Shock

1. Shock Jimmy Durbin, MSN, RN

2. Homeostasis vs. Shock • Homeostasis is balance or equilibrium of the whole body

3. Shock • Whole body response to poor tissue perfusion • Any situation that impairs oxygen delivery to tissue and organs can start the shock syndrome • Shock is a condition, not a disease

4. Shock • Definition: • A condition in which tissue perfusion is inadequate to deliver oxygen and nutrients to support vital organs and cellular function. • Requirements to keep homeostasis • Adequate cardiac pump • Effective vascular (circulatory system) • Sufficient Blood volume If one of these components is compared your perfusion to the tissues is compromised and you can go into shock

5. Shock • Common physiologic responses • Hypoperfusion of the tissues • Hypermetabolism (the body uses up the stored ATP to compensate. It’s anaerobic.) • Activation of the inflammatory response • Body’s response • Activates the sympathetic nervous system and mounts a hypermetabolic and inflammatory response

6. Pathophysiology • Inadequate blood supply to tissues (low blood volume, poor cardiac output, or low blood pressure) • Lack of oxygen and nutrients • Anaerobic metabolism- (which causes)Acidosis • Lactic acid buildup and an acidotic environment. When you have that environment the cell stops working. Shit goes crazy…

7. Pathophysiology • Vascular Response • Blood Pressure Regulation • MAP (Mean arterial Pressure)

8. MAP • Organ perfusion is related to MAP • Three mechanism that influence MAP • Total blood volume (how much blood is circulating at any given time) • Cardiac output (is the heart generating a good, solid beat each time) • Size of the vascular bed (made up of arteries, arterioles, capillaries, and veins. Veins can either dilate or contract. This is what effects our blood pressure)

9. MAP • Average pressure at which blood moves through the vasculature. • ↑ total blood volume or cardiac output ↑MAP • ↓ total blood volume or cardiac out ↓ MAP • ↑vascular bed ↓ MAP (dilation) • ↓ vascular bed ↑ MAP (vasoconstriction)

10. MAP • Blood vessels can increase in diameter by relaxing or dilating vessel walls or decrease by contracting or vasoconstriction. (that’s what’s going to control the MAP)

11. MAP • MAP=cardiac output x peripheral resistance • Cardiac output = stroke volume x heart rate • Stroke Volume=amount of blood ejected at systole • Peripheral resistance-determined by diameter of vessels • Vasoconstriction=increased vascular resistance • Vasodilation=decreased vascular resistance

12. MAP=systolic BP + 2(Diastolic BP) ÷ 3 BP=125/75 125 + 2(75) 3 = 92 An average MAP of 70-80 mmHg is necessary for cells to receive oxygen & nutrients to metabolize energy. MAP (Will be math questions on exam! MEMORIZE THIS!!)

13. Pathophysiology • Baroreceptors/chemoreceptors trigger compensatory mechanisms Drop in BP ↓ SNS responds by →releasing catecholamines (epi and nor-epi) ↓ Vasoconstriction (caused by the epi and nor-epi) →↑BP

14. Patho summed up! • Have to have adequate blood volume, cardiac output, and effective vasculature to maintain BP and tissue perfusion. • When one of the three components fails, the body compensates by increasing the other two. • When compensatory efforts fail, the tissues are poorly perfused and SHOCK results. • Will result in organ failure and death

15. Stages of Shock Three stages of shock • Compensatory/Non Progressive • One isn’t working but the other two try and correct it • Progressive • 2nd one isn’t working • Irreversible • We can’t do anything for them

16. Shock Stage 1 Compensatory or Non-progressive Cellular changes begin • Blood pressure remains normal, MAP ↓ 10-15 mmHg • SNS stimulated • ↑ vasoconstriction, ↑ heart rate So in this first stage the BP is going to stay the same, but your indication is that the heart rate will increase. The kidneys retain fluid (which is why BP remains the same), the Cardiac Output is maintained by vasoconstriction and increased contractility

