Shock Types and Management PDF

🟥 🔸 📌 SHOCK a syndrome characterized by decreased tissue perfusion and impaired cellular metabolism results in an imbalance between the supply of and demand for oxygen and nutrients. Four Main Categories cardiogenic hypovolemic distributive obstructive  Cardiogenic S...

🟥 🔸 📌 SHOCK a syndrome characterized by decreased tissue perfusion and impaired cellular metabolism results in an imbalance between the supply of and demand for oxygen and nutrients. Four Main Categories cardiogenic hypovolemic distributive obstructive  Cardiogenic Shock occurs when either systolic or diastolic dysfunction of the heart’s pumping action results in reduced cardiac output (CO). Mortality rates: approach 60%. leading cause of death from acute MI. Characterized by: SBP 30mmHg HR >60bpm Oliguria With or without evidence of organ congestion  🟥 🔸 Hypovolemic Shock occurs after a loss of intravascular fluid volume volume is inadequate to fill the vascular space. volume loss may be either an absolute or a relative volume loss. Absolute hypovolemia results when fluid is lost through hemorrhage, gastrointestinal (GI) loss (e.g., vomiting, diarrhea), fistula drainage, diabetes insipidus, or diuresis. Relative hypovolemia, fluid volume moves out of the vascular space into the extravascular space (e.g., intracavitary space). Whether the loss of intravascular volume is absolute or relative, the physiologic consequences are similar.  Distributive Shock Neurogenic Shock a hemodynamic phenomenon that can occur within 30 minutes of a spinal cord injury at the fifth thoracic (T5) vertebra or above; it can last up to 6 weeks. Anaphylactic Shock an acute, lifethreatening hypersensitivity (allergic) reaction to a sensitizing substance (e.g., drug, chemical, vaccine, food, insect venom).  🔸 🔻 Septic Shock presence of sepsis with hypotension despite adequate fluid resuscitation, along with inadequate tissue perfusion resulting in tissue hypoxia. three major pathophysiologic effects: vasodilation, maldistribution of blood flow, and myocardial depression. Sepsis a systemic inflammatory response to a documented or suspected infection  🔸 ▪ Obstructive Shock develops when a physical obstruction to blood flow occurs with a decreased CO can be caused by: restricted diastolic filling of the right ventricle from compression (e.g., cardiac tamponade, tension pneumothorax, superior vena cava syndrome) abdominal compartment syndrome (increased abdominal pressures compress the inferior vena cava, thus decreasing venous return to the heart) Pulmonary embolism and right ventricular failure (blood leaves the right ventricle through the pulmonary artery =leads to decreased blood flow to the lungs and decreased blood return to the left atrium = patients experience a decreased CO, increased afterload, and variable left ventricular filling pressures depending on the obstruction; jugular venous distention and pulsus paradoxus Assessment: varies, depending on the degree  🔹 Analysis/ Nursing Diagnosis:: Altered tissue perfusion r/t vasoconstriction or decreased myocardial contractility Impaired gas exchange r/t ventilation-perfusion imbalance Decreased cardiac output related to loss of circulating blood volume or diminished cardiac contractility Altered urinary elimination r/t decreased renal perfusion Fluid volume deficit r/t blood loss Nursing care plan/ Implementation: Goal: promote venous return, circulatory perfusion Position: foot of bed elevated 20 degrees (12-16 inches), avoid Trendelenburg position. Ventilation: monitor respiratory effort, loosen restrictive clothing: O2 ordered. Fluids: Maintain IV infusions -with sepsis, may received 2-6 liters to keep CVP >12 mmHg to prevent end organ hypoxia and renal failure Give blood, plasma expanders as ordered (exception -stop blood immediately in anaphylactic shock). VItal signs: CVP (decreased with hypovolemia) arterial line, PA catheter (increased pulmonary artery wedge pressure indicating cardiac failure). Urine output (insert catheter for hourly output). Monitor ECG (increased rate, dysrhythmias) Medications (depending on type of shock) as ordered: Vasopressors: dobutamine, Norepinephrine, isoproterenol, dopamine (cardiogenic, neurogenic, septic shock) Antiarrhythmics (cardogenic shock) Adenocorticoids (anaphylactic shock) Antibiotics (septic shock) Vasodilators -Nitroprusside (cardiogenic shock) Antihistamine -epinephrine (anaphylactic shock) Mechanical support: Military (or medical) anti shock trousers (MAST) or pneumatic anti shock garments (PASG) used to promote internal auto