Shock 2022 PDF

“Inadequate Tissue Perfusion & Impaired Oxygen Delivery” By Steve Casarez, RN MVC Faculty  Clinical syndrome resulting from inadequate tissue perfusion  Result from decreased blood volume or circulatory stagnation  Resulting in a...

“Inadequate Tissue Perfusion & Impaired Oxygen Delivery” By Steve Casarez, RN MVC Faculty  Clinical syndrome resulting from inadequate tissue perfusion  Result from decreased blood volume or circulatory stagnation  Resulting in a state of Hypoperfusion  Resulting in changes to Hemodynamics  A bodies response to an Extrinsic and Intrinsic factor Examples:  Illness or Sickness  Diseases Processes  Trauma  Stress  Snake bite  Dehydration  Exposures  Hypoperfusion  Shunting of blood bypassing capillary exchange beds  Inadequate aerobic cell metabolism (Krebs Cycle)  Increased CO2 and Lactate blood levels  Increase oxygen consumption  Increase inflammatory process and clotting cascade in areas of Hypoperfusion  Endothelial cell damage activates WBC’s  Severe shock releases potent inflammatory processes leading to vasodilation. This process is massive in Septic Shock.  Anaerobic metabolism increasing Lactate blood levels  Metabolic Acidosis (low HCO3)  Base deficit becomes more negative (-2 - +2)  Severe shock may decreases eTCO2  Increase in WBCs Depending on the type of shock, other cellular responses may take place!  HEMODYNAMICS Pumps, Pipes, Fluids, & Electrical “Shock” Releases a catastrophic cascade of events 1. Identify the etiology 2. Identify type of shock 3. Search for reversal agents and treatment 4. Monitor hemodynamics 5. Treat preload (fill the tank) Story, L. (2012). Pathophysiology: A practical approach. Jones & Bartlett Learning: Burlington, MA. Diastolic Systolic  Pumps, Pipes, Fluids, & Electrical Diastolic Systolic Fluid Loss Pump Loss & Electrical Loss Pipe Loss  MAP Stroke Volume High Afterload Low Afterload 1. NTG 1. Dopamine RV Lungs LV 2. Nitroprusside (Nipride) 2. Dobutamine Pulmonary Systemic 3. Nicardipine 3. Epinephrine 4. Hydralazine 4. Levophed CO/CI = HR x PVR PAP SVR SAC 5. Labetalol 5. Phenylephrine 4-8/2.5-4 60-100 20-120 15-25 800-1200 6. A,B,C,D’s CVP PCWP DPF High Preload Low Preload 0-8 8-15 8-12 1. NTG 1. Fluids 2. Diuretics 2. Blood 3. “Some above” 3. cardiac drugs Contractility Ejection Fraction 60-70% 4. Dialysis 4. pace maker 5. A,B,C,D’s Organ Perfusion Chronotropic Inotropic Dromotropic ( Electrical Impulse) - HR +HR - Contractility +Contractility Electrical Activity 1. ABCD’S 1.Atropine 1. ABCD’s 1. Dopamine SAC = Depolarization = Active phase = PQRS 2.Epinephrine 2. Dobutamine DPF = Repolarization = Resting phase = T 3. Epinephrine  Sympathetic nervous system “Fight or Flight” Vasoconstriction (circulatory shunting)  RAAS Catecholamine release to speed up HR and vasoconstriction of vessels  Aldosterone of RAAS Released to uptake NA+ in the Kidneys to maintain B/P  ADH (Antidiuretic Hormone) Also named Vasopressin Released by the pituitary gland Uptakes of water in the Kidneys to maintain B/P Shock Examples EMS Treatments 1. Hypovolemic 1. Trauma 1. Blood products 2. Cardiogenic 2. MI 2. NS @ AHA drugs 3. Obstructive 3. Tension Pneumothorax 3. Needle T 4. Anaphylactic 4. Drug allergy 4. Epi @ Benadryl 5. Distributive 5. Sepsis 5. NS boluses 6. Neurogenic 6. Brain injury 6. NS boluses 7. Dissociative 7. Oxygen not releasing 7. Oxygen Hgb related to toxins ingestions  Compensatory Decompensated Irreversible S/S: S/S: S/S: HR elevated HR elevated PEA HR bounding +3 HR weak +1 Apnea B/P WNL or High B/P low, may Does not respond RR fast respond to fluid to resuscitation SPO2 WNL challenges efforts Anxiety RR slow or stop Restlessness Skins maybe Weakness dusk or pale, Confused extremities cold Skins way be cool and clammy  Loss of Volume that “is not returned”  Examples: Hemorrhagic  This has its own stages of shock  Will discuss more during Trauma lecture Dehydration N/V/D “Third spacing”  Stage I Stage II Stage III Stage IV Heart Rate 140 Blood Normal Normal Decreased Decreased Pressure Blood Loss Up to 750ml 750-1500ml 1500-2000ml >2000ml % Blood Up to 15% 15-30% 30-40% >40% Volume Pulse +2 or +3 +1 +1 +1 or none Pressure Respiratory 14-20 20-30 30-40 >35 Rate CNS Slight Anxiety Mildly Anxious Anxious, Confused, Confused Lethargic  Delayed when a patient is in shock  Blood shunts away from fingers and toes  Extremities shunt blood  Lungs shunt blood “Inadequate Tissue Perfusion & Impaired Oxygen Delivery” We will have an in-depth discussion on this topic during Trauma Lecture and Winter sessions. Do not study this portion for the test!!  