Shock and Its Management

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Shock and Its

Management
Definition

 Shock is a state of circulatory failure that happens when the organs and body
tissues do not receive enough blood flow to support their oxygen and metabolic
demands, putting them at risk of hypoxia and cellular injury.
 Shock is a continuum of events that progresses through several stages, including
compensated, decompensated or progressive, and irreversible shock.
Stages of Shock

Compensatory stage (Non-progressive shock)


• BP remains within normal limit
• Vasoconstriction , Increase Heart Rate, Increase Contractility of Heart to maintain output

• Stimulation of sympathetic nervous system & release of catecholamines

• Fight & Flight response Activated

• Body shunts blood from organs, such as skin , kidney, heart, GI tract , lungs

Results in cool and clammy skin, Hypoactive, Bowel sounds , Decrease urine output
Metabolic acidosis, Increased respiratory rate, Change in mental status, Confusion
PROGRESSIVE STAGE(Uncompensated shock)
• Compensatory mechanism become ineffective.
• Impaired perfusion results in anaerobic metabolism and cellular
hypoxia.
• Renal ischemia stimulates RAAS which further causes vasoconstriction.

IRREVERSIBLE STAGE( Refractory shock)


• Compensatory mechanisms are ineffective.
• Coronary and cerebral tissue perfusion drops and organ systems fail.
COMPENSATED (NONPROGRESSIVE
SHOCK)
 Reversible stage during which compensatory mechanisms are effective and
homeostasis is maintained.
 Clinical presentation begins to reflect the body’s response to imbalance the
oxygen supply and demand.
 Metabolic changes at cellular level from aerobic to anaerobic , causing the lactic
acid bulid up which is removed by liver, but needs oxygen.
Compensated stage
B.P.
CAUSES OF SHOCK
HYPOVOLEMIC SHOCK

 Most common type of shock which is characterized by decreased intravascular


volume.
Causes – External fluid losses,
Traumatic blood loss
Internal fluid shifts (severe dehydration, severe edema,
ascites)
PATHOPHYSIOLOGY OF
HYPOVOLEMIC SHOCK

Decreased Decreased Decreased


Decreased Decreased ventricular Decreased
cardiac tissue
blood volume venous return filling stroke volume
output perfusion
Clinical manifestation

 Fall in venous pressure


 Rise in peripheral resistance
 Tachycardia
 Cold, moist skin, pallor, thirst, diaphoresis
 Altered sensorium, oliguria, metabolic acidosis, tachypnea
 Most dependable criterion: level of arterial BP
Medical management

 Goals of treatment are


 To restore intravascular volume
 Redistribute fluid volume
 Correct the underlying cause

 If the patient is haemorrhaging, bleeding is stopped by applying pressure or by


surgery.
 Diarrhoea and vomiting are treated with medications.
Fluid and Blood Replacement

 At least , two IV lines are inserted to administer fluid, medications and or blood.
 Lactated Ringer; solution, colloids or 0.9% NS are administered to restore
intravascular volume.
 Blood products are used only if other alternatives are unavailable or blood loss is
extensive and rapid.
Redistribution of fluids

 Position – Trendelenburg position


 Elevation of legs promotes the return of venous blood.

Pharmacologic management
 Vasoactive medications to prevent cardiac failure.
Nursing management

 Closely monitor for risk of fluid deficit


 Assist with fluid replacement before intravascular volume is depleted.
 Ensure safe administration of prescribed fluids and medications and document
effects.
 Monitor signs of complications and effects of treatment.
 Monitor patient closely for adverse effects.
 Monitor for cardiovascular overload, signs of difficulty breathing and pulmonary
edema, hemodynamic pressure, vital signs, ABG, serum lactate levels, Hb, HCT
levels and fluid intake and output.
 Reduce anxiety and fear about the need for an oxygen mask by giving patients
explanations and frequent reassurance.
Septic shock

 Most common type of circulatory shock caused by widespread infection.


 Most common pathogens - Gram negative bacteria
 Other infectious agents -Gram positive bacteria, viruses and fungi can also cause
septic shock.
Risk factors

 Increased use of invasive procedures and indewelling medical devices


 Increased no. of antibiotics- resistant micrroraganisms.
 Elderly person
 Malnutrition persons
 Immunocompromised persons
 Person with chronic illness like diabetes mellitus, hepatitis
Pathophysiology

Microorganism invasion causes immune response. Immune


response activates biochemical cytokines and mediators
associated with inflammatory process and produces a variety of
effects leads to shock.

