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Critical Care Med Surg > Shock Notes > Flashcards

Shock Notes Flashcards

1
Q

Shock

A

Syndrome characterized by decreased tissue perfusion and impaired cellular metabolism.

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2
Q

4 Categories for Shock

A

Cardiogenic
Hypovolemic
Distributive
Obstructive

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3
Q

Cardiogenic Shock

A

systolic or diastolic dysfunction of the heart’s pumping action results in reduced CO , SV & BP.
Most common cause is MI

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4
Q

Cardiogenic Shock c/m:

A

Tachycardia & hypotension - early manifestations
Decreased Cap refill, SV, CO, SVR, PAWP, CVP
Tachypneic & crackles
Decreased urine output, and increase Na+ and H2O retention
Pallor, cool and clammy skin
Anxiety, agitation & confusion
n/v, hypoactive bowel sounds

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5
Q

Hypovolemic Shock

A

Inadequate volume in the intravascular space to support adequate perfusion.
Can be absolute or relative
Pts can compensate a loss of up to 15% of total volume.

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6
Q

Hypovolemic Shock c/m:

A 
Tachycardia, decreased preload, CO, CVP, PAWP, and Cap refill and Increased SVR. 
Tachypnea to bradypnea (late) 
Decreased urine output
Pallor, cool and clammy skin
Anxiety, agitation & confusion
Absent Bowel Sounds
Decreased Hct, Hgb & increased lactate, urine specific gravity
changes in electrolytes
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7
Q

Distributive Shock

A

Neurogenic
Anaphylaxis
Septic

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8
Q

Neurogenic

A

Hemodynamic phenomenon that can occur within 30 min of a spinal cord injury and lasts up to 6 wks.
Gen. associated with cervical or spinal cord injuries.

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9
Q

Neurogenic c/m:

A

Bradycardia, decreased BP, CO, CVP, SVR, change in temperature
Dysfunction r/t level of injury
Bladder dysfunction
Decreased skin perfusion, cool or warm dry skin
Flaccid paralysis below the level of lesion, loss of reflex activity
Bowel dysfunction

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10
Q

Anaphylactic shock

A

acute life-threatening hypersensitivity reaction to a sensitizing substance
Leads to respiratory distress due to laryngeal edema, severe bronchospasm, and circulatory failure

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11
Q

Anaphylactic shock c/m:

A

Tachycardia, increased CO, decreased CVP, PAWP, CP, Third spacing of fluid
SOB, Edema of larynx & epiglottis, wheezing, stridor, and rhinitis
incontinence
flushing, pruritus, uticaria, angioedema
anxiety, feeling of impending doom, confusion, decreased LOC, metallic taste
cramping, abd pain, n/v, diarrhea
sudden onset, hx of allergies, exposure to contrast media.

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12
Q

Sepsis and septic shock

A

Sepsis: life-threatening syndrome in response to an infection.
Septic shock: subset of species characterized by persistent hypotension despite fluid resuscitation and inadequate and inadequate tissue perfusion

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13
Q

Sepsis and septic shock c/m:

A

tachycardia, temperature changes, myocardial dysfunction, biventricular dilation, decreased EF
hyperventilation, crackles, respiratory alkalosis or acidosis, hypoxemia, respiratory failure, ARDS, pulmonary HTN
decreased urine output
warm and flushed skin to cool and mottled skin (late)
change in mental status, agitation , coma
GI bleeding, paralytic ileus
WBC changes, decreased platelets, urine na+, increased lactate, blood glucose, procalcitonin, urine specific gravity, and positive blood cultures.

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14
Q

Obstructive shock

A

develops when a physical obstruction to blood flow occurs with decreased CO.

