Author(s): Kristen Sarna, RN, BSN, 2012
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Kristen Sarna, RN, BSN
Assess and identify the type and phase of
shock in a presenting patient
  Manage the emergency nursing care of the
patien...
 

 
 

Predict differential diagnosis when presented with
specific information regarding the history of a
patient prov...
 
 

 

 
 

Consider age-specific factors in the treatment of
shock state
Apply the medico-legal aspects pertaining ...
Assessment
  Analysis
  Planning and implementation/intervention
  Evaluation and ongoing monitoring
  Documentation o...
Inadequate tissue perfusion
  Multiple causes, but the pathophysiology is
usually the same
  Life threatening
  Imbalan...
Monitor vital signs closely
  Monitor mental status
  Monitor lab values
 

◦  ABG with lactate
◦  CBC – RBC remain nor...
Tachypnea -> bradypnea
  Decreased urine output
  Pallor, cool, clammy skin
  Anxiety, confusion, agitation
  Absent b...
Based on history and physical assessment
  Elevated lactic and a base deficit
  12 lead EKG
  Chest x-ray
  Continuous...
Fluid resuscitation
  Administration of blood products
  Monitor bleeding
 
Vital signs
  Lab values
  Mental status
 
Document any and all patient interventions
and patient response
  Remember to document all vital signs,
watching for subt...
 

Pediatric

◦  Increases cardiac output by increasing heart rate
◦  Sustains arterial pressure despite significant volu...
1. Compensated ( nonprogressive) shock
  2. Uncompensated (progressive) shock
  3. Irreversible (refractory) shock
 
“Reversible stage during which compensatory
mechanisms are effective and homeostasis is
maintained”
  Clinical presentati...
 

At first, blood pressure will decrease, which
happens because of the decrease in cardiac
output (CO) and a narrowing o...
Blood flow to the vital organs, such as the
heart and brain, are maintained, while blood
flow to non-vital organs, the kid...
At this stage, the body is able to compensate
for the changes in tissue perfusion. If the
underlying cause is corrected, t...
 

Neurologic

 

Cardiovascular

◦  Alert and oriented to person, place and time
◦  Restless, apprehensive, confused
◦ ...
 

Respiratory

◦  ↓blood flow to the lungs
◦  hyperventilation

 

Gastrointestinal

◦  ↓blood supply
◦  Hypoactive bow...
 

Hepatic

◦  No changes at this stage

 

Hematologic

◦  No changes at this stage

 

Temperature

◦  Normal to abno...
 

Key laboratory findings
◦  ↑blood glucose
◦  ↑pH
◦  ↓PaO2
◦  ↓PaCO2
This stage of shock begins when the body’s
compensatory mechanisms fail
  Aggressive interventions are need to prevent
th...
Altered capillary permiability allows leakage
of fluid and protein out of the vascular space
into the surrounding intersti...
 

Neurologic

◦  ↓cerebral perfusion pressure
◦  ↓ cerebral blood flow
◦  Listless or agitated
◦  ↓responsiveness to sti...
 

Cardiovascular

◦  ↑capillary permeability → systemic interstitial
edema
◦  ↓ cardiac output = ↓BP and ↑HR
◦  MAP <60m...
 

Respiratory

◦  Acute respiratory distress syndrome (ARDS)
 
 
 
 
 
 
 

↑capillary permeability
Pulmonary vas...
 

Gastrointestinal

◦  Vasoconstriction and decreased perfusion lead to
ischemic gut (stomach, small and large intestine...
 

Renal

◦  Renal tubules become ischemic causing acute
tubular necrosis
◦  ↓urine output
◦  ↑BUN/creatinine ratio
◦  ↑u...
 

Hepatic

◦  Failure to metabolize drugs and waste products
◦  Jaundice
◦  Increase in lactate and ammonia

 

Hematol...
 

