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Definition

An-Najah National University Faculty of Nursing Emergency and disaster nursing Shock Prepared by: Mahdia Kony Submitted to: Dr. Ferial Hayajneh. Definition.

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Definition

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  1. An-Najah National UniversityFaculty of Nursing Emergency and disaster nursing ShockPrepared by: Mahdia KonySubmitted to: Dr. Ferial Hayajneh Mrs.Mahdia Samaha Kony

  2. Definition Shock is a syndrome resulting from inadequate perfusion of tissues, leading to a decrease in the supply of oxygen and nutrients required to maintain the metabolic needs of cells. Mrs.Mahdia Samaha Kony

  3. Mrs.Mahdia Samaha Kony

  4. Adequate blood flow to tissue needs: Mrs.Mahdia Samaha Kony

  5. Mrs.Mahdia Samaha Kony

  6. Mrs.Mahdia Samaha Kony

  7. Compensatory stage • Sympathetic nervous system (SNS): • Increase hart rate and contractility. • Arterial and venous vasoconstriction. • Shunting of blood to the vital organs. Mrs.Mahdia Samaha Kony

  8. Compensatory stage cont.. B) Hormonal compensation: • Activation of renin response. • Production of angiotensin II (causes vasoconstriction). • Release of aldosterone and ADH (leading to sodium and water retention). Mrs.Mahdia Samaha Kony

  9. Compensatory stage cont • Stimulation of adrenal gland by ACTH: - Adrenal cortex: produce glucocorticoids causing rise in blood glucose level. • Adrenal medulla: release of epinephrine and norepinephrine. C) Chemical compensation: • Hyperventilation to neutralize lactic acidosis. Mrs.Mahdia Samaha Kony

  10. Progressive stage • Compensatory mechanisms start to fail. • The small amount of energy created by anaerobic metabolism is not enough to keep the cell function. • The sodium- potassium pump fails, causing cell swell. • The mitochondria swell and rupture. • Irreversible damage occur. Mrs.Mahdia Samaha Kony

  11. Refractory stage Mrs.Mahdia Samaha Kony

  12. Clinical presentation of shock • Hypotension: - SBP less than 90 mmHg. - MAP less than 60 mmHg. - Reduction of more than 40 mmHg from baseline in the absence of other causes of hypotension. Mrs.Mahdia Samaha Kony

  13. Clinical presentation of shock • Tachycardia or bradycardia. • Altered mental status. • Anxiety or agitation • Confusion • Pale, cool, clammy skin • Low or no urine out put • Bluish lips and fingers nails Mrs.Mahdia Samaha Kony

  14. Clinical presentation of shock • Dizziness, light-headedness, or faintness. • Profuse sweating, moist skin • Rapid but weak pulse • Shallow breathing • Chest pain • Loss of consciousness Mrs.Mahdia Samaha Kony

  15. Mrs.Mahdia Samaha Kony

  16. Hypovolemic Shock • The most common shock syndrome to affect trauma patient is caused by hypovolemia. Loss of approximately one-fifth or more of the normal blood volume produces hypovolemic shock Blood Volume Problem Mrs.Mahdia Samaha Kony

  17. Hypovolemic Shock Definition: Hypovolemic shock is a particular form of shock in which the heart is unable to supply enough blood to the body. It is mainly caused by blood loss or inadequate blood volume . Mrs.Mahdia Samaha Kony

  18. Causes of hypovolemia Decrease or loss of circulating volume or components: 1. Blood: - trauma - fracture - major vascular injury - amputation - multisystem injury 2.Plasma: fluid shifts due to increased capillary permeability: - crush injury - burns - snakebites Mrs.Mahdia Samaha Kony

  19. Causes of hypovolemia 3.Water loss / dehydration: Excess wounds or gastrointestinal drainage: Diarrhea Diabetes insipidus High output renal failure Insensible water losses of lungs and skin Hyperosmoral intake (osmotic diuresis) Mrs.Mahdia Samaha Kony

