Shock Monica Patel 1076. Outline Definition Types of Shocks Risk Factors Signs and Symptoms ...
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Transcript of Shock Monica Patel 1076. Outline Definition Types of Shocks Risk Factors Signs and Symptoms ...
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Shock
Monica Patel 1076
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Outline
DefinitionTypes of ShocksRisk FactorsSigns and SymptomsDiagnosisTreatment and ManagementCase Study References
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Pathophysiology ofShock
Systemic hypoperfusion (decreased blood flow) due to reduction in either cardiac output or the effective circulating blood volume
Impaired tissue perfusion occurs when an imbalance develops between cellular oxygen supply and cellular oxygen demand
Often accompanies severe injury or illness Can lead to other conditions such as lack of
oxygen in the body’s tissues (hypoxia), heart attack (cardiac arrest), or organ damage.
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Clinical Features of Shock
Hypotension (Hypovolemic and Cardiogenic) With a weak, rapid pulse
Oliguria (decreased kidney perfusion) Altered mental status (decreased brain
perfusion) Tachypnea Tachycardia Cool, clammy, cyanotic skin
Vasoconstrictive mechanisms to redirect blood from periphery to vital organs
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Stages of Shock
Nonprogressive phase: compensated stage, normal mechanisms will cause recovery. (baroreceptor reflexes, angiotensin secretion by the kidneys, vasopressin-constriction of peripheral arteries and veins).
Progressive phase: the phase characterized by tissue hypoperfusion and worsening circulatory and metabolic abnormalities including lactic acidosis leading to metabolic acidosis.
Irreversible phase: the phase during which damage is so severe that, even if perfusion is restored, survival is not possible.
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Types of ShocksCardiogenic shock
Blood pump problem
Hypovolemic Shock Blood volume problem
Distributive shockSeptic Shock
Blood vessel problem
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Other Type of Shock:
Neurogenic ShockDistributive type of shock
resulting in hypotension with bradycardia
Anaphylactic ShockSerious allergic reaction
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Cardiogenic Shock Low cardiac output due to outflow
obstruction or myocardial pump failure
Inability of the heart to maintain adequate tissue perfusion secondary to impaired pump function or failure
Most commonly the result of a heart attack Other causes: valve disease, arrhythmias,
tamponade, cardiomyopathies
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Risk Factors
Previous history of myocardial infarction
Plaque buildup in the coronary arteries
Long-term valvular disease
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Clinical Presentation
Cool skin Tachypnea Hypotension Fatigue Altered mental status Narrowed pulse pressure Rales, murmur
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Diagnosis
Physical examination (pulse and blood pressure)
Confirm the following tests: Blood pressure measurement Blood tests Electrocardiogram Echocardiography: heart activity and blood
flow Swan-Ganz Catheter: pulmonary catheter to
observe pumping activity of the heart
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Treatment and Management Correct hypotension:
Fluid resuscitation to correct hypovolemia Vasoactive agents:
Dopamine-will increase heart rate and cardiac work
Dobutamine-may drop blood pressure Norepinephrine Epinephrine
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Treatment Continued:
Oxygenation Optimizing pump function:
Morphine as needed (decreases preload, anxiety)
If Myocardial infarction: Heparin and revascularization
If arrhythmia-correct arrhythmia If extracardiac abnormality:
Reverse or treat cause
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Hypovolemic Shock Most common type of shock Life threatening condition that results when you
lose more than 20% of your body’s blood or fluid supply. The severe fluid loss makes it impossible for the heart to pump sufficient blood to your body.
Resulting in decreased cardiac output Causes:
Vomiting, diarrhea, bowel obstruction, burns GI bleeding, trauma,
Can cause organ failure This condition requires immediate emergency
medical attention for survival
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Risk Factors Losing about 1/5 or more of the normal
amount of blood in your body causes hypovolemic shock.
