 5-12 mm Hg
SVO2/ScvO2 measurements - used for what? (just think O2)
Used to monitor adequacy of tissue oxygenation
CVP and PA catheters can have SVO2/ScvO2 sensors
MAP:
Mean Arterial Pressure
Normal 70-90.
MAP= SBP + 2(DBP) /3
CO Cardiac Output - equation
SV X HR = CO
60-130ml X HR
Example: 80 bpm X 100ml = 8L/min
Response to Shock - first a drop in what?
Initially there is a drop in the MAP
Shock may develop rapidly or gradually depending on the severity of the insult
Compensatory Stage of Shock (major organs)
Compensatory measures kick in to maintain perfusion to vital organs
Brain
Heart
lungs
Compensatory Stage of Shock - which nervous system?
Inhibition of Baroreceptor activity:
Stretch receptors in aorta/carotid sinus respond to ↓ MAP and stimulates the vasomotor center of medulla.
This causes activation of the Sympathetic Nervous System
Sympathetic Nervous System stimulation - cause release of what? and stimulates what?
(epi is sympathetic)
Causes release of the catecholamines:
Epinepherine
Norephinepherine
These stimulate
alpha-adrenergic
beta-adrenergic receptors.
Alpha-adrenergic receptors (alpha constricts bc he needs more blood in his brain and heart)
Cause selective peripheral vasoconstriction
↑ Blood flow to the brain and heart
↓ Blood flow to the kidneys, GI, muscles and skin
Beta-adrenergic receptors - Beta 1
(beta get your 1 HR up)
Beta 1 = ↑ HR, ↑ contractility
Increases CO = ↑ BP
ADH (Antidiuretic Hormone)
ADH is released from the pituitary
ADH ↑’s water resorption by the kidneys
This increases fluid volume and Blood pressure
PROGRESSIVE STAGE of SHOCK
MAP continues to fall
Compensatory mechanisms start to fail
Aggressive intervention is necessary to save the patient
Every system in the body is effected
Clinical manifestations of compensatory shock - most reliable signs in compensatory
may be subtle and easy to overlook.
Most reliable sign in compensatory stage:
Restlessness, irritability, apprehension
PROGRESSIVE SHOCK - CNS - behaviors
All body systems are affected:
CNS:
Cerebral hypo-perfusion:
anxiety
apprehension
restless.
PROGRESSIVE SHOCK - Cardiovascular - and what about the pancreas?
(progressive MnD F uck)
Cardiovascular :
Release of MDF: myocardial depressant factor released from the pancreas as it become ischemic
PROGRESSIVE SHOCK - Pulmonary
(progressively arfy lungs)
Increased pulmonary capillary membrane permeability: leaky lungs
Microemboli
ARDS
ARF
Clinical Manifestations in Irreversible Shock - types of breathing
(irreversible agony)
All body systems fail
Pt unconscious
Brady to agonal rhythm
Slow, shallow, irreg Resp (cheyne-stokes)
For adequate tissue perfusion, you need 3 things
Circulating blood volume ( BP/ MAP)
Well functioning cardiac pump
Well regulated vascular tone
shock type - VOLUME PROBLEM
Hypovolemic Shock
Loss of intravascular volume.
Normally have 4 – 5 liters of blood circulating
shock type - pump problem
Cardiogenic and Obstructive Shock-
Impaired ability of the heart to pump
shock type - Distributive - what 3 types of shock?
(distribute the san - itation)
Vasodilation & Maldistribution of circulating bld volume.
Septic
Anaphylactic
Neurogenic
CARDINAL FINDINGS IN ALL SHOCKS - (take the cardinals SHOAM)
HYPOTENSION
OLIGURIA: due to blood shunting or intravavascular blood loss
ABNORMAL MENTAL STATUS: agitation, progresses to confusion and delirium and ends in obtundation and coma
Metabolic acidosis: due to anaerobic metabolism and inability of the liver as well as the kidneys to clear lactate.
Skin: for some cool clammy skin due to vasoconstriction. Pt is early distributive shock may have flushed hyperemic skin.
what are the 2 types of Hypovolemic shock?
Hemorrhage induced
Fluid loss induced
HYPOVOLEMIC SHOCK -15% total blood volume
Spontaneous compensation: 15 % of total blood volume ( around 750 ML)
ABSOLUTE HYPOVOLEMIC SHOCK:
MANAGEMENT- what position for pt?
