hemorrhage and shock

1. SHOCK & ITS MANEGEMENT

2. SHOCK & ITS MANEGEMENT
Definition: Shock is defined as a condition in which tissue perfusion is
inadequate to deliver oxygen and nutrients to support vital organs and
cellular function.
Classification of shock: There are 4 types of shock:-
1. Hypovolemic shock.
2. Cardiogenic shock.
3. Distributive shock.
(a) Septic shock.
(b) Anaphylactic shock.
4. Obstructive shock.

3. STAGES OF SHOCK
•Shock evolves through 3 phases
1.Initial non-progressive phase
2.Progressive phase
3.Irreversible stage
Initial non-progressive phase
• Compensatory mechanism to maintain the homeostasis so that blood supply to vital organs is
maintained
• By neuro humoral mechanism which maintains blood pressure and cardiac output
• Widespread vasoconstriction of vessels except coronary and cerebral vessels
• Fluid conservation by kidney
• Tachycardia

5. Signs and symptoms
Compensated phase
•15 to 25% of fluid loss from vessels and there are subtle signs of
shock
•Mean arterial pressure will be less than 10-15mm Hg from the
baseline
•Increased Renin and Anti-diuretic hormone secretion
•Vasoconstriction
•Increased heart rate
•Decreased pH

6. Progressive phase
•As the stage advances there is failure of compensatory mechanism, dilatation of
arterioles, veinules and capillary bed
•Because of this fluid leaks out of capillaries into interstitial space and there is
sludging of blood
•This reduces the tissue perfusion leading to hypoxia
•Initially body tissue except brain and heart suffers from hypoxia

8. Signs and symptoms
Progessive phase
•25 to 35% of fluid loss from vessels and classical signs of shock
appears
•Mean arterial pressure is less than 20mmHg from Base line
•Tissue hypoxia develops
•Decreased urine output (oliguria)
•Weak rapid pulse
•Decreased pH

9. IRREVERSIBLE PHASE (DECOMPENSATED STAGE)
•Cellular injury and tissue injury is so severe that condition does not revert back to
normal even after correcting hemodynamic defects
•Hypoxic and ischemic cell injury – causes leakage of lysosomal enzymes which
further aggravates condition
•Myocardial infarction and further worsens condition
•Intestinal ischemia causes microbes from intestinal flora to enter the circulation
which produces superimposed septic shock
•Acute tubular necrosis occurs in kidney

10. Signs and symptoms
Irreversible phase
•>35% of fluid loss from vessels, body cells die due to hypoxia
•Anuria
•Excessive organ or tissue damage
•Multi organ failure
•Decreased pH

11. Hypovolemic Shock:
It is occurs as a result of the loss of intravascular fluid volume, due to the fluid loss the body cells cannot get the
oxygen which leads to shock. The degree of shock depends upon
- Volume lost
- compensatory mechanism.
- The rate of loss
- age & physical condition.
Etiology: it may be Internal fluid loss or External
fluid loss
- Trauma (ruptured spleen)
- Gastro intestinal bleed
- - Long bone fracture
- -Burns dehydration
- - Lesions causing hemorrhage
- - Diuresis in hyperglycemic
- - Surgical procedures
- - Diabetic coma

12. Clinical manifestation:
- If fluid loss occurs internally the cause or effects may not
visible immediately.
- External loss is more greedily visible to the nurse.
- Anxiety
- restlessness
- alters mental state
- Decreased cardiac perfusion-hypoxia.
- Hypo tension.
- A rapid weak thread pulse.
- Cool clammy skin.
- Rapid shallow respiration.
- Hypothermia.
- Thirst and dry month.
- Fatigue.
- Distracted look in the eye (pupils dilated).

13. Cardio Genic Shock: This type of shock is caused by the failure of
the heart to pump effectively.
Etiology:
Cardiac:-
• myocardial infarction (AWMI)
• cardiomyopathy
• Congestive heart failure
Non cardiac:-
• severe hypoxemia
• Tension pneumothorax
• Massive pulmonary embolism

15. Clinical Manifestation of cardiogenic shock :
- Distended jugular veins.
- - Absence of pulse due to tachyarrthmia.
- - Anginal pain.
- - Haemodynamic instability.
Septic Shock:
Etiology: This is caused by an over whelming infection leading to vasodilatation
Caused by,
Gram negative bacteria e.g., E. coli, pneumococcal, streptococci
Certain fungi.
Gram positive bacteria.
Viruses.

17. Clinical manifestation of septic shock:
-Hypotension.
-Tachycardia.
-Tachypnea.
-Warm skin.
-Hyperthermia.
-Polyuria.
-Hyperglycemia.
-Metabolic acidosis.
-Pale skin.
-Worsening mental status.
-Nausea and vomiting.
–Diarrhea

18. Neurogenic Shock:
It is the rarest form of shock. It is caused by allergens, spinal anesthesia,
surgeries and drugs that inhibit the sympathetic nerve stimulation.
Etiology:
-Spinal cord injury.
-Spinal anesthesia.
-Head injury.
-Extreme pain.

