Shock Flashcards
What is the definition of shock?
Shock is a syndrome characterised by decreased tissue perfusion and impaired cellular response
What are the 4 classifications of shock?
hypovolaemic
cardiogenic
distributive
obstructive
Hypovolaemic shock is?
loss of fluid from circulation
what is distributive shock?
diminished venous return due to arteriole and capillary dilation
What is obstructive shock?
physical obstruction impeding flow
What happens if shock is not treated?
MODS - multipule organ dysfunction
MOFS - multipule organ failure
What are some causes of hypovolaemic shock?
Remembering that Hypovolaemic shock is loss of fluid not only blood
Haemorrhage
Dehydration
Plasma loss
What are some examples of haemorrhage?
ruptured organs
fractures
surgery
postpartum haemorrhage
What are some examples of dehydration?
vomiting diarrhoea NGT suctioning diuresis diaphoresis
What are some examples of plasma loss?
burns
ascites
peritonitis
oedema
How is the severity of hypovolaemic shock classified?
the percentage volume lost rate of volume lost persons age presence of other preexisting problems?
what are the clinical signs of hypovolaemic shock?
resp rate increase
HR increase
BP decrease
what are the 2 types of hypovolaemic shock?
relative and absolute
explain relative hypovolaemic shock?
Give an example
Fluid volume moves out of the vascular space into the extravascular space eg. third spacing or increased capillary permeability like in burns
explain absolute hypovolaemic shock?
Give an example
when fluid is lost through haemorrhage or gastrointestinal loss
(vomiting diarrhoea, fistula drainage, diabetes insipidus or diureses
explain the course of hypovolaemic shock
decreased circulatory volume - decrease venous return - decreased stroke volume - decreased cellular oxygen supply - decreased tissue perfusion
how do we diagnose hypovolaemic shock?
clinical picture/history
blood test
urine studies
chest x-ray
what is the emergency care for hypovolaemic shock?
ABC - airway breathing circulation assess for haemorrhage assess for manifestations of shock seek immediate medical help O2 and IV fluid ASAP Use of explanation and touch to reduce anxiety
what is treatment for hypovolaemic shock?
if there is bleeding apply direct pressure
oxygen supplementation
fluid resuscitation
drug therapy
what is required for fluid replacement therapy with hypovolaemic shock?
establish vascular access with at east 2 large
central line insertion
fluid resuscitation
what fluids do we use for hypovolaemic shock?
crystalloids - isotonic (normal saline, hartmans) Hypertonic (1.8, 3, 5% saline)
colloids - Albumin (5 or 25%)
blood products -packed red blood cells, fresh frozen plasma, platelets
what are the complications of hypovolaemic shock?
cardiac arrest disseminated intravascular coagulation (DIC) acute respiratory distress centre (ARDS) multiple organ failure (MOFS) death
explain seagulling affect
happens when the heart rate dot is on top of the seagull
your seagull is being shat on
high HR and low BP
what is cardiogenic shock?
caused when the heart pump fails
there is a decreased myocardial contractility which results in decreased cardiac output and impaired tissue perfusion
who is at risk of cardiogenic shock?
Patients who currently have or have experienced:
Diseased coronary arteries Acute MI Greater than 40% damage to L) ventricle Cardiomyopathy Myocarditis Valvular disease Cardiac Tamponade (pressure on the heart itself)
What are the signs and symptoms of cardiogenic shock?
- Tachycardia, hypotension
- Narrow pulse pressure
- Distended neck veins
- Arrhythmias
- Dyspnoea
- Cool, pale, clammy skin
- Oliguria
- Decreased mental state, agitation, anxiety
what is the goal of treatment and treatment options of cardiogenic shock?
Goal is to correct reversible problems, protect the myocardium, and improve tissue perfusion
Oxygen therapy
Vasodilators
Antiarrhythmic agents
Cardioversion
name some vasodilators
Glyceryl triitrate - GTN
- Dilates arterioles and veins of smooth muscle
- Reduces peripheral resistance, cardiac output, and pulmonary wedge pressure
- Decreases the oxygen requirements of heart
- Decreases pulmonary congestion
Frusemide
(given to reduce preload)
What are the 3 types of distributive shock?
Septic
Anaphylactic
Neurogenic
distributive shock
Septic shock is caused by?
Caused by a systemic inflammatory response syndrome (SIRS) as a result from an infection process
- Often caused by gram-negative bacteria which release endotoxins into the blood stream.
- Endotoxins cause the release of cytokines
distributive shock
Septic shock predisposing factors are?
- underlying chronic disease
- alteration in host defenses
- long hospitalisation
- use of invasive catheters and devices
- trauma and surgical wounds
Distributive shock
Septic shock EARLY signs and symptoms are?
Early (Warm)
– Fever(>38oC)
– BP: normal to hypotensive
– Pulse: increased (tachycardia), thready
– Respirations: rapid (tachypnoea) and deep
– Skin: warm, flushed
– MentalState: alert, orientated, anxious
– Urine: normal
– Other: weakness; nausea, vomiting, diarrhoea
Distributive shock
Septic shock PROGRESSIVE signs and symptoms are?
