Shock Flashcards
What is shock?
Complex circulatory dysfunction—>insufficient O2 and nutrient delivery to satisfy tissue requirements
Name the 2 classifications of Shock
- Compensated (normal b/p & decreased flow to non-essential organs)
- Uncompensated (decreased blood flow to all organs)
Name the 2 subtypes of Uncompensated Shock
- Reversible
2. Irreversible
With Compensated Shock, which 3 organs get preferential perfusion?
- Heart
- Brain
- Adrenals
What happens when Compensation is used up?
Anaerobic Metabolism–>Increased Glucose Metabolism–>Metabolic Acidosis & Cellular Dysfunction–>Release of Chemical Mediators–>Further Decreased Tissue Perfusion–>Capillary Leak–>Sluggish Blood Flow–>DIC–>Death
Capillary leak is seen especially w/what type of shock?
Septic Shock
Recite the shock pathway starting with Inadequate tissue perfusion to 1 or more organs.
Inadequate tissue perfusion to 1 or more organs–>Decreased O2 & Nutrients–>Inadequate Delivery to meet Metabolic needs of tissues (lactic acid met.& dec. pH)–>Cellular dysfunction–>Possible cellular death
What is the formula for CO?
CO = HR x SV
SV is the volume of blood ejected in _____ ______.
Heart Beat (from Ventricle)
CO is the amount of blood ejected in each _______.
Minute
What is the only way infants can effect CO?
By altering HR. They can not change SV (like an adult can).
What can be the earliest sign of shock?
Altered HR
What are the factors that negatively affect CO?
Decreased Preload
Increased Afterload (Increased SVR)
Decreased Myocardial Contractility (less blood w/each beat)
Electrolyte, Mineral or Energy Imbalances
Name the 3 types of shock
- Hypovolemic
- Cardiogenic
- Septic
What is the most prevalent type of shock in NICU?
Hypovolemic
What does Hypovolemic shock result from?
Low circulating Blood Volume
When does Cardiogenic shock happen?
When the Heart Muscle functions poorly
True/False: Septic shock includes parts of Hypovolemic and Cardiogenic Shock?
True.
Name the 4 causes of Hypovolemic Shock
- Acute blood loss during Intrapartum Period.
- Postnatal Hemorrhage
- Obstructive (Pneumopericardium, etc)
- Other non-hemorragic causes (cord accidents, dehydration, capillary leak)
What is the estimated blood loss in Compensated Hypovolemic Shock?
How much Replacement volume would you give?
~25%
20 mL/kg
What is the estimated blood loss in Uncompensated, Reversible Hypovolemic Shock?
How much Replacement volume would you give?
~25-40%
20-30 mL/kg
What is the estimated blood loss in Uncompensated, Irreversible Hypovolemic Shock?
How much Replacement volume would you give?
> 40%
> 30 mL/kg
Name causes of Cardiogenic shock
Intrapartum/Postpartum Asphyxia Hypoxia/Metabolic Acidosis Bacterial/Viral Infection Severe RDS Severe Hypoglycemia Severe Metabolic/Elelctrolyte Imbalances (esp Hyperkalemic Crisis--effects Heart pumping) Arrythmias (SVT) CHD's (esp a/w hypoxemia or obstruction of systemic circulation--i.e. Hypoplastic L. H.)
Septic Shock is caused by?
Severe Infection–Viral OR Bacterial.
Usually Gram- Cocci, but can be Gram+
True/False: W/a bacterial infection, many complicated systemic reactions occur that result in circulatory insufficiency
True
In Septic Shock, what allows fluid to leak out of the blood vessels and into the tissue spaces?
Loss of Vascular Integrity
In Septic Shock, Poor Myocardial Contractility leads to…..
Poor tissue Perfusion and Oxygenation
With poor Myocardial Contractility, _____ _________ is a high risk.
Organ Failure
What is the Hallmark of Septic Shock?
They do not respond to Fluid Resuscitation
What are the Altered Areas affected by Shock in Clinical presentation?
Respiratory effort Pulses Peripheral perfusion Color Heart Rate Heart-itself B/P Neuro Exam U.O.
What would you see w/altered Respiratory Effort?
- Increased WOB
- Tachypnea
- Apnea
- Gasping
What is Gasping?
What would you do to tx?
A sign of impending Respiratory Failure
Provide PPV and Possible intubation
What would you look for in Pulses w/Septic Shock?