(absolute trendelenberg)
ABCs
Restore fluid volume:
NS, LR, Plasma
Blood transfusion:
Whole blood/PRBCs, consider FFP if multiple transfusions or high loss, expect hg to go up by 1 for every unit PRBC
Monitor VS, intravascular volume, I&O
Correct the underlying cause
Trendelenburg or modified Trendelenburg is controversial.
SHOCK CLASSIFICATION: WHEN THE PUMP FAILS - mortality rate
CARDIOGENIC SHOCK: occurs when the heart’s diastolic or systolic dysfunction results in reduced cardiac output, leading to decreased tissue perfusion.
It carries a high mortality rate ranging from 50-80%
Mortality rate is 72 – 84%. ( due to multiple MI)
CARDIOGENIC SHOCK - 4 categories (cardio came)
CARDIOMYOPATHY
ARRYTHMIAS
MECHANICAL ABNORMALITIES
EXTRA-CARDIAC ABNORMALITIES
CARDIOGENIC SHOCK:MANAGEMENT
ABCs
Monitor cardiac status for arrhythmias and ischemia
CARDIOGENIC SHOCK:MANAGEMENT - what meds? (don’t want the heart to work too hard)
Vasodilators: to decreased preload and afterload
Antidysrhythmic
NEUROGENIC SHOCK - what vertebre?
A hemodynamic consequence of spinal cord injury or disease at or above the level of T5.
NEUROGENIC SHOCK
DEFINITION
Neurogenic shock is very rare
Massive suppression of sympathetic tone
Leads to extreme vasodilation with ↓ BP
ANAPHYLACTIC SHOCK - causes - what is the main thing that is happening?
Is caused by antibody-antigen hypersensitivity reaction to a substance(drug, vaccine, food, insect bite, venom) resulting excessive histamine release.
ANAPHYLACTIC SHOCK - things that cause it - you know this
Common antigens:
Food
Diagnostic agents
Biologic agents: blood, insulin
Environmental: pollen, molds
Drugs: antibiotics….
Venom: bees, snakes
ANAPHYLACTIC SHOCK
It can lead to respiratory distress due to laryngeal edema, severe bronchospasm and circulatory failure
Onset of symptoms can be very sudden, chest pain, angioedema , flushed skin, pruritis, wheezing, stridor.
Quick medical intervention is warranted
ANAPHYLACTIC SHOCK: ASSESSMENT - when do symptoms start?
Symptoms usually start immediately to 30 minutes
TX of Anaphylaxis
Immediately remove the offending agent: stop blood…..
Airway… Airway…Airway…. ? INTUBATION
SEPTIC SHOCK - what mediators are released?
(septic is necrotic)
It is an exaggerated immune/inflammatory body response to an invading microorganism leading to the release of chemical mediators such as : TNF and ILS
SEPTIC SHOCK - who is susceptable? (ages) - and the big disease
Less than 1 or older 68
DM
AIDS
Substance abuse
Malignancies/ malnutrition
Wounds/ trauma/ immunosuppression
SEPTIC SHOCK: S&SX - skin?
(septic tank is pink)
Fever
Skin pink , warm, flushed, increased temp
SHOCK : TREATMENT MODALITIES
Early recognition is key ( nursing assessment)
The Basics: ABCs.
Identify the underlying cause and treat while stabilizing patient:
Cardiogenic: revascularization through PCI or thrombolytics or surgery. Relieve and manage obstruction.
Hypovolemic: stop the hemorrhage
Septic: identify the microorganism and start antibiotics within the first hour.
Neurogenic: stabilize the spine
SHOCK : TREATMENT MODALITIES
Fluid resuscitation: volume expansion is corner stone of the therapy ( especially in hypovolemic, septic and anaphylactic shocks).
Drugs therapy
Sympathomimetic drug :
Alpha and Beta adrenergic effect.
Dopamine
Dobutamine
Norepinephrine (Levophed) - TEST question - Norepinephrine - what to do first? or it will cause what?
