Critical Care > Shock > Flashcards

Shock Flashcards

(42 cards)

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1
Q

What are the 4 stages of shock ?

A
  1. initial
  2. compensatory
  3. progressive
  4. refractory
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2
Q

What occurs in the initial phase of shock ?

A

not getting enough perfusion to the body systems
- no obvious outwards S&S
- still reversible

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3
Q

What occurs in the compensatory phase of shock ?

A

there is a sustained reduction in tissue perfusion
- S&S become apparent
- SNS starts the compensatory mechanisms (neural, hormonal, chemical)

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4
Q

What are some S&S of compensatory stage of shock ?

A
  • decreased UO: will be more concentrated so darker
  • HR: increased to compensate low BP
  • RR: not very effective, shallow and not deep, tachypnic, CO2 decreased due to increased RR (alkalotic), low O2 sats
  • BP: low BP
  • decreased LOC
  • skin becomes cool
  • elevated glucose
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5
Q

What is the tx for compensatory stage of shock ?

A
  • supplemental O2 (NC)
  • fluids (NS or LR)
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6
Q

What occurs in progressive stage of shock ?

A

compensatory mechanisms begin to fail
- body starts to shunt blood to the vital organs
- anaerobic metabolism (due to lack of O2): you are now requiring 20x the energy to create more energy (glucose will increase to compensate for lack of O2)

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7
Q

What are some S&S of the progressive stage of shock ?

A
  • edema: venous system is dilating out which causes edema but arterial system is constricting to push blood to vital organs
  • intravascular fluid shift: venous system leaky due to dilation which pushes fluid into the tissues along with protein molecules
  • electrolyte imbalance: due to fluid shifting out (low Ca, Na, K which will cause PVCs)
  • RR: tachpnic, low O2 sats
  • BP decreased due to dilation
  • HR: elevated but not as it was in compensatory stage
  • skin cold and clammy
  • decreased UO: (oliguria), azotemia (high BUN and Cr) since kidneys aren’t being perfused well
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8
Q

What is the tx for progressive stage of shock ?

A
  • supplemental O2: ventilator, Bipap
  • fluids: need but won’t be enough to support BP
  • vasopressors (norepi), vasodilators (if cardiogenic shock), antidysrhythmic (amiodarone)
  • enteral nutrition: because metabolism is attempting to keep up with shock, trickle feed cause of risk of ileus
  • glucose control: since glucose will be high and will heal better if we keep it controlled (92-110s)
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9
Q

What occurs in the refractory stage of shock ?

A

severe tissue hypoxia with ischemia and necrosis
- Multiple Organ Dysfunction (MODs)
- failure of 2+ body systems

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10
Q

What are some S&S of the refractory stage of shock ?

A
  • skin: cold because of hypoxia and no perfusion to extremities, jaundice
  • Kidneys: need to be on dialysis (CRRT)
  • GI: hypoactive bowel sounds at best, no movement, will need stool softener
  • Neuro/Mental: unconscious, GCS of 15
  • Liver: high risk of bleeding (function: filter out meds and toxins and makes clotting factors and also break down old clotting factors)
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11
Q

What is the tx of the refractory stage of shock ?

A
  • supplemental O2: ventilator
  • fluids
  • vasopressors, vasodilators, antidysrhythmics
  • enteral nutrition
  • glucose control
  • CRRT: to support kidneys
  • IABP/VAD & /ECMO: to support cardiac system, the ECMO support failing respiratory or cardiac system or both
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12
Q

What is hypovolemic shock ?

A

inadequate fluid volume in the intravascular space
- loss of circulating blood volume
- 4 classes of hypovolemic shock

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13
Q

What are the causes and the hemodynamics of hypovolemic shock ?

A

Causes:
- trauma (gunshot, pt from surgery, vomiting/diarrhea)
Hemodynamics:
- HR: increased
- CO/CI: decreased
- CVP: decreased
- wedge: decreased (due to fluid loss)
- SVR: increased to compensate for low volume and low HR

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14
Q

What are the tx and other S&S of hypovolemic shock ?

