SHOCK

PREPARED BY:

WILBERT ANTONINO CABANBAN, RN

Definition of Shock

• A condition in which systemic blood pressure is inadequate to deliver oxygen and nutrients to support vital organs and cellular function (Mikhail, 1999).

• Inadequate oxygen delivery to meet metabolic demands.• Shock is a physiologic state characterized by systemic

reduction in tissue perfusion, resulting in decreased tissue oxygen delivery.

In short there is a DECREASE TISSUE PERFUSION!!!

Types of shock

• 68 yo M with hx of HTN and DM presents to the ER with abrupt onset of diffuse abdominal pain with radiation to his low back. The pt is hypotensive, tachycardic, afebrile, with cool but dry skin.

WHAT TYPE OF SHOCK IS THIS?

HYPOVOLEMIC SHOCK!!!

HYPOVOLEMIC SHOCK

Hypovolemic Shock

• A state of physical collapse and prostration caused by massive blood loss.

• A particular form of shock in which the heart is unable to supply enough blood to the body.

Causes

• Acute blood loss (common cause)• GI bleed• Massive hemoptysis• AAA rupture• Ectopic pregnancy, post-partum bleeding

• Non-hemorrhagic • Vomiting• Diarrhea• Burns • Environmental (dehydration)

Signs & Symptoms

• Thirst (1st SIGN)• Cold, pale, clammy skin• Decrease sensorium (unconsciousness)• Rapid shallow respiration• Tachycardia (Early stage)• Bradycardia (Late stage)• Anuria (< 25 mL/ hour)

Nsg. Diagnosis

• Ineffective tissue perfusion: Cardiopulmonary• Decrease cardiac output• Deficient fluid volume

Treatment

A. Blood & fluid replacement

Highest Nursing Priority• Initiate a least two intravenous lines for fluid

replacement.

Note: It should be a LARGE BORE/GAUGE!!!

Treatment

B. Control of bleeding

C. Redistribution of fluid

Priority Nsg. Intervention:• 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.

Treatment

Treatment

D. Treatment of Main Cause

Types of Shock

• A 55 yo M with hx of HTN, DM presents with “crushing” substernal CP, diaphoresis, hypotension, tachycardia and cool, clammy extremities

WHAT TYPE OF SHOCK IS THIS?

CARDIOGENIC SHOCK!!!

CARDIOGENIC SHOCK

Cardiogenic Shock

• Occurs when the heart fails to pump adequately, thereby reducing cardiac output and compromising tissue perfusion.

Causes

• Advanced heart block• Cardiomyopathy• Heart failure• MI• Myocarditis• Papillary muscle rupture

• Muscles located in the ventricles of the heart. They attach to the cusps of the atrioventricular valves (a.k.a. the mitral and tricuspid valves) via the chorda tendinae and contract to prevent inversion or prolapse of these valves.

Signs & Symptoms

• Cold, clammy skin• Hypotension (systolic pressure below 90 mmHg)• Narrow pulse pressure• Oliguria (urine output of less than 30 mL/hour)

Nursing Diagnosis

• Decreased cardiac output• Ineffective tissue perfusion: Cardiopulmonary• Ineffective tissue perfusion: Renal

Treatment

A. Oxygen administration

B. Activity changes• Maintaining Bed Rest (w/o Bathroom Priviledges)

C. Dietary changes• Withholding fluids• Withholding Na

D. Drug therapy• Adrenergic agents (epinephrine)• Cardiac glycoside (digoxin)• Cardiac inotropes (dopamine & dobutamine)

Highest Priority Nsg. Intervention

• Monitoring I & O!!!

Types of Shock

• A 34 yo F presents to the ER after dining at a restaurant where shortly after eating the first few bites of her meal, became anxious, diaphoretic, began wheezing, noted diffuse pruritic rash, nausea, and a sensation of her “throat closing off”. She is currently hypotensive, tachycardic and ill appearing.

WHAT TYPE OF SHOCK IS THIS?

ANAPHYLACTIC SHOCK!!!

ANAPHYLACTIC SHOCK

Anaphylactic Shock

• A severe and sometimes fatal systemic allergic reaction to a sentisizing substance.

