Shock, SIRS, and MODS PDF

SHOCK Precy P. Lantin, MAN, RN  Shock  is a life-threatening condition that occurs when the body is not getting enough blood flow.  Affects all body systems  Cellular Effects of Shock  The cell swells and the cell membrane becomes more permeabl...

SHOCK Precy P. Lantin, MAN, RN  Shock  is a life-threatening condition that occurs when the body is not getting enough blood flow.  Affects all body systems  Cellular Effects of Shock  The cell swells and the cell membrane becomes more permeable, and fluids and electrolytes seep from and into the cell. Mitochondria and lysosomes are damaged, and the cell dies. Stages of Shock 1. Compensatory 2. Progressive 3. Irreversible  Compensatory  The patient’s blood pressure remains within normal limits  Vasoconstriction, HR, and contractility of the heart contribute to maintaining adequate cardiac output. release of catecholamines (epinephrine and norepinephrine).  Compensatory Cont.  The patient displays the often-described “fight or flight” response.  The body shunts blood from organs such as the skin, kidneys, and gastrointestinal tract to the brain and heart to ensure adequate blood supply to these vital organs.  Compensatory Cont.  As a result, the patient’s skin is cold and clammy, bowel sounds are hypoactive, and urine output decreases in response to the release of aldosterone and ADH  It may only persist for minutes to hours before progressing to decompensated or irreversible shock if not treated promptly.  Progressive In the progressive stage of shock, the mechanisms that regulate blood pressure can no longer compensate and the MAP falls below normal limits, with an average systolic blood pressure of less than 90 mm Hg. (Abraham et al., 2000)  Irreversible The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive. Despite treatment, blood pressure remains low. Multiple organ dysfunction can occur as a progression along the shock continuum or as a syndrome unto itself.  Overall Management Strategies in Shock o Fluid replacement to restore intravascular volume o Vasoactive medications to restore vasomotor tone and improve cardiac function o Nutritional support to address the metabolic requirements that are often dramatically increased in shock Fluid replacement is administered in all types of shock.  VASOACTIVE MEDICATION THERAPY Vasoactive medications are administered in all forms of shock to improve the patient’s hemodynamic stability when fluid therapy alone cannot maintain adequate MAP. Hypovolemic Shock Cardiogenic Obstructive Distributive  HYPOVOLEMIC SHOCK o It occurs when there is LOW fluid volume in the intravascular system o Hypovolemic shock occurs when there is a reduction in intravascular volume of 15% to 25%. This would represent a loss of 750 to 1,300 mL of blood in a 70-kg (154-lb) person. The average human blood volume is 5L (exact amount depends on the person’s size). So, if a person who has a blood volume of 5L and loses 1L of blood volume (1,000 mL), that would be 20% of their blood volume. This person would start showing signs and symptoms of hypovolemic shock.  Medical Management 1. restore intravascular volume to reverse the sequence of events leading to inadequate tissue perfusion 2. redistribute fluid volume 3. correct the underlying cause of the fluid loss as quickly as possible Proper positioning (modified Trendelenburg) for the patient who shows signs of shock. The lower extremities are elevated to an angle of about 20 degrees; the knees are straight, the trunk is horizontal, and the head is slightly elevated.  Remember the 3:1 rule for crystalloid solutions: For every 1 mL of approximate blood loss, 3 mL of crystalloid solution is given.  CARDIOGENIC SHOCK Cardiogenic shock occurs when the heart’s ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues. The causes of cardiogenic shock are known as either coronary or non-coronary. Coronary cardiogenic Non-coronary causes can be is more common related to metabolic problems seen most often in patients with myocardial infarction. and tension pneumothorax. occurs when a significant amount not affected with disease or of the left ventricular myocardium involving the coronary vessels has been destroyed (Price et al., of the heart 1999)  Medical Management The goals of medical management are to: (1) limit further myocardial damage and preserve the healthy myocardium and (2) improve the cardiac function by increasing cardiac contractility, decreasing ventricular afterload, or both (Price et al., 1999). In general, these goals are achieved by increasing oxygen supply to the heart muscle while reducing oxygen demands. INITIATION OF FIRST-LINE TREATMENT First-line treatment of cardiogenic shock involves the following actions: Supplying supplemental oxygen Controlling chest pain Providing selected fluid support Administering vasoactive medications Controlling heart rate with medication or by implementation of a transthoracic or intravenous pacemaker Implementing mechanical cardiac support  OBSTRUCTIVE SHOCK  is a form of shock associated with a physical obstruction/ blockage of the great vessels or something interfering with the filling or emptying of the heart.  Obstructive Shock - Caused by a mechanical obstruction that prevents an adequate volume of blood from filling the heart chambers. Three of the most common examples: Cardiac tamponade Tension pneumothorax Pulmonary embolism Obstructive Shock: Management Control airway Intubation Treat the underlying cause Tension Pneumothorax: Chest tube Pericardial Tamponade: Pericardiocentesis Pulmonary Embolism: Anticoagulation Isotonic fluids  Circulatory or distributive shock  results from a maldistribution or mismatch of blood flow to the cells.  