A

Tx:
- massive transfusion protocal if tissue is bleeding (blood products)
- if N/V/D then give fluids
S&S:
- anxiety, pallor
- increased HR and RR
- decreased peripheral pulses
- postural hypotension
- decreased LOC that may need to be intubated
- blood loss: Hgb will be low (give transfusion if at 7 or lower)

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15
Q

What is cardiogenic shock ?

A

condition in which the heart can’t pump enough blood to meet the body’s needs
- decreased myocardial contractility

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16
Q

What are the causes of cardiogenic shock ?

A
  • HF
  • MI
  • cardiomyopathy (conditions that cause the heart muscle to need to pump harder)
  • hypertrophy of ventricles
  • SCAD (spontaneous coronary artery dissection)
  • any valvular issue
  • ventral septal defect
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17
Q

What are the hemodynamics of cardiogenic shock ?

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A
  • HR: increased
  • BP: decreased
  • CO/CI: decreased (due to not being able to ctx like they should)
  • CVP: increased
  • wedge: increased
  • SVR: increased
18
Q

What is the treatment for cardiogenic shock ?

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A
  • (+) inotrope: (dobutamine) since it aids in increased contractility
  • can add a vasodilator (very low dose) to help SVR dilate out (be careful because BP is low)
  • may have a dysrhythmia so treat that like A.fib: amiodarone
    VAD, ECMO
  • OR to have a coronary bypass or valve repair
19
Q

What S&S would a cardiogenic shock pt have ?

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A

typical S&S of MI’s
- angina (chest pain)
- Skin: diaphoretic, cool, pale
- anxious
- decreased UO
As the Lt ventricle fails then signs of pulmonary edema:
- crackles and rhonchi
- hypoxemia
- JVD
- dysrhythmias

20
Q

What is obstructive shock ?

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A

circulatory blood flow is impaired by a blockage or compression

21
Q

What are the causes of obstructive shock ?

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A
  • cardiac tamponed: fluid accumulating in pericardial sac that surrounds the heart
  • tension pneumo: air is filling thoracic cavity causing lung to collapse (will see tracheal shift)
  • pulmonary embolism
22
Q

What are the tx for obstructive shock ?

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A
  • cardiac tamponed: pericardiocentesis
  • tension pneumo: chest tube (will help reinflate lungs)
  • pulmonary embolism: antithrombotic & fibrolytic
23
Q

What are some S&S and the hemodynamics of obstructive shock ?

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A

S&S:
- anxious
- SOB
Hemodynamics:
- HR: increased
- BP: decreased
- CO/CI: decreased (due to blood not flowing like it should)
- CVP: normal high/increased
- wedge: normal high/increased
- SVR: increased (to compensate for hypotension)

24
Q

What is distributive anaphylactic shock ?

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A

an antigen/antibody reaction
- caused by food allergies, med allergies, bee stings, etc
- wide spread vasodilation (SVR)