Temperature

◦  Hypothermia
◦  Sepsis: hyper or hypothermia

 

Skin

◦  Cold and clammy

 

Key laboratory findings...
Final stage of shock
  Decreased perfusion from peripheral
vasoconstriction and decreased cardiac
output exacerbate anaer...
Blood pools in the capillary beds secondary to
constricted veins and dilated arteries
  Loss of intravascular volume lead...
 

Neurologic

 

Cardiovascular

 

Respiratory

◦  Unresponsive
◦  Arreflexia
◦  Pupils nonreactive and dilated
◦  Pr...
 

Gastrointestinal
◦  Ischemic gut

 

Renal

◦  anuria

 

Hepatic

◦  Metabolic changes from accumulation of waste
p...
 

Temperature
◦  hypothermic

 

Skin

◦  Mottled, cyanotic

 

Key laboratory findings

◦  ↓ blood glucose
◦  ↑ ammon...
 

 

Crystalloids: increase intravascular volume
through actual volume administered
Colloids: pull fluid into the vascu...
 

 

 

Isotonic: similar in composition to body
fluid. Provides greater intravascular volume
d/t more fluid staying i...
 

0.9% Normal saline: Isotonic fluid

 

0.45% Normal Saline: hypotonic

 

5% Dextrose: hypotonic

 

Lactated Ringe...
Dextran
→
Rarely used. Used to
expand vascular space.
  Hetastarch
→
  Fresh frozen plasma
  Albumin
  Whole blood
  ...
 

 

Fresh frozen plasma: contains all clotting
factors. Used as a blood volume expander
Albumin: preferred as volume e...
 

Packed Red blood cell’s: Administer with
normal saline

◦  Increases oxygen affinity for hgb, and decrease
oxygen deli...
 

Pediatric fluid guidelines

◦  Up to 10 kg = 4ml/kg/hr
◦  11-20kg = 2ml/kg/hr plus 4ml/kg for first 10kg
◦  >20kg = 1m...
 

 

Monitor for fluid overload: continuous pulse
ox, and other vital signs (HR, BP, RR)
Monitor for electrolyte imbala...
Hypovolemic Shock
  Cardiogenic Shock
  Distributive Shock
  Obstructive Shock
 
Loss or redistribution of blood, plasma, or
other body fluids, which results in a
decreased circulatory volume
  Inadequa...
Increased heart rate
  Decreased pulse pressure
  Decreased blood pressure
 
 

Cardiovascular

◦  ↓ preload, stroke volume
◦  ↓ capillary refill

 

Pulmonary

◦  Tachypnea → bradypnea (late sign)...
 

Neurologic

 

Gastrointestinal

 

Diagnostic findings

◦  Anxiety
◦  Confusion
◦  agitation

◦  Absent bowel sound...
 

Treatment:

◦  Correcting the underlying cause
◦  Warm fluids
◦  May need supportive therapy with vasopressors
Occurs when the heart fails as a pump
resulting in significant reduction in
ventricular effectiveness
  When pump failure...
 

Causes of Cardiogenic Shock include:
◦  Myocardial infarction
◦  Cardiomyopathy
◦  Pericardial tamponade
◦  Dysrhythmi...
Increased heart rate
  Decreased pulse pressure
  Decreased blood pressure
 
 

Cardiovascular

◦  Decreased capillary refill
◦  May have chest pain

 

Pulmonary

◦  Tachypnea
◦  Cyanosis
◦  Crack...
 

Renal

◦  ↑ sodium and water retention
◦  ↓ renal blood flow
◦  ↓ urine output

 

Neurologic

◦  ↓ cerebral perfusio...
 

Diagnostic findings

◦  ↑ cardiac markers
◦  ↑ blood glucose
◦  ↑ BUN
◦  Dysrhythmias
◦  Pulmonary infiltrates on ches...
 