shock state resulting from displacement of blood volume creating a relative hypovolemia and inadequate delivery of oxygen to the cells; also called distributive shock. Medical Management  Identifying and eliminating the cause of infection.  Specimens of blood, sputum, urine, wound drainage, and invasive catheter tips are collected for culture using aseptic technique.  Any potential routes of infection must be eliminated. Intravenous lines are removed and reinserted at other body sites.  Antibiotic-coated intravenous central lines may be placed to decrease the risk of invasive line-related bacteremia in high- risk patients, such as the elderly (Eggimann & Pittet, 2001).  Fluid replacement must be instituted to correct the hypovolemia  Crystalloids, colloids, and blood products may be administered to increase the intravascular volume  Classification of Circulatory shock 1. 2. 3. Septic Neurogenic anaphylactic shock shock shock  Septic shock o It can occur in any person with impaired immunity, but elderly people are at greatest risk. o The disorder is thought to be a response to that release microbes or immune mediators, such as tumor necrosis factor and interleukin- 1. o Septic shock occurs due to sepsis and leads to a major decrease in tissue perfusion to organs and tissues.  Management of Septic Shock:  Requires hemodynamic monitoring and high dependency facilities  ABC- - Check the airway is clear - Give high flow oxygen, if refractory hypoxia, intubate and ventilate. - Insert large bore peripheral venous canula to begin fluid resuscitation. - Insert central line and arterial line  Management of Septic Shock:  Early goal-directed resuscitation: during the first 6 hours after recognition (in patients with hypotension and serum lactate more than 4 mmol/L)  Resuscitation goals include: - MAP more than 65 mmHg - Target CVP of 8-12 mmHg (12-15 mmHg if ventilated) - Central venous O2 saturation (ScvO2) equal or more than 70% - Urine output equal to or more than 0.5 mL/kg/h  NEUROGENIC SHOCK Is a shock state resulting from loss of sympathetic tone causing relative hypovolemia. This loss of sympathetic tone results in massive vasodilation and a decrease in peripheral vascular resistance, causing blood to pool in the venous system.  NEUROGENIC SHOCK Symptoms:  low blood pressure (hypotension)  slow heart rhythm (bradyarrhythmia)  flushed, warm skin that gets cold and clammy later  lips and fingernails that look blue  lack of full consciousness  Medical Management Treatment of neurogenic shock involves restoring sympathetic tone either through the stabilization of a spinal cord injury or, in the instance of spinal anesthesia, by positioning the patient properly.  Nursing Management o Elevate and maintain the head of the bed at least 30 degrees.  Elevation of the head of the bed helps to prevent the spread of the anesthetic agent up the spinal cord. o In suspected spinal cord injury, neurogenic shock may be prevented by carefully immobilizing the patient to prevent further damage to the spinal cord.  Anaphylactic shock  is caused by a severe allergic reaction when a patient who has already produced antibodies to aANAPHYLACTIC foreign substance (antigen) SHOCK develops a systemic antigen– antibody reaction. Anaphylactic shock occurs rapidly and is life-threatening.  Medical Management  Removing the causative antigen, administering medications that restore vascular tone, and providing emergency support of basic life functions.  Epinephrine is given for its vasoconstrictive action.  Diphenhydramine (Benadryl) is administered to reverse the effects of histamine, thereby reducing capillary permeability.  Nebulized medications, such as albuterol (Proventil), may be given to reverse histamine-induced bronchospasm.  Intravenous lines are inserted to provide access for administering fluids and medications.  If cardiac arrest and respiratory arrest are imminent or have occurred, cardiopulmonary resuscitation is performed. Endotracheal intubation or tracheotomy may be necessary to establish an airway.  Nursing Management  Assessing all patients for allergies or previous reactions to antigens (eg, medications, blood products, foods, contrast agents, latex) and communicating the existence of these allergies or reactions to others.  Assesses the patient’s understanding of previous reactions and steps taken by the patient and family to prevent further exposure to antigens.  Advises the patient to wear or carry identification that names the specific allergen or antigen. Systemic inflammatory Response Syndrome (SIRS) Precy Lantin, MAN, RN Systemic Inflammatory Response Syndrome (SIRS): overwhelming inflammatory response in the absence of infection causing relative hypovolemia and decreased tissue perfusion. Pathophysiology Stage II: Stage III: 3 Stage Process by Dr. RC Small quantities of local Bone cytokines are released into If homeostasis is not circulation to improve the restored, a significant Stage I: local response. This leads to systemic reaction occurs. growth factor stimulation The cytokine release leads and the recruitment of to destruction rather than There is local cytokine macrophages and platelets. protection. A consequence production to incite This acute phase response is of this is the activation of an inflammatory typically well controlled by a numerous humoral response thereby cascades and the promoting wound decrease in the proinflammatory mediators activation of the reticular repair and endothelial system and recruitment of the and by the release of endogenous antagonists. subsequent loss of reticular endothelial circulatory integrity. This system. The goal is homeostasis. leads to the end of organ dysfunction. Four SIRS criteria: Tachycardia - heart rate >90 beats/min Tachypnea - respiratory rate >20 breaths/min) Fever or hypothermia - temperature >38 or 1,200/mm3,