Shock

1. Presented by: Toni Downen RN, MSN, CEN Shock

2. Objectives • Define shock • Discuss the nursing assessment of the patient in shock • Identify classifications of shock • Identify early and late signs of shock • Treatment priorities in shock

3. Definition of Shock Inadequate tissue perfusion and Cellular hypofunction/ hypoxia

4. Primary Goal • Maintain perfusion to the heart, brain, and lungs • These organs are perfused until the blood pressure decreases below 50

5. Classification of Shock • Hypovolemic shock • Low intravascular volume (Most Common) • Distributive shock • Maldistribution of blood volume • Cardiogenic shock • Poor pumping ability of heart • Dissociative or Obstructive shock • Inability of blood to deliver oxygen

6. Stages of Shock • Compensated Shock • Sympathetic Nervous System response to decreased tissue perfusion • Uncompensated Shock • Compensatory mechanisms no longer able to to maintain tissue perfusion • Irreversible (Refractory) Shock • Progression to cellular, tissue, and organ death

7. Early Signs of Shock • Orthostatic vital signs • An orthostatic systolic decrease of 10 to 20 millimeters of mercury or increase in pulse of 15 beats/min is considered "significant." • Take orthostatic vital signs recumbent and after standing for 1 to 2 minutes. • Decreased Urinary Output-less than 30 Ml/hour • Respiratory alkalosis • Restlessness, anxiety

8. Early Signs of Shock • Tachycardia • Attempts to compensate for decreased cardiac output • Altered mental status • The brain is the most sensitive organ to alterations in cardiac output • Unable to concentrate • Difficulty following commands

9. LATESigns of Shock • Decreased systolic Blood Pressure • Metabolic acidosis • Decreased Level Of Consciousness • Cold clammy skin or mottling • Decreased Urinary Output (oliguria to anuria) • Decreased Cardiac Output

10. Hypovolemic Shock

11. Hypovolemic shock • Inadequate tissue perfusion resulting from inadequate circulating volume • Blood loss • Burns

12. Treatment of Hypovolemic Shock • Slow or stop fluid or blood loss • For dehydration give fluids • 0.9 Normal Saline is the fluid of choice • Lactated Ringers may also be used • For blood loss • Give fluids until blood arrives

13. Distributive Shock

14. Distributive shock • Based on loss of vascular tone resulting in vasodilation and abnormal distribution of blood • Neurogenic Shock/ Spinal cord injury • Septic shock-endotoxins and inflammatory mediators causing vasodilation and other perfusion abnormalities

15. Septic Shock-2 Phases • Warm shock-(hyperdynamic) (1) • High cardiac output and low peripheral vascular resistance from vasodilation(bradykinins, histamine, etc.) • Capillaries become permeable causing leakage of fluid shifting (3rd spacing) • Fever and increased respiratory rate (due to infection causing bacteria) • Diuresis due to high osmotic load handled by the kidneys (due to dying bacteria) • Temporarily increases cardiac output and contractility –Warm phase can last 6-72 hours

16. Cold Phase (late stage) • Low output or high resistance shock • Late and nearly irreversible (can’t distinguish from hypovolemic shock) • Subnormal temperature and low white blood count • Profound hypotension and hypoperfusion • Skin cold and mottled everywhere • Pulse and respirations rapid, but cardiac output decreases • Leads to vasoconstriction of major organ circulation leading to organ death

17. Treatment of Septic Shock • Control infection source • Cultures and appropriate antimicrobials • Drain or debride infected tissue • Support Cardiovascular system and  perfusion • FLUIDS • Vasoconstrictors to reverse massive peripheral vasodilation • Inotropic support to increase cardiac contactility (Dobutamine) • Control temperature

18. Treatment of Septic Shock • Improve oxygenation • Increase O2 delivery to compensate for high O2 consumption • Serum Lactate-To measure cellular perfusion: If lactate is greater than 4 mmol/L it is associated with mortality and shock • Prophylactic heparin, and blood components to treat coagulopathies