Resulting in increased capillary permeability, fluid loss from


capillaries, vasodilatation

Results in inadequate perfusion of oxygen and nutrients to


tissues and cells.
Clinical manifestations

Early stage of septic shock- As sepsis progresses


 BP may remain within normal limits  Low cardiac output with
 Heart and respiratory rate elevated. vasoconstriction
 High cardiac output with vasodilatation.  BP drops
 Hyperthermia with warm, flushed skin,  Skin cool and pale
bounding pulses.  Temperature normal or below
 Urinary output normal or decreased. normal
 Gastrointestinal status compromised e.g.  Heart and respiratory rates
nausea, vomiting, diarrhoea, decreased rapid
bowel sounds  Anuria and MODS
 Subtle change in mental status.
Nursing management
Medical management  Hand hygiene
 Aseptic precautions
 Identify risk for sepsis and septic shock
 Blood, sputum and wound drainage  Monitor IV lines, arterial and venous
specimens are collected to identify puncture sites, surgical incisions, trauma
and eliminate cause of infection. wounds, urinary catheters and pressure
 Reduce risk of infection. ulcers for signs of infections.
 Fluid replacement  Check for fever- Acetaminophen
 Broad spectrum antibiotics  Administer IVF and medications.
 nutritional supplements high protein  Monitor hemodynamic status, fluid intake
diet output and nutritional status.
 Enteral feedings are preferred.  Monitor daily weights, serum albumin and
pre-albumin level to check daily protein
requirements.
Cardiogenic shock
 Occurs when heart ability to contract and to pump blood is impaired & the supply of oxygen is inadequate
for heart and tissues.

Causes

Coronary Non-Coronary

Acute Mi Severe Hypoxia Acisosis

Anterior Wall MI Hypoglycaemia Hypocalcamia

Tension
pneumothorax
Cardiogenic shock - Pathophysiology

Decrease cardiac
contractility

Decrease Stroke
volume &
Cardiac output

Decrease
Pulmonary Decrease systemic
Coronary Artery
Congestion tissue perfusion
Perfusion
Cardiogenic shock – Clinical Manifestation
• Pain of angina
• Dysrhythmia
• Complain of Fatigue
• Express feeling of DOOM
• Sign of Hemodynamic Instability

Cardiogenic shock – Medical Management (Goals)


• To limit further myocardial damage
• To preserve healthy myocardium
• To improve cardiac function by increasing cardiac contractility
• Decrease ventricular after load
Cardiogenic shock – Medical Management
• Correction of underlying cause
• Oxygenation
• Thrombolytic Therapy
• Percutaneous coronary intervention (PCI)
• CABG
• Intraaortic ballon pump therapy
• Correction of acidosis & Electrolyte disturbance
• Treatment of Tension pneumothorax

• Initiation of First line treatment


• Oxygenation : By nasal canula @ 2-6 liter/m
• Pain Control: IV Morphine
• Hemodynamic monitoring
• Laboratory marker monitoring
• Fluid Therapy : Monitor for fluid overload.
• Pharmacological Therapy :
• Vasoactive medications: Vaso dilators, Dopamine, Dobutamine, Nitroglycerine, Epinephrine,
Nor Epinephrine
• Antiarrhythmic Medications
Cardiogenic shock – Nursing Management
• Correction of underlying cause
• Oxygenation
• Thrombolytic Therapy
• Percutaneous coronary intervention (PCI)
• CABG
• Intraarotic ballon pump therapy
• Correction of acidosis & Electrolyte disturbance
• Treatment of Tension pneumothorax

• Initiation of First line treatment


• Oxygenation : By nasal canula @ 2-6 liter/m
• Pain Control: IV Morphine
• Hemodynamic monitoring
• Laboratory marker monitoring
• Fluid Therapy : Monitor for fluid overload.
• Pharmacological Therapy :
• Vasoactive medications: Vaso dilators, Dopamine, Dobutamine, Nitroglycerine, Epinephrine,
Nor Epinephrine
• Antiarrhythmic Medications

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