Shock is a life-threatening condition that occurs when the body is not getting enough blood flow. Lack of blood flow means the cells and organs do not get enough oxygen and nutrients to function properly. Many organs can be damaged as a result.
cardiac arrest is the sudden cessation of heart beat and normal cardiac function resulting in loss of effective circulation. cardiopulmonary resuscitation (CPR) is the immediate first aid treatment in case of a cardiac arrest. CPR has to be initiated within 10 seconds after cardiac arrest. cardiac arrest can be determined by palpating for carotid pulse. carotid pulse is absent in case of cardiac arrest.
cardiac arrest is the sudden cessation of heart beat and normal cardiac function resulting in loss of effective circulation. cardiopulmonary resuscitation (CPR) is the immediate first aid treatment in case of a cardiac arrest. CPR has to be initiated within 10 seconds after cardiac arrest. cardiac arrest can be determined by palpating for carotid pulse. carotid pulse is absent in case of cardiac arrest.
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Pleural effusion, sometimes referred to as “water on the lungs,” is the build-up of excess fluid between the layers of the pleura outside the lungs. The pleura are thin membranes that line the lungs and the inside of the chest cavity and act to lubricate and facilitate breathing.
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Bleeding, also called hemorrhage, is the name used to describe blood loss. It can refer to blood loss inside the body, called internal bleeding, or to blood loss outside of the body, called external bleeding. Blood loss can occur in almost any area of the body.
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Bleeding, also called hemorrhage, is the name used to describe blood loss. It can refer to blood loss inside the body, called internal bleeding, or to blood loss outside of the body, called external bleeding. Blood loss can occur in almost any area of the body.
Shock is the state of not enough blood flow to the tissues of the body as a result of problems with the circulatory system.Initial symptoms may include weakness, fast heart rate, fast breathing, sweating, anxiety, and increased thirst. This may be followed by confusion, unconsciousness, or cardiac arrest as complications worsen.
Shock is divided into four main types based on the underlying cause: low volume, cardiogenic, obstructive, and distributive shock. Low volume shock may be from bleeding, diarrhea, vomiting, or pancreatitis. Cardiogenic shock may be due to a heart attack or cardiac contusion. Obstructive shock may be due to cardiac tamponade or a tension pneumothorax. Distributed shock may be due to sepsis, spinal cord injury, or certain overdoses.
The diagnosis is generally based on a combination of symptoms, physical examination, and laboratory tests. A decreased pulse pressure (systolic blood pressure minus diastolic blood pressure) or a fast heart rate raises concerns. The heart rate divided by systolic blood pressure, known as the shock index (SI), of greater than 0.8 supports the diagnosis more than low blood pressure or a fast heart rate in isolation.
Treatment of shock is based on the likely underlying cause.[2] An open airway and sufficient breathing should be established.[2] Any ongoing bleeding should be stopped, which may require surgery or embolization.[2] Intravenous fluid, such as Ringer's lactate or packed red blood cells, is often given.[2] Efforts to maintain a normal body temperature are also important.[2] Vasopressors may be useful in certain cases.[2] Shock is both common and has a high risk of death.[3] In the United States about 1.2 million people present to the emergency room each year with shock and their risk of death is between 20 and 50%
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Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
2. Introduction
• Shock is a life threatening condition. lt is
characterized by inadequate tissue perfusion
that if untreated results in cell death. The
supply of oxygen to tissues is essential in the
maintenance of life and this can be ensured
when circulatory system is functioning
normally.
• In 1923 Walter and Canner first worked for all
conditions of shock.
SHOCK
4. CLASSIFICATIONOF SHOCK
• Hypovolemic shock.
• Cardiogenic shock.
• Circulatory shock or distributive shock
a. Septic shock.
b. Obstructive shock.
c. Neurogenic shock.
d. Anaphylactic shock.
5. Hypovolemic shock
• This is the most common type of shock, due to
insufficient circulatory volume
• This occurs when there is loss in the
intravascular fluid up to 15% to 25%.
• That is a loss of 750 to 1300 ml of blood in a
70 kg person
8. CLINICAL MANIFESTATIONS
• Decreased cardiac output
• Hypotension
• Altered tissue perfusion
• Cool and clammy skin
• Cyanosis or PaIe skin color (pallor)
• A rapid, weak, thready pulse
• Thirst and dry mouth, due to fluid depletion
• Fatigue due to inadequate oxygenation
• Anxiety, restlessness, altered mental state
9. CARDIOGENIC SHOCK
It is caused by the failure of heart to pump
effectively.