19. Neurogenic Shock • Cause: • Loss of sympathetic tone  massive vasodilation • Spinal cord injury especially involving cervical or high thoracic vertebra • Spinal anesthesia • Vasomotor center depression from head trauma • Priorities • Maintain Airway • Stabilize spine • Support Respirations

20. Treatment of Neurogenic Shock • Correct hypovolemia with the minimum volume needed for systolic Blood Pressure greater than 90 • Vasopressor support for perfusion to constrict vasculature and increase blood pressure • Treat persistent bradycardia with atropine or pacing • Reverse hypoxemia • Maintain body temperature • Slowly rewarm • Remember Airway, breathing and circulation are always a priority and must be reassessed often

21. Cardiogenic Shock

22. Cardiogenic shock • The heart fails to pump blood adequately to all parts of the body • Usually caused by: • Injury to the heart • Myocardial infarction • Electrical shock

23. Treatment of Cardiogenic Shock • Never forget OXYGEN! • Goal is to increase cardiac output • Correct preload • Increase contractility • Correct afterload

24. Decreasing Preload in Cardiogenic Shock • Nitroglycerin (Tridil) • commonly used, especially if there is concern that ischemia is an underlying or precipitating factor • Start at 10 to 20 mcg/min and increase by increments of 10 to 20 mcg/min every 5 minutes until the desired effect is achieved

25. Decreasing Preload in Cardiogenic Shock • Furosemide and other diuretics • Start with 20 mg Intravenous and observe response. • Titrate dose upward until adequate diuresis is established. • If the patient is receiving furosemide over a long-term give 1 to 2 times the usual daily dose by slow (over 1 to 2 minutes) IV bolus.

26. Increasing Contractility in Cardiogenic Shock • Dobutamine (2.5 to 15 mg/kg/min) • Dopamine (2 to 20 mg/kg/ min) • may be needed for pressure support or as a positive inotrope. • Consider pacing when bradycardia is thought to be the cause • Consider cardioversion for arrhythmias

27. Decreasing Afterload Cardiogenic Shock • Nipride or Beta blocker to decrease systemic vascular resistance • Consider an intra-aortic balloon pump if left ventricular failure is suspected • Surgery may be indicated under rare conditions such as valvular heart disease or rupture of ventricular septum

28. Dissociative or Obstructive Shock

29. Dissociative or Obstructive Shock • Inability of Red Blood Cells to deliver oxygen due to obstruction of blood flow • Tension pneumothorax • Clot of a great vessel or Pulmonary Embolis • Cardiac Tamponade • Carbon monoxide poisoning • Abdominal Aortic Aneurism (AAA) • Gravid uterus

30. Treatment of a Tension Pneumothorax • Maintain Airway • Deliver High flow oxygen • Decompress effected side of the chest • Needle decompression • Chest tube placement • Support volume if blood or fluid is the cause

31. Treatment of a Pulmonary Embolus • Support Airway • High Fractional Inspired Oxygen (measured O2) • Cat Scan of the chest • Ventilation perfusion scan • Consider Tissue Plasminogen Activator • Treat with appropriate anticoagulants

32. Treatment of Cardiac Tamponade • Oxygen • IV & lab • Frequent vital signs • Antibiotics • Pericardiocentesis (Aspiration of fluid from pericardial sac) • Surgical pericardiectomy (removal of the sac)

33. Treatment In All Types of Shock • Remember Airway, Breathing and Circulation • These are your top priority • Establish adequate ventilation and oxygenation • Restore optimum circulation and volume • Identify type of shock and Treat underlying causes

34. Treatment In All Types of Shock • Maintain adequate cardiac output • Maintain urine output between 30 - 60 ml/hr. • Usually accomplished by fluids or inotropes • Maintain optimum internal metabolic environment (check your Arterial Blood Gases) • Keep patient warm

35. The End Questions?

36. References • McQuillan, Von Rueden, Hartsock, Flynn and Whalen. Trauma Nursing From Resuscitation through Rehabilitation (3rd edition) (2009) • Sheehy’s Manual of Emergency Care (7th edition) (2013) • Wahl, Sharon C. (2011) Septic Shock: How to Detect it Early