Types of shock

detail description of the type of shock

1. TYPES OF SHOCK MS. SAHELI CHAKRABORTY 2 ND YEAR MSC NURSING RINER, BANGALORE

2. HYPOVOLEMIC SHOCK CARDIOGENIC SHOCK CIRCULATORY SHOCK SEPTIC SHOCK NEUROGENIC SHOCK ANAPHYLACTIC SHOCK TYPES OF SHOCK

3. 1. HYPOVOLEMIC SHOCK :- This is the most common type of shock and based on the insufficient circulatory volume. Primary cause is loss of fluid from circulation from either an internal or external source. Hypovolemic shock occurs when there is a reduction in intravascular volume by 15% to 30% which represents a loss of 750 ml to 1500 ml of blood in a 70 kg person.

4. Risk factors for hypovolemic shock EXTERNAL : Trauma Surgery Vomiting Diarrhoea Diuretics Diabetes Insipidus External bleeding 2. INTERNAL: Haemorrhage Burns Ascites Peritonitis Dehydration Internal bleeding

5. PATHOPHYSIOLOGY OF HYPOVOLEMIC SHOCK: Due to etiological factor Loss of body fluids and bloods Decrease cardiac output Hypo perfusion Compensatory mechanism

6. Norepinephrine and Renin angiotensin and Epinephrine aldosterone stimulation Increase heart rate ADH release. and vascular resistance Intracellular fluid shift to intravascular space Increase blood volume Increase cardiac output

7. Compensatory mechanism fails Decrease cardiac output Decrease blood pressure Decrease perfusion to the vital organs Multisystem organ failure

8. Medical management Treatment of the underlying cause Fluid and blood replacement Crystalloids- 0.9% sodium chloride Ringer lactate solution Hypertonic saline Colloids (Albumin, Dextran ) Redistribution of fluid Pharmacologic therapy ( Vasoactive agents, Insulin therapy, Desmopressin , Antidiarrhoeal , Antiemetics ).

9. NURSING MANAGEMENT Primary prevention of shock is an essential focus of nursing care. Administering blood and fluids safety: Administration of blood transfusion. Blood specimens, cross matching of the blood should be done. Patient should be monitored for cardiovascular overload Hemodynamic pressure, vital signs, arterial blood gases, serum lactate levels, hematocrit and hemoglobin level need to be monitored.

10. Maintain temperature Observing jugular venous pressure for distension The nurse must monitor cardiac and respiratory status 2. Implementing other measures Oxygen is administered. Patient may be irritated and apprehensive so frequent explanations about the patient’s condition may reduce some of the patient’s fear and anxiety.

11. 2. CARDIOGENIC SHOCK Cardiogenic shock occurs when the heart’s ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues. Coronary cardiogenic shock is more common than the non coronary cardiogenic shock. Non coronary causes of cardiogenic shock are the conditions that stress the myocardium such as severe hypoxemia, acidosis, hypoglycaemia, hypocalcaemia, tension pneumothorax, cardiomyopathies , valvular damage, cardiac temponade , dysrhythmias .

12. CLINICAL MANIFESTATION: Distented jugular vein due to increased jugular venous pressure. Absent pulse due to tachyarrhythmia Anginal pain Dysrhythmias . Complain of fatigue Express feelings of doom Signs of hemodynamic instability.

13. PATHOPHYSIOLOGY Myocardial infarction, arrhythmias, congestive heart failure, cardiac myopathy, cardiac valve problem Impaired heart’s ability to contract and pump blood. Decrease stroke volume Increase pulmonary pressure Decrease cardiac output pulmonary edema Decrease oxygenation to the tissues.

14. Hypo-perfusion tissues. Impaired cellular metabolism.

15. MEDICAL MANAGEMENT The goals of medical management in cardiogenic shock are to limit further myocardial damage and preserve the healthy myocardium and to improve the cardiac function. Correction of underlying causes. Initiation of first line treatment. Oxygenation. Pain control. Hemodynamic monitoring Laboratory marker monitoring. Fluid therapy.

16. Pharmacologic treatment :- Dobutamine . Nitroglycerine . Dopamine. Antiarrhythmic medications. Other vasoactive medication. Mechanical assistive devices.

17. NURSING MANAGEMENT Preventing cardiogenic shock Monitoring hemodynamic status. Administering medications and intravenous fluids. Maintaining intra-aortic balloon counter pulsation. Enhancing safety and comfort.

18. 3. CIRCULATORY SHOCK Circulatory shock occurs when blood volume pooled in peripheral blood vessels and results in hypovolemia which leads to inadequate tissue perfusion. Contractility of the heart helps the blood to return to the heart. And the vascular tone is determined by central regulatory mechanism (in BP regulation) and local regulatory mechanism (in tissue demands for oxygen and nutrient) Thereby circulatory shock can be caused either by a loss of sympathetic tone or by release of biochemical mediators from cells.

19. PATHOPHYSIOLOGY :- Precipitating event Vasodilation Activation of inflammatory response Abnormal distribution of blood volume Decreased venous return Decreased cardiac output Decreased tissue perfusion

20. CLASSIFICATION OF CIRCULATORY SHOCK: Septic shock Neurogenic shock Anaphylactic shock

21. 4. SEPTIC SHOCK The most common type of circulatory shock, is caused by widespread of infection. The incidence is more in ICU and is increasing day by day. The most common cause of death. The incidence can be reduced by using strict aseptic technique, thorough hand hygiene techniques. Interventions include prevention of central line infection, early debriding of wounds to remove the necrotic tissues, carrying out standard precaution, adhering to infection control practices, prompt cleaning and maintaining of equipment.

