Module 15- Shock!
John Nation, RN, MSN
From the notes of Nancy Jenkins, RN, MSN
Shock-
Summary-– Lewis p. 1772-1798, 1738-1746– Types of Shock– Stages of Shock– Management of Shock– Nursing Interventions– Systemic Inflammatory Response Syndrome
(SIRS)– Multiple Organ Dysfunction Syndrome (MODS)– Critical Care
Shock Defined
Shock- Clinical syndrome characterized by decreased tissue perfusion and impaired cellular metabolism resulting in an imbalance between the supply and demand for oxygen and nutrients– Put simply, not enough oxygen and not
enough nutrients for body
Types of Shock-
Low blood flow-• Cardiogenic shock• Hypovolemic shock
Maldistribution of blood flow-• Neurogenic shock• Anaphylactic shock• Septic shock
Etiology and Pathophysiology
Cardiogenic shock-– Occurs when systolic or diastolic dysfunction of
the pumping of the heart causes decreased cardiac output
– Cardiac output= stroke volume x heart rate
Cardiogenic Shock (cont’d)
• Causes include:• myocardial infarction• cardiomyopathy• blunt cardiac injury (trauma)• severe systemic or pulmonary hypertension• cardiac tamponade• arrhythmias• valvular defects• myocardial depression from metabolic problems.
Cardiogenic Shock (Cont’d)
Clinical Manifestations:– Tachycardia– Hypotension– Narrowed pulse pressure– Tachypnea– Increased SVR, CVP, and PAWP– Pulmonary congestion– Cyanosis– Cool, clammy skin– Confusion/ agitation– Decreased capillary refill time
Cardiogenic Shock (Cont’d)
Laboratory/ Diagnostic Studies:– Cardiac enzymes (troponin levels)– B-type natriuretic peptide (BNP)– ECG– Chest X-Ray– Echocardiogram– Heart Cathetarization (left, right or both)
Cardiogenic Shock (Cont’d)
• Initially, what clinical condition does this sound similar to?
Cardiogenic Shock (Cont’d)
Treatment-– Restore blood flow to myocardium- early PCI!– Thromboyltic therapy, angioplasty, stenting,
emergency revasularization, valve replacement– Hemodynamic monitoring PAWP – Intraaortic balloon pump (IABP) 50. IABP– Ventricular assist device VAD video – Transplant (rarely)
Cardiogenic Shock (Cont’d)
Treatment (Cont’d)– Medications (depends on cause):
• Aspirin
• heparin
• Dopamine
• Norepiniphrine
• dobutamine
• Diuretics
• Vasodilators
• Amiodarone
PAWP Monitoring
IABP
Cardiogenic Shock (Cont’d)
• Mortaliaty rate of 80-90% when caused by acute MI
• Prior MI, increasing age, and oliguria are associated with worsening outcomes
Hypovolemic Shock-
• Loss of intravascular fluid volume
• Volume inadequate to fill the vascular space
• Categorized as absolute or relative hypovolemia
Hypvolemic Shock (Cont’d)
Absolute hypovolemia-– Results from fluid loss via hemorrhage,
gastrointesinal (GI) loss (vomiting, diarrhea), fistula drainage, diabetes insipidus, hyperglycemia, or diuresis
Relative hypovolemia-– Results from fluid moving out of the
vascular space and into the extravascular space- aka third spacing
Hypovolemic Shock (Cont’d)
Causes:– Bleeding– Vomiting– Diarrhea– Diabetes insipidus– Diuresis– Third spacing
Hypovolemic Shock (Cont’d)
Clinical Manifestations-– Depend on extent of injury, age, general health
status
– Decrease in venous return, preload, stroke volume, and cardiac output
– Increase in heart rate, increase in respiratory rate
Hypovolemic Shock
Clinical Manifestations (Cont’d):– Decrease in stroke volume, pulmonary artery
wedge pressure, and central venous pressure
– Decrease in urine output, absent bowel sounds, cool, clammy skin
– Anxiety, confusion, agitation
Hypovolemic Shock (Cont’d)
Lab/ Diagnostic Tests:– Find the source of blood loss
• CT, ultrasound, surgery
– CBC, electrolytes, blood gases, lactate level
– SpO2– Hourly urine output monitoring
Hypovolemic Shock (Cont’d)
Treatment-– Stop source of fluid loss– Restore circulating volume– 3:1 rule- 3 ml of isotonic crystalloid for
every 1 ml of estimated blood loss
Hypovolemic Shock
1) What is often the priority in the treatment of hypovolemic shock?
2) How might you recognize the development of hypovolemic shock?
3) What would you do about it?