This is due damage of heart muscles, mostly
from myocardial infarction.
13. CLINICAL MANIFESTATIONS
• Pulmonary edema
• Increased central venous pressure
• Distended jugular veins due to increased jugular
venous pressure
• Weak or absent Pulse due to tachyarrhythmia
• Shortness of breath
• Chest pain
14. SEPTIC SHOCK
• It is secondary to infections by micro organisms.
• Septic shock is caused by an overwhelming systemic
infection and inflammation resulting in vasodilation
• Most common gram negative bacteria such as
Escherichia coli, Proteus species, Klebsiella
pneumoniae
• Which release an endotoxin and produce adverse
biochemical,immunological & neurological effects
which are harmful to the body.
16. Pathophysiology
Severe localize infection of gram –ve bacili
Bacterial invasion into bloodstream(septicemia)
Inflammatory response
Endotoxin release into circulation
Histamine & other chemical mediator release
vasodilation
Increased capillary permeability
Inadequate tissue perfusion to vital organ
Multiple organ failure
I
17. CLINICAL MANIFESTATION
• Pyrexia due to increased level of cytokines
• Systemic vasodilation resulting in hypotension
• Warm and sweaty skin due to vasodilation
• Reduced contractility of the heart
• Increased levels of neutrophils
• Increased heart rate
• Increased cardiac output
19. Clinical manifestations
• Tachycardia
• Tachypnea
• Hypotension
• Cyanosis
• Oliguria
• Altered mental status
• jugular veins may be distended
• Pulsus paradoxus in case of tamponade
20. Neurogenic shock
• This is a very uncommon type of shock.
• lt is most often seen in patients who have had
and extensive spinal cord injuries.
• The loss of autonomic and motor reflexes below
level of injury results in loss of sympathetic
control.
• This leads to relaxation of vessels and peripheral
dilation and hypotension.
22. Pathophysiology
Spinal cord injury
Inhibit the sympathetic nerve stimulation
Arterial & venous dilatation
Arterial / venous blood pooling
Hypotenson
Bradycardia, warm dry flushed skin
Decreased perfusion of vital organ
Multisystem organ failure
23. CLINICAL FEATURE
• Hypotension
• Altered mental status
• Bradycardia
• Skin that is warm and dry
• Tachycardia and tachypnea
• Cool and clammy skin
• Priapism due to Peripheral nervous system
stimulation
24. Anaphylactic shock
Anaphylactic shock is caused by severe
reaction to an allergen, antigen, drug or
foreign protein.
When a patient who has already produced
antibodies to a foreign substance develops a
systemic antigen antibody reaction.
Antigen antibody provides mast cells to
release vasoactive substance such as
histamine or bradykinin that cause
vasodilatation
25.
26. PATHOPHYSIOLOGY
• Due to antibody responses
• Release of histamine
• Vasodilatation
• Increased capillary permeability
• Severe broncho constriction
• Decreased oxygen supply and utilization
• Inadequate tissue perfusion.
27. CLINICAL FEATURE
• Skin eruptions and large bumps
• Localized edema, especially around the face
• Laryngeal edema
• Weak and rapid pulse
• Breathlessness and cough
• Tachycardia and tachypnea
• Hypotension
• Cyanosis
• Urticaria and pruritus
• Severe bronchospasm
28. DIAGNOSIS OF SHOCK
• Chest x-rays
• CVP Measurement
• Hemoglobin level measurement
• Arterial Blood Gases (ABG) analysis
• Urinalysis
• Complete blood count
• Blood, urine and sputum culture
• Blood chemistry including kidney function tests
• Cardiac catheterization and Coronary
angiography
• Echocardiogram and Electrocardiogram
• Cardiac enzymes (troponin, CKMB) test
• Computed tomography
30. MANAGEMENT
Management in all types of shock include the
following:
• Management of airway, breathing and
circulation
• Fluid replacement to restore intravascular
volume
• Vasoactive medications to restore vasomotor
tone and improve cardiac function
• Nutritional support to address metabolic
requirement
31. The ABCDE approach
A
B
CD
E
Disability due
to neurological
deterioration
Circulation &
shock
management
Breathing &
ventilation
Airway & oxygenation
Exposure &
examination
32. Airway
• See respiratory pattern
• Head tilt chin lift
• Jaw thrust
• Suction
• Oral airways
• Nasal airways
• Nebulised adrenaline for stridor
• Intubation
• Cricothyroidotomy
– Needle or surgical.
