3 Shock

Dopamine Dobutamine Isoproterenol

Inotropes:

Intraosseous (IO)

Into the bone; a medication delivery route.

absolute hypovolemia

*• External loss of whole blood- Hemorrhage from trauma, surgery, GI bleeding • Loss of other body fluids- Vomiting, diarrhea, excessive diuresis, diabetes insipidus, diabetes mellitus *____ hypovolemia results when fluid is lost through hemorrhage, gastrointestinal (GI) loss (e.g., vomiting, diarrhea), fistula drainage, diabetes insipidus, or diuresis.*

B

A 78-yr-old man has confusion and temperature of 104° F (40° C). He is a diabetic with purulent drainage from his right heel. After an infusion of 3 L of normal saline solution, his assessment findings are BP 84/40 mm Hg; heart rate 110; respiratory rate 42 and shallow; CO 8 L/minute; and PAWP 4 mm Hg. This patient's symptoms are most likely indicative of a. sepsis. b. septic shock. c. multiple organ dysfunction syndrome. d. systemic inflammatory response syndrome.

1 (Direct pressure to the wound is the best initial method to manage uncontrolled bleeding. If this method is ineffective, then clamping a vessel, applying a tourniquet, and elevating the limb can be tried.)

A client who was in an motor vehicle crash is in shock. Which is the best measure for the nurse to initiate to control bleeding? 1.Apply direct pressure. 2.Clamp a visible vessel. 3.Apply a tourniquet. 4.Elevate the injured part.

Shock

A condition in which the circulatory system fails to provide sufficient circulation to enable every body part to perform its function; also called hypoperfusion.

D

A patient has a spinal cord injury at T4. Vital signs include falling blood pressure with bradycardia. The nurse recognizes that the patient is experiencing a. a relative hypervolemia. b. an absolute hypovolemia. c. neurogenic shock from low blood flow. d. neurogenic shock from massive vasodilation.

15

A patient may compensate for a loss of up to ___% of the total blood volume (approximately 750 mL). Further loss of volume (15% to 30%) results in a sympathetic nervous system (SNS)-mediated response. This response results in an increase in heart rate, CO, and respiratory rate and depth. The SV, central venous pressure (CVP), and PAWP are decreased because of the decreased circulating blood volume.

Pediatric anaphylaxis

ABCs Vital signs and history Establish IV Pulse Ox Anaphylaxis?? YES 0.1 mg/kg epi X q5min x2 if no improvement 10-15 L nonrebreather elevate lower extremities Hypotensive? 20 mL/kg NS bolus, titrate to maintain BP nebulized albuterol as needed (see below) NO 1 mg/kg Diphenhydramine IV nebulizer albuterol 2.5 mg with 2.5 mL if wheezing

oxygen

All clients with shock should receive __ therapy

a, c

Appropriate treatment modalities for the management of cardiogenic shock include (select all that apply) a. dobutamine to increase myocardial contractility. b. vasopressors to increase systemic vascular resistance. c. circulatory assist devices such as an intraaortic balloon pump. d. corticosteroids to stabilize the cell wall in the infarcted myocardium. e. Trendelenburg positioning to facilitate venous return and increase preload.

Tachycardia Tachypnea Decreased urine output Diaphoretic Drop in systolic BP Narrowing pulse pressure Decreased LOC Cardiopulmonary failure

As body compensates, signs of shock include:

Stroke volume (SV) Cardiac output (CO) Mean arterial pressure (MAP) Sympathetic nervous system (SNS) Pulse pressure

Basic hemodynamics:

Packed red blood cells Fresh frozen plasma Platelets

Blood or Blood Products: used in All types of shock.

• 1.8%, 3%, 5% NaCl

Hypertonic fluids: May be used for initial volume expansion in *hypovolemic* shock. ***Monitor patient closely for signs of hypernatremia (e.g., disorientation, convulsions). Central line preferred for infusing saline solutions ≥3%, since these may damage veins.

