Distributive Shock: Septic, Anaphylactic, and Neurogenic

What is the treatment for PE?

anticoagulant therapy - usually heparin - to dissolve the clot.

Anaphylactic shock involves the interplay of what two factors? a. IgA, b. Mast cells, C. IgE, d. lymphocytes

b. Mast cells, C. IgE,

According to the ACCP/SCCM definitions of sepsis syndrome, what separates the systemic inflammatory response syndrome (SIRS) from sepsis? a. ScvO2, b. infection, c. SaO2, d. serum lactate level

b. infection

Which factor separates sepsis from septic shock? a. bands greater than 10%, b. Fever greater than 103°F (39.4°C), c. sepsis interventions no longer effective, d. WBC count greater than 12, 000 or less than 4,000

c. sepsis interventions no longer effective

What are the clinical manifestations of tension pneumothorax?

direct pressure on the heart, vena cava, and contralateral lung decreases venous return and CO. Chest pain and air hunger develops, and respiratory distress. Lung sounds absent on affected side. Tracheal deviation may develop.

What are the clinical manifestations of PE?

dyspnea, tachypnea, pleuritic pain, cough, wheezing, crackles, tachycardia, evidence of DVT - unilateral leg pain and swelling.

What are the three types of distributive shock?

septic, anaphylactic, and neurogenic

What is the treatment for tension pneumothorax?

Needle thoracostomy - trapped air is decompressed with a 14 G needle or chest tube.

What is the mortality rate for Sepsis?

30-50%

What is the mortality rate for septic shock?

50-60%

Treatment of sepsis consists of what nursing priorities?

Administer antibiotics within 1 hour after HCP initiates the order. Blood cultures obtained prior to initiating abx. Serum lactate obtained. If > 4, significant tissue hyper perfusion is likely and fluid resuscitation and other interventions are initiated to relieve tissue hypoxia. SvO2 mixed or central should me monitored with a goal of 70% or greater.

What is the pathophysiology of tension pneumothorax?

Air enters pleural space during inspiration but cannot leave during expiration - like a one-way valve. Accumulation of air cause a shift of the mediastinal structures and compression of the other lung and soft tissues on the affected side, impedes venous return and O2 delivery.

What is tension pneumothorax?

Collapsed lung caused by increased pressure within the thoracic cavity. Usually caused form a penetrating chest wound. Can also be result of internal lung problems such as burst bleb in COPD patient.

How does distributive shock impair oxygenation?

Due to altered blood flow distribution. In septic and anaphylactic shock, vascular smooth muscle becomes incapable of constriction d/t endothelial insult. In neurogenic shock, there is loss of sympathetic nervous system response.

Why is the heart impacted by PE?

Obstruction of the pulmonary arteries causes right ventricular dysfunction. Hypoxia and pulmonary vasoconstriction result in increased pulmonary vascular resistance (PVR) which forces the right heart to work harder to push blood into the lungs, leading to right heart strain.

What is the criteria for diagnosis of septic shock?

Sepsis associated with hypotension despite adequate fluid resuscitation, along with the presence of perfusion abnormalities that may include lactic acidosis, oliguria, or an acute alteration in mental status.

What is the criteria for diagnosis of severe sepsis?

Sepsis associated with organ dysfunction, hypo perfusion, or hypotension; hypoperfusion and perfusion abnormalities may include lactic acidosis, oliguria, or an acute alteration in mental status.

What is the criteria for diagnosis of systemic inflammatory response syndrome? (SIRS)

Two or more of the following criteria: 1. Temp > 38°C or < 36°C. 2. HR > 90 bpm. 3. RR > 20 or PaCO2 < 32 mmHg. 4. WBC count > 12,000 or < 4.000 or greater than 10% immature bands.

Regardless of the underlying cause, what is the primary characteristic of all forms of distributive shock?

Vasodilation. It also cause expansion of the size of the intravascular compartment with out increasing the volume of blood, which results in relative hypovolemia.

What is neurogenic shock?

When spinal cord is injured above the mid thoracic region - above T6, and impulses from SNS cannot reach the arterioles, resulting in unopposed vagal stimulation and loss of vasomotor tone. There is unopposed parasympathetic innervation, allowing vasodilation and poling of blood in the periphery.

Which pathophysiologic events are characteristic of septic shock? Select all that apply. a. altered fluid volume, b. increased capillary permeability, c. inhibition of inflammatory mediators, d. maldistribution of circulating volume

a. altered fluid volume, b. increased capillary permeability, d. maldistribution of circulating volume

A patient with septic shock has a high CO and tachycardia. The nurse recognizes that this combination of clinical signs suggests which type of shock? a. hyperdynamic shock, b. hypodynamic shock, c. mild septic shock, d. severe septic shock

a. hyperdynamic shock

A patient is brought into the emergency department in anaphylactic shock. which drugs can the nurse anticipate will be administered? Select all that apply. a. methylprednisolone, b. dopamine, c. epinephrine, d. diphenhydramine

a. methylprednisolone, c. epinephrine, d. diphenhydramine

What are the treatment goals for the patient with neurogenic shock? Select all that apply. a. to restore intravascular volume, b. to minimize hyperthermia, c. to optimize oxygen delivery, d. to stabilize the spine

a. to restore intravascular volume, c. to optimize oxygen delivery, d. to stabilize the spine

A patient with a T5 spinal cord injury is in neurogenic shock. The nurse is aware that this type of shock results from which mechanism? a. unopposed parasympathetic nervous system stimulation. b. loss of spinal reflex activity, c. overstimulation of the SNS, d. loss of vagal stimulation activity

a. unopposed parasympathetic nervous system stimulation.

