Week 12: Shock Flashcards
What is shock?
Acute/progressive circ. dysfunction —> poor O2 delivery to body :(
Cell. Metabolism is bad :(
- more demand/consumption of O2/nutrients
- decrease removal of waste :0
Body goes into acidosis
What does MODS stand for?
Multiple Organ Dysfunction Syndrome (MODS)
In shock, the body’s cellular metabolism is impaired. What type of metabolism does the body shift to?
aerobic to ANAEROBIC metabolism.
What are some key features of anaerobic metabolism? (3)
- body goes into ACIDOSIS
- disruption in making ATP
- Water loss + edema…swelling :(
During shock, there is an accumulation of _________ & __________ in the cell.
sodium and chloride
In shock, _________ leaves the cell. This activates the coagulation pathway, which releases ________________________.
Potassium, lysosomal enzymes
In shock, there is impaired ___________ delivery + uptake.
glucose
What are the key features of “Impaired glucose delivery + uptake”? (4)
Cells shift to:
- glycogenolysis (cell failure)
- lipolysis (cell failure)
- gluconeogenesis (protein breakdown)
—————-
- heart & bones use lactic acid as fuel (temporarily) —> metabolic acidosis
What are the key features of “impaired protein metabolism”? (4)
- organ failure (b/c protein is being used for fuel sooo it’s no longer available to be used for cell structure/function/repair/replication :0)
- increase in ammonia + urea (thx to protein anaerobic met….disrupt cell function)
- decrease in albumin —> decrease in circ. V
- muscle wasting :( (b/c protein breakdown…makes bones and heart muscles weaker)
What are some ways the body compensates during shock?
- SNS increases in symp. flow
- Increase in E & NE
—-> stim. alpha & beta receptors (fight or flight)
——–> therefore increase in HR and SVR
Kidneys: RAAS; aldosterone & vasoconstriction —> more sodium & water out
**Not all compensatory methods will work for certain types of shock…
Compensatory mechanisms try to maintain ____ & ____
Cardiac output (CO) , BP
TRUE or FALSE:
Compensatory mechanisms are effective over the long term, and it is not detrimental if a shock state is prolonged (uncompensated)
FALSE
compensatory mechanisms are NOT effective over long term.
In Neurogenic/Vasogenic shock, what are the compensatory mechanisms?
- loss of sympathetic tone prevents compensatory tachycardia
When it comes to cardiogenic shock, what are the compensatory mechanisms?
When CO (cardiac output) decreases, compensatory activated!!!
—> renin-angiotensin, SNS…
——–> Fluid retention, sys. vasoconstriction, tachycardia
——–> catecholamines increase contractility & HR
**BUT tachy. & vasoconstriction INCREASE <3 O2 consumption…this is <3 dysfunction…
——-> if this continues, CO & BP drop…soooo organ failure :(
When it comes to hypovolemic shock, what are the compensatory mechanisms?
Tachycardia; redistribute blood from skin/gut/kidneys —> brain & heart
- RAAS (renal sodium & water retention)
- Secrete ADH (water retention by kidneys)
In obstructive shock, what are the compensatory mechanisms?
- obstruction to blood flow —> low CO & circ. collapse :O
What treatment of shock is the best/necessary in all shock states?
Oxygenation!
What are the classifications of shock? (4)
- Distributive
- Hypovolemic
- Cardiogenic
- Obstructive
What are the types of distributive shocks? (3)
- Septic shock
- Anaphylactic shock
- Neurogenic/Vasogenic shock
What are the causes of:
- Septic shock
- Anaphylactic shock
- Neurogenic/Vasogenic shock
- septic: cause -infection
- anaphylactic: cause - hypersensitivity
- neurogenic/vasogenic: cause - alteration in vas. smooth muscle tone
What are the causes of:
- hypovolemic shock
- cardiogenic shock
- obstructive shock
- Hypovolemic: cause - not enough intravascular fluid (ex. hemorrhage)
- Cardiogenic: cause - heart failure
- Obstructive shock: cause - mech. blockage (ex. tamponade, P.E., tension pneumothorax)
In septic shock, what are the key manifestation seen?
Increased HR, increased immune response
In anaphylactic shock, what are the key manifestations you will see?
Difficulty breathing, hives, itchiness
In neurogenic shock, what are the key manifestations seen?
low SVR, low HR, low BP
In hypovolemic shock, what are the key manifestations seen?
poor skin turgor, THIRST, increases SVR, cool extremities
In cardiogenic shock, what are they key manifestations seen?
chest pain, JVD seen
In obstructive shock, what are the key manifestations seen?
Depends… low BP, High HR, oliguria
Distributive shock is also called:
Vasodilatory shock
more from slides Manifestations of septic shock include:
- persistent low arterial pressure
- tachypnea (fast breathing)
Septic shock treatment includes: (3)
- CHECK LACTATE LEVELS; obtain blood cultures
- antibiotics & vasopressors (norepinephrine!)
- fluid resus. (IV crystalloids; LR or NS)
- +++ Consider hydrocortisone for adrenal insufficiency.
In anaphylactic shock, _________ causes a huge immune and inflammatory response.
Allergen
more from slides Manifestations of anaphylactic shock include:
- edema (airway, therefore hard time breathing)
- GI cramps
- Hives (urticaria)
- WATCH AIRWAY!!!
Anaphylactic shock treatment includes:
- **remove antigen!!!
- decrease mast cell & basophil degran.
- admin lactated ringers to reverse hypovolemia
- O2
When is it ideal to give Lactated Ringers?
