Nursing Care of the Adult (or anyone) experiencing shock

1. Nursing Care of the Adult (or anyone) experiencing shock Donna Roberson, PhD, APRN, BC Sharon Cherry,MPH,CNE Assistant Lecturer

2. Hypovolemic Vasogenic (Septic) Cardiogenic Neurogenic Hypovolemic most common type resulting from a loss of circulating blood volume Hallmark Clinical Indicators of shock are hypotension, tachycardia, decreased urine output and altered mental status Four Classes of Shock as proposed by Dr. Alfred Blalock in 1934

3. What is shock? • Syndrome of low blood flow and/or abnormal blood flow patterns • Results in imbalance between oxygen and nutrient delivery and consumption on the cellular level • Five types • Low blood flow • Mal-distribution of flow

4. Low Blood Flow Shock • Hypovolemic • Cardiogenic

5. Maldistribution of Blood Flow • Septic • Neurogenic • Anaphylactic

6. Shock • Key factor in any type of Shock is inadequate tissue perfusion • Adequate fluid replacement in shock victims should be indicated by urine outputs of 0.5 to 1ml/kg/hour • Watch liver failure for increasing acidosis when LR fluids are utilized. The liver may not be able to convert lactate to bicarbonate thus increasing lactic acidosis

7. Clicker Question • Prepare Clickers

8. Stages of Shock • Initial • May not have signs and symptoms • Lactic acid accumulates due to anaerobic metabolism, liver cannot excrete (no oxygen) • Compensatory • Neural, hormonal and biochemical mechanisms • Signs and symptoms seen • Reversible stage with treatment

9. Compensatory Stage of Shock • Increased Heart Rate • Slightly decreased Blood Pressure • Pale cool skin • Increased Blood Glucose

10. Second Stage of Shock • Progressive stage • Compensatory mechanisms fail • Third spacing seen – to the extreme • Without aggressive treatment, MODS • Respiratory – increased work, crackles, tachypneic • Cardiac – output falls, ischemia (distal first), dysrrhythmias, MI, complete failure

11. Refractory Stage Third stage can be irreversible • Profound Hypotension and Hypoxemia • Accumulation of waste products throughout system • Cerebral ischemia occurs • Total, multiple organ failure • Recovery unlikely

12. Medical Stressors leading to Hypovolemic Shock Hemorrhage Burns Severe vomiting and diarrhea Peritonitis Nursing Interventions Initiate Intravenous therapy with NS or Lactated Ringers Be prepared to administer Blood products PRBC’s and Platelets Prepare patient for Surgery Hypovolemic Shock

13. Burns can lead to Hypovolemic Shock

14. Blood Replacement Crystalloids eg, 0.9% Saline or Ringers Lactate Colloids eg, Albumin Positive indicators urine output > 0.5 to 1mL/kg/hr, heart rate and mental status WNL Hypovolemic Shock

15. Patient has bleeding in lung Knife removed in surgery Hypovolemic Shock

16. Hypovolemic Shock • Loss of circulating vascular volume • Compounding problem • Decreased circulating volume – decreased venous return – decreased stroke volume – decreased cardiac output – decreased oxygen and nutrients to cells – decreased tissue perfusion – impaired metabolism

17. GSW to chest Hemothorax Note bleeding and collapsed lung Hypovolemic Shock

18. This young women was in a high speed collision Stop sign impaled into abdomen Patient survived with removal of stop sign and right colon Hypovolemic Shock

19. Clicker Question

20. GSW to chest Hemothorax Note bleeding and collapsed lung Hypovolemic Shock

21. Children playing with a machete Patient taken to OR Do you see the possibilities of more that one type of shock Patient survived Tissue Perfusion altered

22. Open Chest CPR Patient Died in the Emergency Department

23. Bleeding of liver and laceration of liver is noted on the right side of this CT scan Emergent surgery What type of shock is this patient at risk for? What nursing interventions are needed prior to surgery? Blount Abdominal Trauma

24. Chest Trauma High speed air bag deployed Pt with low BP and Sats of 91% on 100% nonrebreather bag Combative and agitated Can lead to Cardiogenic Shock of a noncoronary nature TENSION PNEUMOTHORAX

25. Sustained hypotension systolic pressure less than 90 for 30 min Reduced cardiac index less than 2.2 L/min/m2 Pulmonary capillary pressure greater than 15 mm Hg Hemodynamic criteria for Cardiogenic Shock

26. Myocardial Infarction End-stage Heart Failure Cardiac Tamponade Pulmonary Embolism Cardiomyopathy Dysrhythmias Cardiogenic Shock: Patient with enlarged heart (echocardiogram)

27. Clicker Question

28. Cardiogenic Shock from Myocardial Ischemia

29. Cardiogenic shock: EKG Presentation note ST segment elevation This was a result of Pericarditis and pericardial tamonade