Bronchospasm/respiratory infection Drowning Burns Dysrhythmias Foreign body aspiration Gastroenteritis Sepsis Seizures Trauma

Causes of cardiac arrest in children:

Neurogenic shock

Circulatory failure caused by paralysis of the nerves that control the size of the blood vessels, leading to widespread dilation; seen in patients with spinal cord injuries. Imbalance between parasympathetic and sympathetic stimulation of vascular smooth muscle à sustained vasodilation Dramatic reduction in systemic PVR

DOPAMINE DOSAGE low vs high

DOPAMINE DOSAGE low vs high

lactic acid

During the initial phase of shock, the __ may be elevated

neurogenic, septic

Fluids also used to treat __ and __ shock

blood

If hypovolemia is corrected by *crystalloid* fluid replacement at this time (< 30%), tissue dysfunction is generally reversible. If volume loss is greater than 30%, compensatory mechanisms may fail and immediate replacement with ____ products should be started

hypotension

In all types of shock, you will see __ in the latter stages

1.Sufficient cardiac output 2.Uncompromised vascular system 3.Sufficient blood volume 4.Tissues that can abstract and use the oxygen delivered through capillaries

In healthy individuals, homeostatic regulation depends on:

compensatory

In the __ stage of shock, the body is working to maintain perfusion.

• 0.9% NaCl (NSS) • Lactated Ringer's (LR)

Isotonic Fluids: Used for initial volume replacement in most types of shock.

*Child* normal coronary arteries glucose for energy storage diminished sensitivity to insulin greater ability to store glycogen smaller cardiac dimensions right ventricular dominance SVT compliant thoracic cage weaker intercostal muscle short, flat diaphragm smaller airway larger head in proportion to body proportionally large occiput weak neck less volumetric bone mineral density compliant chest wall proportionally large abdomen organs *Adult* CAD HTN long chain fatty acid as energy source left ventricle dominance Vfib larger alveoli less reactive pulmonary bed deeper vertebral facets, well developed spinous process bones have greater strength

Key difference in adults and children in trauma effects:

60

Mortality rates for patients with cardiogenic shock approach __%

Hypovolemic

Most common type of shock in pediatrics

hypovolemic

Most effective treatment for __ shock is to administer IV fluids, blood

hypotension

Occurs LATE in the pediatric shock syndrome Blood pressure is an unreliable indicator of shock

Bradycardia

Ominous sign of shock in the pediatric population:

HISTORY

Patient __ is very important in determining sepsis (shock)

Blood Glucose *If blood glucose <60* D25 IV Glucagon (no IV access) *If blood glucose >60* Normal saline bolus 20 ml/kg (repeat 1 time) *** Consider Zofran for vomiting Consider Dopamine

Pediatric Shock Hypotension (Non-trauma) Treatment:

alleriges (food, drugs, latex, blood, insects, vaccines, etc) drug reactions

Potential causes of anaphylactic shock:

Left anterior wall MI Cardiomyopathy Cardiac tamponade Ventricular hypertrophy Valvular stenosis Cardiac injury Hypertension

Potential causes of cardiogenic shock:

Recent surgery Traumatic injuries Burns Dehydration Vomiting Diarrhea Diabetes Bowel obstruction Fracture of long bones Sepsis

Potential causes of hypovolemic shock:

Spinal cord injuries, spinal anesthesia, drugs, hypoglycemia

Potential causes of neurogenic shock:

Chronically ill Debilitated Invasive procedures

Potential causes of septic shock:

chest pain third spacing of fluid SOB edema of larynx and epiglottis, mouth and lips wheezing stridor rhinitis incontinence flushing pruritus urticaria angioedema anxiety impending doom confusion decreased LOC metallic taste in mouth cramping abdominal pain NV diarrhea

anaphylactic shock signs/symptoms:

Larger head in proportion to body Proportionally larger occiput Relatively weak neck muscles and ligaments Less volumetric bone mineral density Compliant chest walls Proportionally larger abdomen Organs Smaller airways Shorter, flatter diaphragm Weaker intercostal muscles

Puts infants at greater risk for injury/trauma:

hydrocortisone

if adrenal insufficiency is suspected, give __ 2 mg/kg bolus IV max 100 mg *from fluid refractory and dopamine or norepinephrine dependent shock*

diastolic dysfunction

inability of the heart to fill ex. Cardiac tamponade, ventricular hypertrophy, cardiomyopathy