Neurogenic Shock-
– Hemodynamic phenomenon occuring after spinal injury at T5 or above
– Usually within 30 minutes of injury, can last up to 6 weeks
– Causes massive vasodilation without compensation secondary to the loss of sympathetic nervous system vasoconstrictor tone
– Can also be caused by spinal anesthesia
Neurogenic Shock (Cont’d)
Clinical manifestations-– Bradycardia (from unopposed
parasympathetic stimulation)– Hypotension (from massive vasodilation)– Hypothermia (due to heat loss)
• Initially, skin may be warm due to vasodilation• Later, skin may be cool, depending on ambient
temperature
Neurogenic Shock (Cont’d)
Clinical Manifestations (Cont’d)– Bladder dysfunction– Paralysis below level of lesion– Bowel dysfunction
Neurogenic Shock (Cont’d)
Early Signs-– Blood pools in venous and capillary beds– Skin warm and pink– Pulse slow and bounding– Decreased BP– Decreased MAP
Neurogenic (Cont’d)
Late Signs-– Skin pale and cool
Neurogenic Shock (Cont’d)
Treatment-– Depends on the cause– If spinal cord injury, promote spinal stability– Vasopressors and atropine for hypotension
and bradycardia (respectively)– Fluids administered cautiously– Monitor for hypothermia
Anaphylactic Shock
– Acute and life-threatening allergic reaction (hypersensitivity) reaction
– Can be caused by drugs, chemicals, vaccines, food insect venom
– Causes massive vasodilation, release of vasoactive mediators, and an increase in capillary permeability
Anaphylactic Shock (Cont’d)
– Fluid shift from the vascular space to the interstitial space
– Respiratory distress secondary to laryngeal edema, severe bronchospasm, or circulatory failure from vasodilation
Anaphylactic Shock (Cont’d)
Clinical Manifestations-– Anxiety, confusion– Dizziness– Chest pain– Incontinence– Swelling of lip and tongue– Wheezing, stridor, shortness of breath – Flushing, pruritus, and uticaria (hives)– angioedema
Anaphylactic Shock (Cont’d)
Treatment-– Epinephrine is the drug of choice– Diphenhydramine used to block massive release
of histamine– Maintain patent airway – Nebulized bronchodilators (albuterol)– Intubation or cricothyroidotomy (video) be needed– Fluid replacement, primarily with colloids– corticosteroids
• From Seton. Educational use only.
Anaphylactic Shock
• What are you worried about with a medication reaction?
• What are you watching for?
Septic Shock
Septic shock- Presence of sepsis with hypotension, despite fluid resuscitation, with decreased tissue perfusion
Sepsis- systemic inflammatory response to an infection
• Over 750,000 clients diagnosed with severe sepsis annually and 28% to 50% die
Septic Shock (Cont’d)
Course-– Septicemia (initially bacteremia) causes
inflammatory cascade– Commonly caused by gram negative
bacteria– If gram positive infection (Staphylococcus
and streptococcus), up to 50% mortality rate
Septic Shock
Patho:– Invading microorganisms result in massive
inflammatory response:• Causes endothelial damage, microemboli,
vasodilation, increased capillary permeability, platelet aggregation, myocardial depression
Septic Shock (Cont’d)Clinical Manifestations-
– Increased or decreased temperature– Biventricular dilations causing decreased ejection
fraction– Hyperventilation, respiratory alkalosis, respiratory
acidosis, crackles, ARDS– Decreased urine output– Skin warm and flushed, then cool and clammy– Altered LOC– Paralytic ileus, GI bleeding & WBC, platelets, lactate, glucose, urine specific
gravity, urine Na, positive blood cultures
Septic Shock (Cont’d)
Treatment-– Large amounts of fluid replacement– Vasopressor drug therapy– Corticosteroids – Antibiotics– Drotrecogin alpha (Xigris) (no longer used)– Glucose less than 150– Stress ulcer prophylaxis with H2- receptor
blockers and DVT prophylaxis
• From Seton. Educational use only.
