Shock, Sepsis, MODS Flashcards by Megan Johnson

Life-threatening condition in which tissue perfusion is inadequate to delivery o2 and nutrients to support cellular function

Shock

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What 3 symptoms are common to all types of shock?

hypoperfusion, hypermetabolism, and activation of the inflammatory response

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During shock, stress leads to what?

Depletion of glycogen, cell death, and clotting cascade

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This stage of shock has manifestations of the following:
BP within normal limits
Adequate CO
Fight or flight response
Increased respirations
Inadequate perfusion
Anxiety
Confusion

Compensatory

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What are the 3 stages of shock?

Compensatory, progressive, and irreversible

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How is the compensatory stage of shock managed?

Treat underlying cause
Fluid replacement
Oxygen
Decrease anxiety
Maintain BP and perfusion
Frequent assessments (LOC, I&O, HR, BP, MAP >65, narrwed pulse pressure)
Promote safety

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What is being frequently assessed during shock?

LOC
I&O
HR
BP
MAP
Pulse pressure
ABG
Hemodynamics
ECG
Electrolytes

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How often are assessments done for shock patients?

every 15 minutes

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This stage of shock has manifestations of the following:
BP no longer compensated
MAP <65
Decreased LOC
Rapid/shallow respirations
Chest pain
AKI
Liver failure
GI bleeding
Abnormal bruising and petechiae with prolonged clotting times

Progressive

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Describe the pathophysiology of shock

Heart failure
Decreased cellular perfusion
Interstitial edema
Anaerobic metabolism
Hyperactive clotting cascade

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How is the progressive stage of shock managed?

Treat underlying cause
Fluid resuscitation
Respiratory support
Assessment (ABGs, hemodynamics, ECG, LOC, electrolytes)
Nutritional support
Oral care to prevent VAP
Rest and comfort to decrease stress
Skin integrity

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This stage of shock has manifestations of the following:
Severe organ damage
Unable to maintain BP w treatment
Unable to oxygenate w vent support
Unable to maintain MAP
MODS
Severe hypotension
Complete decline in mental status
Oliguria

Irreversible

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Describe the pathophysiology of irreversible shock

Organ damage is too severe to respond to treatment
Acute metabolic acidosis develops
Lactic acidosis develops
Energy stores are depleted

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How is the irreversible stage of shock managed?

Treat underlying cause
Respiratory support
Circulatory support
Nutritional support
Experimental treatments
Comfort measures
Infection prevention
Skin integrity
End of life measures

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Which stage of shock is characterized by a normal BP?

Compensatory

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What nursing management is central to all types of shock?

fluid replacement
vasoactive medications
nutritional support

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What colloid is the preferred choice for fluid resuscitation for shock?

Albumin

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When are vasoactive medications used during shock?

when fluid therapy does not maintain MAP

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Vasoactive medications should be given through what when possible?

a central line

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Why is nutritional therapy needed during shock?

to meet increased metabolic demands and prevent catabolism due to glycogen depletion

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Why is glutamine given during shock?

To maintain plasma levels and prevent MODS

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Why are H2 blockers and PPIs given during shock?

To prevent stress ulcers

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What is the most common type of shock?

hypovolemic shock

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What are external fluid loss causes of hypovolemic shock?

Trauma, surgery, diarrhea

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What are internal fluid loss causes of hypovolemic shock?

Hemorrhage and burns

When does hypovolemic shock occur with internal fluid loss?

Occurs with 15-30% reduction in intravascular volume

What are the manifestations of hypovolemic shock?

Decreased blood volume Decreased CO Decreased tissue perfusion

How is hypovolemic shock managed?

1. Treat underlying cause 2. Fluids: NS, LR, blood/albumin @ 3:1 rule 3. O2 4. Meds - vasopressors

Type of shock that occurs when the heart's ability to contract and pump blood is impaired leading to inadequate supply of oxygen to heart and tissues

Cardiogenic shock

What are the clinical manifestations of cardiogenic shock?

Angina Unstable BP Arrhythmias Fatigue Feelings of doom ECG changes Increased cardiac enzymes and cardiac biomarkers

How is cardiogenic shock managed?

1. Treat cause 2. O2 3. Drugs 4. Pain and fluids

What 3 drugs are used for cardiogenic shock?

Dobutamine Nitroglycerin Dopamine

How does dobutamine effect cardiogenic shock?

Decrease left ventricular pressure and raises BP by increasing CO

Why is dobutamine preferred over dopamine?

It does not cause vasoconstriction so therefore it is preferred when there is a need to increase CO

How does dopamine effect cardiogenic shock?

