Med-Surg 1: Ch 34 - Shock

Why do you need to monitor shock pts closely who are using vasodilators?

because these drugs can cause shock progression w/ volume depletion

What is the main indicator of shock during assessment?

HR/Pulse rate and quality = first sign of shock Systolic BP may not change at all in initial stage of shock Decreased urine output

S/S of shock

R/T POOR PERFUSION! Low BP Rapid, weak, thready pulse Flat neck/hand veins Slow cap refill Increased thirst Cold, clammy skin, cyanosis Restlessness Decreased motility =Diminished/Absent bowel sounds decreased urine output

cardiogenic shock

•Necrosis of more than 40% of left ventricle •not enough oxygen is delivered to the tissues of the body, caused by low output of blood from the heart. •severe complication of a large acute myocardial infarction, as well as other conditions.

Cardiogenic Shock: Management ( REVIEW!!!)

•Pain relief and decreased myocardial oxygen requirements through preload and afterload reduction •Oxygen therapy •Drug therapy: nitroglycerin, dobutrex, dopamine, epinephrine, morphine

MEWS score

Modified Early Warning System to identify sepsis early

S/S cardiogenic shock

↑ HR ↑ RR ↓ BP ↓ urinary output •Cold, clammy skin •Poor peripheral pulses •Agitation, restlessness, confusion •Pulmonary congestion •Tachypnea •Continuing chest discomfort

septic shock

Shock caused by severe infection, usually a bacterial infection.

obstructive shock

Shock that occurs when there is a block to blood flow in the heart or great vessels, causing an insufficient blood supply to the body's tissues. Ex.) pericarditis = biggest cause cardiac tamponade, Arterial stenosis, PE, Pulmonary hypertension Tension pneumothorax

Septic shock: SIRS VS

T: >100.4 F / <96.8 G RR: >20 HR: >90 WBC: >12000/ <4000 w/ >10% bands O2: <32 mmHg

DIC and shock

This reduces perfusion in septic shock It occurs as a result of excessive clotting/ uncontrolled bleeding due to organ failure. (not clotting factors)

Septic shock treatment

WITHIN 1 HR: *Oxygen/mechanical ventilation *Drug therapy: -measure lactate -blood culture before abx -abx -rapid administration 30mL/kg crystalloid for hypotension/lactate >4 -vasopressors to maintain MAP of >65 mm Hg -other: corticosteroids, insulin, heparin therapy -urine/wound/sputum cultures *Blood products as needed

Distributive shock occurs when:

blood pools in expanded vascular beds and tissue perfusion decreases Ex.) neural induced, pain, stress, anesthesia, spinal cord injury, head trauma, sepsis, burns, extensive trauma, liver impairment. - Neural-induced - Chemical-induced * Sepsis * Anaphylactic * Capillary-leak syndrome

Why do you check lactic acid levels with shock?

chemical byproduct of anaerobic respiration which occurs during shock normal level = 0.3-0.8 mmol/L OR 3-7 mg/dl (arterial) 0.6-2.2 mmol/L (venous)

hypovolemic shock

shock resulting from blood or fluid loss Ex.) hemorrhage = MOST COMMON, trauma, surgery, inadequate clotting, vomiting, diarrhea, diabetes insipidus, etc.

qSOFA

to identify sepsis early H (100) A (15) T (22) 2 or more of: Hypotension: SBP less than or equal to 100 mmHg Altered mental status (any GCS less than 15) Tachypnoea: RR greater than or equal to 22 identified patients with suspected infection who are likely to have a prolonged ICU stay or to die in the hospital

Hypovolemic shock treatment

*Oxygen therapy *IV therapy = ringers lactate / 0.9% NS *Blood products *Drug therapy = vasoconstrictors (dopamine/norepinephrine), entopic drugs, dobutamine *Monitor VS and LOC *Surgery to correct cause if indicated

Stages of Shock

1. initial stage 2. compensatory stage 3. progressive stage 4. refractory stage

What is a life-threatening stage of shock?

3. Progressive stage Vital organs only tolerate this situation for a short time before development of multiple organ dysfunction syndrome = permanent damage. O2 sat goes down to 75-80% Conditions must be corrected w/in 1 hr. of this stage

anaphylaxis (anaphylactic shock)

An extreme, life-threatening systemic allergic reaction that may include shock and respiratory failure.

Late S/S of shock

Decreased LOC (lethargy - coma) Falling BP Irregular breathing Mottling or cyanosis Absent peripheral pulses Muscle weakness / absent deep tendon reflexes Sluggish pupillary response to light

septic shock risk factors

Immunosuppression Extremes of age (<1 yr and >80 yrs) Malnourishment Chronic illness Invasive procedures Emergent and/or multiple surgeries Wounds

stages of septic shock

Infection/Bacteremia SIRS Sepsis: lactate >4mmol Septic shock: lactate >4mmol Death