Impaired pump, decreased cardiac output Decrease tissue perfusion with increase in demand History  AMI  CHF  CPR  Aneurysm  Rupture  MI  Myocarditis  Pulmonary Embolism  Cardiomyopathy  Prolonged cardiac  Hemorrhagic Trauma surgery  Heart failure  Ventricular aneurysm  Hypothermia  Ventricular wall rupture  Severe electrolyte/acid-  Cardiac dysrhythmias base imbalance  Rupture of ventricular septum  Generalized Vasodilation Decreasing the preload, stroke volume, and cardiac output Examples of four types:  Septic  Endotoxins evade circulatory system  Inflammatory mediators are triggered  Increasing capillary permeability and fluid shifts  Neurogenic  Loss of sympathetic tone  Increasing smooth muscle relaxation and massive dilation  Anaphylactic  Burns  ALOC  Hypotension despite adequate fluid resuscitation  Along with presence of perfusion abnormalities  Will have a source of infection  Will have an elevated temperature  Increase in lactate  May have low capnography reading  Decreased urine output  Body exposed to a substance that produces a severe allergic reaction. This is not anaphylactic shock  Dust, pollen, mold, animal  Local anesthetics dander  Medications  Foods:  NSAIDs  milk, eggs, nuts  ASA, ibuprofen,  shellfish, beans  IV contrast dyes  Latex/rubber products  Radiocontrast media  Blood components  Antibiotics  Insect venom  S/S  TX Airway problems Remove pt from unusual lung sounds environment Rash/hives O2 Hypotension Cardiac Monitor N/V/D IV Past Hx of this event Clinically Treat pt  Neurogenic shock Disruption in Central Nervous System (CNS) sympathetic system Results in massive Vasodilation  General anesthesia  Spinal anesthesia  Injury to head or spinal cord (above T6)  Loss of sympathetic tone below injury  Spinal cord injury is the most common cause  Spinal Shock is not SHOCK!  Spinal Shock is a transient depression of reflex activity below the level of injury.  It presents like Shock.  Neurogenic shock Etiology and history  General anesthesia  Spinal anesthesia  Ingestion of barbiturates or phenothiazine's  Injury to head or spinal cord (above T6)  Loss of sympathetic tone below injury History  Spinal cord injury is the most common cause  Assess for pain, paresthesia, loss of LOC  Vasodilation occurs below injury  Widened pulse pressure with eventual decrease in BP  Variations in palpable pulses  Increased respirations  Skin pale, mottled, cyanotic  Manual C-spine until full spinal stabilization  Open airway with jaw thrust maneuver  High concentration of O2, consider ventilation  Pulse-oximetry/capnometry >95% saturation  ECG monitor, IV fluids/medications  Check glucose level  Reassess patient frequently  Maintain body temperature  Description and definition  Cardiac Tamponade  Tension Pneumothorax  Tension Hemothorax  Massive Pulmonary Embolism  Obstruction of blood flow to heart  Etiology  Cardiac tamponade results from fluid (blood) in the pericardial sac  Excess fluid buildup compresses heart  Heart’s ability to relax and fill during diastole is impaired  Impaired filling reduces cardiac output and preload  Tension pneumothorax caused by air in pleural space  Pulmonary embolus results in ventilation/perfusion mismatch  Left ventricular rupture occurs due to AMI/cardiac tamponade Physical findings  Dyspnea  Anxiety  Tachycardia and tachypnea  Affected breath sounds (tension)  Hypotension  Muffled heart tones (tamponade)  Altered mental status  Diaphoresis  Beck’s triad (tamponade)  JVD  Dissociative shock (special category) Heart, volume, and container are intact and normal The problem is with the oxygen-carrying capabilities of the tissues Common causes:  Severe Anemia  Methemoglobinemia  When hemoglobin UNABLE to carry oxygen (rare)  Carbon Monoxide Poisoning  Cyanide Poisoning Caused by the inability of O2 to reach cells Left Shift