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15
Q

Obstructive shock c/m

A 
Tachycardia, decreased BP, preload, CO and increased SVR, CVP, JVD and pulsus paradoxus
Tachypnea to bradypnea (late), SOB
decreased urine output
Pallor, cool and clammy skin
anxiety, agitation, confusion
Decreased to absent bowel sounds
Specific to cause of obstruction
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16
Q

Stages of shock

A

Initial
Compensatory
Progressive
Refractory

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17
Q

Neurologic Compensatory Stage

A

Oriented to person, place, time
Restless, apprehensive, confused
Change in level of consciousness

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18
Q

Cardiovascular Compensatory Stage

A 
Sympathetic nervous system response:
• Release of epinephrine/norepinephrine (vasoconstriction)
• ↑ MVO2
• ↑ Contractility
• ↑ HR
Coronary artery dilation
Narrowed pulse pressure
↓ BP
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19
Q

Respiratory Compensatory Stage

A 
Blood flow to the lungs:
• ↑ Physiologic dead space
• ↑ Ventilation-perfusion mismatch
• Hyperventilation
• ↑ Minute ventilation (VE)
• Tachypnea
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20
Q

GI Compensatory Stage

A

↓ Blood supply
↓ GI motility
Hypoactive bowel sounds
↑ Risk for paralytic ileus

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21
Q

Renal Compensatory Stage

A

↓ Renal blood flow
↑ Renin resulting in release of angiotensin (vasoconstrictor)
↑ Aldosterone resulting in Na+ and H2O reabsorption
↑ Antidiuretic hormone resulting in H2O reabsorption

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22
Q

Temperature and Skin Compensatory Stage

A

Normal or abnormal
Pale and cool
Warm and flushed

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23
Q

Neurologic Progressive Stage

A

↓ Cerebral perfusion pressure
↓ Cerebral blood flow
↓ Responsiveness to stimuli
Delirium

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24
Q

Cardiovascular Progressive Stage

A

↑ Capillary permeability → systemic interstitial edema
↓ CO → ↓ BP and ↑ HR
MAP <60 mm Hg (or 40 mm Hg drop in BP from baseline)
↓ Coronary perfusion → dysrhythmias, myocardial ischemia, MI
↓ Peripheral perfusion → ischemia of distal extremities, ↓ pulses, ↓ capillary refill

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25
Q

Respiratory Progressive Stage

A 
ARDS:
• ↑ Capillary permeability
• Pulmonary vasoconstriction
• Pulmonary interstitial edema
• Alveolar edema
• Diffuse infiltrates
• Tachypnea
• ↓ Compliance
• Moist crackles
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26
Q

GI Progressive Stage

A 
Vasoconstriction and ↓ perfusion → ischemic gut (e.g., stomach, small and large intestines, gallbladder, pancreas):
• Erosive ulcers
• GI bleeding
• Translocation of GI bacteria
• Impaired absorption of nutrients
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27
Q

Renal Progressive Stage

A 
Renal tubules become ischemic → acute tubular necrosis
↓ Urine output
↑ BUN-to-creatinine ratio
↑ Urine sodium
↓ Urine osmolality and specific gravity
↓ Urine potassium
Metabolic acidosis
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28
Q

Hepatic Progressive Stage

A

Failure to metabolize drugs and waste products
Cell death (↑ liver enzymes)
Jaundice (↓ clearance of bilirubin)
↑ NH3 (ammonia) and lactate

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29
Q

Hematologic Progressive Stage

A

DIC:
• Thrombin clots in microcirculation
• Consumption of platelets and clotting factors

30
Q

Temperature and Skin Progressive

A

Hypothermia or hyperthermia

Cold and clammy

31
Q

Neurologic Refractory Stage

A

Unresponsive
Areflexia (loss of reflexes)
Pupils nonreactive and dilated

32
Q

Cardiovascular Refractory Stage

A

Profound hypotension
↓ CO
Bradycardia, irregular rhythm
↓ BP inadequate to perfuse vital organs

33
Q

Respiratory Refractory Stage

A

Severe refractory hypoxemia

Respiratory failure

34
Q

GI Refractory Stage

A

Ischemic gut

35
Q

Renal Refractory Stage

A

Anuria

36
Q

Hepatic Refractory Stage

A

Metabolic changes from accumulation of waste products (e.g., NH3, lactate, CO2)

