Identification of Shock States Caralee Brommé, RN, MSN, CCRN

Identification of Shock States Types of shock Hypovolemic Distributive/ Vasogenic Anaphylactic Neurogenic Septic Cardiogenic Clinical manifestations Compensated/Progressive Decompensated/ Nonprogressive Irreversible Diagnosis& treatment History Physical Case study

Types of shock

Hypovolemic

Distributive/ Vasogenic

Anaphylactic

Neurogenic

Septic

Cardiogenic

Clinical manifestations

Compensated/Progressive

Decompensated/ Nonprogressive

Irreversible

Diagnosis& treatment

History

Physical

Case study

Identification of Shock States Shock, or circulatory failure is a complex clinical syndrome characterized by inadequate tissue perfusion to meet the metabolic demands of the body , which results in cellular dysfunction and eventual organ failure and death The causes are different, but the physiologic consequences are the same Hypotension,tissue hypoxia, and metabolic acidosis

Shock, or circulatory failure is a complex clinical syndrome characterized by inadequate tissue perfusion to meet the metabolic demands of the body , which results in cellular dysfunction and eventual organ failure and death

The causes are different, but the physiologic consequences are the same

Hypotension,tissue hypoxia, and metabolic acidosis

Identification of Shock States Hypovolemic shock Characterized by a reduction in circulating volume or extra cellular loss Blood loss - trauma , GI bleeding, intracranial hemorrhage Plasma loss - increased capillary permeability associated with sepsis and acidosis, burns,peritonitis Extra cellular loss - vomiting diarrhea, glycosuric diuresis, and sunstroke

Hypovolemic shock

Characterized by a reduction in circulating volume or extra cellular loss

Blood loss - trauma , GI bleeding, intracranial hemorrhage

Plasma loss - increased capillary permeability associated with sepsis and acidosis, burns,peritonitis

Extra cellular loss - vomiting diarrhea, glycosuric diuresis, and sunstroke

Assessment findings and classification with acute hemorrhage >35 30-40 20-30 14-20 Resp Rate Normal Normal Normal Normal Blood Pressure >140 >120 >100 <100 Pulse rate >2000 1500-2000 750-1500 <750ml Blood loss >40 30-40 15-30 <15% Blood loss Class 4 Class 3 Class 2 Class 1 Assessment

Identification of Shock States Distributive shock Characterized by systemic vasodilatation Vasogenic Anaphylaxis - allergen mediated Sepsis - overwhelming sepsis with circulating bacterial toxins Myocardial depression and peripheral dilation Neurogenic Spinal cord injury

Distributive shock

Characterized by systemic vasodilatation

Vasogenic

Anaphylaxis - allergen mediated

Sepsis - overwhelming sepsis with circulating bacterial toxins

Myocardial depression and peripheral dilation

Neurogenic

Spinal cord injury

Identification of Shock States Cardiogenic shock Results from impaired cardiac function resulting in reduced cardiac output Myocardial Infarction Primary pump failure- myocarditis, trauma, congestive heart failure Dysrhythmias- Paroxysmal atrial tachycardia, Ventricular dysrhythmias Obstructive Conditions Large Pulmonary emboli Tension Pneumothorax Pericardial Tamponade

Cardiogenic shock

Results from impaired cardiac function resulting in reduced cardiac output

Myocardial Infarction

Primary pump failure- myocarditis, trauma, congestive heart failure

Dysrhythmias-

Paroxysmal atrial tachycardia,

Ventricular dysrhythmias

Obstructive Conditions

Large Pulmonary emboli

Tension Pneumothorax

Pericardial Tamponade

Identification of Shock States Clinical manifestations Compensated/ progressive Increased heart rate/ tachycardia Vasoconstriction Decreased perfusion of the hands and feet Irritability Thirsty Decrease urinary output - Normal BP with narrowing pulse pressure Example moderate dehydration

Clinical manifestations

Compensated/ progressive

Increased heart rate/ tachycardia

Vasoconstriction

Decreased perfusion of the hands and feet

Irritability

Thirsty

Decrease urinary output -

Normal BP with narrowing pulse pressure

Example moderate dehydration

Identification of Shock States Decompensated shock Pronounced tachycardia Tachypnea Very lethargic, confused, apathetic Cool pale extremities with decreased capillary refill and skin turgor vasodilatation of the microcirculation BP might be maintained, but increasingly narrow in pulse pressure Moderate metabolic acidosis lactic acidosis from anaerobic metabolism Will progress to tissue hypoxia,metabolic acidosis and eventually organ dysfunction

