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NurseReview.Org - Identification of Shock

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NurseReview.Org - Identification of Shock

  1. 1. Identification of Shock States Caralee Brommé, RN, MSN, CCRN
  2. 2. Identification of Shock States <ul><li>Types of shock </li></ul><ul><ul><li>Hypovolemic </li></ul></ul><ul><ul><li>Distributive/ Vasogenic </li></ul></ul><ul><ul><ul><li>Anaphylactic </li></ul></ul></ul><ul><ul><ul><li>Neurogenic </li></ul></ul></ul><ul><ul><ul><li>Septic </li></ul></ul></ul><ul><ul><li>Cardiogenic </li></ul></ul><ul><li>Clinical manifestations </li></ul><ul><ul><li>Compensated/Progressive </li></ul></ul><ul><ul><li>Decompensated/ Nonprogressive </li></ul></ul><ul><ul><li>Irreversible </li></ul></ul><ul><li>Diagnosis& treatment </li></ul><ul><ul><li>History </li></ul></ul><ul><ul><li>Physical </li></ul></ul><ul><li>Case study </li></ul>
  3. 3. Identification of Shock States <ul><li>Shock, or circulatory failure is a complex clinical syndrome characterized by inadequate tissue perfusion to meet the metabolic demands of the body , which results in cellular dysfunction and eventual organ failure and death </li></ul><ul><li>The causes are different, but the physiologic consequences are the same </li></ul><ul><li>Hypotension,tissue hypoxia, and metabolic acidosis </li></ul>
  4. 4. Identification of Shock States <ul><li>Hypovolemic shock </li></ul><ul><li>Characterized by a reduction in circulating volume or extra cellular loss </li></ul><ul><ul><ul><li>Blood loss - trauma , GI bleeding, intracranial hemorrhage </li></ul></ul></ul><ul><ul><ul><li>Plasma loss - increased capillary permeability associated with sepsis and acidosis, burns,peritonitis </li></ul></ul></ul><ul><ul><ul><li>Extra cellular loss - vomiting diarrhea, glycosuric diuresis, and sunstroke </li></ul></ul></ul>
  5. 5. Assessment findings and classification with acute hemorrhage >35 30-40 20-30 14-20 Resp Rate Normal Normal Normal Normal Blood Pressure >140 >120 >100 <100 Pulse rate >2000 1500-2000 750-1500 <750ml Blood loss >40 30-40 15-30 <15% Blood loss Class 4 Class 3 Class 2 Class 1 Assessment
  6. 6. Identification of Shock States <ul><li>Distributive shock </li></ul><ul><li>Characterized by systemic vasodilatation </li></ul><ul><ul><li>Vasogenic </li></ul></ul><ul><ul><ul><li>Anaphylaxis - allergen mediated </li></ul></ul></ul><ul><ul><ul><li>Sepsis - overwhelming sepsis with circulating bacterial toxins </li></ul></ul></ul><ul><ul><ul><li>Myocardial depression and peripheral dilation </li></ul></ul></ul><ul><ul><li>Neurogenic </li></ul></ul><ul><ul><ul><li>Spinal cord injury </li></ul></ul></ul>
  7. 7. Identification of Shock States <ul><li>Cardiogenic shock </li></ul><ul><li>Results from impaired cardiac function resulting in reduced cardiac output </li></ul><ul><ul><li>Myocardial Infarction </li></ul></ul><ul><ul><li>Primary pump failure- myocarditis, trauma, congestive heart failure </li></ul></ul><ul><ul><li>Dysrhythmias- </li></ul></ul><ul><ul><ul><li>Paroxysmal atrial tachycardia, </li></ul></ul></ul><ul><ul><ul><li>Ventricular dysrhythmias </li></ul></ul></ul><ul><ul><li>Obstructive Conditions </li></ul></ul><ul><ul><ul><li>Large Pulmonary emboli </li></ul></ul></ul><ul><ul><ul><li>Tension Pneumothorax </li></ul></ul></ul><ul><ul><ul><li>Pericardial Tamponade </li></ul></ul></ul>
  8. 8. Identification of Shock States <ul><li>Clinical manifestations </li></ul><ul><ul><li>Compensated/ progressive </li></ul></ul><ul><ul><ul><li>Increased heart rate/ tachycardia </li></ul></ul></ul><ul><ul><ul><li>Vasoconstriction </li></ul></ul></ul><ul><ul><ul><ul><li>Decreased perfusion of the hands and feet </li></ul></ul></ul></ul><ul><ul><ul><li>Irritability </li></ul></ul></ul><ul><ul><ul><li>Thirsty </li></ul></ul></ul><ul><ul><ul><li>Decrease urinary output - </li></ul></ul></ul><ul><ul><ul><li>Normal BP with narrowing pulse pressure </li></ul></ul></ul><ul><ul><li>Example moderate dehydration </li></ul></ul>