Treatment:

◦  Correct dysrhythmias
◦  Drug Therapy:
 
 
 
 

Nitrates
Inotropes
Diuretics
Beta blockers
Neurogenic Shock
  Anaphylactic Shock
  Septic Shock
 
Results from spinal cord trauma (usually T5
or above) or spinal anesthesia
  Injury results in major vasodilation without...
Spinal anesthesia can block transmission of
impulses from the SNS resulting in
neurogenic shock
  Signs/symptoms
 

◦  H...
 

Cardiovascular

 

Pulmonary

 

Renal

 

Skin

◦  ↑/↓ Temperature
◦  Bradycardia
◦  Dysfunction r/t level of inju...
 

Neurologic

◦  Flaccid paralysis below the level of the lesion/injury
◦  Loss of reflex activity

 

Gastrointestinal...
 

Treatment:

◦  High dose steroids: to help decrease inflammation
surrounding spinal cord
◦  Treat the symptoms
Acute and life-threatening allergic reaction to
a sensitizing substance
  Immediate response causing massive
vasodilation...
 

Sudden onset of symptoms
◦  Chest pain
◦  Dizziness
◦  Incontinence
◦  Swelling of lips and tongue
◦  Wheezing and str...
 

Cardiovascular

◦  Chest pain
◦  Third spacing of fluid

 

Pulmonary

◦  Swelling to tongue and lips
◦  Shortness of...
 

Renal

◦  Decreased urine output

 

Skin

◦  Flushing
◦  Pruritus
◦  Urticaria
◦  angioedema

 

Neurologic

◦  Anx...
 

Gastrointestinal
◦  Cramping
◦  Abdominal pain
◦  Nausea
◦  Vomiting
◦  Diarrhea

 

Diagnostic findings

◦  Sudden o...
 

Treatment:

◦  Airway management
◦  Epi 0.3mg SQ or IM to vastus lateralis
◦  BLS/ACLS
Sepsis: systemic inflammatory response to a
documented or suspected infection
  Septic Shock: presence of sepsis with
hyp...
The body responds through both hyperinflammatory and anti-inflammatory means.
Endotoxins released by the invading
organism...
 

As a result, there is widespread cellular
dysfunction to the endothelium, resulting in
vasodilation, increased capilla...
 

Cardiovascular

◦  ↑/↓ Temperature
◦  Biventricular dilation
  ↓ ejection fraction

 

Pulmonary

◦  Hyperventilatio...
 

Renal

◦  Decreased urine output

 

Skin

◦  Warm and flushed then cool and mottled

 

Neurologic

◦  Alteration i...
 

Diagnostic findings

◦  ↑/↓ WBC
◦  ↓ Platelets
◦  ↑ Lactate
◦  ↑ Glucose
◦  ↑ Urine specific gravity
◦  ↓ Urine sodium...
 

Treatment

◦  Fluid administration
◦  Monitor VS
◦  Antibiotics: broad spectrum until source is
identified
◦  Vasopres...
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GEMC - Shock and Initial Resuscitation - for Nurses

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This is a lecture by Kristen Sarna from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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GEMC - Shock and Initial Resuscitation - for Nurses

