Shock PDF - Care of Patients

# Care of Patients in Shock - By Angela Banks, RN, PhD # Stages of Shock - Initial stage - Nonprogressive stage - Progressive stage - Refractory stage # Initial Stage of Shock - Baseline MAP decreased by less than 10 mm Hg - Heart and respiratory rate increased from the baseline or a slight...

# Care of Patients in Shock - By Angela Banks, RN, PhD # Stages of Shock - Initial stage - Nonprogressive stage - Progressive stage - Refractory stage # Initial Stage of Shock - Baseline MAP decreased by less than 10 mm Hg - Heart and respiratory rate increased from the baseline or a slight increase in diastolic blood pressure - Adaptive responses of vascular constriction and increased heart rate # Nonprogressive Stage ## Compensatory - MAP decreases by 10 to 15 mm Hg - Kidney and hormonal adaptive mechanisms activated. - Tissue hypoxia in nonvital organs - Acidosis # Progressive Stage of Shock - Sustained decrease in MAP of more than 20 mm Hg from baseline. - Vital organs develop hypoxia. - Life-threatening emergency. - Immediate interventions are needed. - Conditions causing shock need to be corrected within 1 hour of the onset of the progressive stage. # Refractory Stage of Shock - Too much cell death and tissue damage result from too little oxygen reaching the tissues - Body can no longer respond effectively to interventions, and shock continues - There is irreversible cell and tissue death # Multiple Organ Dysfunction Syndrome (MODS) - Metabolites are released from dead cells - Micro thrombi form in various locations throughout the body, depending on the specific circumstances of the infection and the individual's health status - MODS occurs first in the liver, heart, brain, and kidney # Classification of Shock by Functional Impairment - Hypovolemic shock - Cardiogenic shock - Distributive shock - Obstructive shock # Hypovolemic Shock | Feature | Description | |---|---| | Intravascular Volume | ↓ | | MAP | stimulates baroreceptors | | Stimulation of SNS | ↑ tachycardia, ↑ contractility | | Cardiac output | ↓ temporarily | | Coronary arteries | dilate ↑ BP | | Tissue perfusion | ↓ | # Causes of Hypovolemic Shock - Hemorrhage - Dehydration - Fluid shifts - Trauma - Burns # Treatment for Hypovolemic Shock - Control the source of the blood loss - Replace the volume loss - Colloids - Increase serum osmotic pressure - Albumin, Dextran, Hetastarch - Crystalloids - Isotonic solutions which increase BP - Normal Saline, Lactated Ringers - Blood products - Replace the blood loss - Packed RBCs, Whole Blood # Cardiogenic Shock - Actual heart muscle is unhealthy, and pumping is directly impaired. - Myocardial infarction is the most common cause of direct pump failure. # Clinical Manifestations | Feature | Description | |---|---| | Poor myocardial contractility | | | High venous pressure | leads to fluid extravasation and oedema | | Despite normal or high BP, organs are poorly perfused | due to a reduction in blood flow | | Cardiogenic shock | | | Sympathetic over activity | leads to vasoconstriction in order to maintain BP | | Tachycardia | | | Cardiac output | ↓ | | Blood pressure | ↓ | | Narrowing pulse pressure | | | Vasoconstriction | | | Crackles | | # Treatment of Cardiogenic Shock - βta-Adrenergic agonists - Norepinephrine - Dobutamine - Dopamine - different effects depending on dosage - 2 mcg/kg/min (Low dosages) - dilates real and mesenteric arteries and ↑renal perfusion - 5mcg/kg/min (Moderate dosages) - ↑HR, contractility and cardiac output - 10mcg/kg/min (High dosages) - ↑vasoconstriction - Vasodilators - Decreases the workload of the heart, preload and ↓ afterload - Nitroprusside - Nitroglycerin # Mechanical Assist Devices - The Intra-aortic balloon pump (IABP) - Mobility restricted - Pedal pulses # Obstructive Shock - Caused by problems that impair the ability of the normal heart muscle to pump effectively. - Causes - Pulmonary embolism - Cardiac tamponade # Treatment for Obstructive Shock ## Pulmonary Embolism - Heparin - Fibrinolytic Therapy - Streptokinase - Alteplase ## Cardiac Tamponade - Pericardiocenthesis - Pericardial window - Drain # Distributive Shock # Pathogenesis of Septic Shock | Event | Description | |---|---| | Local Infection | | | Systemic Infection | | | Systemic Inflammatory Response Syndrome (SIRS) | | | Sepsis | | | Organ Failure (Severe Sepsis) | | | Septic Shock | | | Death | | # Severe Sepsis - All tissues have some degree of hypoxia - Microthrombi formation is extensive - Amplified systemic inflammatory response - Anaerobic metabolism continues # Septic Shock - Most common cause of death in non-cardiac ICU's in the US - Most cases are nosocomial - Increased incidence due to advanced invasive technology - Elderly are at greatest risk - Mortality: 40%-85% # Septic Shock: Interventions - Blood cultures - Antibiotic therapy - Oxygen therapy - Vancomycin (Vancocin) - Aminoglycosides - Tobramycin (Nebcin) - Gentamicin (Garamycin) - Penicillins - Systemic Penicillin - Amoxicillin (Amoxil) - Piperacillin (Tazocin) - Cephalosporins - Ancef (Kefzol) - Steroid Therapy - Hydrocortisone (Cortef) - Fludrocortisone (Florinef) - Anticoagulant Therapy - Heparin # Anaphylactic Shock - Antigen-Antibody Reaction - Histamines and Leukotrienes - Bronchoconstriction - Periperhal Vasodilation # Treatment for Anaphylactic Shock - Airway management - Bronchodilators - Albuterol (Proventil) - Epinephrine (Adrenalin) to stabilize mast cells and increase BP - IV therapy - Normal Saline to increase vascular volume - Steroids - Methylprednisolone (Solumedrol) to decrease inflammation