Progressive (cold) – severe hypotension – reduced perfusion – pulse: tachycardia, arrhythmias – respirations: rapid, shallow, dyspnoea – skin: cool, pale, oedematous – mental state: lethargy to comatose – oliguria/anuria – Other: normal to decreased body temperature, acidosis, progressing to multi-organ failure
Distributive shock
Septic shock treatments and preventions include?
– prevent through proper hand washing and good aseptic technique
– need to restore vascular tone through vasopressor therapy
– fluid resuscitation
– antibiotic therapy
Distributive shock
Neurogenic shock is caused by?
– injury or disease to the upper spinal cord
– spinal anaesthaesia
– nervous system damage
– vasomotor depression (e.g. drugs, severe pain, hypoglycaemia).
Distributive shock
Neurogenic shock signs and symptoms are?
- Spinal cord injury – paralysis
- Hypotension
- Bradycardia
- Loss of temperature control – poikilothermia
Distributive shock
Neurogenic shock treatments
- Vasopressor therapy
* Spinal cord decompression and realignment
Distributive shock
Anaphylactic shock is?
provide examples
• Severe allergic reaction due to antigen- antibody response
– Medication administration
– Contrast media
– Blood transfusions
– Ingestion
– Bites/stings
• Results in vasodilatation, increased capillary
permeability and smooth muscle contraction
Distributive shock
Anaphylactic shock signs and symptoms are?
- Mental state: restless, anxious, lethargic to comatose
- BP: hypotension
- Pulse: increased, arrhythmias
- Respirations: dyspnoea, stridor, wheezes, laryngospasm, bronchospasm, pulmonary oedema
- Skin: warm, oedematous (lips, eyelids, tongue, hands, feet, genitals)
- Other: abdominal cramps, vomiting, diarrhoea
Distributive shock
Anaphylactic shock treatments are?
- Stop drug or substance exposure
- 100% oxygen & IV therapy ASAP
- Maintain airway
- Give adrenaline
- Secondary management: antihistamine, corticosteroid, adrenaline infusion, treat acidosis as required, bronchodilators
What is obstructive shock?
Develops when a physical obstruction to blood flow resulting in a decreased cardiac output
What are some causes of obstructive shock?
Pulmonary embolism
cardiac tamponade
aortic stenosis
What are the 3 stages of shock?
Compensatory stage
Progressive stage
Irreversible stage
What signs and symptoms are in the compensatory stage?
BP: normal to slightly decreased
Pulse: slightly increased from baseline
Respirations: normal (baseline)
Skin: cool, peripherally pale, moist (mild vasoconstriction)
Mental state: alert and orientated
Urine Output: slightly decreased
Other: thirst, decreased capillary refill time
in the compensatory stage what will happen to the body systems?
- as shock progresses, the prolonged reduced cardiac output initiates compensatory mechanisms involving the nervous and endocrine systems.
- Symptoms become more apparent.
- Shock may still be reversed if appropriate interventions are initiated.
Explain the Progressive stage
- If the cause of shock is not corrected, or if compensatory mechanisms continue without reversing the shock, further patient deterioration occurs.
- Eventually compensatory mechanisms begin to fail leading to a vicious cycle that can lead to death.
What are the signs and symptoms of the progressive stage?
- agitated, confused, progressive decrease in activity
- progressive thirst
- pulse > 120
- BP decreased
- tachypnoea (30 - 40), crackles
- urine output 5 - 15 mls/hr
- definite delay in capillary refilling
- cold and moist skin
what happens in the irreversible stage?
- Prolonged inadequate tissue perfusion that is unresponsive to therapy which causes multiple organ failure and death.
- All compensatory mechanisms have failed.
- Treatment is mostly unsuccessful.
What are the signs and symptoms of the irreversible stage?
- confused, lethargic, unconscious
- dilated pupils may be evident
- pulse >140 weak and often irregular
- severe hypotension (35)
- negligible urine output (anuria)
- no capillary refilling observed
- cold, mottled and cyanotic skin
- Other: loss of reflexes, decreased or absent peripheral pulses
What are some nursing interventions to assess shock?
Nursing assessment – Neurological status – Cardiovascular status – Respiratory status – Renal status – Body temperature – Personal hygiene – Emotional support
What is PAWP and what does it do?
Pulmonary artery wedge pressure
pressure from the right side of the heart looks through the pulmonary capillary bed to the pressure in the left side of the heart
Used to assess the function of the left side of the heart
What needs to happen for the body to function normaly?`
adequate blood volume
sufficient oxygen-saturated haemoglobin circulating
adequate pump
Arterioles need to have enough tone
enough tone in the veins and functional valves
Major vessels must be free of any kind of major obstruction
What happens in cellular death?
Cells deprived of oxygen switch to anaerobic metabolism in order to function
this makes blood more acidic damaging blood vessel walls
How does shock progress?
Cause - inadequate tissue perfusion - impaired cellular metabolism - SHOCK!
