Chapter 46

In this stage of shock, perfusion is reduced to essential tissues, such as the brain and heart. Widespread cellular hypoxia and anaerobic metabolism also occur.

In the irreversible stage of shock, the body's compensations have failed to maintain adequate blood flow to the brain and heart. As these primary tissues are compromised, further compensatory and regulatory mechanisms fail. Anaerobic metabolism and cell death begin to occur.

In this stage of shock, decreased perfusion of kidney, liver, and GI tract develop. Decreased urination and buildup of waste products in the blood occurs.

In the progressive stage of shock, the body compensates for circulatory failure by initiating vasoconstriction to tissues such as the GI tract, liver, and kidneys. The decreased perfusion of the kidneys results in reduced urine formation and decreased removal of waste products from the blood.

A patient is in the initial stages of shock. Which of the following can be expected? Select all that apply.

Increased heart rate, Activation of the renin- angiotensin-aldosterone system ( RAAS) , Peripheral Vasoconstriction, Decreased gastrointestinal (GI) blood flow.

A patient presents at the emergency department in shock. Blood glucose levels are elevated. Which of the following may explain this development relative to the state of shock?

The patient has released the stress hormones cortisol and epinephrine. During time of stress , blood glucose elevating hormones such as cortisol and epinephrine are released.

In this type of shock, multiple specialists are involved in the treatment. Appropriate antibiotics are needed, and vasoconstrictors and/or respiratory support may be required. Some cases must be resolved with surgery. Control of hyperglycemia is critical.

Septic shock treatment involves a multidisciplinary team approach. Antibiotics are essential when the infection is bacterial in nature. Surgical removal of the source of infection may be necessary. Control of hyperglycemia through IV insulin is required. Other approaches such as vasoconstrictors, respiratory, and renal support may be needed.

A nurse is monitoring a patient in shock. Which of the following levels are likely to be elevated?

Serum blood urea nitrogen ( BUN) and creatine(Cr)

A clinician is ordering atropine, an anticholinergic agent, for a patient in shock. Which type of shock is suspected?

NEUROGENIC

Which of the following signs and symptoms are indications of the body's attempt to compensate for hypovolemic shock? Select all that apply.

Pale, cool skin, Elevated Respirations, Decreased urine output.

A patient in shock is not responding to fluid replacement or vasopressor administration. Which type of shock might the patient be experiencing?

SEPTIC

A patient with a severe systemic infection is displaying hypoxemia and elevated lactate levels, along with an altered mental state. Which type of shock is the patient most at risk for experiencing?

SEPTIC

In this type of shock, an infectious organism is actively replicating and producing toxins that disrupt circulation. Hypotension results as venous return is decreased to the heart.

Septic shock is the result of a widespread inflammatory response to an infectious agent. The infectious agents often produce toxins that disrupt circulation. As circulation is disrupted, hypotension and decreased perfusion of tissues occurs.

Which of the following may appear in anaphylactic shock but be absent in other forms of shock?

Stridor and wheezing

A nurse is reviewing hypovolemic shock causes. Which of the following is an unlikely cause of hypovolemic shock?

Syndrome of inappropriate antidiuretic hormone ( SIADH) release.

A patient presents with shock. An intra-aortic balloon pump device is used for treatment. Which type of shock is the patient most likely experiencing?

Cardiogenic

Which type of shock occurs when the heart is unable to meet the body's demands and systolic blood pressure drops below 90 mm Hg for 30 minutes?

Cardiogenic

A patient arrives at the emergency department in a state of hypovolemic shock. Fluid replacement is initiated. Which of the does the clinician expect to increase as the patient is treated and begins recovery? Select all that apply.

- Blood pressure - Urine output- Renal perfusion

A patient in severe hypovolemic shock has developed acidosis. Please place the events in the proper sequence leading to this state.

1st Decrease venous return to the heart 2nd Decreased Cardiac output 3rd Decreased tissue perfusion 4th Tissue Hypoxemia 5th Increased lactic acid

A child is brought to the emergency department suffering from suspected anaphylactic shock due to bee sting. What are the immediate treatments considered? Select all that apply.

IV epinephrine, IV saline administration, Glucocorticoids,Antihistamines.

Which of the following may be observed in a patient suffering from shock?

Activation of the sympathetic nervous system. Increased susceptibility to clot formation. Decreased kidney perfusion leading to oliguria.