22. PATHOPHYSIOLOGY 1. Severe localized infection of gram negative bacili (E. Coli, Klebsella ) 2. Septicemia (invasion of bacteria into the blood stream) 3. Inflammatory response 4. Release of endo -toxin into circulation 5. Immune system releases histamine and other chemical mediators. Massive vasodilation Increase capillary permeability 6. Severe broncho constriction

23. 7. Decrease oxygen supply to the tissues 8. Decrease tissue perfusion 9. Shock.

24. MEDICAL MANAGEMENT Fluid replacement therapy Pharmacolgic therapy Broad spectrum antibiotic Drotrecogin alfa (acts as an anti-inflammatory cytokine, it stimulates fibrinolysis , restoring balance in the coagulation –anticoagulation homeostatic process of the body’s inflammatory response to injury and infection Nutritional therapy ( should start first 24 hours after ICU admission)

25. NURSING MANAGEMENT :- All invasive procedure must be carried out with aseptic technique. IV lines, arterial and venous puncture sites , surgical incision, traumatic wounds, urinary catheter and pressure ulcers must be monitored for signs of infection. Patients with elderly and immunosuppressive, extensive trauma, burns, or diabetes should be given most attention. Elevated temperature is common in septic shock and increase the metabolic rate so it should not be treated unless it reaches to the dangerous level.

26. The nurse administers prescribed IV fluids and medications including antibiotic agents and vasoactive mediators to restore vascular volume. Blood levels of BUN, creatinine , WBC, hemoglobin , hematocrit , platelet levels, coagulation studies should be monitored. Fluid intake and output, nutritional status, daily weights should be checked. Close monitoring of the serum albumin and pre-albumin levels help determine the patients protein requirements.

27. 5. NEUROGENIC SHOCK In neurogenic shock vasodilation occurs as a result of a loss of balance between parasympathetic and sympathetic stimulation. Sympathetic stimulation causes vascular smooth muscle to constrict, and parasympathetic stimulation causes vascular smooth muscle to relax or dilate. In neurogenic shock the sympathetic system not able to respond to the body stressors. Therefore neurogenic shock are signs of parasympathetic stimulation. Parasympathetic stimulation causes vasodilation that results in hypovolemic state and gradually leads to hypotension and shock.

28. ETIOLOGY: Spinal cord injury Spinal anesthesia Nervous system damage. Depressant action of medication

29. PATHOPHYSIOLOGY Spinal cord injury , anaesthesia. Loss of autonomic nervous system and motor function below the level of injury Loss of sympathetic control Increase sympathetic tone Arterial of venous pooling Dilatation of blood vessels Hypotension Warm, dry, flushed skin and bradycardia . Decrease tissue perfusion to the vital organ Multisystem organ failure.

30. MANAGEMENT :- Elevate the head of the bed at least 30 degree angle when the patient receives spinal or epidural anaesthesia. Because it helps in the prevention of the spread of anaesthetic agent up the spinal cord. Carefully immobilize the patient in case of patient with spinal cord injury. Supporting of cardiovascular and neurologic function. Apply anti-embolism stockings. Elevate the foot end to prevent the venous pooling of the blood in the legs because it may increase the risk of thrombus formation.

31. The nurse must monitor the lower extremity pain, redness, tenderness and warmth. Patient should be evaluated for deep vein thrombosis by assessing the calf muscle pain. Administer heparin or low molecular weight heparin ( lovenox ) as prescribed. Application of anti-embolism stockings or use of pneumatic compression of the legs may prevent thrombus formation. Passive range of motion of the immobile extremities helps promote circulation. The nurse must monitor the patient for signs of internal bleeding that could lead to hypovolemic shock.

32. 6. ANAPHYLACTIC SHOCK Anaphylactic shock occurs rapidly and is life threatening. Anaphylactic shock occurs in patients who has already exposed to an antigen and who have developed antibodies to it. Caused by an severe anaphylactic reaction to an allergen, antigen, drug, foreign protein causing the release of histamine which causes vasodilation leading to hypotension and increased capillary permeability.

33. pathophysiology Antigen re-exposure. Hypersensitivity antibody response Activation of mast cells Release of vasoactive substances such as bradykinin , histamine. Arterial vasodilation Increase capillary permeability Severe bronchospasm Decrease oxygen supply and increase demand of oxygen Inadequate tissue perfusion Shock and death.

34. MEDICAL MANAGEMENT Remove the causative antigen Emergency basic life support. Epinephrine is given for its vasoactive action Diphenydramine -to reverse the effects of histamine thereby reducing the capillary permeability. Nebulized medication such as albutarol to reverse the histamine induced bronchospasm . CPR in case of cardiac or respiratory arrest. Endotracheal intubation or tracheostomy to establish the airway.

35. NURSING MANAGEMENT Check the vitals, respiration, BP and Mean arterial pressure. The nurse must assess for previous reaction of the allergy to medication, blood products, foods, contrast agents. Observe patient for allergic reaction while administering the medication. The nurse must identify patients who are at risk for anaphylactic reactions to contrast agents used for diagnostic tests. This information need to be communicated to the diagnostic testing site. After recovery from anaphylaxis the patient and family require an explanation of the event.

36. 7. Endocrine shock based on endocrine disturbances Hypothyroidism in critically ill patient reduces cardiac output, lead to hypotension and respiratory insufficiency. Thyrotoxicosis may induce a reversible cardiomyopathy . Acute adrenal insufficiency may results in shock Surgery and patients on corticosteroid therapy may lead to shock in severe cases.