SHOCK

MS ANITA DEVI
CLINICAL INSTRUCTOR
ARMY COLLEGE OF NURSING
 Organizational Chart

TYPES OF SHOCK

CIRCULATORY SEPTIC ANAPHYL

HYPOVOLEMI CARDIOGENIC NEUROGENI
SHOCK SHOCK A-CTIC
C SHOCK SHOCK C SHOCK
SHOCK
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.
 RISK FACTORS FOR HYPOVOLEMIC SHOCK

1. EXTERNAL : 2. INTERNAL:
• Trauma • Haemorrhage
• Burns
• Surgery
• Ascites
• Vomiting
• Peritonitis
• Diarrhoea
• Internal
• Diuretics
bleeding
• Diabetes Insipidus
• External bleeding
PATHOPHYSIOLOGY OF HYPOVOLEMIC SHOCK:
Due to etiological factor
↓
Loss of body fluids and bloods
↓
Decrease cardiac output

Hypo perfusion

Compensatory mechanism
↓
Norepinephrine and Renin angiotensin and
Epinephrine aldosterone stimulation

Increase heart rate and

ADH release
vascular resistance
Intracellular fluid shift
to intravascular space

Increase blood volume

Increase cardiac output

Compensatory mechanism fails

Decrease cardiac output

Decrease blood pressure

↓
Decrease perfusion to the vital
organs
↓
Multisystem organ failure
 1. Treatment of the underlying cause
2. Fluid and blood replacement
• Crystalloids- 0.9% sodium chloride
MEDICAL • Ringer lactate solution
• Hypertonic saline
MANAGEMENT • Colloids (Albumin, Dextran)
3. Redistribution of fluid
4. Pharmacologic therapy
(Vasoactive agents, Insulin therapy,
Desmopressin, Antidiarrhoeal,
Antiemetics).
NURSING MANAGEMENT
• Primary prevention of shock is an essential focus of nursing
care.
1. 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.
• 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.
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, cardiac
temponade, dysrhythmias.
 • Distended jugular vein due
to increased jugular venous
pressure.
CLINICAL • Absent pulse due to
MANIFESTATIONS: tachyarrhythmia
• Anginal pain
• Dysrhythmias.
• Complain of fatigue
• Express feelings of doom
• Signs of hemodynamic
instability.
PATHOPHYSIOLOGY
1. Myocardial infarction, arrhythmias, congestive heart failure,
cardiac myopathy, cardiac valve problem.
2. 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.

 Hypo-perfusion of tissues

Impaired cellular metabolism.

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.
1. Correction of underlying causes.
2. Initiation of first line treatment.
• Oxygenation.
• Pain control.
• Hemodynamic monitoring
• Laboratory marker monitoring.
• Fluid therapy.
Pharmacologic treatment :-

> Dobutamine.
> Nitroglycerine.
> Dopamine.
> Antiarrhythmic medications.
> Other vasoactive medication.
> Mechanical assistive devices.
NURSING MANAGEMENT

1. Preventing cardiogenic shock

2. Monitoring hemodynamic status.
3. Administering medications and intravenous fluids.
4. Maintaining intra-aortic balloon counter pulsation.
5. Enhancing safety and comfort.
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.
PATHOPHYSIOLOGY :-
1. Precipitating event
2. Vasodilation
3. Activation of inflammatory response
4. Abnormal distribution of blood volume
5. Decreased venous return
6. Decreased cardiac output
7. Decreased tissue perfusion
CLASSIFICATION OF CIRCULATORY
SHOCK:

1. Septic shock
2. Neurogenic shock
3. Anaphylactic shock
4. SEPTIC SHOCK

• The most common type of circulatory shock, is caused by

widespread of infection.
• 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.
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

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

1. Fluid replacement therapy

2. 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
3. Nutritional therapy (should start in first 24 hours after ICU
admission
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.
• 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.
 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.
ETIOLOGY:

• Spinal cord injury

• Spinal anesthesia
• Nervous system damage.
• Depressant action of medication
PATHOPHYSIOLOGY

1. Spinal cord injury, anaesthesia.

2. Loss of autonomic nervous system and motor function below
the level of injury
3. Loss of sympathetic control
4. Arterial or venous pooling
5. Dilatation of blood vessels
6. Hypotension
7. Warm, dry, flushed skin and bradycardia.
8. Decrease tissue perfusion to the vital organ
9. Multisystem organ failure.
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 anesthetic 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.
• 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.
• 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.
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.
PATHOPHYSIOLOGY
1. Antigen re-exposure.
2. Hypersensitivity antibody response
3. Activation of mast cells
4. Release of vasoactive substances such as bradykinin,
histamine.
5. Arterial vasodilation
6. Increase capillary permeability
7. Severe bronchospasm
8. Decrease oxygen supply and increase demand of oxygen
9. Inadequate tissue perfusion
10. Shock and death.
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.
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.
THANKYOU