37
Q

Hematologic Refractory Stage

A

DIC progresses

38
Q

Emergency Management of Shock

A

Initial:
• If unresponsive, assess circulation, airway, and breathing (CAB).
• If responsive, monitor airway, breathing, and circulation (ABC).
• Stabilize cervical spine as appropriate.
• Control any external bleeding with direct pressure or pressure dressing.
• Give high-flow O2 (100%) by nonrebreather mask or bag-valve-mask.
• Anticipate need for intubation and mechanical ventilation.
• Establish IV access with 2 large-bore catheters (14- to 16-gauge) or an intraosseous access device; aid with central line insertion.
• Begin fluid resuscitation with crystalloids (e.g., 30 mL/kg repeated until hemodynamic improvement is seen).
• Draw blood for laboratory studies (e.g., blood cultures, lactate, WBC).
• Assess for life-threatening injuries (e.g., cardiac tamponade, liver laceration, tension pneumothorax).
• Consider vasopressor therapy if hypotension persists after fluid resuscitation.
• Insert an indwelling urinary catheter and nasogastric tube.
• Start antibiotic therapy after blood cultures if sepsis is suspected.
• Obtain 12-lead ECG and treat dysrhythmias.
Ongoing Monitoring:
• ABCs
• Level of consciousness
• Vital signs, including pulse oximetry; peripheral pulses, capillary refill, skin color and temperature
• Respiratory status
• Heart rate and rhythm
• Urine output

39
Q

Fluid Therapy

A

Isotonic Crystalloids
Hypertonic Crystalloids
Blood Products
Colloids

40
Q

Isotonic Crystalloids: Mechanism of Action & Indication

A

0.9% NaCl, normal saline solution (NSS) or Lactated Ringer’s (LR) solution
Fluid primarily stays in the intravascular space, ↑ intravascular volume.
Used for initial volume replacement in most types of shock.

41
Q

Isotonic Crystalloids: Nursing Implications

A

Monitor patient closely for circulatory overload. Do not use LR in patients with liver failure.LR may be used if hyperchloremic acidosis develops from use of NSS in fluid resuscitation.

42
Q

Hypertonic Crystalloids: Mechanism of Action & Indication

A

1.8%, 3%, 5% NaCl
Fluid stays in the intravascular space, increases serum osmolarity, shifts fluid volume from intracellular space to extracellular space to intravascular space.
May be used for initial volume expansion in hypovolemic shock.

43
Q

Hypertonic Crystalloids: Nursing Implications

A

Monitor patient closely for signs of hypernatremia (e.g., disorientation, seizures).
Central line preferred for infusing saline solutions ≥3%, since these may damage veins.

44
Q

Blood Products: Mechanism of Action & Indication

A

Packed red blood cells
Fresh frozen plasma
Platelets
Replaces blood loss, increases O2-carrying capability.
Replaces coagulation factors.
Helps control bleeding caused by thrombocytopenia
All types.

45
Q

Blood Products: Nursing Implications

A

Same precautions as any blood administration

46
Q

Human serum albumin (5% or 25%): Mechanism of Action & Indication

A

Colloids
Can increase plasma colloid osmotic pressure.
Rapid volume expansion.
All types except cardiogenic and neurogenic shock

47
Q

Human serum albumin (5% or 25%): Nursing Implications

A

Use 5% solution in hypovolemic patients. Use 25% solution in patients with fluid and sodium restrictions.
Monitor for circulatory overload. Mild side effects of chills, fever, and urticaria may develop.
More expensive than crystalloids.

48
Q

dextran (dextran 40): Mechanism of Action & Indication

A

Colloids
Hyperosmotic glucose polymer.
Limited use because of side effects, including reducing platelet adhesion, diluting clotting factors.

49
Q

dextran (dextran 40): Nursing Implications

A

Increases risk for bleeding.

Monitor patient for allergic reactions and AKI. Has maximum volume recommendations per manufacturer.

50
Q

Cardiogenic Shock & Septic Shock: Oxygenation Interprofessional Care

A

Provide supplemental O2 (e.g., nasal cannula, nonrebreather mask)
Intubation and mechanical ventilation, if needed
Monitor ScvO2 or SvO2

51
Q

Hypovolemic Shock:

Oxygenation Interprofessional Care

A
  • Provide supplemental O2

* Monitor ScvO2 or ScvO2

52
Q

Neurogenic, Anaphylactic & Obstructive Shock: Oxygenation Interprofessional Care

A
  • Maintain patent airway
  • Provide supplemental O2
  • Intubation and mechanical ventilation (if needed)
53
Q

Cardiogenic Shock: Circulation Interprofessional Care

A

Restore blood flow with angioplasty with stenting, emergent coronary revascularization
• Reduce workload of heart with circulatory assist devices: IABP, VAD