Strength of Pulses
Comparison of them
What would you see w/Altered Peripheral Perfusion in Shock?
- Poor Perfusion
- Prolonged Cap Refill time
- Cool Skin
- Mottled Skin
What color might you see in shock?
Cyanosis (and desaturations)
Pallor (may not have enough RBC’s to even turn cyantoic–Very BAD)
What 2 Heart Rate types might you see in Shock?
Tachycardia
Bradycardia
Which is a more concerning sign, Bradycardia or Tachycardia?
Bradycardia
Which is often displayed 1st, Tachycardia or Bradycardia?
Tachycardia
What 3 things lead to Bradycardia?
- Hypoxemia
- Hypotension
- Acidosis
In terms of the Heart on x-ray, what might you see?
Enlarged
Compressed (bilateral pneumo, pneumopericardium)
If a mom has SLE, what might baby have?
Neonatal Heart block
What might you hear on heart exam?
Murmur
W/shock is B/P high or low?
Either high or low
B/P alteration is an Early or Late sign of Cardiac Decompensation?
LATE
Lower extremity B/P’s are usually higher or lower than Upper extremity B/P’s?
Higher
Compare lower to upper
Too small cuff results in falsely _______ b/p.
Elevated
In addition to B/P, you also want to evaluate the _____ ________.
Pulse Pressure
What is the normal PP for a Preemie?
15-25
What is the normal PP for a Term?
25-30
What does a Narrow PP mean?
Cardiac Compression
What does a Widened PP mean/where might you see this?
PDA
AV malformations
Truncus
How do you measure PP?
Systolic b/p -Diastolic b/p
What do you examine on Neuro assessment?
Lethargy
What is a concerning U.O. ?
< 1mL/kg/hr OR declining UO in presence of signs of Hypoperfusion
What labs would you want to evaluate w/Shock?
Blood gas Glucose Electrolytes iCa LFT's Renal Fxn tests Coags Blood Lactate CBC w/d Blood Cx Cardiac Enzymes
ECHO (fxn)
ECG (rhythm)
UO
Ammonia (and other metabolic screens)
How do you treat Shock?
ID the cause
What are the Tx Goals of Shock?
Increasing CO–>Increases Tissue perfusion–>Increases Tissue oxygenation–>Decreases Anaerobic Metabolism–>Decreases Lactic Acid build-up–>Increases pH = Happy NNP & Baby :-)
How do you Tx Hypovolemic Shock?
- Note Acute blood loss
2. Volume Replacement
What type of volume replacement is used?
- Crystalloid Solutions (NS –usually used 1st, but could be LR)
- Colloid Solutions (not used much except w/Hydrops–5% Albumin, Plasminates. They stay in vascular space longer, expensive, allergies dev, are blood derivative)
- Blood Products
Will infants with Hx of Chronic blood loss in Severe Shock tolerate volume boluses?
No. They’ve adapted to the decreased volume.
The boluses are reserved for ACUTE blood loss.
What is the emergency blood replacement?
O-
Get it released from Blood Bank
What is a good test to try to have done before transfusion if possible?
NBMS
How do you Tx Cardiogenic Shock?
Tx underlying problems Negatively affecting Heart Fxn
What medications might be used w/Cardiogenic Shock?
Volume Expanders
NaHCO3 4.2% (controversial)
Dopamine (most common inotrope used-is renal dosing)
Epinephrine (increasing use esp W/O response to Dopamine)
How do you Tx Septic Shock?
Combo of Hypovolemic and Cardiogenic Shock therapies
Does a baby w/Septic Shock need More or Less fluid boluses than other types of shock?
Why?
Usually More
D/T movement of fluid from Intravascular to Interstitial Space
W/Septic Shock, Oxygenation and Ventilation must be ________.
Maximized
What medications may be used to Tx Septic shock?
Volume expanders
NaHCO3 4.2%
Dopamine
When might NaHCO3 be considered as Tx?
If given, what needs to be considered?
Severe Metabolic Acidosis
Adequate Ventilation
Rate of Infusion (linked to IVH in preemies)
Dopamine has ______ related effects.
Has ________ solutions.
Monitor ____, _____ & _________ ____
Dose-related
Standardized
HR, B/P, & infusion site (PIV site, NEVER in Artery, ONLY IN VEINS)
