Distributive Shock
Neurogenic & Anaphylactic SHOCK
Different Pathophysiology VERY SIMILAR GOALS 1.Support ventilation and oxygenation 2.Promote adequate Cardiac Output 3.Monitor for complications 4.Provide emotional support.
Emergency surgeries: Anaphylactic
Emergency Airway- Cricothrotomy
Anaphylactic Shock: Etiology & Risk Factors
Etiology/Cause ALLERGEN Risk factors: Eating food (Children) Venomous Bite (Adults) Taking any drug...ever.
Neurogenetic shock Etiology and RF
Etiology: SCI (T6 and above) TBI Risk Factors: High-risk behaviors (Speeding -> MVA) (Bike-> no helmet) Falls, Athletes, DV
Gas Station analogy: Anaphylactic SHOCK
Gas Pump: initially...Works! Hose: TOO WIDE to deliver gas and it's LEAKING
Hemodynamic Monitoring: FAQ
Phlebostatic Axis 4th intercoastal space at midaxillary line *point of reference"
Arterial Lines
•VERY accurate Blood Pressure & MAP if placed correctly •Check the monitor reading against a MANUAL BP •Measures CVP = Preload •Monitoring of 5 P's Needed for continuous blood pressure monitoring and blood specimens for ABGs and other tests. -Monitor circulation in the limb with the arterial line (capillary refill, temperature, color). -Arterial lines are not used for IV fluid administration
Anaphylactic Shock
Most serious manifestation of allergic disorders. Caused by an Allergen Involves TWO or more organs to be considered shock "Shock->unstable"
Circulation = Neurogenic Shock, Bradycardia & Pacing
NCLEX Client Need: Physiological Adaptation lists PACING as a possible NCLEX question. Pacer spike before every QRS (ventricles) 1:1 V-paced PACER setting- on external device
Circulation = Crystalloids Neurogenic and Anaphylactic Shock
NS Goal: MAP ⬆️65 Output 30ml/hr Lactate ⬇️ CVR will increase (FLUIDS) *foley needed
Neurogenic Shock Cues during Assessment
•Vital signs? RAPID DROP BP-Hypotension, HR-Tachycardia, RR- Increase Temp-no •Neurological Finding? Anxious, Scared, Impending doom, Metallic Taste (food allergy finding) •Cardiac Findings? Prolonged Cap refill. Swollen extremities (3rd space edema) Respiratory Findings? SOB Bronchoconstriction, dyspnea, wheezing-> stridor Angioedema, Larynx swelling •Gastro/Renal Findings? Pain, cramping in ab, N/V/D Incontinence •Skin? Flushing, Hives (Urticaria) Itchy(purticrities) swelling,
Anaphylactic Shock: Recognizing Cues & Hemodynamics
↓ Sympathetic Tone •Cardiac Output/Index ⬇️ •CVP ⬇️ (fluids, LEAKING) •PCWP ⬇️ •SVR ⬇️ ↑Parasympathetic Response •Blood Pressure ⬇️ •Heart Rate ⬆️ (Body is ABLE to compensate)
Vasopressors: Neurogenetic Shock
Phenylephrine Gtt Mechanism of Action: A 1 Agonist - Most Common Side Effects ⬆️ SVR pvc, tacky, htn, Adverse/Killer Reactions Dysrhythmias Nursing Consideration Central line (sluffy off skin)
Anaphylactic Shock complications
RESPIRATORY Collapse
Neurogenetic Shock Cue and Hemodynamics
Sympathetic Dysfunction •Cardiac Output ⬇️ (Normal- 4-8L per min) •Cardiac Index ⬇️ •CVP ⬇️ (1-6 mmHg preload-fluid waiting to be squeezed out) *f luids would increase CVP Pressures •MAP ⬇️ (65-100) •SVR ⬇️ (800-1200) **Vasopressors for MAP/SVR Parasympathetic Response HR (DOWN!! the only shock with LOW HR)
Neurogenetic Shock Assessment findings
Vital signs? • LOW bp, Bradycardia, warm extremities, dry skin, hypothermia (heat loss) Neurological Finding? • GCS = 8 Fatigue, dizzy, weakness, ALC, confusion •Cardiac Finding Arrythmia Prolonged Cap refill Diminished/Weak pulse bradycardia ⬇️60 •Respiratory Findings? Depends on Level of injury Look at symptoms! c-4 = breath no more (pos ventilate) •Gastro/Renal Findings? Dysfunction- incontinence Digital stimulation for bowel (brain not able to tell bowels to empty) Foley/Straight cath (less likey to get infection •Skin? Warm dry **but they FEEL cold**
Neurogenetic shock
causes blood to pool in peripheral vessels Gas Pump: initially works Hose: TOO WIDE to deliver gas
Neurogenetic Shock Patho
damage to brain and SC ⬇️ Loss of sympathetic tone ⬇️ PNS is unopposed ⬇️ Uncontrolled Vasodilation ⬇️ LOW BP
Imaging to expect Neurogenetic Shock
looking for cite of injury CT X-ray MRI
The broken hose can be from...