Congenital heart disease Immunocompromised Chronic diseases Underprivileged Crowded living

Risk factors for sepsis in children:

PALS algorithm

ScVo2 > 70%, low BP (warm shock) additional fluid bolus + norepinephrine +/- vasopressin ScVo2 < 70%, normal BP, poor perfusion Transfuse to Hgb > 10 g/dL, fluid bolus, milrinone or nitroprusside, consider dobutamine ScVo2 < 70%, low BP, poor perfusion (cold shock) Transfuse to hgb > 10 g/dL, fluid bolus, epi or dobutamine AND norepinephrine

vasodilation maldistribution of blood flow myocardial depression

Septic shock has three major pathophysiologic effects:

•History and physical exam •Hemoglobin, hematocrit •ABGs •Serum BUN, electrolytes, creatinine •Urine specific gravity, osmolality •Blood cultures •WBC and differential •Serum cardiac enzymes (CPK, troponin) •Central venous catheterization •X-rays, CT scan, MRI •Endoscopic examination •Echocardiogram

Shock Diagnostic Tests:

Vasoconstrictors Inotropes Vasodilators Diuretics Sodium bicarbonate Antidysrhythmic agents Antibiotics Calcium Morphine Epinephrine, antihistamines, and inhaled beta2-agonists

Shock Pharmacological Therapy:

Hypovolemic shock

Shock caused by fluid or blood loss. Decrease in intravascular volume ≥ 15% Decrease in blood to heart

Cardiogenic shock

Shock caused by inadequate function of the heart, or pump failure. Heart's pumping ability compromised Causes of loss of function Decrease in CO leads to decrease in MAP

Septic shock

Shock caused by severe infection, usually a bacterial infection. Septicemia Leading cause of death in client in ICUs Part of progressive syndrome (SIRS)

MAP

Shock is triggered by sustained drop in __ caused by Decrease in cardiac output Decrease in circulating blood volume Increase in size of vascular bed

Diminished blood flow--decreased CVP, CO, BP Increased heart rate, vasoconstriction, PVR Catecholamine, ADH, adrenocorticosteroids, aldosterone released to keep fluids Blood shunting away from non-essential organs (only to heart/brain) Skin cool/clammy, increased capillary refill, decreased urine output Anaerobic metabolism--lactic acid build up Acidosis Tachypnea to relieve acidosis Vessels dilate due to fatigue Pooling in capillary beds (blood not returning to the heart)

Shock physiology:

Advancing cardiac disease High-risk behaviors Diseases that slow body's ability to clot

Shock risk factors:

septic

Shock where skin is warm and flush

Decreased LOC Grunting respirations and increased WOB Poor air entry and decreased breath sounds Bradycardia Apnea, bradypnea Decreased consolability Abnormal look/gaze Abnormal speech/cry Retractions, flaring Pallor, mottling, cyanosisf

Signs of respiratory failure in a child:

Quiet Lethargic Respiratory distress Poor nutrition Vomiting Distended abdomen Hypothermia (potentially)

Signs/symptoms of shock in children:

Early, reversible, and compensatory shock Baroreceptors detect sustained drop in MAP SNS increases heart rate Symptoms almost *imperceptible* Pulse slightly elevated Compensatory shock after MAP falls *Compensatory mechanisms short-acting* Anabolism starts causing lactic acid build up

Stage I Shock: *initial phase*

respiratory

kids usually experience __ arrest before cardiac arrest.

Immediate or progressive shock After sustained decrease MAP of 20 mmHg *measures needed to maintain CO and tissue perfusion* Cells switch to anaerobic metabolism Lactic acid formation Sodium-potassium pump failure Cells swell Heart rate, vasoconstriction increase Perfusion of organs decreases Cells in heart, brain hypoxic Generalized acidosis and hyperkalemia Hypotensive Decreased CO Vasoconstriction with release of epinephrine/norepinephrine Blood shunted to perfuse vital organs only VQ mismatch (some of the blood is not oxygenated in lungs)t