  9. 9. Identification of Shock States <ul><li>Decompensated shock </li></ul><ul><ul><li>Pronounced tachycardia </li></ul></ul><ul><ul><li>Tachypnea </li></ul></ul><ul><ul><li>Very lethargic, confused, apathetic </li></ul></ul><ul><ul><li>Cool pale extremities with decreased capillary refill and skin turgor </li></ul></ul><ul><ul><ul><li>vasodilatation of the microcirculation </li></ul></ul></ul><ul><ul><li>BP might be maintained, but increasingly narrow in pulse pressure </li></ul></ul><ul><ul><li>Moderate metabolic acidosis </li></ul></ul><ul><ul><ul><li>lactic acidosis from anaerobic metabolism </li></ul></ul></ul><ul><li>Will progress to tissue hypoxia,metabolic acidosis and eventually organ dysfunction </li></ul>
  10. 10. Identification of Shock States <ul><li>Irreversible shock </li></ul><ul><ul><li>Pronounced vasoconstriction </li></ul></ul><ul><ul><li>Severe tachycardia with progression to bradycardia- thready weak pulse </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Coma </li></ul></ul><ul><ul><li>Apnea </li></ul></ul><ul><ul><li>Irreversibly organ damage </li></ul></ul><ul><ul><ul><li>Kidneys, brain, heart </li></ul></ul></ul>
  11. 11. Identification of Shock States <ul><li>Diagnosis </li></ul><ul><ul><li>History </li></ul></ul><ul><ul><ul><li>Type of illness- trauma vs. illness </li></ul></ul></ul><ul><ul><ul><li>Length of illness-hours to days </li></ul></ul></ul><ul><ul><ul><li>Find causative agent. </li></ul></ul></ul><ul><ul><li>ABG for acid/ base & oxygenation status </li></ul></ul><ul><ul><li>Lactic acid level </li></ul></ul><ul><ul><li>CBC, blood chemistry, full body fluid cultures </li></ul></ul><ul><ul><li>EKG,CXR </li></ul></ul><ul><ul><li>CVP, Arterial line </li></ul></ul>
  12. 12. Identification of Shock States <ul><ul><li>Physical exam </li></ul></ul><ul><ul><ul><li>Level of consciousness </li></ul></ul></ul><ul><ul><ul><li>Heart rate/ Respiratory rate </li></ul></ul></ul><ul><ul><ul><ul><li>O2sat (difficult d/t perfusion) </li></ul></ul></ul></ul><ul><ul><ul><li>Capillary refill (perfusion) </li></ul></ul></ul><ul><ul><ul><li>BP (Art/ Doppler) </li></ul></ul></ul><ul><ul><ul><li>Urinary output </li></ul></ul></ul><ul><ul><ul><li>Cardiac monitoring </li></ul></ul></ul><ul><ul><ul><li>Temperature monitoring </li></ul></ul></ul><ul><ul><ul><li>Full hemodynamic monitoring in sever cases </li></ul></ul></ul>
  13. 13. Identification of Shock States <ul><li>Therapeutic Management </li></ul><ul><ul><li>Ventilation </li></ul></ul><ul><ul><ul><li>Establish airway- prep for intubation </li></ul></ul></ul><ul><ul><ul><li>Administer O2 by mask </li></ul></ul></ul><ul><ul><li>Replace fluids </li></ul></ul><ul><ul><ul><li>Establish IV/ IO access </li></ul></ul></ul><ul><ul><ul><li>Restore volume with fluid boluses </li></ul></ul></ul><ul><ul><ul><ul><li>20cc/kg isotonic solution </li></ul></ul></ul></ul><ul><ul><li>Improve pump action </li></ul></ul><ul><ul><ul><li>Administer vasopressors </li></ul></ul></ul><ul><ul><ul><ul><li>Epinephrine .01mg/ kg </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Dopamine 2-20 mcg/kg/min </li></ul></ul></ul></ul>
  14. 14. Identification of Shock States <ul><li>General support </li></ul><ul><ul><li>Keep pt flat with leg raised above level of heart </li></ul></ul><ul><ul><li>Keep pt warm and dry </li></ul></ul><ul><li>Septic Shock </li></ul><ul><ul><li>Administer broad-spectrum antibiotics </li></ul></ul><ul><li>Anaphylaxis </li></ul><ul><ul><li>Remove allergen </li></ul></ul><ul><ul><ul><li>Tourniquet above injection site </li></ul></ul></ul>
  15. 15. Identification of Shock States in Infants and Children <ul><li>Children have an intense vasoconstrictor response: </li></ul><ul><ul><li>Systolic blood pressure will be maintained at the expense of peripheral perfusion </li></ul></ul><ul><ul><li>Observe poor peripheral perfusion and narrow pulse pressure before hypotension is evident </li></ul></ul><ul><ul><li>A decrease in heart rate below normal range will cause a significant fall in cardiac output </li></ul></ul>
  16. 16. Identification of Shock <ul><li>Type and degree of shock? </li></ul><ul><li>Initial intervention? </li></ul><ul><li>What signs of improvement will you see with treatment? </li></ul>
  17. 17. Identification of Shock States <ul><li>Summary </li></ul><ul><ul><li>The type and degree of shock must be diagnosed early and treatment started immediately. </li></ul></ul><ul><ul><li>In infants and children, hypotension is a very late manifestation. </li></ul></ul><ul><ul><li>Heart and respiratory rate, level of consciousness and capillary refill are essential parts of the physical exam. </li></ul></ul>

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