• O2 administer,if airway open
33. Breathing
Consider ventilation
with AMBU bag.
Position upright if
struggling to breath
Specific treatment
i.e.: β agonist for
wheeze, chest
drain for
pneumothorax
34. circulation
• Position supine with legs raised
– Left lateral tilt in pregnancy
• IV access
• Fluid challenge
– colloid or crystalloid?
• ECG Monitoring
• Specific treatment
36. Disability - interventions
• Optimise airway, breathing & circulation
• Treat underlying cause if drug induced
causes.
– i.e.: naloxone for opiate toxicity
• Treat blood glucosei,e hypoglycemia
– 100ml of 10% dextrose (or 20ml of 50%
dextrose)
• Control seizures
• Seek expert help for CVA or ICP
37. Exposure & Examine
• Remove clothes and examine head to toe
front and back.
– Haemorrhage, rashes, swelling, sores,
catheter etc
• Keep warm
• Maintain dignity
45. DEFINITION
• Hemorrhage or bleeding is termed as escape
or loss of blood from the circulatory system.
• It may be internally (from blood vessels) and
externally (through natural opening such as
mouth, anus or vagina). It may be termed as
exsanguination (complete loss of blood) and
desanguination (massive blood loss).
47. TYPES OF HEMORRHAGE
• According to the vessels involved:-
• Arterial hemorrhage:- It is bleeding from
artery, which is bright red in color and sprouts
as a jet, rises and falls in time with the pulse.
• Capillary hemorrhage:- The blood oozes over
the surface or comes out from capillary and is
darkish red in color.
• Venous hemorrhage:- bleeding from vein and
is dark in color.
48. • According to time of wound:-
• Primary hemorrhage:- It is immediate
hemorrhage which occurs when there is damage
to any blood vessels and bleeding occur
immediately e.g. cut on finger.
• Reactionary or intermediate hemorrhage:- It
occurs in first 24 hrs. after operation. E.g.
operation of kidney and thyroid etc.
• Secondary hemorrhage:- It is due to sloughing off
the wall of blood vessel due to bacterial infection
and action of enzyme such as acid pepsin on
peptic ulcer.
49. • Clinical classification of the hemorrhage:-
• Revealed or external hemorrhage:- Bleeding is
seen externally.
• Concealed or internal hemorrhage:- The
bleeding can not be seen externally. E.g. bleeding
in cavities.
50. • According to the American College Of Surgeons’ Advanced
Trauma Life Support (ATLS)
• Class I:- It involves upto 15% of blood volume and vital
signs may not change. It does not require fluid
resuscitation.
• Class II:- It involves 15- 30% of total blood volume and
tachycardia and narrowing of systolic & diastolic BP occur.
The skin may look pale and be cool. It is treated by volume
resuscitation with crystalloid (NS or RL) and does not
require blood transfusion.
• Class III:- It involves 30-40% of circulating blood volume.
The patient’s BP will fall, heart rate increases and
peripheral perfusion such as capillary refill worsen and
mental status worsens. It is treated by fluid resuscitation
with crystalloid and blood transfusion.
• Class IV:- It involves loss of >40% of circulating blood
volume. The limit of body’s compensation is reached and
aggressive resuscitation is required to prevent death.
51. • According to WHO grading of hemorrhage:-
• Grade 0:- No bleeding
• Grade 1:- Petechial bleeding
• Grade 2:- Mild blood loss
• Grade 3:- Gross blood loss requires
transfusion (severe)
• Grade 4:- Debilitating blood loss, retinal or
cerebral fatality
52. CLINICAL MANIFESTATIONS:-
• Early sign & symptoms
• Pain
• Restlessness and anxiety
• Feeling faint
• Coldness (temperature slightly subnormal)
• Slightly increased pulse
• Pallor
• Thirsty
• Difference between systolic and diastolic pressure
53. • Sign & symptoms after severe hemorrhage
• Extreme pallor
• Chilled sensation
• Air hunger or hypoxia rapid thread pulse
• Extreme low blood pressure
• Extreme thirst
• Diminished urine volume
• Disability
• Confused mental status
• Bruising
• Blindness, tinnitus and coma occur prior to death
54. DIAGNOSTIC STUDIES:-
• History collection:-
• Cause and duration of injury
• Sign & symptoms at the time and after bleeding
• Amount of bleeding
• h/o bleeding disorder and taking medications
• quick management of bleeding
• physical examination:-
• vital signs, color of skin, capillary refill, mental
status and skin turgor
• site of bleeding and depth of injury
• Assess sign & symptoms of bleeding.