  20. Hypovolemic Shock • Pathophysiology: - Decrease circulating volume. - Decrease venous return. - Decrease stroke volume - Decrease cardiac output. - Decrease cellular oxygen supply. - Impaired tissue perfusion. - Impaired cellular metabolism. Mrs.Mahdia Samaha Kony

  21. Mrs.Mahdia Samaha Kony

  22. Hypovolemic Shock • Investigations: • CBC • Blood group and cross match(6units) • Serum electrolytes(Na, K, Cl, HCO3, BUN, creatinine, glucose levels ) • ABGs • Prothrombin time, activated partial thromboplastin time • Urinalysis (in patients with trauma) Mrs.Mahdia Samaha Kony

  23. Hypovolemic Shock • Radiological studies: 1- Ultrasonographic examination in the ED if an abdominal aortic aneurysm is suspected 2- An upright chest radiograph should be obtained if a perforated ulcer is a possibility. Mrs.Mahdia Samaha Kony

  24. Radiological studies: 3- If GI bleeding is suspected, a nasogastric tube should be placed, and gastric lavage should be performed. 4- Endoscopy can be performed (usually after the patient has been admitted) to further delineate the source of bleeding. Mrs.Mahdia Samaha Kony

  25. Management of patient withhypovolemia Goals of management in the emergency department are as follows: (1) Maximize oxygen delivery by : Ensuring adequacy of ventilation Increasing oxygen saturation of the blood restoring blood flow (2) Control further blood loss (3) Fluid resuscitation. Also, the patient's disposition should be rapidly and appropriately determined. Mrs.Mahdia Samaha Kony

  26. Management of patient withhypovolemia • In the patient with GI bleeding, intravenous vasopressin is administered • Long-bone fractures should be treated with traction to decrease blood loss. Mrs.Mahdia Samaha Kony

  27. Management of patient withhypovolemia Control further blood loss: depends on the source of bleeding: • Direct pressure should be applied to external bleeding vessels to prevent further blood loss. • Internal bleeding requires surgical intervention Mrs.Mahdia Samaha Kony

  28. Management of patient withhypovolemia Fluid resuscitation: • Crystalloids or colloids fluid replacement • Isotonic sodium chloride solution, lactated Ringer solution, hypertonic saline • Albumin, fresh frozen plasma • Blood, whole blood, packed red blood cells, platelets. Mrs.Mahdia Samaha Kony

  29. Management of patient withhypovolemia • Closely monitor patients at risk for fluid deficit (younger than one year or older than 65 years of age) • Ensure safe administration of prescribed fluids and medications • Monitor and report signs of complications and effect of treatment. Mrs.Mahdia Samaha Kony

  30. Management of patient withhypovolemia • Monitor for cardiovascular overload and pulmonary edema: hemodynamic pressure, vital signs, arterial blood gases, and fluid intake& output • Reduce fear and anxiety about the need for oxygen mask by giving patient explanation and frequent reassurance Mrs.Mahdia Samaha Kony

  31. Cardiogenic Shock • Cardiogenic shock is the result of failure of the heart to pump blood forward effectively. Blood Pump Problem Mrs.Mahdia Samaha Kony

  32. Cardiogenic Shock • Etiology: Primary ventricular ischemia: - MI ( it occur in 6- 20% of MI patient) - Cardiopulmonary arrest. - Open heart surgery. Mrs.Mahdia Samaha Kony

  33. Cardiogenic Shock Structural problem: - Septal rupture. - Papillary muscle rupture. - Cardiomyopathies. - Myocardial contusion or blunt cardiac injury (BCI). - Valvular dysfunction. - Atrial thrombus, and pulmonary embolus. Mrs.Mahdia Samaha Kony

  34. Cardiogenic Shock Dysrhythmias: - Bradydysrhythmias. - Tachydysrhythmias Mrs.Mahdia Samaha Kony

  35. Cardiogenic Shock • Pathophysiology cont. - Impaired pumping ability of ventricles. - Decrease in stroke volume. - Increase in the blood left in the ventricles - Backup of the blood into pulmonary system - Development of pulmonary edema. - Impaired gas exchange & tissue perfusion. Mrs.Mahdia Samaha Kony