Which type of shock results from an IgE-mediated allergic reaction?

Anaphylactic

A patient falls from an outdoor deck located on the second floor of a building and injures his back. The patient is displaying signs of shock. The clinician suspects that neurogenic shock may be present. Which of the following patient assessment results would indicate neurogenic shock?

Bradycardia and Hypotension

This type of shock occurs when systolic blood pressure falls to less than 90 mm Hg despite adequate fluid volume and venous return. Baroreceptors detect the fall in blood pressure and activate the sympathetic nervous system. Decreased perfusion of the kidneys activates RAAS, which increases fluid volume within the body.

Cardiogenic, As the name implies, cardiogenic shock is related to the functioning of the heart. In this type of shock, fluid volume and other factors are sufficient; the failure to maintain blood pressure results from inadequate cardiac function.

This type of shock is manifested by IgE-mediated massive degranulation of mast cells in response to an allergen. Chemical signals result in pronounced vasodilation and bronchospasm.

In anaphylactic shock, an allergen has precipitated a massive immune-mediated response that liberates chemical mediators from mast cells. These chemical mediators cause bronchoconstriction, blocking air passage into and out of the lungs. In addition, the signals cause vasodilation and capillary leakage, resulting in reduced blood return to the heart.

A patient in a state of hypovolemic shock is most likely to present with which acid-base imbalance?

Metabolic acidosis

In this type of shock, the cornerstone of treatment is epinephrine, either intramuscular or IV administration. Glucocorticoids are also a standard treatment. Intubation may be necessary.

Epinephrine counteracts many of the responses that lead to anaphylactic shock, such as bronchoconstriction. Glucocorticoids are used to suppress the overwhelming immune response. As bronchospasm is common in anaphylactic shock, intubation may be necessary.

Which of the following are general signs and symptoms of shock?

Hypotension Increased respiratory rate Tachycardia Oliguria

This form of shock results from decreased blood volume, often as a result of trauma. Inadequate blood returns to the heart, reducing cardiac output and blood pressure.

Hypovolemic shock often results from trauma causing hemorrhagic blood loss. The loss of blood prevents adequate venous return to the heart. With insufficient blood to pump, the heart is unable to maintain pressure and perfusion to the tissues.

In this type of shock, fluid replacement is the key treatment. Although initial form of replacement fluid is under debate, most agree that Ringer's lactate or normal saline can be used. Blood transfusions may eventually be necessary.

Hypovolemic shock treatment requires adequate fluid management. Discussions continue as to which fluid should be used first for replacement. However, the key is getting fluid levels to the point that adequate pressure and perfusion can be maintained. Later, the type of fluid infusion or the need for blood transfusions can be considered.

In this type of shock, parasympathetic-drive bradycardia must be counteracted. Atropine, an anticholinergic agent, may be given. Vasoconstrictors and fluid may be administered to maintain blood pressure.

In neurogenic shock, decreased responsiveness of the cardiac system occurs with sympathetic nervous system disruption. Normally, the sympathetic nervous system increases heart rate to compensate for low blood pressure. If the sympathetic nervous system is not functioning properly, this does not occur as needed. Thus, treatments center on maintain adequate heart rate by blocking parasympathetic bradycardia and using vasoconstrictors to maintain blood pressure.

In this type of shock, disruption of the sympathetic nervous system, as occurs in spinal cord or brain injury, causes widespread vasodilation. The body is unable to compensate for decreases in blood pressure as expected because of disruption of the sympathetic nervous system.

In neurogenic shock, disruption of the nervous system, specifically the sympathetic nervous system, results in dysfunction of the circulatory system.

In this stage of shock, a decrease in blood pressure is detected, which activates the sympathetic nervous system. Activation of RAAS also occurs, as the response is similar to the alarm stage of the stress response.

In the initial stages of shock, a decrease in blood pressure is often the first sign detected by the body. The fall in blood pressure is noted by the baroreceptors which activate the sympathetic nervous system. The activation of this system counteracts the falling blood pressure by increasing the heart rate and contractility of the heart. Reduced blood pressure in the kidneys prompts the juxtaglomerular (JG) cells to release renin, activating the renin-angiotensin-aldosterone system (RAAS). This increases blood volume to maintain blood pressure. Stress hormones epinephrine and cortisol are released.

What are the three stages of shock?

Initial Progressive Irreversible