  1. 1. Author(s): Kristen Sarna, RN, BSN, 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike 3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
  2. 2. Citation Key for more information see: http://open.umich.edu/wiki/CitationPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  3. 3. Kristen Sarna, RN, BSN
  4. 4. Assess and identify the type and phase of shock in a presenting patient   Manage the emergency nursing care of the patient with shock  
  5. 5.       Predict differential diagnosis when presented with specific information regarding the history of a patient provided by the pre-hospital personnel Describe multiple organ dysfunction syndrome (MODS) as complication from shock Fluid and blood products: ◦  Differentiate between colloids and crystalloids and explain the use for each within the emergency setting ◦  Differentiate between the different blood products available and explain use for each within the emergency setting ◦  Describe the advantages and disadvantages of the different fluids used during resuscitation
  6. 6.           Consider age-specific factors in the treatment of shock state Apply the medico-legal aspects pertaining to shock emergencies with regard to the emergency nurse Apply the above listed knowledge when analyzing a case scenario (paper based and real life scenarios) List and know the drugs used in your unit to manage shock Delineate the nursing process in the management of the patient with any of the above-mentioned conditions.
  7. 7. Assessment   Analysis   Planning and implementation/intervention   Evaluation and ongoing monitoring   Documentation of interventions and patient response   Age-related considerations (pediatric/ geriatric)  
  8. 8. Inadequate tissue perfusion   Multiple causes, but the pathophysiology is usually the same   Life threatening   Imbalance between the supply of and demand of oxygen and nutrients  
  9. 9. Monitor vital signs closely   Monitor mental status   Monitor lab values   ◦  ABG with lactate ◦  CBC – RBC remain normal, HCT- decreased and HGB- increased ◦  Coagulation panel- PT and PTT are prolonged, INR and d dimer are also prolonged (watch for DIC) ◦  Troponin, TCK, BUN, Creatinine are elevated ◦  Glucose initially elevated, then decreases after glycogen is depleted
  10. 10. Tachypnea -> bradypnea   Decreased urine output   Pallor, cool, clammy skin   Anxiety, confusion, agitation   Absent bowel sounds  
  11. 11. Based on history and physical assessment   Elevated lactic and a base deficit   12 lead EKG   Chest x-ray   Continuous pulse ox  
  12. 12. Fluid resuscitation   Administration of blood products   Monitor bleeding  
  13. 13. Vital signs   Lab values   Mental status  
  14. 14. Document any and all patient interventions and patient response   Remember to document all vital signs, watching for subtle changes.   Mental status   Strict inputs and outputs  
  15. 15.   Pediatric ◦  Increases cardiac output by increasing heart rate ◦  Sustains arterial pressure despite significant volume loss ◦  Loses 25% of circulating volume before signs of shock occur   Geriatric ◦  Shock progression is rapid ◦  Reduced compensatory mechanisms ◦  Preexisting disease states contribute to comorbidities
  16. 16. 1. Compensated ( nonprogressive) shock   2. Uncompensated (progressive) shock   3. Irreversible (refractory) shock  
  17. 17. “Reversible stage during which compensatory mechanisms are effective and homeostasis is maintained”   Clinical presentation begins to reflect the body’s response to the imbalance of oxygen supply and demand   Lewis, Heitkemper, Dirksen, O'Brien, Bucher(2007). Medical Surgical Nursing. St. Louis, MO: Mosby Elsevier
