Jessica Powers RN, MSN, CEN

SHOCK = INADEQUATE PERFUSION OF TISSUES WITH OXYGENATED BLOOD

Response to Hypoxia Response to poor perfusion

Respiratory:•Increased RR and Depth

Cardiovascular: •Increased HR •Increased SVR

•Blood is shunted•Increased preload•Increased contractility

Cardiovascular:•Increased cardiac output

Liver:Mobilization of stored blood

Baroceptors stimulated sympathetic response

Compensatory MechanismsCompensatory Mechanisms

What is our goal when we treat shock?

to maximize the body’s ability to supply oxygen to the cells in order to preserve tissue and organ function.

Stages of ShockStages of Shock

Types of ShockHypovolemic

Distributive

Cardiogenic

Inadequate Venous Return

Pump Failure

Hypovolemic ShockCaused by excessive loss of intravascular

volumeHemorrhageVomiting/DiarrheaBurns

Hypovolemic ShockDecreased blood volume = decreased venous

returncompensatory mechanisms initiated

Increased HR, RR, SVR Increased workload on heart more oxygen

demand Blood volume is shunted

Anaerobic metabolism lactic acidosis Cellular inflammation -> increased capillary

permeability -> more decreased volume

AssessmentHistoryPhysical Findings

Neuro

Respiratory

Skin

Pulses

•Vital Signs?•Urine Output?

Laboratory StudiesSerum lactate

increasedABG

Acidosis, increased base deficitCBC

Hemoconcentration/hemodilutionBMP

Renal functionElectrolyte abnormalities

Management of Hypovolemic ShockFix the causeRestore circulating volume

Isotonic fluidsBlood loss

PRBCsVolume expanders in resuscitation phase

Oxygenation

CautionsPulmonary congestionHypothermiaCoagulopathies

QuestionThe nurse suspects that a patient injured in a

motor vehicle accident is going into hypovolemic shock. Which of the following compensatory mechanisms will help maintain a patient’s blood pressure?

A. Increased urinary output

B. Decreased respiratory effort

C. Decreased preload

D. Increase in systemic vascular resistance (SVR)

15

AnswerD. Increase in systemic vascular resistance

(SVR)

Rationale: The release of catecholamines causes a peripheral vasoconstriction and therefore an increase in the systemic vascular resistance (SVR) as well as venous vasoconstriction, which increases the preload. Respirations increase to supply more oxygen to the tissues. Urinary output decreases to conserve sodium and water under the influence of ADH.

16

Cardiogenic ShockPump Failure (Extreme CHF)Causes:

MI MyocarditisValvular diseaseVentricular Septal RuptureDysrythmias

Mr. Wells89 year old male s/p LV MI with PCIHx: CAD –CABG x1 in 2009, DM, GERD,

Prostate CA in 1980, hypercholesterolemia, HTN, AVR, CRF, Afib, DVT in 1995

Which of these factors make Mr. Wells at high risk for developing cardiogenic shock?

Current TreatmentsO2 @ 4LNCNSS @ 150cc/hr x 2LCardiac dietDiltiazem gtt @ 10mg/hrMorphine 2mg IV Q 4H PRN

Your Initial AssessmentVS: T- 97.9, RR-20, BP 102/60, HR 94, P.Ox- 94%

on 4L NC

Your Initial AssessmentA+Ox2Mild JVDPulse irregular, threadyAbdominal retractions and

distentionInspiratory crackles,

wheezing+2 pitting edemaPallor5/10 midsternal CP20 cc UO in 1 hour

Labs and DiagnosticsCBC:

WBC 9.1, Hgb 12 g/dL, Hct 45%BMP:

Na 140 , K 6.2, Cl 110, CO2 15, BUN 48, Cr 2.4Trop: 6.0BNP: >4000INR: 2.1CXR – pulmonary congestionEcho – EF 35%

Another look at Mr. WellsVS: T- 97.9, RR-46, BP 78/43, HR 126, P.Ox- 88% on

4L NC

DiaphoreticIncreased confusionNo urine output x 1hr

ABG: pH 7.50, H 30, paO2 50, paCO2 24, HCO3 26.0

Cardiogenic Shock

Management of Cardiogenic ShockWhat will we do for Mr. Wells and pts like

him?OxygenationAttention to preload (LVEDP)

How do we measure it? IVF Diuresis

Electrolyte replacementNarcotics

Management of Cardiogenic ShockIncreasing contractility

Sympathomimetics: norepinephine, epinephrine Problem – increased HR and SVR (workload)

Postive inotropes: dopamine, dobutamine, amrinone, milnorone Problem – increased workload