Excessive blood loss due to: Bleeding from cuts
Bleeding from other injuries
Internal bleeding, such as in the GI tract
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Clinical Presentation
Tachycardia and tachypnea Weak, thready pulses Hypotension Cool and clammy skin Mental status changes Decreased urine output (dark and
concentrated)
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Diagnosis
In addition to physical symptoms the following testing methods can be done to confirm: Blood testing to check for electrolyte imbalances
and kidney function CT scan or an ultrasound to visualize body organs Echocardiogram to measure heart rhythm Endoscopy to examine esophagus and other GI
organs Right heart catherization to check how blood is
circulating Urinary catherization to measure the amount of
urine in the bladder
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Treatment and Management
Pre-hospital care: External bleeding should be controlled by direct
pressure Immobilization patient (if trauma is involved) Securing adequate airway Ensuring ventilation Maximizing circulation Medications to increase the heart’s pumping
abilities (dobutamine, epinephrine, norepinephrine)
**delay in any of the above can be harmful to the patient and can lead to death
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Septic Shock Systemic inflammation response
syndrome (SIRS) secondary to a documented infection.
Response is a state of acute circulatory failure involving persistent arterial hypotension despite adequate fluid resuscitation or by tissue hypoperfusion unexplained by other causes.
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Risk Factors
Risk factors: certain groups of people are more at risk. Why? They have weaker immune systems. Newborn babie, elderly people, pregnant
women, people with long-term health conditions (diabetes, cirrhosis, or kidney failure), people with lowered immune systems (people with HIV or AIDS or receiving chemotherapy)
Traumatic wounds Use of invasive catheters Drug therapy
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Signs and Symptoms
Hyperthermia (Early state) Hypothermia (late stage) Tachycardia Wide pule pressure Decreased blood pressure
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Diagnosis Important points for diagnosis:
Identify subtle presentations Screen patient for evidence of tissue
hypoperfusion, such as cool or clammy skin, and elevated shock index (heart rate to systolic blood pressure > 0.9)
A lactic acid level higher than 4 mm/dL has been used as an entry criterion for early goal-directed therapy (EGDT) and an indicator of severe tissue hypoperfusion
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Treatment Hospitalization is required
Adequate antibiotic therapy is required (as early as possible)
Resuscitate the patient using supportive measures to correct hypoxia, hypotension, and impaired tissue oxygenation (hypoperfusion)
Identify the source of infection, and treat with antimicrobial therapy, surgery, or both.
Antibiotics
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Treatment Continued
• Antibiotics- Survival correlates with how quickly the correct drug was given
• Cover gram positive and gram negative bacteria• Zosyn 3.375 grams IV and ceftriaxone 1 gram IV or• Imipenem 1 gram IV
• Add additional coverage as indicated• Pseudomonas- Gentamicin or Cefepime• MRSA- Vancomycin • Intra-abdominal or head/neck anaerobic infections-
Clindamycin or Metronidazole • Asplenic- Ceftriaxone for N. meningitidis, H.
infuenzae• Neutropenic – Cefepime or Imipenem
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Case Study
Mrs. S is a 65 year old obese female who presents to ED complaining “crushing” substernal chest pain, tachycardia, cool, clammy extremities. History of myocardial infarction is present. Husband also states she has become slightly confused.
Vitals: HR 46, BP 68/32, RR 23, SpO2 95% on RA, Afebrile.Labs: WBC 8.1, Hgb 12.1, BUN 12, Creat 1.0, Troponin 3.1, BG 121.
EKG shows ST elevation in II, III, aVF
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What kind of shock does the patient have?????
A. Cardiogenic
B. Hypovolemic
C. Septic
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Cardiogenic Shock!!!!
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References Robbins, Stanley L., Vinay Kumar, and Ramzi S. Cotran. “Shock.” Robbins and
Cotran Pathologic Basis of Disease. 8th ed. Philadelphia, PA: Saunders/Elsevier, 2010. 129-33. Print.
Medscape Reference. 1994 (Online accessed 20 June 2014) URL: http://emedicine.medscape.com/article/152191-treatment#showall.
Medscape LLC. 2014 (Online access on 20 June 2014) URL: http://emedicine.medscape.com/article/760145-treatment.