  18. 18.   At first, blood pressure will decrease, which happens because of the decrease in cardiac output (CO) and a narrowing of the pulse pressure. The baroreceptors in the carotid and aortic bodies immediately respond by activating the sympathetic nervous system (SNS). The SNS stimulates vasoconstriction and release of epinephrine and norepinephrine (potent vasconstrictors) Lewis, Heitkemper, Dirksen, O'Brien, Bucher(2007). Medical Surgical Nursing. St. Louis, MO: Mosby Elsevier
  19. 19. Blood flow to the vital organs, such as the heart and brain, are maintained, while blood flow to non-vital organs, the kidneys, liver, skin, GI tract and the lungs, is shunted.   Decreased blood flow to the kidneys activates the renin-angiotensin system.   Renin is released, which activates angiotensinogen to produce angiotensin I, which is then converted to antiotesnsin II.   Angiotensin II causes vasoconstriction in both the arteries and venous system   Lewis, Heitkemper, Dirksen, O'Brien, Bucher(2007). Medical Surgical Nursing. St. Louis, MO: Mosby Elsevier
  20. 20. At this stage, the body is able to compensate for the changes in tissue perfusion. If the underlying cause is corrected, the patient will recover with little to no residual effects.   If the body is unable to compensate the body will enter the progressive stage of shock   Lewis, Heitkemper, Dirksen, O'Brien, Bucher(2007). Medical Surgical Nursing. St. Louis, MO: Mosby Elsevier
  21. 21.   Neurologic   Cardiovascular ◦  Alert and oriented to person, place and time ◦  Restless, apprehensive, confused ◦  Change in level of consciousness ◦  Release of epinephrine/norepinephrine which promotes vasoconstriction ◦  ↑contractility ◦  ↑heart rate ◦  Coronary artery dilation ◦  Narrow pulse pressure ◦  BP remains adequate to perfuse vital organs
  22. 22.   Respiratory ◦  ↓blood flow to the lungs ◦  hyperventilation   Gastrointestinal ◦  ↓blood supply ◦  Hypoactive bowel sounds   Renal ◦  ↓renal blood flow ◦  ↑renin resulting in release of angiotensin (vasoconstrictor) ◦  ↑aldosterone resulting in sodium and water reabsorption ◦  ↑ antidiuretic hormone resulting in water re-absorption
  23. 23.   Hepatic ◦  No changes at this stage   Hematologic ◦  No changes at this stage   Temperature ◦  Normal to abnormal   Skin ◦  Pale and cool ◦  Warm and flushed (early septic shock)
  24. 24.   Key laboratory findings ◦  ↑blood glucose ◦  ↑pH ◦  ↓PaO2 ◦  ↓PaCO2
  25. 25. This stage of shock begins when the body’s compensatory mechanisms fail   Aggressive interventions are need to prevent the development of multiple organ dysfunction syndrome (MODS)   Continued decreased cellular perfusion and resulting alerted capillary permeability are the distinguishing features of this stage  
  26. 26. Altered capillary permiability allows leakage of fluid and protein out of the vascular space into the surrounding interstitial space causing a decrease in circulating volume and an increase in systemic interstitial edema.   This fluid leak from the vascular space also affects the solid organs, liver, spleen, GI tract, lungs, and peripheral tissues by further decreasing oxygen perfusion   Lewis, Heitkemper, Dirksen, O'Brien, Bucher(2007). Medical Surgical Nursing. St. Louis, MO: Mosby Elsevier
  27. 27.   Neurologic ◦  ↓cerebral perfusion pressure ◦  ↓ cerebral blood flow ◦  Listless or agitated ◦  ↓responsiveness to stimuli
  28. 28.   Cardiovascular ◦  ↑capillary permeability → systemic interstitial edema ◦  ↓ cardiac output = ↓BP and ↑HR ◦  MAP <60mmHG ◦  ↓Peripheral perfusion   Ischemia of distal extremities   Diminished pulses   ↓capillary refill ◦  ↓Coronary perfusion resulting in         Dysrhythmias Myocardial ischemia Myocardial infarction Myocardial dysfunction → impaired cardiac output