  36. Cardiogenic Shock • Clinical manifestations of Cardiogenic shock: • Systolic blood pressure < 90mmHg. • Heart rate > 100 beats/min. • Weak, thready pulse. • Diminished heart sounds. ( murmurs) • Urine output < 30 ml/hr. • Cool, pale, moist skin. • Chest pain. • Tachypnea and crackles. Mrs.Mahdia Samaha Kony

  37. Cardiogenic Shock • Management: - The goals of therapy are: 1. Treat the underlying cause. 2. Enhance the effectiveness of the pump. 3. Improve tissue perfusion. Mrs.Mahdia Samaha Kony

  38. Cardiogenic Shock • Management: - Inotropic agents: increase contractility. - Vasodilating agents & diuretics: afterload and preload reduction. - Antidysrhythmic agents: To suppress or control dysrhythmias that can affect cardiac output. Mrs.Mahdia Samaha Kony

  39. Cardiogenic Shock • Management: Therapies to increase myocardial oxygen supply: 1. Supplemental oxygen. 2. Intubation and mechanical ventilation. 3. Coronary artery vasodilator ( Nitroglycerine). 4. Thrombolytic agents. 5. Intracoronary stent. 6. Coronary artery bypass surgery . 7. Intraaortic balloon pump. Mrs.Mahdia Samaha Kony

  40. Obstructive Shock • Obstructive shock results from an inadequate circulating blood volume because of an obstruction or compression of the great veins, aorta, pulmonary arteries, or the heart itself. • Etiology: • Cardiac tamponade. 2. Tension Pneumothorax & hemothorax. Mrs.Mahdia Samaha Kony

  41. Obstructive Shock Cardiac Tamponade: • Pathophysiology: - Compress the heart during diastole. - Atria cannot adequately fill. - Decrease in stroke volume. - Decrease in cardiac output. Mrs.Mahdia Samaha Kony

  42. Obstructive Shock Clinical manifestations of Cardiac Tamponade : - Elevated CVP with neck vein distended. - Hypotension. - Muffled heart sound. Mrs.Mahdia Samaha Kony

  43. Obstructive Shock • Management of Cardiac Tamponade: Immediate treatment is required to remove the accumulation of fluid in the pericardial sac by : 1. Pericardiocentesis: Aspiration of fluid from pericardium using large- bore needle. Be alert: there is risk of laceration of coronary artery. 2. Thoracotomy or median sternotomy. Mrs.Mahdia Samaha Kony

  44. Obstructive Shock Tension Pneumothorax & hemothorax • Pathophysiology: - Displacing the inferior vena cava. - Obstructing the venous return to the right atrium. - Decrease atrial filling. - Decrease stroke volume & C.O. Mrs.Mahdia Samaha Kony

  45. Obstructive Shock Clinical manifestations: - Sever respiratory distress. - Hypotension, & signs of shock. - Distended neck veins, head & upper extremity veins. - Tracheal deviation toward uninjured side. Mrs.Mahdia Samaha Kony

  46. Obstructive Shock Tension Pneumothorax & hemothorax - Management: A large-bore needle or chest tube inserted into the affected lung to release of air or blood. Mrs.Mahdia Samaha Kony

  47. Distributive Shock • Is a shock syndrome that resulting from poor distribution of blood flow. • Intravascular volume is maldistributed because of alteration of blood vessels. Mrs.Mahdia Samaha Kony

  48. Distributive Shock • Etiology: - Neurogenic shock. - Anaphylactic shock. - Septic shock. Mrs.Mahdia Samaha Kony

  49. Neurogenic Shock • A type of distributive shock that results from the loss or suppression of sympathetic tone. (the rarest one) • Most common cause: Spinal cord injury above T 6. Mrs.Mahdia Samaha Kony

  50. Neurogenic Shock • Pathophysiology: - loss vasomotor tone: Peripheral vasodilatation (venous pooling) maldistribution of blood volume decrease venous return, stroke volume, and cardiac output. Mrs.Mahdia Samaha Kony

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