54
Q

Hypovolemic Shock: Circulation Interprofessional Care

A
  • Rapid fluid replacement using 2 large-bore (14–16 gauge) peripheral IV lines, an intraosseous access device, or central venous catheter
  • Restore fluid volume (e.g., blood or blood products, crystalloids)
  • End points of fluid resuscitation:
  • CVP 15 mm Hg
  • PAWP 10–12 mm Hg
55
Q

Septic Shock: Circulation Interprofessional Care

A
  • Aggressive fluid resuscitation (e.g., 30 mL/kg of crystalloids repeated if hemodynamic improvement is noted)
  • End points of fluid resuscitation are based on:
  • Focused physical examination including vital signs, cardiopulmonary assessment, capillary refill, peripheral pulses, and skin or any 2 of the following:
  • ScvO2 >70 or SvO2 >65
  • CVP 8–12 mm Hg
  • Cardiovascular ultrasound
  • Assessment of fluid responsiveness with passive leg raise or fluid challenge
56
Q

Neurogenic Shock: Circulation Interprofessional Care

A

Cautious administration of fluids

57
Q

Anaphylactic Shock: Circulation Interprofessional Care

A

Aggressive fluid resuscitation with colloids

58
Q

Obstructive Shock: Circulation Interprofessional Care

A
  • Restore circulation by treating cause of obstruction

* Fluid resuscitation may provide temporary improvement in CO and BP

59
Q

Cardiogenic Shock: Drug Therapy

A
  • Nitrates (e.g., nitroglycerin)
  • Inotropes (e.g., dobutamine)
  • Diuretics (e.g., furosemide)
  • β-Adrenergic blockers (contraindicated with ↓ ejection fraction)
60
Q

Septic Shock: Drug Therapy

A
  • Antibiotics as ordered
  • Vasopressors (e.g., norepinephrine)
  • Inotropes (e.g., dobutamine)
  • Anticoagulants (e.g., low-molecular-weight heparin)
61
Q

Neurogenic Shock: Drug Therapy

A
  • Vasopressors (e.g., phenylephrine)

* Atropine (for bradycardia)

62
Q

Anaphylactic Shock: Drug Therapy

A
  • Epinephrine (IM or IV)
  • Antihistamines (e.g., diphenhydramine)
  • Histamine (H2)-receptor blockers (e.g., ranitidine [Zantac])
  • Bronchodilators: nebulized (e.g., albuterol)
  • Corticosteroids (if hypotension persists
63
Q

Cardiogenic Shock: Supportive Therapy

A

Treat dysrhythmias

64
Q

Hypovolemic Shock: Supportive Therapy

A
  • Correct the cause (e.g., stop bleeding, GI losses)

* Use warmed IV fluids, including blood products (if appropriate)

65
Q

Septic Shock: Supportive Therapy

A
  • Obtain cultures (e.g., blood, wound) before beginning antibiotics
  • Monitor temperature
  • Control blood glucose
  • Stress ulcer prophylaxis
66
Q

Neurogenic Shock: Supportive Therapy

A
  • Minimize spinal cord trauma with stabilization

* Monitor temperature

67
Q

Anaphylactic Shock: Supportive Therapy

A
  • Identify and remove offending cause
  • Prevent via avoidance of known allergens
  • Premedicate with history of prior sensitivity (e.g., contrast media)
68
Q

Obstructive Shock: Supportive Therapy

A

• Treat cause of obstruction (e.g., pericardiocentesis for cardiac tamponade, needle decompression or chest tube insertion for tension pneumothorax, embolectomy for pulmonary embolism)

69
Q

Phenylephrine: Mechanism of Action and Indications

A

α-Adrenergic agonist (peripheral vasoconstriction)
Renal, mesenteric, splanchnic, cutaneous, and pulmonary blood vessel constriction
↑ HR, BP, SVR
↑/↓ CO
Neurogenic shock

70
Q

Phenylephrine: Nursing Implication

A

Monitor for reflex bradycardia, headache, restlessness.
Monitor for renal failure from ↓ renal blood flow.
Give via central line (infiltration leads to tissue sloughing).

Critical Care Med Surg (17 decks)

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