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Complex Care > Shock week 4 > Flashcards

Shock week 4 Flashcards

1
Q

Basis of shock

A

Shock is a syndrome of hypoperfusion and hypotension that leads to inadequate o2 delivery to the tissues and impaired cellular metabolism that ultimately results in organ dysfunction/failure

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2
Q

There are a few things going on when a patient is in shock: what are they?

A
  1. A state of hypoperfusion/hypotension (low BP)
  2. O2 does not get to the tissues (causing global hypoxia)
  3. Cells don’t function properly (go into anaerobic metabolism = lactic acid production)
  4. Organs start to fail
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3
Q

Hypovolemic shock

A

occurs when the body loses too much fluid through bleeding, vomiting, diarrhea, burns, polyuria, third-spacing.

The bucket does not have enough fluid in it– results in decreased venous return to heart and decreased CO

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4
Q

Distributive shoch

A

occurs when the bucket is too big and there is decreased vascular resistance. Vessels are dialted out.

Types include septic, anaphylaxis, spinal/neuro

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5
Q

Cardiogenic shock

A

occurs when the pump (heart) has failed Typically seen after a massive MI, valve problems, arrhythmias, cardiomyopathy

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6
Q

Obstructive shoch

A

occurs when a mechanical barrier, such as cardiac tamponade, PE, tumor, tension pneumothorax happens.

Anything that abstructs circulating blood volume can be the precursor for hypoperfusion

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7
Q

How do we lose volume with a burn?

A

hink of skin like seran wrap, if we pole holes in
it, fluid will escape out. if patient has full body burns,
we have lost barrier that keeps fluid in and we lose
fluid very quickly

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8
Q

What is the initial result of hypovolemic, cardiogenic and septic shock?

A

Hypovolemic: initial result = low blood volume

Cardiogenic: initial result = pump failure

Septic shock: initial result = immune response, initiates massive systemic vasodilation

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9
Q

General Assessment of Shock

A

Regardless which classification of shock, you will assess…

a. heart rate
b. respiratory rate/effort
c. blood pressure
d. hemodynamics
e. mentation
f. UOP
g. skin color/temp

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10
Q

Initial shock s/s

A 
Tachycardic (10-20 BPM higher) 
Tachypnic
Blood pressure typically still normal 
UOP still maintained 
Extremities: slightly cool (may be warm in distributive shock)
Anxiety
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11
Q

Compensatory stage: what is happening

A

The body starts to kick into high gear and compensate. This stage is where we most likely ID our patient is in trouble

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12
Q

What is happening in the initial stage of shock

A

the body is typically compensating for the hypoperfusion/hypotension

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13
Q

Compensatory stage: s/s

A 
Increased HR
Vasoconstriction
Increased RR (high 20-30s)
Increased BG (glucogenolysis occurring in pt. w/o DM)
Decrease UOP
Decreased bowel sounds: body shunting blood to vital organs
Delayed cap refill and cold extremities
Agitation
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14
Q

What is happening in the progressive stage of shock?

A

The patient is very sick. Compensatory mechanisms are starting to fail and hemostasis can not be maintained

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15
Q

Progressive stage: s/s

A 
Hypotension
ALOC
Increase RR rate and effor 
Lactic acidosis 
Tachycardia
Low UOP
Poor skin perfusion
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16
Q

What is occurring in the refractory stage of shock?

A

NOT GOOD. very hard to save patient. called “refractory” because it is not typically responsive to treatments

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17
Q

Refractory stage: s/s

A 
Decrease LOC
UOP very very very low if there is any
Respiratory rate is high (above 35) if not intubated
Skin signs very poor (moddling) 
BP low despite fluids/vasoactive meds
Low O2 saturation despite O2 therapy
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18
Q

Which of the following assessment findings is congruent with the onset of the uncompesated stage of shock?
bradycardia, decrease UOP, systemic edema, or N/V

A

decreased UOP

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19
Q

General treatment for shock

A

Treatment for all shock states is generally the same with a few differences related to the cause. The idea is to STABILIZE the patient with broad-based treatment and then target therapies based on the specific patient

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20
Q

Treatment: optimize o2 delivery

A

Provide o2
– many patients will need to be intubated, but if caught early, supplement o2 via NC/mask

Restore volume with fluids/RBC

Medications (depending on type of shock)

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21
Q

Treatment: reduce o2 consumption

A

Decrease work of breathing (intubate or give o2)
Treat pain & anxiety
Keep patient normothermic (shivering increases o2 demand)
Decrease o2 demands w ventilation, sedation, neuromuscular blockers

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22
Q

What are neuromuscular blockers?