The nurse is preparing to assess a patient experiencing neurogenic shock. Which vital signs should the nurse anticipate? a. BP 132/74, b. HR 53, c. RR 14, d. temp 100.2°F (37,9°C)

b. HR 53

The various forms of distributive shock have which characteristics in common? a. endothelial injury, b. massive vasodilation, c. constriction of vascular smooth muscle, d. loss of sympathetic nervous system response

b. massive vasodilation

Anaphylactic shock is associated with increased capillary permeability. Based on this particular pathophysiologic problem, which assessment should the nurse focus on immediately? a. severe diarrhea, b. respiratory distress, c. cardiac dysrhythmias, d. uticaria and pruritus

b. respiratory distress,

What is the most common pathogen implicated in septic shock? a. bacteria, b. viruses, c. fungus, d. parasites

b. viruses

What are the clinical manifestations of anaphylactic shock?

cardiovascular and pulmonary issues such as hypotension, upper airway obstruction from angioedema, tongue or laryngeal edema and laryngospasm, flushing, uticaria, and pruritus, abdominal cramping, diarrhea

What is a pulmonary embolism? (PE)

clot, air, or tissue that obstructs blood flow through any part of the lungs. It can range from clinically unimportant thromboembolism to massive embolism with sudden death.

What are the most common nursing therapies for sepsis/septic shock?

fluid resuscitation, hydrocortisone therapy, activated protein C, monitoring of physiologic and laboratory parameters, monitoring trends, interpreting results, consulting with other team members, and addressing other physical and psychosocial needs.

What is the pathophysiology of PE?

hyper coagulability leads to promotion of thrombi in the deep veins of the legs, pelvis, or arms. They dislodge and embolize, flowing with venous blood to the right hear and into the pulmonary artery via the vena cava. The pulmonary arteries become obstructed, which results in impaired gas exchange.

During early septic shock, what are the s/s?

hyperdynamic as compensatory mechanisms are activated, warm, CO is normal or high, tachycardia, SV normal, SVR decreased, DBP decreased and widening pulse pressure.

What happens in the later stages of shock?

hypo dynamic or cold phase: cold extremities, mottling, increased serum lactate, and ScvO2 decreases, tissue perfusion becomes increasingly compromised.

What are clinical manifestations of neurogenic shock?

hypotension, bradycardia, hypothermia. Decreased SVR, pooling of blood in dilated vessels, diminished venous return, low CVP and BP.

Define sepsis.

infection and systemic inflammatory response syndrome criteria.

What is the treatment of anaphylactic shock?

maintain airway, support BP, administer O2, intubation, aggressive fluid resuscitation, drug therapies such as epinephrine, methylprednisolone, diphenhydramine, rantidine, albuterol, ipatropium bromide

What is the treatment of neurogenic shock?

maintain stability of spine, optimize O2 delivery, and restore intravascular volume

What is Beck's triad?

may be present during cardiac tamponade - elevated RAP, decreased BP, and muffled heart sounds.

What causes obstructive shock?

mechanical barrier to blod flow that blocks oxygen delivery to tissues. Can be caused by PE, tension pneumothorax, and cardiac tamponade.

As the compensatory mechanisms fail, what happens in septic shock?

myocardial depressant, hypoxemic effects, tissue hypoperfusion.

What is cardiac tamponade?

pressure exerted on the heart, compressing the heart wall and restricting heart actions.

What are the clinical manifestations of cardiac tamponade?

pulsus paradoxus - an exaggerated decrease of the systolic blood pressure during inspiration. Also distant heart sounds, elevated right arterial pressure (RAP), elevated pulmonary artery wedge pressure (PAWP).

What is anaphylactic shock?

severe systemic allergic reaction to allergens sucha s food, drugs, blood products, insect venom, and latex.

What type of hypersensitivity is anaphylactic shock? Which immunoglobulin is included? What other cellular responses?

severe type 1 hypersensitivity, IgE, mast cells, vasoactive substances such as histamine and kinins

What is neurogenic shock associated with?

spinal cord injury (SCI), can also be from tremors, disk degeneration, and inflammation/infection

What two types of shock can result from SCI?

spinal shock and neurogenic shock

What is the pathophysiology of infection leading to shock?

systemic response to infection triggers a series of cellular and humoral events. Pathogens and endotoxins stimulate the release of inflammatory mediators that impair microvasculature, resulting in increased capillary permeability and vasodilation.

What do these circulating mediators cause?

systemic vasodilation and increased capillary permeability, edema d/t massive fluid shift out of vasculature into interstitial , relative hypvolemia, decreased venous return, decreased CO, decreased O2 delivery.

What is spinal shock?

temporary loss of spinal reflex activity that develops below the level of cord injury, characterized by sensorimotor function loss, hypertension, followed by hypotension, and flaccid paralysis that includes the bladder and bowel. It is temporary.

How does cardiac tamponade develop?

usually secondary to accumulation of fluid, such as blood, in the pericardial sac. Chest trauma, blunt or penetrating is the most common cause. Pressure on the chambers causes them to not be able to fill. Leads to significant decrease in CO, cardiovascular collapse, and death

What is the treatment of cardiac tamponade?

volume resuscitation while preparing for surgery to remove pericardial fluid - pericardiocentesis.