This document discusses the identification and treatment of various types of shock states. It defines hypovolemic, distributive, cardiogenic, and septic shock and their clinical manifestations. Early diagnosis is key, involving history, physical exam assessing vital signs, perfusion, and urinary output. Treatment focuses on establishing airway, supplying oxygen, restoring circulating volume with fluids, and using vasopressors to improve cardiac output as needed based on the type and severity of shock. Children in particular can maintain blood pressure while showing signs of poor peripheral perfusion.

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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

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

17. 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.