Shock Flashcards by Elizabeth Gausin

Stages of shock

Initial
Compensatory
Progressive
Refractory

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What should we watch when it comes to shock?

Watching for vitals , checking for trends and progression
Knowing that it can go back ward n forward

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Initial stage

No visible changes
Changes occurring at cellular level

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Compensatory

Body compensating to restore tissue perfusion and oxygenation

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Refractory

Total body failure

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Shock definition

Inadequate tissue perfusion
Widespread inadequate oxygen supply to provide nutrients for cellular function

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Class 1 shock of hypovolemia is in the initial stage of shock.. what is the blood loss up to ?

15%

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Initial stage clinical finding

Subtle or no clinical manifestations
Hypoxia
( production of pyruvic and lactic acid)

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Compensatory clinical findings

Confusion
Hypotension
Tachy cardia
Tachypnea
Cool clam
Urinary output decrease
Respiratory alkalosis

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For each unit of blood loss is a

3% drop of the hematocrit

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Skin in a septic shock pt

Warm and flushed

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Skin in a neurogenic pt

Normothermic

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In the compensatory stage there is a clas 2 shock due to hypovolemia.. what is the blood loss

15-30%

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Why is urine output decreased in compensatory

Due to compensatory .. the kidneys might want to hang on to what it can

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Progressive clinical findings

Lethargic and confused
Severe hypotension < 90/60
Tachycardic>150
Tachypneic ,shallow , crackles
Pao2<80mmhg
Paco2 >45mmhg
Mottling,petechia, caprefill >4
Anuria
Metabolic acidosis

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GCS at the progressive stage

9-12

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Pao2 at progressive

<80

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Paco2 progressive

> 45 mmHg

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Classic 3 shock hypovolemic in the progressive stage

Blood loss 30-40%

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Intake goal in critical care

1/2/kg/hr

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What is contraindicated in a shock pt

Trendelenburg position .. increases icp

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What is important for hypovolemic pt

Get o2
Then fluids

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Refractory clinical finding

Coma
Hypotension-need vasoconstrictors
Dysrhythmias- (possible MI)
Pulmonary edema , bronchconstriction (respfailure)
Hepatic failure
Renal failure
Tissue ischemia, necrosis
Anasarca
Profound metabolic acidosis

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What can we do to treat hypotension in progressive stage?

Raising the legs, compressor, vasopressor

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GCS for pt in refractory stage

8 or less

Dysrhythmias in refractory

Asystole Check pulse PVC then vtach

Bronchoconstriction

Anaphylactic reaction , obstructive, PE

how would you know hepatic and renal failure

Jaundice, decrease urinary output , BUN, creatine, ast, alt

What happens when a person is on epinephrine for too long

Necrosis

What can vasoconstrictors cause

Lack of cap refill

Pump issue in a shock

Cardiogenic

Volume issue ins hock

Hypovolemic

Pipe issue in shock

Distributive Obstructive

Absolute hypovolemia shock

Hemorrhage, bleeding from trauma, surgery, GI bleed, ruptured aortic aneurysm & non hemorrhagic Vomiting , diarrhea, excessive diuresis , DI

Relative hypovolemic shock

Fluid shift that stays internal Extravascular or intracavity Such as acites , burn injury, peritonitis , bowel obstruction

Cues for hypovolemic a shock

Confused, vascular resistance increased, hypotensive, oliguria ,normothermic

How much fluid resuscitate for hypovolemia

Every 1 unit of blood loss 3 units of fluid for

How do we position a hypovolemic pt

Lay them flat ..elevate the legs

S/s of cardiogenic shock

JVD, pulmonary edema( fluid clear ,bubbly,frothy ) , muffled heart sounds

What can an injury when the chest pressed against the steering wheel cause?

Cardiogenic shock Bruising or stamp mark

Treatment for cardiogenic shock

O2 Position of comfort Diuretics Lower bp Nasopresser , metropolol Watch I&O Minimize fluids Balloon pump & VAD

Distributive shock (pipes)

Anaphylactic Neurogenic Septic

What should we be careful when it comes to latex allergies

Be cautious what you insert like Foley catheters , gloves etc

Signs of MODS ( multiple organ dys system ) Multiple organ failure

BUN and creatine high with low urine output = kidney Higher we go up on Fio2 and paO2 goes down shows that the lungs are failing

At what stage is MODS considered?

Refractory

What can we use when a pt has bradycardia for neurogenic shock

Atropine(short term)

Obstructive shock causes

Pulmonary embolism Pericardial tamponade Hemopneumothorax Tension pneumothorax

What is tension pneumothorax caused by

High peep

Physical assessment or obstructive shock

Signs of organ perfusion

What does someone with pulmonary embolism present

Chest pain , dont hear anything abnormal in lungs or heart

What would we hear in pneumothorax

Decreased breath sounds on the side it is collapsed

What would you hear with hemopneumothorax

Wont hear anything on side it is ad or it will be decreased That’s why it is important to listen to all areas of the lungs

How to calculate pulse pressure

Systolic pressure - diastolic blood pressure

Normal pulse pressure

Normal 40-60 mmHg

Narrow pulse pressure

<40 mmHg Early indication of shock than drop in systolic BP

Widened pulse pressure

>80mmhg Septic pt

Sustained intracranial pressure

above 20 mmHg Widened pulse

Labs for obstructive shock

ABGs respiratory alkalosis to respiratory acidosis Lactic acid- severe o2 deprivation CBC - H&H, infection

When do we expand volume

Septic , hypovolemic, anaphylactic

How can we expand the volume

Crystaloids (NS , lactated ringers) Colloid ( albumin, RBC , )

Albumin

Volume expander Large protein that pulls volume from out to interstitial vascular space

What is important to note about products such as RBC , plasma, albumin when administering

Assess for anaphylactic reactions and over load

Why do you want to give diuretic with products such as albumin or RBC

To help regulate , we dont want to drown them

When administering RBCs to patient we want to keep in mind that RBCs do not clot … what intervention should we do in regards to this?

Replace clotting factors Cryo

Favorite vasopressor

Norepinephrine

Volume expansion

Septic , hemorrhagic , hypovolemic

Fluid responsiveness determined by

Vitals Cerebral, abdominal pressure Cap refill Skin temp Urine output

Vasopressor drugs

Norepi Antidiuretic Dopamine Phenylehrine

Vasodialator

Nitroglycerin Nitroprusside

Goal of vasodilator

Maintain or achieve MAP greater than 65 mmHg Decrease the after load

Stress ulcer prophylaxis

Pantoprazole

VTE prophylaxis

Heparin , ENOXAPARIN

Side effects of gluccocorticods

High blood sugar , trouble sleeping

How to assess weight

One sheet and no more than two pillows

When to start tpn

Within first 24 hours

Important to note about the vasopressor dopamine

It increases HR , hardens the heart - watch dosing and keep up with the trends of the HR

Phenylephrine vasopresser

Over the counter , constricter