Sympathomimetic/ Vasopressor
Must have enough fluid on board or will cause tissue ischemia
DOPAMINE - Beta 1 does what? (beta increase contractility)
Sympathomimetic / Inotropic
Beta 1: Inotropic = ↑ cardiac contractility,
↑ HR = Chronotrope
OTHER VASOPRESSORS
Neo-Synephrine (Phenylephrine)
Used in Neurogenic shock
Vasopressin
Used when other vaso-constrictors not enough
Epinephrine (Adrenalin)
Anaphylactic Shock
Cardiogenic Shock
NIPRIDE AND NITROGLYCERIN - esp used when? (nifty heart)
Used for pts with excessive vasoconstriction and poor tissue perfusion
Especially used in cardiogenic shock.
MORPHINE SULFATE- what does it dilate? and what does it decrease?
(Morphine Sulfate) Narcotic, potent venous dilator that decreases preload, and some arterial dilation to decrease afterload.
Hydrocortisone Solu-Cortef - used for what types of shock?
(hydrocortisone works, my ass)
USED IN:
Anaphylactic Shock if hypotension persists
Septic Shock not responding to fluids and vasopressors
normal MAP range
Normal MAP is 70 to 90 mm Hg
stages of shock (shock needs CPR)
Compensatory stage
Progressive stage
Refractory stage
Compensatory stage
AKA preshock or warm shock
Progressive stage
the compensatory mechanisms are overwhelmed
Refractory stage
irreversible organ damage then death
beta - Chronotropic drug - EXAMPLE
(chron atop my heart)
Chronotropic = ↑ HR (Atropine)
beta - Inotropic drug - and examples (D inotropic increases contractility)
Inotropic = ↑ contractility (Dopamine, dobutamine)
SVO2 (Venous oxygen saturation)
SVO2 = mixed venous oxygen saturation of hemoglobin from PA line sensor
ScvO2 (think CV)
ScvO2 = Central venous oxygen saturation from CVP sensor
Mixed arterial and venous blood -
Normal percentage
60 – 80%
SVO2/ScvO2 = high levels Can indicate (sv02 door)***
hypothermia, sepsis (↓ ability of tissue to use O2)
SVO2/ScvO2 = = Low levels can indicate (swav is low when his heme and CO are low, but high with O2)***
↓ hgb, ↑ O2 demand, ↓ CO (cardiac output)
cardiac output - Olympic athletes - how many L a minute?
40 L/minute
Normally have 4 – 5 Liters blood in body
THREE STAGES OF SHOCK - Compensatory
(compensate for fight or flight)
THREE STAGES OF SHOCK:
Compensatory =Fight or flight response
THREE STAGES OF SHOCK = Progressive
Compensatory mechanisms fail. Aggressive management is necessary
Irreversible or Refractory
Aggressive management has failed. Death becomes imminent.
beta receptors (b for bronchodilation)
Beta 2 = Bronchodilation. ↑ breathing
shock (K+, acid?)
(shocked by high levels)
Hypoxia, acidosis, hyperkalemia, tissue ischemia
compensatory stages of shock - BP if pt is supine? HR?
If pt supine, Bp may normal or slightly decreased.
Heart rate moderately increased.
Orthostatic hypotension
Respiration increase in depth and rate
compensatory stages of shock - urine? pt may complain of what?
Urine output decreased and may C/O of thirst.
progressive shock - sympathetic nervous system
Vasodilation
Cardiac , respiratory and thermal regulator fail
progressive shock - cardiovascular
what fails?
Myocardial hypo-perfusion
Ventricular failure ensues
Hypotension
progressive shock - Hematologic
(just one thing - he’s a progressive dic)
DIC
progressive shock - GI
(progessive sepsis)
hypo-perfused gut and translocation of bacteria causing sepsis.
progressive shock - renal
(progressively necrotic kidneys)
ATN - Acute tubular necrosis
Other : acidosis
irreversible shock - urine and skin
(irrevesibly clammy)
Oliguria, anuria
Skin cold and clammy
↓ body temp
Cyanosis
Death
Septic
(end the septic)
Endotoxins
Anaphylactic
antibody-antigen reaction
Neurogenic
(sympathetic neuro)
loss of sympathetic vaso-tone
findings in all shock - urine
OLIGURIA: due to blood shunting or intravavascular blood loss
findings in all shock - neurologic
ABNORMAL MENTAL STATUS: agitation, progresses to confusion and delirium and ends in obtundation and coma
findings in all shock - acidosis?
Metabolic acidosis: due to anaerobic metabolism and inability of the liver as well as the kidneys to clear lactate.
findings in all shock - skin
but 1 exception
Skin: for some cool clammy skin due to vasoconstriction. Pt is early distributive shock may have flushed hyperemic skin.
hypovolemic shock - 15-30% of total blood loss - what is activated?