Stage II Shock: *compensatory phase*

*compensatory mechanisms fail* Refractory or irreversibly shock Changes in mental status Generalized tissue anoxia Widespread cellular death Death of cells followed by death of tissues, results in death of organs anasarca (diffuse profound edema) pulmonary system is often the first system to display signs of critical dysfunction *No treatment can reverse damage*

Stage III Shock: *progressive phase*

*total body failure* decreased perfusion from peripheral vasoconstriction and decreased CO exacerbate anaerobic metabolism accumulation of lactic acid contributes to increased capillary permeability and dilation Decreased coronary blood flow leads to worsening myocardial depression and a further decline in CO hypotension and hypoxemia accumulation of waste products, such as lactate, urea, ammonia, and CO2

Stage IV shock: *refractory phase*

Position (elevate legs with hypotension) Oxygen Epinephrine Antihistamines (cimetidine) H2 Blockers Inhaled B-adrenergic blockers agents

Steps of anaphylactic shock:

Inotropes

Strengthen cardiac contraction

septic, hypovolemic, anaphylactic

The cornerstone of therapy for ___ shock is volume expansion with administration of the appropriate fluid. Fluid resuscitation should start using one or two large-bore (e.g., 14- to 16-gauge) IV catheters; an intraosseous (IO) access device; or a central venous catheter.

cardiogenic, hypovolemic, distributive, obstructive

The four main categories of shock are:

sepsis

The fourth leading cause of death in infants and the second leading cause of death in children:

systolic dysfunction

The heart's inability to pump the blood forward is called __. ex. *Myocardial infarction*, cardiomyopathy, blunt cardiac injury, severe systemic or pulmonary hypertension, myocardial depression from metabolic problems

D (Restlessness is an early sign of impending hypovolemic shock. Bowel sounds are not expected 2 hours after surgery. A blood pressure of 110/70 is a normal postoperative finding. A negative Homan sign indicates the client has not formed a thrombosis in the legs.)

The nurse is caring for a client 2 hours after abdominal surgery. The nurse monitors for signs of complications and would notify the physician upon assessing: 1.Absent bowel sounds in all four quadrants. 2.Negative Homan sign. 3.Blood pressure of 110/70. 4.Restlessness.

2 (The endotoxins released by bacteria stimulate the release of vasoactive proteins causing peripheral vasodilation and decreased peripheral resistance. Cardiogenic, hypovolemic, and obstructive shock are not characterized by these symptoms.)

The nurse is caring for a client who is diagnosed with shock. For which type of shock will the nurse provide interventions if the client presents with widespread vasodilation and decreased peripheral resistance? 1.Cardiogenic shock 2.Septic shock 3.Hypovolemic shock 4.Obstructive shock

2 (The client in hypovolemic shock requires blood replacement and plasma expanders to keep the hematocrit and hemoglobin at acceptable levels. Narcotic analgesics would be given every 1-2 hours, but might be withheld until the client's blood pressure is stable. Normal saline and dextrose solutions cannot replace lost hemoglobin or plasma factors and would not be given until the client is stabilized.)

The nurse is reviewing the orders for a client who is experiencing hypovolemic shock and expects to note which of the following? 1.Narcotic analgesics for pain every 6 hours 2.Packed red blood cells and albumin 25% 3.Intravenous normal saline run wide open 4.D10 half normal saline

1 (Ultimately, shock is a systemic imbalance between oxygen supply and demand. Sufficient cardiac output is not shock; insufficient cardiac output is. Hemorrhage is a cause of one type of shock, but it does not define shock. Abnormal blood pressure is not a definition of shock; blood pressure can be either high or low depending on the stage of shock.)

The nurse is teaching the parents of a child who have asked the nurse what shock is. The nurse tells the parents that shock is: 1.A systemic imbalance between oxygen supply and demand. 2.Sufficient cardiac output. 3.Hemorrhage. 4.Abnormal blood pressure.

anaphylactic, neurogenic, septic

Three types of distributive shock:

Intraosseous (IO)

Use an ____ access device for emergency resuscitation when IV access cannot be obtained. • Insertion sites include sternum, proximal and distal tibia, and proximal and distal humerus. • Remove IO devices within 24 hours of insertion or as soon as possible after peripheral or central IV access is obtained.

