Shock

Precise guide for DGNM, B.Sc Nursing & M.Sc Nursing Students .. regarding shock, types of shock, stages of shock and its management. Highly recommended for II B.Sc Nursing Students.

1. Shock 1 Mr.Aby Thankachan , M.Sc (N),PGDSH Senior Nursing Tutor Dept. Of medical Surgical Nursing

2. D EF I NI T I O N 2 Shock can be best be defined as a condition in which tissue perfusion is inadequate to deliver oxygen and nutrients to support vital organs and cellular function. Shock is a syndrome characterized by decreased tissue perfusion and impaired cellular metabolism. This results in an imbalance between the supply of and demand for oxygen and nutrients.

3. Con t d …. 3 Shock is a condition where the tissues in the body do not receive enough oxygen and to allow cells to function. Shock is defined as failure of the circulatory system to maintain adequate perfusion to vital organs.

4. It’s critical and life threatening medical emergency / complex syndrome results from acute, generalized, inadequate perfusion involving reduction in blood flow to the tissues below that needed level to deliver the oxygen and nutrition for normal tissue function leading to dysfunction of organs and cells.

5. PATHOPHYSIOLOGY If untreated shock progress through three stages. Inadequate management allows shock to progressively worsen passing through these stages until death occurs.

6. STAGES OF SHOCK Initial Stage Compens a t ory Stage Pro g r e s si v e Stage I r r e v e r s ible Stage

7. INITIAL STAGE Initially, the body compensates with the onset of shock. No changes are noted clinically. Changes are beginning to occur on the cellular level.

8. COMPENSATORY STAGE Activation of SNS - activation of epinephrine and nor epinephrine. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. Kidneys release renin into blood formation of angiotensin & release of aldosterone, ADH

9. Decreased CO SNS stimulation Epinephrine & nor epinephrine released Vasoconstriction Increased SVR Renin secreted by kidney Angiotension Aldosterone ADH Increase blood volume hydrostatic pressure fluid pulled into capillary Blood Pressure Maintained

10. CLINICAL MA N I F ES T A T I ONS 10 Normal B.P Increased respiratory rate Skin- cold & clammy Hypoactive bowel sounds Decreased urine output Mental status changes- confusion

11. MANAGEME N T 11 • • • • • MEDICAL MANGEMENT Fluid replacement Medication therapy NURSING MANAGEMENT Monitoring tissue perfusion Reducing anxiety Promoting safety

12. PROGRESSIVE STAGE Vicious circle of compensation eventually leads to decompensation. Mean arterial pressure starts to fall - SBP below 90.

13. CLINICAL FEATURES RESPIRATORY: o rapid & shallow Crackles Decreased arterial oxygen Increased CO2 Pulmonary edema Interstitial inflammation & fibrosis ARDS 4 7

14. CARDIOVASCULAR: D y sr h y th m i as Ischemia 14 o o o o o o o o Rapid HR- > 150 bpm Chest pain Rised cardiac enzyme levels NEUROLOGIC Mental status changes-Confusion Lethargy Dilated pupils, sluggish reaction to light

15. RENAL EFFECTS Acute renal failure HEPATIC EFFECTS susceptible to Infection Elevated liver enzymes& bilirubin levels 15

16. GI EFFECTS Stress ulcer Bloody diarrhea Bacterial toxin translocation HEMATOLOGIC EFFECTS DIC 16

17. MEDICAL MANAGEMENT 17 IV FLUIDS& MEDICATIONS Early enteral support Antacids, histamine-2 blockers, or anti-peptic agents.

18. NURSING MANAGEMENT Preventing complications Promoting rest and comfort Supporting family members 18

19. IRREVERSIBLE STAGE 19 Severe organ damage Low B.P Complete renal and liver failure Multiple organ dysfunction progressing to complete organ failure has occurred, and death is imminent.

20. MANAGEME N T 20 MEDICAL Same as progressive stage Antibiotic agents & immunomodulation therapy NURSING Offering brief explanations to the patient Provide opportunities for the family to see, touch, and talk to the patient.