57. MANAGEMENT
• First aid or immediate measures of external
bleeding:-
• Assess & maintain the victim’s ABCs.
• Rest:- Rest the client in one place because frequent
movement will increase the bleeding.
• Direct pressure:- Apply firm pressure on the wound
to stop the flow of blood.
• Elevation:- Elevate the injured part to stop venous
capillary bleeding above the heart level.
• Dressing:- Once the bleeding is slowed or stopped,
apply firm pressure sterile dressing over the
bleeding site.
58. • First aid for internal bleeding:-
• Lay down the victim with head low and leg raise.
• Reassure and keep him calm.
• Immobilize and ambulant the patient.
• Maintain the body temperature with thin blanket
or coat.
• Do not give anything to eat or drink to prevent
aspiration.
• Assess the victim’s vital signs and condition of
injured site and measure oxygen and cardiac
function.
• Do not apply ice bags or hot water bottles on
bleeding site.
• Take the victim to the hospital as early as
possible.
59. • Fluid replacement:-
• Insert IV cannula to provide blood
replacement.
• Withdrawal blood sample for analysis, typing
and cross- matching.
• Fluid replacement with crystalloid solution (RL
& NS) and blood, depends on chemical
estimation and the severity of blood loss.
• Infuse fresh whole blood, platelets and
coagulation factors
60. • Additional measure:-
• Administer humidified oxygen.
• Monitor ECG and sign of cardiac arrest and
shock.
• Use anti- shock garments
• Non- pneumatic anti-shock garments:- It is a
first aid device used to treat hypovolemic
shock and decrease bleeding from the part.
• Pneumatic anti- shock garments:- It is an
inflatable garments used to combat shock,
stabilize fractures, promote hemostasis and
increase peripheral vascular resistance
61. • MEDICATIONS
• Coagulation:- To coagulate the blood e.g.
vitamin k(phytomenadion), antifibrinolytic
drug( tranexamic acid) and blood products
(factors VIII, IX & fresh frogen plasma).
• Styptics:- To control bleeding and act as
astringent. E.g. adrenaline & thrombin etc.
• Surgical ligation:- It is used for internal
hemorrhage and persistent bleeding.
62. NURSING MANAGEMENT
• Nursing assessment
• Assess the ABCs , vital signs & ECG of the
patient.
• Assess the site of bleeding and duration &
amount of bleeding.
• Assess the sign & symptoms of patient.
• Take history of bleeding disorders and use of
medicine.
• Perform physical examination of the patient.
63. • Nursing diagnosis
• Altered tissue perfusion related to bleeding.
• Risk fo fluid volume deficit related to severe
bleeding.
• Ineffective breathing pattern related to
decrease blood flow.
• Hypothermia related to decrease blood
supply.
• Risk of complications: shock, coma & infection
related to excess bleeding and delayed
treatment.
64. BIBLIOGRAPHY
• Brunner &Suddarth’s, Textbook of Medical- Surgical Nursing, volume-2;
Twelfth edition; New Delhi; Wolters Kluwer pvt. Ltd; 2011; p.p- 2161-
2163.
• BrarNavdeepKaur, Rawat HC, Textbook of Advanced Nursing Practice, First
edition; New Delhi; Jaypee Brothers medical publishers (p) ltd; 2015; p.p-
405-413.
• Basher P. Shebeer and Khan, A concise textbook of Advanced Nursing
Practice, first edition; Bangalore; emeses medical publishers; 2015; p.p-
233-237.
• Clement I, The textbook of first aid and emergency nursing, 6th edition;
New Delhi; Jaypee brothers medical publishers (p) ltd; 2014; p.p- 120,63.
• www.hemorrhage.medline.co.in
• https://en.wikipedia.org/wiki/bleeding
• James H. Approach to the patient in shock,International journal of general
medicine,30 jan 2016;32(4);207-12