25
What are the hemodynamics for distributive anaphylactic shock ?
- HR: elevated - BP: decreased - CO/CI: decreased - CVP: decreased (due to vasodilation) - wedge: decreased (due to vasodilation) - SVR: decreased
26
What is the tx for distributive anaphylactic shock ?
- Epi (IM): anticipate even higher HR due to already being tachy and then giving Epi (helps constrict and increase BP but also causes vasodilation of bronchioles with aids in breathing) - benadryl: to decrease inflammation response - pepsid/H2 blocker: due to increased acid production - steroids: to decrease symptoms and further reaction - fluids: due to vasodilation - O2
27
What is distributive neurogenic shock and its causes ?
loss of sympathetic tone so widespread vasodilation occurs - severe spinal cord injury (usually cervical)
28
What are the hemodynamics of distributive neurogenic shock and other S&S ?
- IT ALL GOES DOWN - paralysis (neck down) - can't breathe properly (intubation or rescue breathing)
29
What is the tx for distributive neurogenic shock ?
- gives meds to support - send to surgery to stabilize spinal cord - vasopressor of choice: epi (aids BP and raise HR) - fluid bolus & maintenance IVF
30
What is distributive septic shock ?
syndrome caused by an infection which causes a systemic response (body overreacts)
31
What are the causes of distributive septic shock ?
- immunosuppressed people (chemo pt's) - extreme ages (super young or old): immune system not well developed or strong - chronic health issues: due to body already dealing with chronic issues and then having to deal with infection - anyone with a invasive procedure: tubes, lines (foley, central line, chest tube, intubation) - prolonged hospitalization - traumas
32
What is the hemodynamics of distributive septic shock ?
- HR: increased initially due to vasodilation - CO: initially normal or even a bit high, the further they progress the worse it gets (will drop) - Early septic/warm: CO normal or high due to compensatory mechanisms still working, also get fever - Late septic/cold: CO drops and can't compensate anymore (infection so bad you can't develop the fever compensatory reaction) - WBCs will be elevated
33
What is the tx for distributive septic shock ?
- antibiotics - fluids - vasopressors: because fluids may not be enough - intubation - Kidneys: CRRT - anticipate mechanical interventions
34
What is SOFA ?
sequential organ failure assessment (SOFA) - tool to predict pt's mortality depending on how many body systems are failing - 0-24 - higher the number the higher the mortality rate - used in distributive septic shock
35
What is the SSC ?
surviving sepsis campaign 1. fluid resuscitation (if not enough then move onto vasopressors) 2. if suspect infection get cultures before giving antibiotics 3. check arterial lactate levels (anything over 2 is high) - for fever give Tylenol - need to show that you did all this or hospital will be fines
36
What is MODS ?
Multiple Organ Dysfunction Syndrome - failure of 2+ organ systems that leads to disruption in homeostasis (overexaggerated inflammatory response)
37
Who is at risk for MODS ?
- trauma pt's - acute pancreatitis - sepsis - burns - multiple blood transfusions - ischemic/reperfusion events - surgical complications
38
What are the clinical manifestations of MODS ?
- Kidneys: oliguria, anuria, azotemia, actue tubular necrosis - Pancreas: releases MDF (myocardial depressant factor), glucose will be abnormal - Liver: disruption in clotting factor production, jaundice, bilirubin (>2) - Pulmonary: tachypneic or bradyonic - GI: hyperactive bowel sounds, ileus - Metabolic & Nutrition: will need more support - Brain: decreased LOC (need MAP of at least 67 to be able to perfuse brain) - Cardiovascular:: decreased ctx - Coagulation: DIC - Immune: immunosuppressed due to tumor necrosis factor, leaky vessels make them more susceptible to infection
39
What is primary MODS ?
directly attributed to the injury itself - like blunt force trauma to kidneys - small % of cases
40
What is secondary MODS ?
consequence of systemic inflammation - develop latently - damage to endothelium: where we see fluid shift - disrupts immune cell function: body will release tumor necrosis factor and pancreas will release myocardial depressive factor which tells heart to not ctx well - hypermetabolism: Body will try to heal itself and go into hypermetabolism which will cause it to eat itself cause its using energy stores in muscle and fat (need high protein, fat and cal diet to combat this) - maldistribution of circulatory volume: damage to endothelium will cause use to lack volume (may look overloaded but their is not enough volume)
41
What is the tx for MODS ?
- fluids: NS, LR, 30 mL/kg/hr - hemodynamic support: if fluids not enough give vasopressors, then positive inotropes - prevent & tx infection: antibiotics, CHG baths - maintain tissue oxygenation: supplemental O2, NC or ventilator or anything in between - nutrition & metabolic support: tube feedings: high cal, protein and fat - comfort & emotional support: if vented can give sedative like profolol or dexmedatadine - preservation of individual organs: thru devices like balloon pump, ECMO, etc - pain: oxycodone
42
What are the different types of shock ?
- hypovolemic: loss of fluid - cardiogenic: cardiac pump failure - obstructive: blockage or compression - distributive (maldistribution of circulating blood vol) : neurogenic, anaphylactic, septic
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