A

Paralytics (reduces the o2 consumption because the diaphragm, lungs, intercostal muscles require o2)

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23
Q

Why are colloids a great choice when replacing the volume in a patient in shock?

A

they have protein molecules that help pull fluid into vascular space

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24
Q

Crystalloids include

A

0.9% nacl
LR
hypertonic saline

25
Q

0.9% NaCl: pros and cons

A

Pro: widely available, inexpensive
Cons: Requires large volume of infusion. Can cause hyperchloremic metabolic acidosis, pulmonary edema

26
Q

LR: pros and cons

A

Pro: Lactate ion helps buffer metabolic acidosis

Con: Requires large volume of infusions, can cause pulmonary edema; should not be used in patients with severe hyperkalemia or patients with severe liver dysfunction

27
Q

Hypertonic saline (3%, 5%, 7.5%): pros and cons

A

Pros: small volume needed to restore intravascular volume

Cons: Danger of hypernatremia, central pontine myelinolysis, and increased serum osmolality

28
Q

What are examples of colloids?

A

Albumin
Dextran
Hetastarch

29
Q

Albumin (5%, 25%): pro and cons

A

Pros: rapidly expands plasma volume

Con: Expensive; requires human donors; limited supply; can cause heart failure

30
Q

Dextran (40, 70): pros and cons

A

Pros: Synthetic plasma expander
Cons: Interferes with platelet aggregation; not recommended for patients with hemorrhagic shoch

31
Q

Hetastarch: pros and cons

A

Pros: synthetic; less expensive than albumin; effects last up to 36 hours

Cons: prolongs bleeding and clotting times

32
Q

True or false: Vasoactive medications should not be administered through a central line rather than a peripheral intraveneous catheter.

A

FALSE - vasoactive meds should be administered through a central line

there are times where they are administered through a peripheral IV; however, if it has to be
adminstered through peripheral IV, we want it to be a short time because they are costic
to out vessels. The central line is in a bigger vessel which has faster blood flow and it does not
cause harm to the vessel itself

33
Q

Hypovolemic shock: s/s

A 
Decreased CO (normal 4-8) Increased SVR (normal 900-1300) Decreased CVP (normal 2-8)
Cool skin, delayed capillary refill Low BP & UOP
Tachycardia
34
Q

Hypovolemic shock: tx

A

Improve oxygen delivery, we need to FILL THE BUCKET!

    • If due to blood loss…. give blood!
    • If due to fluid loss…. give fluid!

Identify and treat the source of the loss

    • If bleeding…. need intervention STAT!
    • If vomiting.. give medication to fix (Zofran, Reglan, etc)

Ensure good IV access (2 large bore IVs at all times)

May need a central line

Monitor for improvements in HR, BP, UOP
– typically see HR first, then BP, then UOP

35
Q

Anaphylactic shock

A

Anaphylactic shock occurs with massive allergic reactions! A large amount of vasoactive substances are released in the body causing systemic vasodilation and increased capillary permeability. This results in sudden blood pressure drop and respiratory

36
Q

Anaphylactic shock: s/s

A

Hypotension
Tachycardia
Wheezes, hives, urticaria, itching Tightness in chest, throat swelling

37
Q

Anaphylactic shock: tx

A

MAINTAIN the airway (may need an ET tube!) Epinephrine
Fluids to support BP
Histamine blockers (Pepcid, Benadryl) Bronchodilators
Steroids to reduce airway inflammation REMOVE THE ANTIGEN!!

38
Q

What is neurogenic shock?

A

Neurogenic shock occurs in patients with spinal cord injuries and causes a loss of sympathetic innervations. Most common in C3-C5 level injuries.

39
Q

Neurogenic shock s/s

A

Massive vasodilation and decreased venous return
– Decreased SVR, CVP, CO, PAWP

Decreased HR (remember the PNS is in charge now)
Pooling of blood in the vessels
Warm, flushed skin
Hypotension with wide pulse pressure

normally, HR would be high, but since sns is not intact, the pns kicks in and slows it down

40
Q

Neurogenic shock tx

A

New spinal injury…so need to stabilize the spine!

patient on backboard and wearing a c-spine collar

spine stabilization is KEY to getting SNS working again!

