Shock Primer Flashcards
Normal MAP range?
• 70-100 mmHg
Normal CVP range?
• 2-6 mmHg
What is Shock?
• A critical condition where the body has decreased tissue perfusion eventually leading to organ failure and death
What are the 5 steps in the pathophysiology of shock?
- Not enough blood flow to organs
- Inflammatory response is triggered
- Anaerobic metabolism
- Metabolic acidosis
- Multiple Organ Dysfunction Syndrome (MODS)
What is the body’s immediate reaction to not enough blood flow to the organs?
• It speeds up the heart and respiratory rates in an attempt to get more blood/O2 out to the body
What triggers the inflammatory response of shock?
• Organs start to become damaged due to lack of blood flow
What does the inflammatory response trigger?
- Vasodilation
- Capillary permeability which leads to third spacing of fluids
- Third spacing causes blood to become more viscous and causes blood to clot
Vasodilation in shock causes…
- Low blood pressure
- Swelling
True or False
The severity of the inflammation stage of shock is the same regardless of the type of shock.
• False, there is a greater swelling response with septic and anaphylactic shock
Describe what is meant by anaerobic metabolism in shock.
- As the tissues of the body aren’t getting enough oxygen, the body tries to function temporarily without oxygen.
- If not corrected, this will lead to metabolic acidosis
Explain the relationship between anaerobic metabolism and metabolic acidosis.
- As the body tries to work without oxygen, it produces a waste product of lactic acid
- This causes the blood pH to drop and impairs the body’s ability to function
Untreated shock will eventually lead to MODS. What is this?
- Multiple Organ Dysfunction Syndrome
- This is when 2 or more organs fail.
- Due to acidic and anaerobic conditions within the body, organs begin shutting down, leading to death
What are the circulatory s/s of shock?
- Tachycardia
- Low BP
- Cap refill >3sec
- Decreased peripheral pulses
- Cyanosis
What are the respiratory s/s of shock?
• Tachypnea
What are the neurologic s/s of shock?
• Agitation and confusion
What are the GI/GU s/s of shock?
- Decreased urine OP
- Absent bowel sounds
What happens regarding temperature and shock?
- The initial vasodilation will cause the patient to be warm
- As shock progresses, vasoconstriction will occur to try and bring up BP, this will cause the pts temp to drop
What are the nursing interventions for shock?
- Give O2 and maintain airway
- Start IV and admin fluids
- Collect labs
- Insert foley
- Get type and x-match
- Continue to assess
A patient arrives at the ED at risk of shock. What factors do we keep in mind regarding IVs?
- Do not remove field start (IV placed in ambulance) until a new IV is placed
- Make sure IV is patent and ready to go
- Warm fluids before giving to maintain body temp
- A CVC line may be inserted to give fluids/meds faster
True or False
The type of fluids given depends on the type of shock.
• True
What Labs might we want to collect for shock?
- Hct/Hgb
- ABG
- PT, PTT
- Cardiac enzymes (cardiogenic shock)
- Creatinine/BUN
- Electrolytes
Why is a foley catheter needed for patients in shock?
• To be able to accurately monitor renal function and success/failures of interventions
Why do we continue to assess the patient with shock?
• It is a medical emergency and can take a negative turn quickly
What is Obstructive Shock?
• A type of shock caused by something blocking the blood flow from moving forward in the circulatory system
What are some examples of conditions that may cause obstructive shock?
- Pulmonary embolism: block blood from moving through lungs
- Cardiac tamponade: pressure restricts pumping of heart
- Tension pneumothorax: pressure restricts pumping of heart and perfusion of lungs
What is Distributive Shock?
• A systemic reaction when the blood vessels of the body vasodilate
What is an example of something that may cause distributive shock?
• Sepsis
What are the different types of shock?
- Cardiogenic
- Neurogenic
- Spinal
- Hypovolemic
- Septic
- Anaphylactic
What is the general cause Hypovolemic Shock?
• An overall lack of blood circulating in the body (20% loss).
What are the two types of hypovolemic shock?
- Absolute
- Relative
What is absolute hypovolemic shock?
• Actual loss of fluids from the body
Give examples of absolute hypovolemic shock.
- Loss of whole blood from trauma, surgery, GI bleed
- Loss of body fluids from vomiting, diarrhea, diabetes insipidus/mellitus, excessive diuresis
What is relative hypovolemic shock?
• Change in vascular fluid levels to internal spaces
Give examples of relative hypovolemic shock.
- Pooling of blood: bowel obstruction
- 3rd spacing of fluids (burns, ascites)
- Internal bleeding (ruptured spleen/appendix)
- Massive vasodilation (as occurs in sepsis)
S/S of hypovolemic shock?
- Anxious, agitated and pale
- Skin is cool and clammy (due to vasoconstriction to try and raise BP)
- Urine OP decreases
- Absent bowel sounds
Treatment for hypovolemic shock?