transfusion of blood from legs and abdomen to central circulation at lower pressures may control bleeding and promote hemostasis; do notremove (deflate) suddenly to examine areas or BP will drop precipitously compartment syndrome may result with prolonged use and high pressure controversial  ☑ Management of Cardiogenic Shock Give oxygen and support ventilation Obtain vascular access and obtain labs Administer a dose of 5 to 10 mL/kg boluses of isotonic cystalloid bolus slowly over 10 to 20 minutes PRN Conduct ancillary studies Obtain assess for pulmonary edema Administer the following medications: Catecholamine – Dobutamine – if necessary Catecholamine – Dopamine – if necessary Vasodilator – Nitroglycerin – 0.25 to 0.5 µg/kg per minute IV/IO and increase to 0.5 to 1 µg/kg per minute every 3 to 5 minutes PRN Vasodilator – Sodium Nitroprusside – 1 to 8 µg/kg per minute IV/IO for 40 kg child These may be required: Milrinone – Loading dose of 50 mcg/kg for 1 to 60 mins, followed by 0.25 to 0.75 mcg/kg/min Nitrogylcerin – 1 to 5 mcg/kg/min Nitroprusside initial dose 0.3 to 1 mcg/kg/min  🔘 ☑ 🟥 Management of Hypovolemic Shock Nonhemorrhagic Hypovolemia Key to management: infusion and retention of fluids. Infusion of 20 isotonic crystalloid =up to 3 boluses can be given if the patient doesn’t improve. Hemorrhagic Hypovolemic Shock Fast infusion of isotonic crystalloid in boluses of 20 mL/kg and give up to 3 boluses for a total of 60 mL/kg. For every 1 mL of blood loss, it is important to supplement 3 mL of crystalloid for the initial treatment. If the patient remains unresponsive consider Packet Red Blood Cells (PRBCs) transfusion in 10 mL/kg boluses. Nopharmacological interventions that are effective for either hemorrhagic or nonhemmorrhagic hypovolemic shock. Therapy includes fluid dosage, identifying the cause of volume loss and correcting metabolic imbalance. Management of Neurogenic Shock Give oxygen and support ventilation Obtain vascular access and obtain labs Adminiter a dose of 20 mL/kg boluses of isotonic cystalloid bolus over 5 to 20 minutes and repeat to restore blood pressure and tissue perfusion Conduct ancillary studies Position head down to improve venous return Consider using vasopressors such as norepinephrine or epinephrine for hypotension Epinephrine – 0.1 to 1 mcg/kg/min or Norepinephrine –.05 –.1 mcg/kg/min Provide cooling or warming as needed  ☑ Management of Anaphylactic Shock Primary goal in the treatment: to target problems associated with bronchoconstriction and vasodilation. Give oxygen and support ventilation Obtain vascular access and obtain labs Adminiter a dose of 20 mL/kg boluses of isotonic cystalloid bolus over 5 to 20 minutes and repeat to restore blood pressure and tissue perfusion Conduct ancillary studies Administer the following medications for rapid recovery Epinephrine – IM epi or epi by autoinjector — a second dose of epi injection may be needed after 10-15 mins at a low dose of < 0.05 mcg/kg/min Albuterol for bronchospasm – 4 to 8 puffs every 20 minutes or 2.5-5 mg/dose every 20 minutes for nebulizer Antihistamine- H1 blocker Diphenhydramine – 1 to 2 mg/kg IV/IO/IM every 4 to 6 hours with max dose of 50 mg Corticosteroid- Methylprednisolone – 2 mg/kg IV/IO/IM for max dose of 80 mg Continue treatment and monitoring until child is out of shock Give oxygen and support ventilation Obtain vascular access and obtain labs Within the first hour administer repeated doses of 20 mL/kg boluses of isotonic fluid Management of Septic Shock Methods in treating septic shock: Give oxygen and support ventilation Obtain vascular access and obtain labs Within the first hour administer repeated doses of 20 mL/kg boluses of isotonic fluid Correct hypoglycemia and hypocalcaemia Give the first dose of antibiotics Order STAT vasopressor drip and stress-dose hydrocortisone If there is no response to the fluid treatment start with vasoactive drug treatment For Normotensive start with dopamine For Hypotensive vasodilated (warm) shock start with norepinephrine For Hypotensive vasoconstricted (cold) shock start with epinephrine Evaluate the Scvo2 (N = sat >70% If Scvo2 10 g/dL and think of giving milrinone or nitroprusside and dobutamine If Scvo2 10 g/dL and give epinephrine or dobutamimne+norepinephrine If Scvo2 >70% with low BP and warm shock give additional fluid boluses and norepinephrine with/ without vasopressin If there is response to fluid therapy transfer to ICU and continue monitoring Evaluation/outcome criteria: Vital signs stable, within normal limits. Alert, oriented. Urine output >30 ml/hr.