17. Shock Stage 1 • “Fight or Flight” response – cold, clammy skin; hypoactive bowel sounds, decreased urine output. • Shunts all your blood to your heart and brain. These people are all the above symptoms because your brain and heart are the 2 most important things in your body. Build up of lactic acid which leads to metabolic acidosis. • Acidosis→↑ respiratory rate (you’re body is trying to get back to homeostasis by doing this. Can lead to respiratory alkalosis?) • Possible changes in mental status • Prognosis is good if we pick up on this early

18. Shock Stage 2 Progressive – MAP ↓ 20 mmHg or more • BP falls to 90mmHg or less • Cardiac pump fails • No regulation of microcirculation • Fluids shift into the cells (when fluids go into the cell they’re not really in the circulating volume. You can have a lot of fluid in your body but it’s not really a functionable thing in the cell. Like a 3rd spacing deal. Survival depends on the persons health before they went into shock. Sick people may not recover from this but a healthy person might.

19. Rapid/shallow respirations Decreased 02 saturations Pulmonary congestion Rapid heart rate Chest pain Decreased mental status Unconsciousness Acute renal failure GI bleed Widespread clotting Bleeding simultaneously (DIC or disceminated intervascular coagulation) Really devastating when they clot and bleed at the same time Signs/Symptoms Progressive Stage

20. Shock Stage 3 Irreversible stage – Organ damage so severe patient will not respond to any treatment • Multiple organ systems begin to fail → Multiple Organ Dysfunction syndrome (MODS) This is where they have massive tissue injury due to trauma. Most common manifestation from Shock.

22. Classifications of Shock • Hypovolemic Shock • Decrease in intervascular volume • Cardiogenic Shock • Pump (heart) isn’t working • Circulatory Shock • Septic Shock (caused by infection) • Neurogenic Shock (caused by injury or induced when dr’s give people meds, spinal anesthesia, whatever) • Anaphylactic Shock (allergic to something like peanuts. First time reaction won’t be too bad, could go straight to full on reaction)

24. Hypovolemic Shock • Hypovolemia –body fluid depletion • Hemorrhage • Trauma • GI ulcer (and associated bleeding with that ulcer) • Surgery • Inadequate clotting • Dehydration • Vomiting & Diarrhea • Diuretic therapy (Lasix and all that mess. If you pee too much you could go into hypovolemic shock) • NG suction • Can also be loss of plasma from burns… • A state of hypovolemic shock begins when the intervascular volume has decreased by about 15%

25. Hypovolemic Shock Manifestations: • Poor skin turgor • Thirsty • Oliguria- diminished capacity to make urine. Less than 500mL in a 24 hour period. Like it to be 30mL an hour • Rapid heart rate • Thready pulse • Mental status deterioration

26. Hypovolemic Shock • Treatment: • Restore intravascular volume • Redistribute fluid volume • Correct the underlying cause of fluid loss

27. Hypovolemic Shock Fluid Resuscitation • Crystalloids • Isotonic solutions - move freely between compartments • Lactated Ringers • Normal Saline • Colloids • Blood • Whole blood & PRBC’s (Packed red blood cells) • Blood products • Albumin, hetastarch, plasmanate • When you work with these type patients you have to remember that LR, NS, all that stuff, none of these have an oxygen carrying capacity. If they’ve lost all their blood and you fill ‘em full of this, they won’t have enough stuff in them that carries oxygen. You can overload them with fluid and it won’t help them out much cause they can’t get oxygen from their lungs to their body tissues.

28. Hypovolemic Shock • Nursing Management • Ensure a patent airway (always #1) • Make sure client has patent IV access • If they need something in an emergency you want them to have a patent line. • Administer oxygen • Place client in Modified Trendelenburg • If overt bleeding, apply pressure to the site • Monitor vital signs every 5 minutes • Those vitals can change very quickly. • Administer meds as ordered • Increase the rate of fluid delivered

29. Circulatory Shock • Circulatory • decreased vascular volume or tone • Further divided by • Septic Shock • Neurogenic Shock • Anaphylactic Shock

30. Septic Shock • Causes • Widespread infection • Gram negative bacteria • Sepsis is most prevalent in pt’s with bacterimia and pneumonia • The most common type of circulatory shock is Septic Shock!!