Obstructive Shock
• Physical obstruction to blood flow
• Causes:– Cardiac tamponade, tension
pneumothorax, PE, left ventricular thrombi
• Decreased cardiac output, increased afterload
• Fix the underlying problem is primary treatment
Common Diagnostic Tests
• CBC• BMP• Arterial blood gases• Blood cultures• Cardiac enzymes (cardiogenic shock)• Glucose
Common Diagnostic Tests (Cont’d)
• DIC (Disseminated Intravascular Coagulation) screen: FSP, fibrogen level, platelet count, PTT and PT/INR, and D-dimer
• Lactic Acid
• Liver enzymes- ALT, AST, GGT
Diagnostic Tests (Cont’d)
Electrolytes-– Sodium level increased early, decreased
later if hypotonic fluid administered
– Potassium decreased in early shock, then increased later with cellular breakdown and renal failure
Common Nursing Diagnoses
• Decreased cardiac output
• Altered tissue perfusion
• Fluid volume deficit
• Anxiety
• Fear
Stages of ShockCompensatory Shock-
Mean Arterial Pressure (MAP) blood pressure (but adequate to perfuse vital organs) cardiac output– Sympathetic nervous system (SNS) stimulation causes
vasoconstriction. Blood flow to heart and brain maintained, while blood flow to the kidneys, GI tract, skin, and lungs is diverted
– Decreased blood flow to kidneys causes activation of renin-angiotensin system, leading to sodium retention and potassium excretion
– In this stage the body is able to compensate for changes in tissue perfusion
Progressive Shock
• Altered capillary permeability (3rd spacing)• Alveolar and pulmonary edema, ARDS, PA
pressures cardiac output, coronary perfusion, can
cause arrhythmias and MI• Acute tubular necrosis• Jaundice, ALT,AST GGT• DIC• Cold, clammy skin
Refractory Stage
• Anaerobic metabolism- lactic acid build-up• Increased capillary blood leak• Profound hypotension, inadequate to perfuse vital
organs• Respiratory failure• Unresponsive • Anuria• DIC• hypothermia
Collaborative Care
Successful management involves:– Identifying at risk clients– Integration of client’s medical history,
assessment findings to establish diagnosis– Interventions to address cause of
decreased perfusion– Protection of organs– Multisystem supportive care
Collaborative Management (Cont’d)
– Start with ABCs! Ensure patent airway and oxygen delivery
– Volume expansion and fluid administration cornerstone of treatment of septic, hypovolemic, and anaphylactic shock
– Primary goal of therapy is correction of decreased tissue perfusion
– Hemodynamic monitoring, drug therapy, circulatory assist
Nursing Implementation
Health Promotion-– Identify at risk clients– Prevent shock (monitoring fluid balance,
good hand washing to prevent infection, community education and health promotion)
Interventions (Acute)
• Assess neurologic status- check LOC every hour or more often
• Monitor heart rate/ rhythm, BP, central venous pressure, pulmonary artery pressure, cardiac output
• Trendelenburg position not supported by research and may compromise pulmonary function and increase ICP
• Monitor EKG for dysrhythmias, S3 or S4 heart sounds
Interventions
Assessment (Respiratory)-
– Respiratory rate and effort– Pulse oximetry– ABGs for acid/base balance– Intubation/ ventilation
Assessment-– Hourly urine output– If less than 0.5 ml/kg/hour, may indicate
inadequate kidney perfusion– BUN and creatinine– Temperature– Capillary refill– Monitor skin for pallor, flushing, cyanosis,
diaphoresis, piloerection
Assessment (Cont’d)-– Check bowel sounds– If NG tube present, check drainage for
blood– Passive ROM and oral care– Talk with client, even if sedated or
intubated
Systemic Inflammatory Response Syndrome (SIRS)
Systemic Inflammatory Response Syndrome (SIRS)- a systemic inflammatory response to a variety of insults, including infection, ischemia, infarction, and injury– Characterized by generalized inflammation of
organs– Two or more of the following conditions:
temperature >38.5°C (101.3 F) or <35.0°C (95.0 F); heart rate of >90 beats/min; respiratory rate of >20 breaths/min or PaCO2 of <32 mm Hg; and WBC count of >12,000 cells/mL, <4000 cells/mL, or >10 percent immature (band) forms
Multiple Organ Dysfunction Syndrome (MODS)
– Results from SIRS– Characterized by failure of two or more
organ systems such that homeostasis can not be obtained without intervention
– Often culminates in ARDS– Can cause massive vasodilation and
myocardial depression– Commonly manifests as changes in LOC– Acute renal failure common
• GI tract highly vulnerable to ischemic injury secondary to shunting in early stages
• At risk for ulceration and GI bleeding• Potential for bacterial translocation from GI
tract to cirulation• Causes hypermetabolic state• Failure of coagulation system manifests as DIC• Electrolyte changes and fluid shifts
Critical Care
• Care of the critically ill patient
• Invasive monitoring capabilities
• Bedside procedures possible
• 2 to 1 patient to nurse ratio
• Intensivists or pulmonary/ critical care physicians and advanced practice nurses
Critical Care
• Post-surgical pathways often include going to ICU
• Certain medications, devices, and frequency of testing require placement in ICU
• Medications must be reconciled with any move to or from critical care to other level of care
• Notify family members
The End!