Anaphylactic Shock

Types• Anaphylaxis – a severe systemic

hypersensitivity reaction characterized by multisystem involvement • IgE mediated

• Anaphylactoid reaction – clinically indistinguishable from anaphylaxis, do not require a sensitizing exposure• Not IgE mediated

Causes

• Systemic exposure to or ingestion of sensitizing drugs or other substances such as:

• Allergen extracts• Diagnostic chemicals

• Insect venoms (honeybees, fire ants, mosquitoes, etc..)• Vaccines

Signs & Symptoms

• First- Pruritus, flushing, urticaria appear

• Next- Throat fullness, anxiety, chest tightness, shortness of breath and lightheadedness

• Finally- Altered mental status, respiratory distress and circulatory collapse

Signs & Symptoms

Note!!!• A “lump in my throat” and “hoarseness” heralds life-

threatening laryngeal edema.

Nursing Diagnosis

• Risk for suffocation• Decreased cardiac output• Anxiety

Treatment

• O2 administration• CPR in cardiac arrest• Endotracheal tube insertion (Hospital premises)

Drug Therapy• Epinephrine

• 0.3 mg IM of 1:1000 (epi-pen) • Repeat every 5-10 min as needed

• Corticosteroids• Methylprednisolone 125 mg IV • Prednisone 60 mg PO

• Antihistamines• H1 blocker- Diphenhydramine 25-50 mg IV• H2 blocker- Ranitidine 50 mg IV

• Bronchodilators• Albuterol nebulizer• Atrovent nebulizer• Magnesium sulfate 2 g IV over 20 minutes

• Glucagon• For patients taking beta blockers and with refractory hypotension• 1 mg IV q5 minutes until hypotension resolves

Types of Shock

• A 41 yo M presents to the ER after an MVC complaining of decreased sensation below his waist and is now hypotensive, bradycardic, with warm extremities

WHAT TYPE OF SHOCK IS THIS?

NUEROGENIC SHOCK!!!

NEUROGENIC SHOCK

Neurogenic Shock

• Occurs after acute spinal cord injury• Sympathetic outflow is disrupted leaving unopposed

vagal tone• Results in hypotension and bradycardia• Spinal shock- temporary loss of spinal reflex activity

below a total or near total spinal cord injury (not the same as neurogenic shock, the terms are not interchangeable)

“SNAKE BITE”

Snake Bite

Snake venom consists primarily of proteins with a broad range of physiologic effects. Multiple organ systems, especially the neurologic, cardiovascular, and respiratory systems, may be affected.

Common Victims;Between 1 – 9 y.o

Common Site of Bite;Upper Extremities

Biting Time;Daylight hours into evening during

summer months.WHY???

Common Venomous Snake

• PIT VIPER (America)

Common Venomous Snake

• COBRA (Philippines)

PERCENTAGE OF ENVENOMATION

20% to 25% results to envenomation due to snake bite.

TYPES OF SNAKE BITE

1. DRY BITE – WITHOUT VENOM

2. WET BITE – WITH VENOM

TYPES OF TOXINS FROM A SNAKE BITE

1. Neurotoxins

- Directly affects the brain.

2. Hemotoxins

- Directly affects the blood thereby causing heart attack.

3. Cytotoxins

- Directly affects the nearby living cells from the bite site.

TYPES OF TOXINS FROM A SNAKE BITE

4. Myotoxins (most common)

- Directly affecting the muscles which leads to compartment syndrome.

NSG. INTERVENTION:

W.O.F – 4 P’s with S

1. PALLOR

2. PULSELESSNESS

3. PAIN

4. PARESTHESIA

5. SWELLING

TREATMENT: FASCIOTOMY

- To relieve the pressure!!!

Management

In the site; Let the patient lie down Instruct the patient to calm down Remove all constrictive items Providing warmth Cleansing the wound (use soap if available)

Note: Do not suck the site of snake bite!!! Immobilize the injured body part below the level of the

heart “Ice or a tourniquet is not applied in the acute stage”

Management

D.O.C ANTIVENIN (ANTITOXIN)

NSG. INTERVENTION:• Best Time: (the golden time)

Within 12 hours after the incidence• Dosage:

Depending on the type of snake & severity of bite

Note: Children needs more antivenin

• Skin and eye test to be perform before giving the antivenin to determine antivenin allergy.

• Diphenhydramine & cimetidine are given prior to antivenin administration.

• Best Route:IntravenousIM (can be used)

Note:Antivenin should be diluted to 500 to 1000 mL of

PNSS.

• The antivenin should be infused within 4-6 hours.

Note:It should be on a KVO rate for the first 10 mins. &

regulate @ desired flow rate after.

When symptoms is decreased the affected site should be checked every 30 to 60 mins. for 2 days!!!