Norepinephrine Metaraminol

Vasoconstrictors:

Nitroglycerine, Nitroprusside

Vasodilators:

0.5 mL/kg/hr

What is the minimum, adequate amount of urine output?

Relative Hypovolemia

• Pooling of blood or fluids- Bowel obstruction • Fluid shifts- Burn injuries, ascites • Internal bleeding- Fracture of long bones, ruptured spleen, hemothorax, severe pancreatitis • Massive vasodilation- Sepsis *____ hypovolemia, fluid volume moves out of the vascular space into the extravascular space (e.g., intracavitary space). This type of fluid shift is called third spacing.*

Anaphylactic shock

Widespread hypersensitivity reaction Vasodilation Occurs in contact with allergen

Distributive shock (vasogenic shock)

Widespread vasodilation, decreased PVR

Shock

___ is a syndrome characterized by decreased tissue perfusion and impaired cellular metabolism. This results in an imbalance between the supply of and demand for O2 and nutrients.

Neurogenic

___ shock is a hemodynamic phenomenon that can occur within 30 minutes of a spinal cord injury and can last up to 6 weeks

tachycardia low BP decreased capillary refill chest pain tachypnea crackles cyanosis increased Na and water retention decreased renal blood flow decreased urinary output pallor cool, clammy decreased cerebral perfusion (confusion, anxiety) decreased bowel sounds NV increased cardiac biomarkers increased BNP increased blood glucose increased BUN ECG arrhythmias ecocardiogram CXR pulmonary infiltrates

cardiogenic shock signs/symptoms:

congenital heart disease (hypoplastic left heart, coarctation of aorta, VSD, mitral stenosis, mitral atresia, tricuspid atresia, transposition of the great arteries, ) dysrhythmias (SVT, ventricular tachycardia, atrioventricular block) metabolic (acidosis, hyperkalemia, hypercalcemia, glycogen storage disease ASD, aortic stenosis) acquired/ischemic (Kawasaki's, anomalous left coronary, scorpion sitting, ccb, myocarditis, MI, chemo toxicity, anemia) trauma (tension pneumothorax, hemopericardium, myocardial contusion cardiac aneurism)

causes of cardiogenic shock in children:

blood loss fluid loss (vomiting, diarrhea, fever) infection

causes of pediatric hypotensive shock (non-trauma)

Oriented to person, place, time Restless, apprehensive, confused Change in level of consciousness • Release of epinephrine/norepinephrine (vasoconstriction) • ↑ MVO2 • ↑ Contractility • ↑ HR ↓ BP ↓ Blood flow to the lungs: • ↑ Physiologic dead space • ↑ Ventilation-perfusion mismatch • Hyperventilation • ↑ Minute ventilation (VE) • Tachypnea ↓ Blood supply ↓ GI motility Hypoactive bowel sounds ↑ Risk for paralytic ileus temperature Normal or abnormal Pale and cool Warm and flushed

compensatory phase (stage II) clinical manifestations:

Pulse pressure

difference between systolic and diastolic pressure *Early indicator of shock*

• Restlessness • Confusion • Anxiety • Feeling of impending doom • Decreased level of consciousness • Weakness • Rapid, weak, thready pulses • Dysrhythmias • Hypotension • Narrowed pulse pressure • Cool, clammy skin (warm skin in early onset of septic and neurogenic shock) • Tachypnea, dyspnea, or shallow, irregular respirations • Decreased O2 saturation • Extreme thirst • Nausea and vomiting • Chills • Pallor • Cyanosis • Obvious hemorrhage or injury • Temperature dysregulation

general shock clinical manifestations:

Initial • If unresponsive, assess circulation, airway, and breathing (CAB). • If responsive, monitor airway, breathing, and circulation (ABC). • Stabilize cervical spine as appropriate. • Control any external bleeding with direct pressure or pressure dressing. • Give high-flow O2 (100%) by non-rebreather mask or bag-valve-mask. • Anticipate need for intubation and mechanical ventilation. • Establish IV access with two large-bore catheters (14- to 16-gauge) or an intraosseous access device, or assist with insertion of central line. • Begin fluid resuscitation with crystalloids (e.g., 30 mL/kg repeated until hemodynamic improvement is noted). • Draw blood for laboratory studies (e.g., blood cultures, lactate, WBC). • Assess for life-threatening injuries (e.g., cardiac tamponade, liver laceration, tension pneumothorax). • Consider vasopressor therapy if hypotension persists after fluid resuscitation. • Insert an indwelling urinary catheter and nasogastric tube. • Start antibiotic therapy after blood cultures if sepsis is suspected. • Obtain 12-lead ECG and treat dysrhythmias. Ongoing Monitoring • ABCs • Level of consciousness • Vital signs, including pulse oximetry; peripheral pulses, capillary refill, skin color and temperature • Respiratory status • Heart rate and rhythm • Urine output