15-30% of total blood loss: SNS activation
hypovolemic shock - Over 30% of total blood loss
Over 30% of total blood loss: prompt medication intervention is needed for survival
when pump fails, treatment
TX: Admit CCU, Hemodynamic monitoring, support heart function with meds, IABP….
cardiogenic shock - CARDIOMYOPATHY types - 2 of them
CARDIOMYOPATHY: AMI, DILATED CARDIOMYOPATHIES
cardiogenic shock - ARRYTHMIAS (and the cute one)
A.FIB/ FLUTTER, BRADY, ARRYTHMIAS, COMPLETE HEART BLOCK: ALL REDUCE CO. V.FIB: ABOLISHES CO
MECHANICAL
cardiogenic shock - MECHANICAL ABNORMALITIES:
VALVULAR DEFECTS, SEPTAL DEFECTS/RUPTURE OF PAPILARY MUSCLES.
cardiogenic shock = EXTRA-CARDIAC ABNORMALITIES (OBSTRUCTION)
PE, TENSION PNEUMO, TAMPONADE, SEVERE PHTN.
cardiogenic shock - meds (doubt it’s cardio)
Administer sympathomimetics: must have enough fluids on board:
Inotrope + mild vasodilation
Decreases SVR
doboutamine
cardiogenic shock - what procedures?
(Angie in shock)
Angioplasty, CABG, thrombolytics
IABP
VAD (ventricular assist device)
neurogenic shock - what happens?
(neuro pools)
The injury results in massive vasodilation compensation due to the loss of SNS vasoconstrictive tone leading to blood pooling in the vessels.
hallmark of neurgenic shock? (just 2 things)
The hall mark of this shock is Hypotension and Bradycardia (all other types have tachycardia)
neurogenic shock -For hypovolemia: treat with fluids and vasopressors: - which meds?
(my neuro neo needs dopamine)
For hypovolemia: treat with fluids and vasopressors:
Neosynephrine or dopamine (high doses)
anaphalytic shock - what does histamine do?
(his dilates)
Histamine results in massive vasodilation and increased capillary permeability which in turn results in leaking of fluids to the interstitial space.
anaphalytic shock - symptoms
OTHER MANIFESTATIONS INCLUDE:
BRONCHO SPASMS & CONSTRICTION
LARYNGEAL EDEMA
EXCESSIVE MUCUS SECRETION
anaphalytic shock - skin, respiratory - what type of breathing, neuro
Cutaneous: pruritis, erythema, urticaria (welts), angioedema
Respiratory: lump in throat, dysphasia, wheezing, stridor
Neuro: restlessness, anxiety
anaphalytic shock - GI (you guessed right the first time)
GI: N/V/D, abd cramping and pain
septic shock - hallmark - just vasodilation - and what type of bacteria?
Hall mark: massive vasodilation and maldistribution of blood flow to the tissue.
Gram negative bacteria is responsible for half of the septic shock cases.
Carries a high mortality rate: 24-41% of patients die within one month of the onset of septic shock
septic shock - pulmonary? (v/q in the septic tank)
Pulmonary vasoconstriction: V/Q mismatch: hypoxemia.
Treatment:
Indentify the infection: blood/urine/wound culture
Initiate ABTX
Surgical intervention: I&D
Temp control
Aggressive fluid resuscitation
shock treatment - before you give Norepinephrine, do what?
make sure you have adequate circulating volume before administration.
Norepinephrine - alpha - test question- what do you need to do before you give it?
Alpha (potent vasoconstrictor)
Beta Adrenergic
Inotropic (muscles)
Dilates Coronary arteries
Norepinephrine - test question - how much?
2 to 20 mcg/min IV infusion
dopamine - Alpha does what to the body?
(the alpha constricts me)
Alpha: peripheral vasoconstriction
dopamine - small doses can cause
(dopamine has small kidneys)
Small doses (1 – 4 mcg/kg) cause ↑ renal perfusion
dopamine - small, moderate, and high doses?