neurogenetic and anaphylactic shock
Classic definition of Neurogenic Shock
vasodilation hypotension bradycardia No compensation phase in this shock
Airway breathing for Neurogenic Shock
1. Control C-Spine 2. Slight Elevation (lower ICP) 3. 02? Intubation? **look at pt, what do they need? Intubation??? ⬇️ GCS ⬆️C-4 Report: Drool, Ineffective Cough reflux
Airway/breathing for Anaphylactic Shock
1. Try to remove allergen (stinger, venom) 2. Epinephrine Access Airway Establish AIRWAY
Anaphylactic Shock: Pathophysiology
1.First Exposure: Sensitization (Minimal/No symptoms) 2.2nd Exposure: IgE mediated Activation of Basophils/Mast Cells → Cytokines/Prostaglandins/Histamines 3.Bloodstream Clinical Pearl: Anaphylactoid Reactions are defined as those reactions that produce the same clinical picture as anaphylaxis but are not IgE mediated...
Distributive Shock
A condition that occurs when there is widespread dilation of the small arterioles, small venules, or both.
Anaphylactic SHOCK
A severe reaction that occurs when an allergen is introduced to the bloodstream of an allergic individual.
STAT MEDICATIONS & Heart Monitor: Neurogentic
ATROPINE Mechanism of Action: Increasing HR (firing of pacer) Desired Effect: ⬆️ HR Most Common Side Effects: Tachycardia Adverse/Killer Reactions: RARE Nursing Consideration Flushing
Autonomic Dysreflexia
Anxiety, HA, Nasal Stuffiness, bradycardia, HTN BELOW INJURY- diaphoresis (potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure)
Eval Outcome
Cardiac Tissue Perfusion Pulmonary Tissue Perfusion Gastric Tissue Perfusion Urinary Tissue Perfusion
Emergency surgeries: Neurogenetic
Decompress via SX??
Neurogenic Shock Possible Complications
EARLY Respiratory Distress/Failure Cardiac Complications (Blood is not making it back to heart) Hypothermia LATE Autonomic Dysreflexia
Vasopressors: Anaphylactic Shock
EPINEPHRINE Mechanism of Action: Mass cell inhibition Desired Effect: CO improve, Bronchodilation Most Common Side Effects Dysarthria's Adverse/Killer Reactions Rare- Nursing Consideration
STAT MEDICATIONS & Heart Monitor: Anaphylactic
EPINEPHRINE IM injection Q 5 mins Mechanism of Action: Mass cell inhibition Desired Effect: CO improve, Bronchodilation Most Common Side Effects Dysarthria's Adverse/Killer Reactions Rare- Nursing Consideration Other Possibilities: Antihistamines (Diphenhydramine) Corticosteroids **swelling (Hydrocortisone succinate) Bronchodilators **breathing
Gas Station analogy: broken ___
Hose Distributive shock occurs when intravascular volume pools in peripheral blood vessels. This abnormal displacement of intravascular volume causes insufficient blood returns to the heart, leading to inadequate tissue perfusion