For anaphylactic shock; to reverse relative hypovolemia
Define neurogenic/vasogenic shock:
Widespread vasodilation happens b/c there’s an imbalance between parasympathetic & sympathetic stimulation.
Causes continuous vasodilation & creates relative hypovolemia
—-> SVR decreases DRASTICALLY
Causes include:
- trauma, severe pain/stress/ anesthesia, depressant drugs
What is the treatment for neurogenic shock?
- positioning: RECUMBENT (lay on side); good for venous return…try not to turn head…legs up :)
- bolus fluids (supports CO)
- give vasopressors (treats fluid-refractory hypotension)
- Temp. reg (warm/cool)
- pain manage
Define cardiogenic shock:
Heart can’t pump enough blood to tissues & organs :(
- continuous hypotension & lack of tissue perfusion + left filling pressure problems :(
more from slides Manifestations of cardiogenic shock include:
dyspnea (+ the ones on my paper)
Cardiogenic shock treatments include:
- if there’s a problem with the PUMP, put in an IABP (Intra-aortic Balloon Counterpulsation)
- in general: mechanical support/surgery/pharm
A person develops cardiogenic shock after an acute MI. The nurse understands this will produce a(n):
a) inhibition of the sympathetic nervous system
b) decreased activation of the complement system
c) stimulation of the renin-angiotensin system
d) lowered production of catecholamine system
c
** b & d would be right if it said the opposite
Define hypovolemic shock:
Not enough intravascular fluid volume; loss of blood, plasma, or interstitial fluid
ex. hemorrhage, burns, emesis, diuresis (peeing a lot), diaphoresis (sweating), diabetes
more from slide Manifestation of hypovolemic shock is:
Low urine output
Treatment for hypovolemic shock includes: (4)
- hemorrhage control**
- fluid replacement
—–> adults: iso. crystalloids
—–> kids: iso. crystalloids OR colloids - blood replacement
- monitor for hypervolemia
Define obstructive shock:
Mechanical blockage that blocks blood flow to/from heart.
**commonly duo with cardiogenic shock :0
Treatment for obstructive shock includes: (4) **
- restore sys. O2 & perfusion
- eliminate blockage
- maintain airway, oxygenate, ventilate
- bolus fluids
Define MODS:
Lack of perfusion; massive inflammation b/c multi-organ damage :(
- happens b/c uncontrolled sys. inflammatory response to severe illness/injury
- progressive dysfunction of 2+ organs
The 2 most common causes of MODS are:
Shock and sepsis
**but can be caused by any injury/disease that starts huge sys. inflammation (ex. trauma, burns, etc.)
Diffrentiate between the 2 types of MODS:
Primary:
- directly because of injury
- 3-7 days after injury
Secondary:
- occurs later
- associated with more organ dysfunctions :(
What is primary MODS triggered by?
Low perfusion
What happens in primary MODS?
Neutrophils and macrophages are “primed” by cytokines…prepping WBCs to fight inflammation…
What are some key points about Secondary MODS? (3)
- O2 free radicals damage cells; leads to tissue necrosis
- platelet-activating factor damages endothelium, stim. clot formation, and activate more phagocytes.
- poor distribution of blood flow & poor perfusion to organs
What is the “pathway” of secondary MODS? (5)
SHOCK —> inflammation —> neutrophil/platelet —> endothelium —> MODS
What are the key manifestations of MODS? (2)
renal failure, altered mental status
Endothelial cell dysfunction and mediator release in multiple organ dysfunction syndrome produces:
a) a net procoagulant state
b) vasoconstriction
c) a reduction in oxygen free radicals
d) decreased proteases
a
**not b since we’re most concerned about VASODILATION
**not c b/c it’s an INCREASE in O2 free radicals
**not d b/c it’s an increase in proteases
In secondary MODS, the body goes into ______drive.
Overdrive
Which MODS is more concerning? Primary or Secondary?
Secondary; big clots can disturb blood flow :(
What are some manifestations of secondary MODS?
- first 24hrs: low-grade fever, tachy, fast breathing, altered mental status, hyperdynamic/hypermetabolic state
- 24-72 hrs: start of lung failure :(, potentially ARDS :0
- 7-10 days: hypermeta/hyperdynamic state intensifies, bacteremia common :0, more organ failure…
- end: heart & hematologic failure
Consequences of MODS include: (5)
- translocation of bacteria
- maldistribution of blood flow
- hypermetabolism
- imbalance in O2 supply & demand
- myocardial depression
True or false: vital signs are a reliable when it comes to assessing shock in children
FALSE
What are some things a nurse should assess for in a child suspected of experiencing shock?***
- extremely irritable
- lethargy
—–> LOC is going down - decrease response to pain stimuli
——> indicates severe heart/lung/neuro compromise :0 - resps, skin colour
In terms of skin colour and shock in children, what are abnormal findings?***(3)
- Mottling
—> marble/blotchy appearance; but might not be shock if mottling comes from a cold environment - Pallor (poor perfusion)
- Flushed, bright red skin (sepsis!)
True or false: In a child, BP may be normal up until the very late stages of shock.
True
True or false: Liver enzymes (serum lactate) should be assessed for a child who is suspected to be experiencing shock.
true
Which parameter will the nurse monitor to best determine the systemic perfusion in a child?
a) urinary output
b) partial pressure of arterial oxygen (PaO2)
c) systolic hypotension
d) serum lactate
d
**not a; this is good for burn victims
**not b; not an indication of sys. perfusion
**not c; this is late course…BP not a good indicator
What is the best indicator of shock?
Lactate
