shock (decreased tissue perfusion):
- a syndrome of hypoperfusion and hypotension that leads to inadequate oxygen delivery to the tissues and impaired cellular metabolism that ultimately results in organ dysfunction/failure.
— A state of hypoperfusion/hypotension (low blood pressure)
— Oxygen does not get to the tissues (causing global hypoxia)
— Cells don’t function property (they shift from aerobic metabolism into anaerobic metabolism when they don’t get enough oxygen). Anaerobic metabolism results in the production of lactate and ultimately leads to metabolic acidosis.
— Organs start to fail
TYPES OF SHOCK
- Hypovolemic shock
- Distributive shock
- Cardiogenic shock (weak heart)
- Obstructive shock(impeding blood flow)
Hypovolemic shock:
- occurs when the body loses too much fluid through bleeding, vomiting, diarrhea, burns, polyuria, and third spacing
- Resulting in decreased Venus return to the heart, which then leads to decreased cardiac output and hypoperfusion
Hypovolemic shock: S/S
- decreased cardiac output
- Increased SVR (normal = 900-1300)
- Decreased CVP (normal = 2-6 mmHg)
- Cool skin, delayed Cap refill
- Low BP, low urine output
- Tachycardia
Hypovolemic shock: Treatment
- Administer blood/fluids
- treat the source of the loss (stop bleeding/vomiting)
- Insure two large bore IVs
- Monitor patient for improvements in HR, BP and urine output
Distributive shock:
decreased peripheral vascular resistance
Types of Distributive shock
- Septic shock (infection)
- Anaphylactic shock (allergic)
- Neurogenic shock (neuro/ Spinal trauma)
- Endocrine disorders
Septic shock (infection)
occurs in cases of severe infection that trigger a complex series of events leading to massive vasodilation and increased capillary permeability. The result is hypotension and global tissue hypoxia.
Septic shock (infection) S/S:
- Elevated temperature above 38 (100.4) (elderly/young children/immunocompromised, May have low temps below 36)
- Tachycardia
- tachypnea
- Elevate WBC/ very low WBC
- Decreased CVP
- Decreased SVR
- Hypotension, despite fluid resuscitation
Septic shock (infection): treatment
- Fluids
- Vasopressors
— Levophed: 1st
— vasopressin: 2nd
— Epinephrine/ phenylephrin: 3rd (to increase SVR/blood pressure) - Antibiotics
Anaphylactic shock (allergic):
occurs with massive allergic reactions. Large amounts of vasoactive substances are released from mast cells, causing systemic vasodilation and increased capillary permeability. This result is a sudden and global drop in blood pressure. The most acute problem your patient has is the respiratory compromise that accompanies the reaction
Anaphylactic shock (allergic): S/S
- Hypotension
- Tachycardia
- Wheezes, hives (urticaria), itching (pruritis), cutaneous flushing
Anaphylactic shock (allergic): Treatment
- Maintain airway
- Epinephrine
- Fluids to support blood pressure
- Histamine blockers
- Bronchodilators
- Steroids to reduce airway inflammation
Neurogenic shock (neuro/ Spinal trauma):
occurs in patients with spinal cord injury, and is due to a loss of sympathetic innervation. It’s more likely to present in patients with an injury at C3–C5 level
Neurogenic shock (neuro/ Spinal trauma): S/S
- Massive vasodilation and decreased Venous return leading to decreased SVR, CVP, CO and PAWP
- Decreased heart rate
- Pooling up blood vessels
- Warm,flushed skin
- Hypotension
- Wide pulse pressure
Neurogenic shock (neuro/ Spinal trauma): Treatment
- Stabilize the spine
- Backboard/ C- spine collar
- IV. Fluids to help restore preload.
- Vasopressors
- Treat bradycardia as needed
Cardiogenic shock (weak heart)
occurs when the heart has failed. This can be due to a massive MI, a valve problem, arrhythmias, or cardiomyopathy.
Cardiogenic shock (weak heart):
Left sided heart failure s/s:
- Pulmonary congestion
- Dyspnea
- Coarse lung sounds
- Distant heart sounds
- Elevated PAWP
- Low cardiac output
Cardiogenic shock (weak heart):
Right sided heart failure s/s:
- Systemic venous congestion and peripheral edema
- Elevated CVP
- Jugular Venous distension (JVD)
- normal or low PAWP
Cardiogenic shock (weak heart): Treatment
- Reduce myocardial oxygen demand while improving oxygen supply
- Give fluids (unless patient is fluid overloaded)
- Inotropes to improve cardiac output
— Dobutamine or dopamine
— Milrinone to also decrease afterload (has vasodilators effects) - Diuretics to remove excess fluid
- Vasopressors to increase BP via vasoconstriction
- Very sick patients may need IABP
- MI= revascularization
Obstructive shock(impeding blood flow)
occurs due to a mechanical barrier, such as cardiac tamponade, a pulmonary embolism, tumors, or a tension pneumothorax
Obstructive shock(impeding blood flow): PE s/s:
- SOB, increased WOB
- tachypnea
- Decreased O2 sats
- Feelings of impending doom
- Chest pain
- Cough with or without hemoptysis
- Pulsus paradoxus (SBP increases on expiration, drops on inspiration by 10 mmHg or more)
Obstructive shock(impeding blood flow): Pneumothorax s/s:
- Drop in BP due to decreased Venous return
- Increased SOB and WOB; drop in O2 sats
- Displaced trachea
- Decreased or absent lungs sound on affected side
Obstructive shock(impeding blood flow):
Cardiac tamponade s/s:
- Beck’s Triad: elevated CVP, decreased BP, muffled heart tones
- PEA (pulseless electrical activity)
- pulsus paradoxus