19. Pathophysiology:

20. Clinical manifestation:
-Bradycardia.
-Hypotension.
-Extreme pain.
-Altered body temperature.
-Placid paralysis.
-Loss of bladder and bowel function.
-Decreased skin perfusion.

21. Anaphylactic Shock:
It is caused by a severe anaphylactic reaction to an allergen,
antigen, drug or foreign protein.
Risk factor:
-Penicillin sensitivity.
-Transfusion reaction.
-Bee sting allergy.
-Severe allergic to food and medicine.
-Pollen hypersensitivity.

23. Clinical manifestation
-Feeling of uneasiness.
-Head ache.
-Severe anxiety.
-Disorientation.
-Decreased LOC.
-Laryngeal edema.
-Hoarseness.
-Dyspnea, wheezes, coughing.
-Pruritis.
-Angio edema. (is the rapid edema, or swelling, of the area beneath the skin or mucosa. It is
normally an allergic reaction)
Obstructive Shock: In this situation the flow of blood is obstructed which impedes circulation
and can result in circulatory arrest.

24. Diagnostic Evaluation:
-Clinical history-A thorough history of patient with vomiting, diarrhea, trauma, any hemorrhage from wound, fever,
history of Bee sting.
Physical examination:
A thorough examination from head to foot to be done to assess the tachypnea, tachycardia, rapid shallow breathing,
purities, hypotension, Fever, vomiting, sweating, altered consciousness.
Laboratory examination:
a.) CULTURE-culture for blood, sputum, urine, surgical and non surgical wound to rule out the organism.
b.) BLOOD-Elevated WBC, decreased Hb it may decreases with progression of shock.
c.) ABG-To rule out respiratory alkalosis
d.) ECG-To rule out dysarrthmias, MI.
e.) ECHO CARDIOGRAM-To rule out aortic stenosis and pulmonary embolism.
f.) CT SCAN
g.) CHEST AND ABDOMEN RADIO GRAPHY.
h.) CARDIAC MONITOR-SpO2, pulse, temp, BP. monitored continuously.
i.) CVP-Fluid loss.

25. Management of Shock:
Medical management:
a.) Non Invassive:
-To identify the causes
-To control the external hemorrhage via pressure.
-Use of MAST (medical antishock trousers)
Mast : - It also called pneumatic antishock garments.
- External pressure provided by MAST. It increases the vascular resistance and reduces the
diameters of blood vessels in the abdomen and leg. It results decrease in blood leakage so tissue
perfusion increases to the vital organ.
Intra aortic balloon Pump: -It is used to client with carcinogenic shock after open heart Surgery.
External Counter Pulsation: It is same principle of intra abdomen balloon pump .But applied
externally to the legs it is a air/ water filled tubular bags connected to a pumping unit. Pressure is
applied to legs during diastole and is released during systole.

26. b.) Invasive intervention:
- Continuous hemodynamic monitoring.
- Monitor means arterial pressure.
- Administration of IV fluids, blood products.
- Oxygen administration.
- Continuous monitoring urine output.
- Ventricular ass‘s devices.
- External / parenteral nutrition support.

27. Pharmacological Management:
1. Crystalloids – RL, NS.
2. Colloids- albumin, plasma substitute.
3. Inotropic- dopamine, dobutamine.
4. Vasodilators – NTG, sodium nitrofruside.
5. Dauretics –frusemide.
6. Antibiotics – gentamycin, aminoglycosides.
7. Antihistamines – epineprene.
8. Brinchodilators- aminophyline atropine.
9. Anticoagulants- heparine.
10. Steroids- prevent intra cellular release of enzymes.

28. Surgical Management:
1. wound debridement: In case of chronic infected wound, burns wound debridement done for fast
healing.
2. Amputation: In case of diabetic foot amputation to be performed
3. Angioplasty: In case of acute myocardial infarction angioplasty can be performed
4. Tracheotomy For bronco spasm.
Nursing Management:
- Asses the patient level of conscious.
- Close monitoring of vital signs.
- Oxygen administration.
- Ventilator care.
- IV fluid administration.
- Continuous cardiac monitoring.
- Administration of medication.
- Skin care.
- Support the family members.

29. Complication:
ARDS- (acute respiratory distress syndrome) In case of septic shock
patient may go for ARDS
DIC - disseminated intravascular coagulation Due to ineffective
perfusion, decrease venous return
Multiple Organ Failure: Due to in adequate tissue perfusion and
decreased venous return. Multiple organ failure occurs.