Decompensated shock

Pronounced tachycardia

Tachypnea

Very lethargic, confused, apathetic

Cool pale extremities with decreased capillary refill and skin turgor

vasodilatation of the microcirculation

BP might be maintained, but increasingly narrow in pulse pressure

Moderate metabolic acidosis

lactic acidosis from anaerobic metabolism

Will progress to tissue hypoxia,metabolic acidosis and eventually organ dysfunction

Identification of Shock States Irreversible shock Pronounced vasoconstriction Severe tachycardia with progression to bradycardia- thready weak pulse Hypotension Coma Apnea Irreversibly organ damage Kidneys, brain, heart

Irreversible shock

Pronounced vasoconstriction

Severe tachycardia with progression to bradycardia- thready weak pulse

Hypotension

Coma

Apnea

Irreversibly organ damage

Kidneys, brain, heart

Identification of Shock States Diagnosis History Type of illness- trauma vs. illness Length of illness-hours to days Find causative agent. ABG for acid/ base & oxygenation status Lactic acid level CBC, blood chemistry, full body fluid cultures EKG,CXR CVP, Arterial line

Diagnosis

History

Type of illness- trauma vs. illness

Length of illness-hours to days

Find causative agent.

ABG for acid/ base & oxygenation status

Lactic acid level

CBC, blood chemistry, full body fluid cultures

EKG,CXR

CVP, Arterial line

Identification of Shock States Physical exam Level of consciousness Heart rate/ Respiratory rate O2sat (difficult d/t perfusion) Capillary refill (perfusion) BP (Art/ Doppler) Urinary output Cardiac monitoring Temperature monitoring Full hemodynamic monitoring in sever cases

Physical exam

Level of consciousness

Heart rate/ Respiratory rate

O2sat (difficult d/t perfusion)

Capillary refill (perfusion)

BP (Art/ Doppler)

Urinary output

Cardiac monitoring

Temperature monitoring

Full hemodynamic monitoring in sever cases

Identification of Shock States Therapeutic Management Ventilation Establish airway- prep for intubation Administer O2 by mask Replace fluids Establish IV/ IO access Restore volume with fluid boluses 20cc/kg isotonic solution Improve pump action Administer vasopressors Epinephrine .01mg/ kg Dopamine 2-20 mcg/kg/min

Therapeutic Management

Ventilation

Establish airway- prep for intubation

Administer O2 by mask

Replace fluids

Establish IV/ IO access

Restore volume with fluid boluses

20cc/kg isotonic solution

Improve pump action

Administer vasopressors

Epinephrine .01mg/ kg

Dopamine 2-20 mcg/kg/min

Identification of Shock States General support Keep pt flat with leg raised above level of heart Keep pt warm and dry Septic Shock Administer broad-spectrum antibiotics Anaphylaxis Remove allergen Tourniquet above injection site

General support

Keep pt flat with leg raised above level of heart

Keep pt warm and dry

Septic Shock

Administer broad-spectrum antibiotics

Anaphylaxis

Remove allergen

Tourniquet above injection site

Identification of Shock States in Infants and Children Children have an intense vasoconstrictor response: Systolic blood pressure will be maintained at the expense of peripheral perfusion Observe poor peripheral perfusion and narrow pulse pressure before hypotension is evident A decrease in heart rate below normal range will cause a significant fall in cardiac output

Children have an intense vasoconstrictor response:

Systolic blood pressure will be maintained at the expense of peripheral perfusion

Observe poor peripheral perfusion and narrow pulse pressure before hypotension is evident

A decrease in heart rate below normal range will cause a significant fall in cardiac output

Identification of Shock Type and degree of shock? Initial intervention? What signs of improvement will you see with treatment?

Type and degree of shock?

Initial intervention?

What signs of improvement will you see with treatment?

Identification of Shock States Summary The type and degree of shock must be diagnosed early and treatment started immediately. In infants and children, hypotension is a very late manifestation. Heart and respiratory rate, level of consciousness and capillary refill are essential parts of the physical exam.

Summary

The type and degree of shock must be diagnosed early and treatment started immediately.

In infants and children, hypotension is a very late manifestation.

Heart and respiratory rate, level of consciousness and capillary refill are essential parts of the physical exam.