21. OVERALL MANAGEMENT IN SHOCK 21 Fluid replacement Vasoactive medications Nutritional support

22. TYPES OF SHOCK Hypovolemic Shock Cardiogenic Shock Distributive Shock Neurogenic shock Septic shock Anaphylactic shock Obstructive shock

23. Most common type of shock Decreased intravascular volume Primary cause = loss of blood or body fluids from an internal or external source 23 HYPOVOLEMIC SHOCK Scalp laceration 3 rd degree/full thickness burn

24. CON T D… INTERNAL: Hemorrhage, severe burns, severe dehydration EXTERNAL: Trauma, Surgery, Vomiting, Diarrhoea, Diuresis, Diabetes insipidus 24

25. CLINICAL FEATURES 25 A rapid, weak, thready pulse Cool, clammy skin Rapid and shallow breathing Hypothermia Thirst and dry mouth Cold and mottled skin (Livedo reticularis)

26. MANAGEME N T 26 MEDICAL  Treatment of the underlying cause - - Fluid & blood replacement Redistribution of fluid by positioning  Pharmacologic therapy NURSING o Administering blood & fluids safely o oxygen

27. CARDIOGENIC SHOCK PATHOPHYSIOLOGY Decreased cardiac contractility Decreased stroke volume and cardiac output Pulmonary congestion, Decreased systemic tissue perfusion, D ecr e ase d coron ar y artery p erfusi o n 6 1

28. MANAGEME N T MEDICAL Correction of underlying causes Initiation of first-line treatment • • Supplying supplemental oxygen Controlling chest pain Providing selected fluid support 6 2

29. CON T D… • • • Administering vasoactive medications Controlling heart rate with medication or by implementation of a transthoracic or intravenous pacemaker Implementing mechanical cardiac supp ort 6 3

30. NU R S I N G Preventing cardiogenic shock. Monitoring hemodynamic status. Administering medications and intravenous fluids. Maintaining intra-aortic balloon counter pulsation. 6 4

31. Circulatory or distributive shock – abnormal displacement of blood volume in the vasculature. 6 5 DISTRIBUTIVE SHOCK Urticaria/anaphylaxis Meningococcic sepsis

32. TYPES Septic shock Neurogenic shock Anaphylactic shock 6 6

33. RISK FACTORS Septic shock- immuno suppression, extremes of age, malnourishment, chronic illness, invasive procedures. Neurogenic shock – spinal cord injury, spinal anesthesia, depressant action of medications, glucose deficiency. Anaphylactic shock- penicillin sensitivity, transfusion reaction.bee sting allergy, latex sensitivity. 6 7

34. SEPTIC SHOCK Caused by widespread infection. Vasodilation Maldistribution of blood volume Decreased venous return Decreased stroke volume Decreased cardiac output Decreased tissue perfusion 34

35. MANAGEME N T 35 • • • • MEDICAL identifying and eliminating the cause of infection. Fluid replacement. PHARMACOLOGIC THERAPY Antibiotic sensitivity. 3 rd generation cephalosporin + amino glycoside

36. NUTRITIONAL THERAPY 7 serum albumin. • • • • • • Nutritional supplementation - within the first 24 hours . Enteral feedings NURSING MANAGEMENT Follow aseptic technique. Monitor for signs of infection. Monitor hemodynamic status, fluid intake& output& nutritional status. Daily weight & close monitoring of

37. NEUROGENIC SHOCK 7 1 vasodilation occurs as a result of a loss of sympathetic tone. may have a prolonged course (spinal cord injury) or a short one (syncope or fainting) Dry, warm skin & bradycardia.

38. MANAGEME N T MEDICAL Restoring sympathetic tone through stabilization of a spinal cord injury or, in the instance of spinal anaesthesia, by positioning the patient properly. Specific treatment depends on its cause. If hypoglycemia (insulin shock) is the cause, glucose is rapidly administered. 7 2

39. NU R S I N G • • • Elevate and maintain the head of the bed at least 30 degrees. . In suspected spinal cord injury, neurogenic shock may be prevented by carefully immobilizing the patient. Applying elastic compression stockings and elevating the foot of the bed 7 3

40. • Check the patient daily for any redness, tenderness, warmth of the calves, and positive Homans sign (calf pain on dorsiflexion of the foot). • Administering heparin or low- molecular-weight heparin (Lovenox) as prescribed, applying elastic compression stockings, or initiating pneumatic compression of the legs may prevent thrombus formation. 7 4

41. • 41 Performing passive range of motion of the immobile extremities. • In the immediate post injury period, the nurse must monitor the patient closely for signs of internal bleeding that could lead to hypovolemic shock.

42. ANAPHYLACTIC SHOCK 42 Caused by severe allergic reaction when a patient who has already produced antibodies to a foreign substance (antigen) develops a systemic antigen–antibody reaction.