  29. 29.   Respiratory ◦  Acute respiratory distress syndrome (ARDS)               ↑capillary permeability Pulmonary vasoconstriction Pulmonary interstitial edema Alveolar edema Diffuse infiltrates ↑ respiratory rate ↓ compliance ◦  Moist crackles
  30. 30.   Gastrointestinal ◦  Vasoconstriction and decreased perfusion lead to ischemic gut (stomach, small and large intestines, gallbladder and pancreas) ◦  Erosive ulcers ◦  GI bleeding ◦  Translocation of GI bacteria ◦  Impaired absorption of nutrients
  31. 31.   Renal ◦  Renal tubules become ischemic causing acute tubular necrosis ◦  ↓urine output ◦  ↑BUN/creatinine ratio ◦  ↑urine sodium ◦  ↓Urine osmolarity and specific gravity ◦  ↓urine potassium ◦  Metabolic acidosis
  32. 32.   Hepatic ◦  Failure to metabolize drugs and waste products ◦  Jaundice ◦  Increase in lactate and ammonia   Hematologic ◦  DIC   Thrombin clots in microcirculation   Consumption of clots in microcirculation
  33. 33.   Temperature ◦  Hypothermia ◦  Sepsis: hyper or hypothermia   Skin ◦  Cold and clammy   Key laboratory findings ◦  ↑ liver enzymes: ALT, AST, GGT ◦  ↑ bleeding times ◦  thrombocytopenia
  34. 34. Final stage of shock   Decreased perfusion from peripheral vasoconstriction and decreased cardiac output exacerbate anaerobic metabolism   Lactic acid accumulates and contributes to an increased capillary permeability and dilation of the capillaries   Increased capillary permeability allows for fluid and plasma to leave the vascular space and move to the interstitial space   Lewis, Heitkemper, Dirksen, O'Brien, Bucher(2007). Medical Surgical Nursing. St. Louis, MO: Mosby Elsevier
  35. 35. Blood pools in the capillary beds secondary to constricted veins and dilated arteries   Loss of intravascular volume leads to worsening of hypotension and tachycardia resulting in a decrease in coronary blood flow   Decreased coronary blood flow results in decreased cardiac output   Cerebral blood flow cannot be maintained and cerebral ischemia results   Lewis, Heitkemper, Dirksen, O'Brien, Bucher(2007). Medical Surgical Nursing. St. Louis, MO: Mosby Elsevier
  36. 36.   Neurologic   Cardiovascular   Respiratory ◦  Unresponsive ◦  Arreflexia ◦  Pupils nonreactive and dilated ◦  Profound hypotension ◦  ↓ cardiac output ◦  Bradycardia, irregular rhythm ◦  Unable to perfuse vital organs ◦  Severe hypoxemia ◦  Respiratory failure
  37. 37.   Gastrointestinal ◦  Ischemic gut   Renal ◦  anuria   Hepatic ◦  Metabolic changes from accumulation of waste products (ammonia, lactate, carbon dioxide)   Hematologic ◦  DIC
  38. 38.   Temperature ◦  hypothermic   Skin ◦  Mottled, cyanotic   Key laboratory findings ◦  ↓ blood glucose ◦  ↑ ammonia, lactate and potassium ◦  Metabolic acidosis
  39. 39.     Crystalloids: increase intravascular volume through actual volume administered Colloids: pull fluid into the vascular space through osmosis
  40. 40.       Isotonic: similar in composition to body fluid. Provides greater intravascular volume d/t more fluid staying in the vascular space Hypotonic fluid: shift fluid into intracellular spaces. Useful in preventing cellular dehydration. They deplete circulatory volume Hypertonic: move fluid from cells to extravascular space, may be used to replace electrolytes and promote diuresis
  41. 41.   0.9% Normal saline: Isotonic fluid   0.45% Normal Saline: hypotonic   5% Dextrose: hypotonic   Lactated Ringer: Isotonic   Hypertonic Saline (7.5%): hypertonic, pulls fluid from interstitial and intracelluar spaces into the vascular space
  42. 42. Dextran → Rarely used. Used to expand vascular space.   Hetastarch →   Fresh frozen plasma   Albumin   Whole blood   Packed red blood cells  