Reducing SVR and LVEDPVasodilators: nipride, tridil, ACE inhibitors

Increasing BPVasoconstrictors: Phenylephrine, pitressin

Mechanical Support IABP LVADInflates during diastolePerfusion of Coronary

arteries Increases CO

Mechanical pump

Distributive ShockAnaphylactic NeurogenicSeptic

Anaphylactic ShockAllergic reaction

IgE mediated Immune response to specific antigen

Non-IgE mediated Anaphylactoid reaction Direct activation of mediators Commonly associated with NSAIDS

PathophysiologyAntibody-antigen reaction causes mast cells

and basophils to secrete:HistamineLeukotrienesEosinophil chemotactic substanceHeparinProstaglandinsNeutrophil chemotactic substancePlatelet-activating factor 2

PathophysiologyHistamine, prostagandins, and leukotrienes cause:

Systemic vasodilationIncreased capillary permeabilityBronchoconstrictionCoronary vasoconstrictionUrticaria

Other substances cause:Myocardial depressionInflammationExcessive mucous secretionPeripheral vasodialtion

Management of Anaphylaxis

Neurogenic ShockSpinal cord injury above T6Other causes: spinal

analgesia, emotional stress, pain, drugs, other CNS problems

Loss of sympathetic tone -> peripheral vasodilation

Hypotension and Bradycardia

Septic Shock

Systemic Inflammatory Response Syndrome (SIRS)Systemic response to infection manifested by two

or more of the following:Temperature >38 C or <36C (>100.4 F or <96.8 F)HR >90 bpmRR >20 breaths/min or PaCO2<32 mmHgWBC > 12,000 cell/mm3, <4,000 cells/mm3 or

>10% immature (band) forms

SEPSIS is SIRS with an identified SEPSIS is SIRS with an identified sourcesource

Severe SepsisSepsis with organ dysfunction,

hypoperfusion, or hypotensionPatient responds to fluids

How can you measure fluid responsiveness?

Signs of hypoperfusion?Lactic acidosis, oliguria, mental status change

Septic ShockSepsis with hypotension despite adequate

fluid resuscitation along with perfusion abnormalities.

What about patients who are on vasopressors and maintaining an adequate BP?

Risk Factors For Septic ShockHost Treatment-related

Elderly, young Invasive catheters

Malnutrition Surgical procedures

Chronic illness/debilitation Traumatic/thermal wounds

Drug/alcohol use Invasive diagnostic procedures

Neutropenia Medications – antibiotics, cytotoxic agents, steroids

Splenectomy

Organ failure

Loss of Homeostasis

Cardiovascular AlterationsNitric Oxide is released from endothelial cells

Widespread vasodilationTumor necrosis factor-a and endothelin

Vasoconstriction in microvasculatureFormation of small fibrin clots

Hypoxia to distal cells/tissuesInflammatory cascade, NO, lactic acidosis

myocardial depression

Pulmonary AlterationsCapillaries leak into the pulmonary tissues

Interstitial edemaAreas of poor pulmonary perfusionPulmonary hypertensionIncreased respiratory workloaddecreased pulmonary compliance,impaired gas exchange hypoxemia

Pulmonary Alterations- ARDSFluid accumulation

spills to alveoli -> infiltrates

Mechanical ventilation = mode of entry

Pneumonia (may even be a different organism)

Metabolic AlterationsHypermetabolic stateCatecholemines cause excessive glucose

production and insulin resistanceMuscle breakdown accumulation of amino

acidsFat catabolism ketones produced

Liver function decreases lactic acid productionAs shock progresses, body cant use glucose,

protein, and fats for energy no ATP production cell death

Assessment findingsAltered

mental statusIncreased RRAltered tempEdemaBleedingAltered CO

Labs and DiagnosticsCBC – increased WBC and bandsBMP – hyperglycemiaABG – metabolic acidosisCT, X-rays, Cultures to find sourceLactateSvO2 – assess oxygen delivery and

consumption

Management of Septic ShockEarly, goal directed therapyAntibiotics within 6 hours with broad spectrum

Each hour delayed: 8-9% increase in mortalityFluid resuscitation

CVP 10-12, MAP 65Maintain CO

Vasopressors: dopamine and levophed preferred

Oxygenation – add PEEPNutritional support- enteral is preferred Coagulation – Xigris recommended ????

Multiple Organ Dysfunction Syndrome (MODS)Failure of several organ systemsBody cannot maintain homeostasis without

interventionLungs, heart, and kidneys are usually firstNo organ system is independent

Case StudiesFive Groups - Each given a type of shockAnswer the questions accompanying the case

studyPresent a summary of the case and answers

to the questions to the class

Case StudiesGroup 1Group 2Group 3Group 4Group 5

Study GuideGame Questions

Click to MakeYellow Car Move

Click to MakeRed Car Move

Click to MakeBlue Car Move

Click to MakeGreen Car Move

Click to MakeOrange Car Move