- O2
- Fluids (Lactated Ringers or NS)
- Catheterize
- Treat source of fluid loss
What is the general cause Anaphylactic shock?
A severe allergic reaction where the immune system overreacts
What are some examples of things that can trigger anaphylactic shock?
- Drugs/vaccine
- Food (peanuts)
- Insect venom
What method of transmission is used for allergen to trigger an anaphylactic response?
- Contact
- Inhalation
- Ingestion
- Injection
What is the pathophysiology of anaphylactic shock?
- Massive vasodilation w/ capillary permeability and fluid leak
- Resulting inflammation causes respiratory distress, laryngeal edema and/or bronchospasm
- Severity of inflammation can cause circulatory failure
S/S of anaphylactic shock?
- Dizziness, anxiety, confusion, sense of impending doom
- Swelling of lips and tongue
- Wheezing and stridor, Chest pain
- Skin changes
What type of skin changes might be seen with anaphylactic shock?
- Flushing
- Puritis
- Uticaria
- Angioedema (swelling in face)
What is the treatment for anaphylactic shock?
- O2
- Epinephrine (immediate)
- Followed by
- IV antihistamines, steroids
- Possible bronchodilators (such as albuterol) later
What is general cause of Septic Shock?
• A widespread bloodborne infection
What is the pathophysiology of septic shock?
• Acquired infection causes a systemic cytokine release inside the bloodstream that causes extreme vasodilation and fluid leakage from capillaries (triggering the systemic shock process)
What are the two major conditions that will develop if septic shock is not treated?
- DIC as the body tries to plug up the leaky capillaries
- ARDS as O2 exchange will not be able to occur
What are some examples of infections that can lead to septic shock?
- Parasites
- Fungi
- Bacteria
- Viruses
How often should LOC/vitals be assessed w/ a patient experiencing hypovolemic shock?
Every 10-15mins
What labs should be taken for the patient with hypovolemic shock?
- CBC
- U&E’s (urea and electrolytes)
- BUN
- LFTs
- Type and Cross
If source of bleeding causing hypovolemic shock is GI related, what may be indicated and why?
- Placement of NG tube
- For gastric decompression
What is partial arterial wedge pressure (PAWP)?
pressure within the pulmonary arterial system when catheter tip ‘wedged’ in the tapering branch of one of the pulmonary arteries
The normal pulmonary arterial wedge pressure is between…
4 to 12 mmHg
True or False
Anaphylactic shock is not normally due to the first exposure but the second causes a trigger response and mass release of chemical mediators.
True
What is the treatment for anaphylactic shock?
- Make sure airway is patent
- Supply 100% O2 on 15 liters via re-breather mask
- Insert 2 large bore IVs
- Remove stinger (if cause)
- Administer meds
What is the order of meds given for anaphylactic shock?
- Epinephrine (immediate)
- Nebulized albuterol
- Benadryl (IM or IV)
- Antihistamines
- Corticosteroids
- Antipuritics
- Anti-mast cell drugs
What do mast cells do?
They are responsible for releasing cytokines triggering immediate allergic reactions
Patients with beta blockers may be resistant to epinephrine treatment during anaphylactic shock and can develop _____ and _____.
bradycardia and hypotension
If a pt on beta blockers is resistant to the epinephrin tx for anaphylaxis, what should be given instead?
Glucagon
Which patients are most at risk for developing septic shock?
- Those with recent, prolonged, or multiple hospitalizations
- Neutropenic patients,
- Those with difficult-to-treat, multidrug-resistant microorganisms.
The major focus of resuscitation from septic shock is on supporting
cardiac and respiratory functions.
For those experiencing septic shock, early intubation and mechanical ventilation should be strongly considered for patients with any of the following:
- Oxygen requirement
- Dyspnea or tachypnea
- Persistent hypotension
- Evidence of poor peripheral perfusion
What actions must be completed w/in the first 3hrs of septic shock?
- Obtain the lactate level
- Obtain blood cultures before administering antibiotics
- Administer broad-spectrum antibiotics
- Administer 30 mL/kg of crystalloid solution for hypotension or for lactate levels of 4 mmol/L or higher
- Goal is to achieve normal CVP @ 8-12 mm Hg
What should be done within 6 hours if septic shock hypotension has not responded to initial fluid resuscitation?
Admin vasopressors to maintain a Map of ≥ 65mm Hg
Why might a pt in septic shock experience massive diuresis?
The body is trying to get rid of the dead and dying bacteria
Petechiae and mottling of legs and feet is a sign that…
Clotting factors are being used up and the pt is at risk of DIC
How do we control temperature when treating shock?
Antipyretics
Sponging or cooling blankets
_____ use is preferred to dopamine for managing septic shock
Norepinephrine
If hemoglobin levels fall below ____, red blood cell (RBC) transfusion is recommended to a target hemoglobin range of ___.
- 7 g/dL
- 7-9 g/dL
True or False
Albumin should be used only when substantial amounts of crystalloid solution are required.
True