  43. 43.     Fresh frozen plasma: contains all clotting factors. Used as a blood volume expander Albumin: preferred as volume expander when risk from producing interstitial edema is great (pulmonary and heart disease)
  44. 44.   Packed Red blood cell’s: Administer with normal saline ◦  Increases oxygen affinity for hgb, and decrease oxygen delivery to the tissues ◦  May cause: hypothermia, hyperkalemia, or hypocalcemia   Whole blood: can be administered without normal saline, reduces donor exposure ◦  May require greater amt than packed RBC’s to increase oxygen-carrying capacity of blood ◦  Not cost effective. Rarely used
  45. 45.   Pediatric fluid guidelines ◦  Up to 10 kg = 4ml/kg/hr ◦  11-20kg = 2ml/kg/hr plus 4ml/kg for first 10kg ◦  >20kg = 1ml/kg/hr plus 2ml/kg for each kg 11 through 20 plus 4ml/kg for first 10 kg   Volume replacement with crystalloids ◦  Administer 2 ml for each ml lost ◦  Pediatric: IV bolus of 20ml/kg of NS or LR ◦  IV bolus of 200-300 ml NS in adults
  46. 46.     Monitor for fluid overload: continuous pulse ox, and other vital signs (HR, BP, RR) Monitor for electrolyte imbalances
  47. 47. Hypovolemic Shock   Cardiogenic Shock   Distributive Shock   Obstructive Shock  
  48. 48. Loss or redistribution of blood, plasma, or other body fluids, which results in a decreased circulatory volume   Inadequate fluid returning to the heart results in decreased cardiac output   Third spacing occurs due to capillary permeability   Example: hemorrhagic shock from trauma, intraabdominal bleeding, significant vaginal bleeding, GI bleeding or vomiting and diarrhea  
  49. 49. Increased heart rate   Decreased pulse pressure   Decreased blood pressure  
  50. 50.   Cardiovascular ◦  ↓ preload, stroke volume ◦  ↓ capillary refill   Pulmonary ◦  Tachypnea → bradypnea (late sign)   Renal ◦  ↓ urine output   Skin ◦  Pallor ◦  Cool, clammy
  51. 51.   Neurologic   Gastrointestinal   Diagnostic findings ◦  Anxiety ◦  Confusion ◦  agitation ◦  Absent bowel sounds ◦  ↓ hematocrit ◦  ↓ hemaglobin ◦  ↑ lactate ◦  ↑ urine specific gravity ◦  Changes in electrolytes
  52. 52.   Treatment: ◦  Correcting the underlying cause ◦  Warm fluids ◦  May need supportive therapy with vasopressors
  53. 53. Occurs when the heart fails as a pump resulting in significant reduction in ventricular effectiveness   When pump failure occurs, the myocardium cannot forcibly eject blood   Stroke volume decreases d/t decreased contractility, which decreases cardiac output and blood pressure, resulting in decreased tissue perfusion   Decreased oxygenation to heart further complicates patient condition  
  54. 54.   Causes of Cardiogenic Shock include: ◦  Myocardial infarction ◦  Cardiomyopathy ◦  Pericardial tamponade ◦  Dysrhythmias ◦  Trauma ◦  Structural abnormalities   Valvular abnormality   Ventricular septal rupture   Tension pneumothorax
  55. 55. Increased heart rate   Decreased pulse pressure   Decreased blood pressure  
  56. 56.   Cardiovascular ◦  Decreased capillary refill ◦  May have chest pain   Pulmonary ◦  Tachypnea ◦  Cyanosis ◦  Crackles ◦  rhonchi   Skin ◦  Pallor ◦  Cool, clammy
  57. 57.   Renal ◦  ↑ sodium and water retention ◦  ↓ renal blood flow ◦  ↓ urine output   Neurologic ◦  ↓ cerebral perfusion   Anxiety   Confusion   agitation   Gastrointestinal ◦  ↓ bowel sounds ◦  Nausea/vomiting
  58. 58.   Diagnostic findings ◦  ↑ cardiac markers ◦  ↑ blood glucose ◦  ↑ BUN ◦  Dysrhythmias ◦  Pulmonary infiltrates on chest x-ray ◦  Left ventricular dysfunction on echocardiogram
  59. 59.   Treatment: ◦  Correct dysrhythmias ◦  Drug Therapy:         Nitrates Inotropes Diuretics Beta blockers
  60. 60. Neurogenic Shock   Anaphylactic Shock   Septic Shock  