Small doses (1 – 4 mcg/kg) cause ↑ renal perfusion
Moderate doses (5 - 10mcg/kg) causes heart squeeze (↑ heart contractility) High doses (10 – 20mcg/kg) causes total body squeeze (peripheral vaso-constriction)
dopamine - high doses do what? (you know this)
High doses (10 – 20mcg/kg) causes total body squeeze (peripheral vaso-constriction)
nitroglycerin - goal of MAP
Goal to maintain MAP 70- 80 mmhg (monitor closely so that IV fluid can be increased or medication decreased.
Nipride - how to store it
Nipride:
Administer only with D5W+ protect from light (foil wrap)
Nipride - warning
(pride the cyanide)
Thiocyanate toxicity and cyanide poisoning if used more than 72 hrs
Nipride - adminster how?
(pride can’t do PVC)
NTG IV:
Must administer with non-PVC tubing and glass bottle to maintain potency.
Nipride - monitor for what after you give it?
(pride is tachy)
Observe for reflex tachycardia.
cardiogenic shock - when can you use Dobutamine? (doubt you can use with severe htn)
Used if there is no profound hypotension - systolic should be above 90
anaphalytic shock - GU
(ana is incontinent)
GU: incontinence
anaphalytic shock - heart? (same)
CV: hypotension, tachycardia
hypovolemic shock - Hemorrhage induced
causes include blunt or penetrating trauma , upper and lower GI bleed, fractures
hypovolemic shock - Fluid loss induced
causes include: diarrhea, vomiting, heat stroke, burns,, and third spacing ( relative hypovolemic shock)
PCWP or PAWP: (Swanz Ganz Catheter) - helps determine
lung from cardiac issues
arterial (art) line
most accurate way to measure bp
compensatory stage - RAS
decreased perfusion to kidneys - renin released from kidneys-
angiotensinogen from liver converted to angotensin I by renin
angotensin I joins with ACE from lungs to form angotensin II
angotensin II causes adrenal cortex to release aldosterone -
pituatary releases ADH
absolute shock from
(absolute hemmorage)
hemmorages
hypovolemic shock
loss of fluid
relative shock (third relative)
burns, third spacing, massive vasodilation
sepsis - give antibotics how quickly?
within the first hour
norephenephrine is what type of drug - think veins
vasopressor
dopamine is what type of drug?
inotropic (hr goes up w/ dopamine)
dopamine used for what type of shock?
cardiogenic
HR goes up for all shocks except
neurogenic
pulse pressure for all shocks?
down
bp for all shocks?
down
tx of anaphalyxis - Epinephrine
Epinephrine 1:1000 → 0.3 – 0.5mg SQ/IM every 5 – 10 min… then 1 – 4 mcg/min IV of 1:10,000 solution for shock. (can also be given endotracheal)
tx of anaphalyxis - fluids
Fluids (NS, LR)
tx of anaphalyxis - Diphenhydramine - what does it do?
Diphenhydramine (H1 blocker) 25 -50mg PO/IM/IV up to 100 mg
tx of anaphalyxis - Pepcid
Pepcid (H2 Blocker) 20mg IVPB (esp w/ Urticaria)
tx of anaphalyxis - Solumedrol
Solumedrol 40 – 250mg IVPB: reduces capillary permeability and chemical mediators
Albuterol nebulizer tx
alpha med - ex. (Neo is an alpha)
Neosynephrine
neurogenic shock - what meds for bradycardia?
Bradycardia usually present: Tx symptomatically :Atropine
Hypoxemia : chest wall paralysis : may need mechanical vent.
neurogenic shock - what about blood pooling? meds?
Prevent DVT: from pooling of Blood: SCD, anticoagulation
dopamine doses - small
(1 – 4 mcg/kg)
dopamine doses - moderate
(5 – 10 mcg/kg)
dopamine doses - high
(10 – 20mcwg/kg)
when would skin be flushed hyperemic? Only one time
Pt in early distributive shock - so SAN
V/Q mismatch - which type of shock?
(glen is not septic)
septic shock
dobutamine - what type of drug?
doubt I NO it
dopamine - type of drug
dope, I NO
neurogenic shock - HR
(the neurosurgeon doesn’t stress)
decreased - think PNS only working
atropine for which shock?
neurogenic
complaining of thirst? which stage of shock
compensatory
what stage of shock for ARDS and ARF?
progressive
trendeleberg for what type of shock?
hypovolemic
what drug class do you need enough fluid before administering?
sympathomemetics (ie norepinephrine)
flushed warm skin - what type of shock?
(the septic tank is warm)
septic shock
what stage is SNS activated?
compensatory
