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What is the benefit of hemodynamics monitoring?
- provides quantitative information about:
- vascular capacity
- blood volume
- pump effectiveness
- tissue perfusion
What is the ultimate problem with hypoperfusion?
decreased blood flow to body tissues resulting in cellular and eventually organ failure.
Definition of shock
- a syndrome characterized by:
- decreased tissue perfusion and impaired cellular metabolism
4 categories of shock
3 ways to get cardiogenic shock
- systolic dysfunction causing the heart to be unable to pump blood forward
- structural problems
2 ways to get hypovolemic shock
absolute or relative
Describe absolute hypovolemic shock
external loss of whole blood from hemorrhage
loss of other body fluids from vomitting, diarrhea, excessive diuresis, diabetes insipidus and mellitus
Describe relative hypovolemic shock
- pooling of blood or fluids-bowel obstruction
- fluid shifts from burns or ascites
- internal bleeding from a fx of long bone, or hemothorax or ruptured spleen
- massive vasodilation from sepsis
Name 3 types of distributive shock
What is distributive neurogenic shock?
a hemodynamic consequence of spinal cord injury and or disease at or above T5.
OR from spinal anesthesia or vasomotor center depression from severe pain, drugs hypoglycemia or injury
What is anaphylactic distributive shock?
- allergic reaction to a sensitizing substance like:
- contrast media, blood, drugs, insect bites, food, anesthetic agents, vaccines, environmental agents, latex
What is septic distributive shock?
shock as a result of infection...pna, peritonitis, UTI, respiratory tract infection, invasive procedure, indwelling lines and catheters
What is obstructive shock?
When something impedes the filling or outflow of blood, resulting in reduced cardiac output.
Give examples of illnesses that cause obstructive shock
- cardiac tamponade
- tension pneumothorax
- compartment syndrome
- pulmonary embolism
4 stages of shock
What happens during the initial stage of shock
- MAP decreases 5-10mmHg from baseline
- Increase in sympathetic stimulation
- Mild vasoconstriction
- Increased heart rate
VERY SUBTLE CHANGES
Describe the compensatory stage of shock
- MAP decreases 10-15mmHg
- Cont. sympathetic stimulation
- Moderate vasoconstriction
- Increased HR
- Increased Pulse Pressure
- Chemical Compensation
During the compensatory stage of shock what:
hormones are released?
what's the metabolism?
what's the lab changes?
- Renin, Aldosterone and ADH
- Anaerobic metabolism
- Mild acidosis and hyperkalemia
Describe the Progressive stage of shock
- MAP >20mmHg from baseline
- oxygen demand exceeds supply....leading to MODS
Describe what you will see when a person is in the progressive stage of shock
- Increased lactic acid
- Increased glucose
- HR >150bpm
- Urine less than 20
- Elevated Bun/Creat
- Hypoventilation-respiratory acidosis
- LOC severely depressed
- Absent bowel sounds
What happens when the liver fails to metabolize drugs and waste
- elevated liver enzymes
- loss of immune function
- Risk for DIC
- Significant bleeding
What is SIRS?
Systemic Inflammatory Response syndrome
it is a widespread inflammatory response to a variety of severe clinical injuries
SIRS is clinically indicated by the presence of 2 or more of the following:
- temperature >38 or above <36
- HR >90/min
- PaCO2 <32
- WBC >12 or <4 or with >10% bands
What is sepsis
the person has the clinical signs of SIRS but with the addition of a definitive infection
What is Severe sepsis?
- when you have SIRS and an infection that is accompanied by:
- Organ dysfunction
What are the s/s of hypoperfusion?
- lactic acidosis
- acute change in LOC
Describe septic shock
sepsis with hypotension despite adequate fluid replacement combined with perfusion abnormalities
Another sign that a person has septic shock
- despite fluid replacement they are also requiring:
- inotropic or vasopressor support
How do you provide fluid resuscitation for a person in shock?
- IV fluids of 2-3L of crystalloids, and blood admin
- CVP initiated
If the patient has persistent hypotension after fluid resuscitation and has a normal CVP (8-12), what is the next line of treatment?
vasopressors -levophed, inotropin, dobutamine
What is the goal of drug therapy when a person is in shock?
to get/maintain a MAP of >65mmHg to correct decreased tissue perfusion
2 ways for a patient to get drugs in to a patient with shock
central line or IV
Vasodilator drugs given for cardiogenic shock
nitroglycerin and nitroprudsside
Describe how the person in shock will get enteral nutrition
slow continuous drip at 10mL/hr
What is the benefit of enteral nutrition for a person in shock?
it enhances the GI tract and helps maintain the integrity of the gut mucosa
Use it or lose it, and dont want that
S/S of MODS.....GU and LABS
- <0.5ml/kg or less than 30mL x 2 HOURS!!
- Creatnine increase >0.5mg/dl baseline
- INR >1.5
- Lactate >2
- Billi >4
- Platelets <100,000
What do you assess on a person in shock?
- focused assessment of tissue perfusion
- Peripheral pulses
- Cap Refill
Goals for treating a person with shock
- Adequate tissue perfusion
- Restore BP
- Return/Recover of organ function
- Avoidance of complications from prolonged hypoperfusion
BP and different stages of shock
- progressive-SBP<80-90 and MAP<65
- refractory-profound hypotension
HR at different stages of shock
- progressive- >150, irregular
- refractory-severe tachy and dsyrhythmias
Peripheral pulses and shock
- compensatory-rapid, weak, thready
- progressive-extremely weak, thready, absent?
- refractory-may be absent
Urine output and different stages of shock
RR and different stages of shock
- compensatory->20 and TV
- progressive-rapid, shallow, crackles
- refractory-ventilator dependent w/ high FiO2
Bowel sounds and different stages of shock
- compensatory-hypoactive w/mild distention
- progressive-absent, ileus
Pupils and different stages of shock
- compensatory-dilated 6-8mm w/light rxn
- progressive-dilated w/ sluggish-absent light rxn
- refractory-dilated and unresponsive to light
Labs and different stages of shock
- compensatory-mild met. alk, hyperkalemia
- progressive-severe met. alk, hyperk, hypoxemia, inc. BUN, CRT, AST, ALT
- refractory-respiratory acidosis, hyperk, MODS, DIC
The key to recognizing organ dysfunction is by
clinical presentation and lab analysis
3 hour bundle
- measure lactate level (>4)
- obtain blood cultures prior to antibiotics
- administer broad spectrum antibiotics
- administer 30mL/kg crystalloid for hypotension or a lactate >4
Name crystalloid IV fluids
6 Hour Bundle
- Admin. Vasopressors to get MAP >65
- Monitor CVP w/ goal of 8-12
- Monitor SVO2 w/ goal of 70%
- Remeasure lactate if initial lactate was elevated
When doing the 6 hour bundle what will be an indicator that the bundle is working?
remeasure the lactate level, and if the level has dropped, then they are getting good organ perfusion
When performing the 6 hour bundle, what lab test will tell if an antibiotic is working?
What will I infuse for persons with the different amounts of blood loss....
- mild and moderate -LR, NS or Albumin
- severe-NS and blood
- profound-NS and blood
Example of colloid IV infusion
When a person has lost a lot of blood how much is transfused back?
1cc for each cc lost
For a person who has lost a lot of blood how much is transfused back with crystalloids?
3cc for each 1cc of blood lost
For a person who has lost a lot of blood, how much is transfused back with colloids?
1cc for each 1 cc of blood lost