  61. 61. Results from spinal cord trauma (usually T5 or above) or spinal anesthesia   Injury results in major vasodilation without compensation due to loss of sympathetic nervous system vasoconstrictor tone   Major vasodilation leads to pooling of blood in the blood vessels, tissue hypoperfusion and ultimately impaired cellular metabolism  
  62. 62. Spinal anesthesia can block transmission of impulses from the SNS resulting in neurogenic shock   Signs/symptoms   ◦  Hypotension ◦  Bradycardia ◦  Inability to regulate temperature
  63. 63.   Cardiovascular   Pulmonary   Renal   Skin ◦  ↑/↓ Temperature ◦  Bradycardia ◦  Dysfunction r/t level of injury ◦  Bladder dysfunction ◦  ↓ skin perfusion ◦  Cool or warm ◦  dry
  64. 64.   Neurologic ◦  Flaccid paralysis below the level of the lesion/injury ◦  Loss of reflex activity   Gastrointestinal ◦  Bowel dysfunction   Diagnostic findings ◦  history
  65. 65.   Treatment: ◦  High dose steroids: to help decrease inflammation surrounding spinal cord ◦  Treat the symptoms
  66. 66. Acute and life-threatening allergic reaction to a sensitizing substance   Immediate response causing massive vasodilation, release of vasoactive mediators, and an increase in capillary permeablity   Can lead to respiratory distress d/t laryngeal edema or severe bronchospasm, and circulatory failure d/t vasodilation  
  67. 67.   Sudden onset of symptoms ◦  Chest pain ◦  Dizziness ◦  Incontinence ◦  Swelling of lips and tongue ◦  Wheezing and stridor ◦  Flushing, pruritis, urticaria ◦  Angioedema ◦  Anxious and confused
  68. 68.   Cardiovascular ◦  Chest pain ◦  Third spacing of fluid   Pulmonary ◦  Swelling to tongue and lips ◦  Shortness of breath ◦  Edema of larynx and epiglottis ◦  Wheezing ◦  Rhinitis ◦  stridor
  69. 69.   Renal ◦  Decreased urine output   Skin ◦  Flushing ◦  Pruritus ◦  Urticaria ◦  angioedema   Neurologic ◦  Anxiety ◦  Decreased LOC
  70. 70.   Gastrointestinal ◦  Cramping ◦  Abdominal pain ◦  Nausea ◦  Vomiting ◦  Diarrhea   Diagnostic findings ◦  Sudden onset ◦  History of allergens ◦  Exposure to contrast media
  71. 71.   Treatment: ◦  Airway management ◦  Epi 0.3mg SQ or IM to vastus lateralis ◦  BLS/ACLS
  72. 72. Sepsis: systemic inflammatory response to a documented or suspected infection   Septic Shock: presence of sepsis with hypotension despite fluid resuscitation along with the presence of tissue perfusion abnormalities.  
  73. 73. The body responds through both hyperinflammatory and anti-inflammatory means. Endotoxins released by the invading organisms prompt release of hydrolytic enzymes from weakened cell lysosomes, which causes cellular destruction of bacteria and normal cells   When the body is unable to control the proinflammatory mediators, it produces a systemic inflammatory response  
  74. 74.   As a result, there is widespread cellular dysfunction to the endothelium, resulting in vasodilation, increased capillary permeability, and platelet aggregation and adhesions to the endothelium
  75. 75.   Cardiovascular ◦  ↑/↓ Temperature ◦  Biventricular dilation   ↓ ejection fraction   Pulmonary ◦  Hyperventilation ◦  Respiratory alkalosis then respiratory acidosis ◦  Hypoxemia ◦  Respiratory failure ◦  ARDS ◦  Pulmonary hypertension ◦  crackles
  76. 76.   Renal ◦  Decreased urine output   Skin ◦  Warm and flushed then cool and mottled   Neurologic ◦  Alteration in mental status ◦  Confusion ◦  Agitation ◦  coma   Gastrointestinal ◦  GI bleeding
  77. 77.   Diagnostic findings ◦  ↑/↓ WBC ◦  ↓ Platelets ◦  ↑ Lactate ◦  ↑ Glucose ◦  ↑ Urine specific gravity ◦  ↓ Urine sodium ◦  *positive blood cultures*
  78. 78.   Treatment ◦  Fluid administration ◦  Monitor VS ◦  Antibiotics: broad spectrum until source is identified ◦  Vasopressors

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