31. Risk Factors of Sepsis • Broad spectrum antibiotics (bugs are resistant to overuse of these broad spectrum guys) • Immunosuppressive therapy • If they get a minor infection they’ll end up in the hospital for a week or more. Don’t cough on these sick ass bitches. • Burns or other trauma • Anatomic obstruction • Bowel obstruction can keep blood from getting in there. Part of the bowel can die and they have to go in and cut it out • Age (very young & very old) • Malignancy, diabetes, AIDS • Nosocomial infection • Really critical for the immunosuppresed bastards

32. Septic Shock • Systemic response to infection manifested by two or more of the following: • Temp >100.9 or <96.8 • Heart rate >90 • Respirations >20 • Leukocyte >12,000 or <4000, or >10% bands

33. Cardiovascular Manifestations of Septic Shock • Hyperdynamic-warm phase (temp up and WBC above 12,000) • Pink, warm flushed skin • Tachycardia • Tachypnea • Slight BP increase • Urine output normal to less than normal

34. Cardiovascular Manifestations of Septic Shock • Hypodynamic –cold phase (temp low and WBC less than 4000) • DIC-endotoxins cause clotting of blood & consumption of platelets • Cardiac output, systolic BP, & pulse pressure all↓ • Pale, cool, clammy skin • Weak thready pulse (you’ll have to work to find it) • Tachycardia & tachypnea • Hypotension • ↓ urine output, pulmonary congestion, edema

35. Septic Shock • Treatment • Identify and eliminate cause • Pharmacologic Therapy • Broad spectrum antibiotics • Sometimes these are the culprits of sepsis, but whatever, you still use them. It’s also why it’s important to get a culture • Nutritional Therapy • Aggressive nutritional supplementation

36. Septic Shock • Nursing Management • Asepsis and hygiene • Culture & Sensitivity • Parenteral therapy and medication

37. Neurogenic Shock • Causes • Spinal cord injury • Spinal anesthesia • Nervous system damage • Trauma, drugs, anesthetics, and severe emotional stress. Fun fun!

38. Neurogenic Shock • Manifestations: • Low BP • Bradycardia • Oliguria, ↓LOC, dyspnea, etc. • The hallmark symptom of neurogenic shock is very low BP! Bradycardia is the most obvious symptom and is present in the early stages.

39. Neurogenic Shock • Treatment • Restoring sympathetic tone • If they’ve had anesthisia or whatever we’re going to take them off that drug that’s causing the problem • Depends on cause of shock

40. Neurogenic Shock • Nursing management • Elevate and maintain HOB 30 degrees • Most everyone on a neuro floor has the HOB up 30 • Support cardiovascular and neurologic function • Prevent blood pooling in lower extremities • Apply TED hose • Prevent DVTs

42. Anaphylactic Shock • Severe allergic reaction • Antigen-antibody reaction (transfusion reaction, stay in room for 15 mins to check for this). • Massive vasodilation • Latex is an allergy that is starting to become more and more frequent. Betadine is one also Occurs rapidly and is life-threatening! PCN is a common allergy. Make sure to include teaching saying that the first time you have the reaction may be limited/small but the very next one could be fucking major and kill you. Good assessments are key, like they are with every other thing on the face of the planet

43. Anaphylactic Shock • Manifestations • Anxiety • Dyspnea • GI cramps • Edema • Hives • Sensations of burning or itching skin

44. Anaphylactic Shock Medical Management • ABC’s • Epinephrine 1:100(0? Maybe) (0.3 – 0.5 ml) • Antihistamines • Oxygen • Bronchodilators • Steroids • Fluid replacement/volume expanders

45. Anaphylactic Shock • Nursing Implications • Assess for allergies • Communication • Knowledgeable about s/s (and how to deal with them should they arise) • Teach about future exposures (and inform the families also so they can help)

46. Tidbits to remember • Pulse & blood pressure alone are not reliable indicators of shock! • Blood pressure is made up of 5 factors: • Blood volume • Cardiac output • Elasticity of blood vessels • Size of blood vessels • Viscosity of the blood