43. Due to antibody responses Release of histamine Vasodilatation Increased capillary Permeability Severe bronchoconstriction Decreased oxygen supply and utilization Inadequate tissue Perfusion 43

44. MANAGEME N T 44 MEDICAL  Removing the causative antigen (e.g., discontinuing an antibiotic agent), administering medications that restore vascular tone, and providing emergency support of basic life functions.

45.  Epinephrine Diphenhydramine Nebulized medications ( albuterol) cardiopulmonary resuscitation ET Intubation or tracheotomy NURSING Assessing all patients for allergies or previous reactions to antigens and communicating the existence of these allergies or reactions to others. 7 9

46.  Assess the patient’s understanding of previous reactions and steps taken by the patient and family to prevent further exposure to antigens. Advise the patient to wear or carry identification that names the Specific allergen or antigen. When administering any new medication, the nurse observes the patient for an allergic reaction. 8

47. Identify patients at risk for anaphylactic reactions to contrast agents (radiopaque, dye-like substances that may contain iodine) used for diagnostic tests. Take immediate action if signs and symptoms occur, and must be prepared to begin cardiopulmonary resuscitation if cardio respiratory arrest occurs. 47

48.  In addition to monitoring the patient’s response to treatment, the nurse assists with intubation if needed, monitors the hemodynamic status, ensures intravenous access for administration of medications, and administers prescribed medications and fluids, and documents treatments and their effects. 48

49. Obstructive shock  may be due to cardiac tamponade or a tension pneumothorax. Obstructive shock is a form of shock associated with physical obstruction of the great vessels or the heart itself. Pulmonary embolism and cardiac tamponade are considered forms of obstructive shock. Obstructive shock has much in common with cardiogenic shock, and the two are frequently grouped together.

50. DIAGNOSIS No laboratory Test -but high index suspicion and physical signs of inadequate tissue perfusion and oxygen are base to initiate treatment.

51. INITIAL MANAGEMENT Successful management of shock patient requires team work . Senior team of anesthetist, Specialist - Physician, hematologist, and nurse other support staff like neonatologist, radiologist, theatre team and dedicated porter. To be in contact.

52. Management should start once diagnosis made aiming for prompt restoration of tissue perfusion and oxygenation. Management of underlying etiology is next step until resuscitation is initiated. Cont’d

53. ABC AIRWAY Airway-high flow oxygen (15lts/min by mask with reservoir bag) Protected by tracheal intubation if there is potential compromise BREATHING ventiation should be checked and supported if inadequate CIRCULATION insert two widebore peripheral intravenous canulas Initial circulatory management aims to restore circulating volume and reverse hypotension with crystaliod. keep ready blood for transfusion (6 units) Samples can be drawn for full blood count, coagulation screen, urea, electrolytes and cross matching. Continues monitoring the response. Cont’d

54. SPECIFIC MANAGEMENT Hemorrhagic shock: Infusion and transfusion Blood transfusion is must Crystalloids- Normal saline has to be infused initially for immediate volume replacement. colloids- polygelatin solutions ( Heamaccel) are iso-osmotic with plasma maintenance of cardiac efficiency. 6liters of crystalloids may be needed for loss of 1liter of plasma volume. Hemodynamic monitoring should be aimed to maintain systolic BP>90mmhg, mean arterial pressure > 60mmNg, CVP 12-15mm H2O and pulmonary capillary wedge pressure 14-18 mmHg.

55. Administration of oxygen to avoid metabolic acidosis In the later phases, ventilation by endo- tracheal intubation may be necessary. Oxygen delivery should be continued to maintain O2 saturation>92%, PaCO2 30-35mmHg and PH<7.35 Cont’d

56. MECHANICAL SUPPORT Intra-aortic balloon pump (IABP) Ventricular assist device (VAD) Artificial heart (TAH) Extracorporeal membrane oxygenation (ECMO)

57. PREVENTION OF SHOCK Preoperatively: His blood should be adequate in quantity and volume. His tissues should be adequately hydrated. He should be mobile. Patient should be kept warm on his journey from ward to theatre. 8 4

58. Post operatively: Fluid and electrolyte replacement normal saline, dextrose 5%, plasma and rest and relief from the pain continues. Gentle handling by nursing staff will help in prevention of shock. Diuretics like mannitol . If oliguria persists furosemide can be given. Dopamine

59. COMPLICATIONS 60 ARDS Multiple Organ Failure