Increase cardiac contractility

Why is nitroglycerin used in cardiogenic shock?

It is a powerful vasodilator allowing for increased perfusion of the cells and decreased workload of the heart

3 types of distributive shock

septic neurogenic anaphylactic

Type of shock that involves pooling of peripheral blood vessels

distributive shock

What is the most common type of distributive shock?

septic

What lab result is key with septic shock?

Lactic acid

Describe the pathophysiology of septic shock

microorganism invades Immune response is triggered Inflammatory response is triggered Leads to decreased perfusion

Type of shock that involves a systemic inflammatory response syndrome (aka cytokine storm)

septic shock

This type of shock has manifestations of the following: Hyperthermia (fever) Tachycardia Bounding pulses Hypotension Decreased urine output N/V/decreased GI motility Change in LOC Cool, mottled skin MODS

Septic shock

What is the biggest, most immediate sign of septic shock in the elderly?

Subtle change in LOC and increasing temperature

How is septic shock managed?

Septic bundle - 1. Abx 2 Fluids - 30 ml x kg over 30 min 3. Norepinephrine 4. O2

What is done prior to starting broad spectrum abx for septic shock?

cultures

Type of shock caused by an imbalance between parasympathetic and sympathetic stimulation

Neurogenic shock

Causes of neurogenic shock

SCI, spinal anesthesia, or nervous system damage

Describe the pathophysiology of neurogenic shock

Sympathetic stimulation occurs causing vascular smooth muscle contraction Parasympathetic stimulation occurs causing vascular smooth muscle dilation, leading to blood volume displacement and inadequate perfusion

What are the manifestations of neurogenic shock?

Hypotension Bradycardia Syncope Dry, warm skin

Which shock is characterized by warm, dry skin?

neurogenic shock

How is neurogenic shock managed?

By restoring sympathetic tone through stabilizing the spinal injury Treat underlying cause Prevent through proper alignment and positioning of a patient with a SCI Support CV and neuro function

Type of shock that is due to a severe allergic reaction

Anaphylactic shock

What are the most common triggers of anaphylactic shock?

Foods Meds Insect stings and bites

What are the 3 defining characteristics of anaphylactic shock?

-Acute onset -Presence of two or more of: respiratory distress, hypotension, GI distress, skin or mucosal irritation -CV compromise

Describe the pathophysiology of anaphylactic shock

Previously produced antibodies are exposed to an antigen and develop a systemic reaction (IgE) Mast cells release potent vasoactive substances like histamine and bradykinin Leads to inflammation with significant vasodilation and capillary permeability

Type of shock that includes manifestations of: -signs that occur w/in 2-30 min of exposure -mild signs like: HA, lightheadedness, N/V, pruritus, flushing, dyspnea, bronchospasm, arrhythmias, hypotension -severe signs like: rapid hypotension, decreased LOC, respiratory distress, and cardiac arrest

Anaphylactic shock

How is anaphylactic shock managed?

#1 Remove antigen #2 Epinephrine #3 Activate EMS #4 Fluid replacement #5 Meds like Benadryl #6 CPR

PICS =

Post-intensive care syndrome

Syndrome that involves physical, cognitive, and mental impairments that can have an adverse effect on a patient's long-term recovery.

PICS

How can the nurse prevent PICS?

Early mobilization Assess and manage delirium Promoting adequate sleep Respiratory weaning if on ventilator

What are the risk factors or causes of septic shock?

Immunosuppression Extremes of age Malnourishment Chronic illness Invasive procedures Emergent or multiple surgeries

Risk factors for anaphylactic shock

History of med sensitivity Transfusion reaction History of reaction to insect bites Food allergies Latex sensitivity

Risk factors for neurogenic shock

SCI Spinal anesthesia Depressant action of meds

What needs to be completed within 1 hr of septic shock symptoms?

Measure lactate level Obtain blood cultures prior to abx's Admin broad spectrum abx Begin rapid infusion of 30 mL/kg crystalloid for hypotension or lactate >4

What needs to be completed within 3 hrs of septic shock symptoms?

Measure lactate level Obtain blood cultures prior to abx's Admin broad spectrum abx Begin rapid infusion of 30 mL/kg crystalloid for hypotension or lactate >4

What needs to be completed within 6 hrs of septic shock symptoms?

Begin vasopressor agents if hypotension is not corrected by fluids Reassess VS using 2 of the following: measurement of CVP or scVo2, bedside CV US, or assess fluid responsiveness w PLR or fluid challenge

scVo2 should be maintained at what?

>70%