30. Clicker Question

31. Septic Shock • Systemic inflammatory response to infection (usually bacterial) that has moved into the blood stream • High mortality rate • Bacteria release endotoxins • Systemic Inflammatory Response Syndrome (SIRS)

32. Patients at risk for Sepsis • Immunocomprised ( AIDS, Cancer, Alcoholism, Diabetes) • Invasive procedures • Indwelling medical devices • Increased number of resistant organisms • Increased older population

33. Medical Stressors leading to Septic shock Blood Stream Rank 1st Lungs 2nd Urinary tract infections 3rd Gram Negative Organisms Most common cause of septic shock eg,pseudomonas, acetobacter, E coli, Salmonella Gram Positive Organisms Fluid rescuitation with CVP of 15 is adequate Antimicrobial agents Inotropic agents Vasopressors Watch for bleeding abnormalities decreased platelets Assess for DIC Septic Shock

34. Other Gram Negative Bacteria • There are many groups of Gram-Negative bacteria such as Cyanobacteria, Spirochaetes, Green-Sulphur and Green Non-Sulphur Bacteria and Proteobacteria etc. Out of which, proteobacteria is one of the major group of known Gram-Negative bacteria (it includes bacteria like E-coli, Salmonella, Pseudomonas, Moraxella, Helicobacter, Stenotrophomonas, Legionella, Acetic Acid Bacteria etc.).

35. Systemic Inflammatory Response Syndrome (SIRS) in response to Sepsis • Temperature greater than 38 or less than 36 • Heart rate greater than 90 • Respiratory rate greater than 30 • PaCO2 less than 32 • WBC count greater than 12000 or less than 4000 or greater than 10% immature bands

36. Multiple organ dysfunction syndrome in response to Sepsis • Cardiovascular Hypotension • Respiratory Hypoxemia • Renal Increased Creatinine • Hematologic Thrombocytopenia • Metabolic lactic acidemia • Neurologic Altered LOC • Hepatic elevated liver function tests

37. Septic shock • 6-10 liters of crystalloids, 2-4 liters of colloids • Invasive monitoring (ICU patient) • Vasopressors and inotropics added if fluid fails • Ventilator • ANTIBIOTICS – broad spectrum until cultures back, then specific agents • Xigris – administered over 96 hours, boosts activated protein C (unknown action – possibly anti-inflammatory)

38. Clicker question

39. Specifics to Type • Cardiogenic • Diagnostic tests (caths) and supportive pumps (IABP or VAD) • Medications – diuretics, ACEI, Beta-blockers, nitrates, (+) inotropes

40. Cardiogenic Shock Angioplasty Left Descending Coronary Artery Stenosis

41. Medical Stressors leading to Neurogenic shock Spinal Cord injury Severe Pain Epidural Block Spinal Anesthetics Treat hypotension and bradycardia Administer medications as ordered Ephedrine and possible need for Vaspressin if patient has used ACE inhibitors Keep HOB elevated 30 after spinal or epidural anesthesia Immobilize spine with injury Lovenox needed during period of inactivity and SCD’s Neurogenic Shock

42. Neurogenic Shock • Occurs after spinal cord injury at T5 or above • Massive vasodilation without sympathetic nervous system compensation (ex. SCI) • Pooling with bradycardia and hypotension • Also may have hypothalmic dsyfunction • Temperature deregulated • poikilothermia

43. Neurogenic Shock • Usually begins within 30 minutes of injury and can last weeks • Also caused by spinal anesthesia and BZDs • Diagnosed based on cause and VS • Treatment

44. Distributive Shock or Neurogenic Shock C-5 Burst Fracture Before and after repair

45. Cervical Spine disk 2 fracture Hangman Fracture from look of a hanging Caused by fall or MVA Type of Shock nurse would assess for? Distributive Shock (Neurogenic Shock)

46. Neurogenic shock • Stabilize spine • Support hypotension – volume, neo-synephrine (alpha adrenergic agonist) • Keep warm • Methylprednisolone (Solu-medrol) prevents secondary cord injury from inflammatory mediators

47. Clicker question

48. Medical Stressors leading to Anaphylactic shock Insect bites Vaccines Adverse reactions to medications or foods Intravenous Epinephrine Inhalation bronchodilators Colloidal fluid replacement eg, Albumin Benadryl Corticosteroids H2 blockers eg, Tagamet Assess for Respiratory failure Anaphylactic Shock

49. Medical Stressors leading to Anaphylactic shock Insect bites Vaccines Adverse reactions to medications or foods Intravenous Epinephrine Inhalation bronchodilators Colloidal fluid replacement eg, Albumin Benadryl Corticosteroids H2 blockers eg, Tagamet Assess for Respiratory failure Anaphylactic Shock

50. Anaphylactic Shock • Life-threatening hypersensitivity to a substance (bee stings, medications, food) • Massive vasodilation, vasoactive mediators released and increased capillary membrane permeability • Laryngeal edema, hypotension, wheezing/stridor, skin changes – death! • c/o dizziness, chest pain, difficulty swallowing or breathing, anxiety