IV fluids to restore CVP

Vasopressors to support SVR and BP

Treat bradycardia as needed

41
Q

Septic shock: what is it?

A

Septic shock occurs when a severe infection triggers a complex series of immune responses in the body. This causes massive vasodilation and increased capillary permeability (leaky vessels). This results in hypotension and global tissue hypoxia!

42
Q

Septic shock: s/s

A

Elevated temperature (remember infection)
– Young children or immunocompromised
patients may have low temps

Tachycardia and Tachypnea

Elevated WBC or very low WBC

Decreased CVP and SVR

Hypotension despite fluid resuscitation

43
Q

Septic shock: tx

A

When patient screens “positive” on the sepsis screen…we immediately treat with FLUIDS! Typically 30 mL/kg

Vasopressors to increase SVR and BP
– Levophed first–then vasopressin

Antibiotics
– Controls the source of infection… this is KEY!!!!!

44
Q

What do nurses use to assess if their patients have septic shock?

A

SIRS (systemic inflammatory response syndrome)

45
Q

What is the hour-1 bundle if a patients SIRS assessment comes back positive for septic shock?

A
  1. Measure lactate level
  2. Obtain blood cultures before administering abx
  3. Administer broad-spectrum
  4. Begin rapid administration of 30mL/kg crystalloid for hypotension or lactate > (or equal to) 4mmol/L
  5. Apply vasopressors if hypotensive during or after fluid resusitation to maintain a mean arterial pressure > (or equal to) 65 mmHg
46
Q

What is cardiogenic shock?

A

Cardiogenic shock is a pump problem! The heart has failed and is no longer able to pump blood through the body adequately. Signs will be specific to what is causing the pump to fail, most common is left-sided heart failure.

47
Q

Cardiogenic shock: s/s

A

Common signs associated with left-sided HF:

  • Pulmonary congestion, coarse lung sounds
  • Dyspnea
  • Elevated PAWP
  • Low CO

Common signs associated with right-sided HF

  • systemic venous congestion, peripheral edema
  • elevated CVP
  • JVD
48
Q

Cardiogenic shock: treatments

A

Reduce myocardial o2 demand while improving o2 supplied

Give fluids (unless pt. in fl. overload)

Inotropes to improve CO (dobutamine or dopamine, milrinone)

Possible diuretics to remove excess fluid

Vasopressors to increase BP

Cardiac devices (IABP)

49
Q

inotropes improve what?

A

contractility

50
Q

obstructive shock is what?

A

Obstructive shock happens when there is a THING obstructing blood flow in the great vessels or heart. That “THING” can be fluid around the heart (tamponade), tension pneumothorax (putting pressure on heart), or blood clot in the lungs (PE).

51
Q

s/s PE

A

SOB, increased RR and effort, dropping O2 Feeling of impending doom
Chest pain
Cough
Pulsus paradoxes (SBP increases on expiration and drops during inspiration)

52
Q

Tension pneumothorax s/s

A

Drop in BP due to less venous return Increased SOB and RR and effort; drop in O2 sat
Displaced trachea
Decreased/absent lung sounds on side of pneumo

53
Q

Cardiac tamponade s/s

A

Beck’s Triad
PEA
Pulsus paradoxus

54
Q

Becks triad consists of what?

A

elevated CVP, decreased BP, muffled heart tones

55
Q

Pulmonary embolism: treatment

A

Anticoagulant (Heparin)
Thrombolytic therapy (-ase)
Possible IVC filter

56
Q

Tension pneumo: tx

A

Needle decompression

Chest tube

57
Q

Cardiac tamponade

A

Pericardiocentesis

Open chest surgery

58
Q

Multiple organ dysfunction (MOD)

A

Altered organ function in acutely ill patients that requires medical intervention to support continued organ function

Defined as severe organ dysfunction of at least two organ systems lasting at least 24 to 48 hours in the setting of sepsis, trauma, burns, or severe inflammatory conditions

59
Q

MOD treatment

A

Treatment is aimed at controlling the initiating event, promoting adequate organ perfusion, and providing nutritional support

  • anticipate for a lot of labs
  • foley to monitor UOP diligently
  • cardiac monitor
  • antipate central line, PA cath., arterial line
  • set up hemodynamic monitoring lines

Complex Care (2 decks)

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