general shock nursing interventions:

decreased preload decreased stroke volume decreased capillary refill tachypnea-> bradypnea (late) decreased urinary output pallor, cool and clammy decreased cerebral perfusion (confusion, anxiety) absent bowel sounds decreased hgb, hct increased lactate increased urine specific gravity changes in electrolytes

hypovolemic shock signs/symptoms:

peripheral percutaneous access *if unsuccessful* intraosseous needle @ anteromedial tibia, distal femur

management of hypotensive shock in peds

*decreased BP* increases/decrease temperature (vasodilation) *bradycardia* bladder dysfunction decreased skin perfusion cool or warm and dry flaccid paralysis below level of lesions bowel dysfunction

neurogenic shock signs/symptoms:

decreased BP decreased preload tachypnea -> bradypnea (late) decreased urine output pallor, cool and clammy decreased cerebral perfusion (confusion, anxiety) decreased to absent bowel sounds

obstructive shock signs/symptoms:

↓ Cerebral perfusion pressure ↓ Cerebral blood flow ↓ Responsiveness to stimuli Delirium ↑ Capillary permeability → systemic interstitial edema ↓ Cardiac output → ↓ BP and ↑ HR ↓ Coronary perfusion → dysrhythmias, myocardial ischemia, myocardial infarction ↓ Peripheral perfusion → ischemia of distal extremities, diminished pulses, ↓ capillary refill Acute respiratory distress syndrome (ARDS): • ↑ Capillary permeability • Pulmonary vasoconstriction • Pulmonary interstitial edema • Alveolar edema • Diffuse infiltrates • Tachypnea • ↓ Compliance • Moist crackles Renal tubules become ischemic → acute tubular necrosis ↓ Urine output ↑ BUN/creatinine ratio ↑ Urine sodium ↓ Urine osmolality and specific gravity ↓ Urine potassium Metabolic acidosis Failure to metabolize drugs and waste products Cell death (↑ liver enzymes) Jaundice (decreased clearance of bilirubin) ↑ NH3 and lactate DIC Hypothermia or hyperthermia Cold and clammy

progressive phase (stage III) clinical manifestations:

Unresponsive Areflexia (loss of reflexes) Pupils nonreactive and dilated Profound hypotension ↓ Cardiac output Bradycardia, irregular rhythm ↓ BP inadequate to perfuse vital organs Severe refractory hypoxemia Respiratory failure Anuria Metabolic changes from accumulation of waste products (e.g., NH3, lactate, CO2) DIC progresses hypothermia Mottled, cyanotic

refractory phase (stage IV) clinical manifestations:

lactic acid

removed by the liver, but requires O2 - with decreased tissue perfusion build up occurs

increase/decrease temperature myocardial dysfunction biventricular dilation decreased EF (resolves 7-10 days with ventricle dilation) *hypotension despite resuscitation, euvolemic* *hypoxia* hyperventilation crackles respiratory alkalosis -> acidosis hypoxemia respiratory failure ARDS pulmonary HTN decreased urine output warm and flush -> cool and mottled alterations in mental status (coma) GI bleed paralytic ileum decreased/increased WBC increased PLT increased lactate increased blood sugar increased procalcitonin increased urine specific gravity decreased urine Na positive blood cultures

septic shock signs/symptoms:

restlessness, confusion, weakness dizziness increased HR, rapid pulse decreased BP pale, cool, clammy skin delayed cap refill sunken fontanel dry mucus membrane reduced skin turgor oliguria sudden weight loss

signs and symptoms of hypotensive shock in peds