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What is the benefit of hemodynamics monitoring?
- provides quantitative information about:
- vascular capacity
- blood volume
- pump effectiveness
- tissue perfusion
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What is the ultimate problem with hypoperfusion?
decreased blood flow to body tissues resulting in cellular and eventually organ failure.
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Definition of shock
- a syndrome characterized by:
- decreased tissue perfusion and impaired cellular metabolism
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4 categories of shock
- cardiogenic
- distributive
- hypovolemic
- obstructive
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3 ways to get cardiogenic shock
- systolic dysfunction causing the heart to be unable to pump blood forward
- dysrhythmias
- structural problems
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2 ways to get hypovolemic shock
absolute or relative
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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
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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
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Name 3 types of distributive shock
- neurogenic
- anaphylactic
- septic
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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
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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
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What is septic distributive shock?
shock as a result of infection...pna, peritonitis, UTI, respiratory tract infection, invasive procedure, indwelling lines and catheters
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What is obstructive shock?
When something impedes the filling or outflow of blood, resulting in reduced cardiac output.
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Give examples of illnesses that cause obstructive shock
- cardiac tamponade
- tension pneumothorax
- compartment syndrome
- pulmonary embolism
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4 stages of shock
- initial
- compensatory
- progressive
- refractory
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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
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Describe the compensatory stage of shock
- MAP decreases 10-15mmHg
- Cont. sympathetic stimulation
- Moderate vasoconstriction
- Increased HR
- Increased Pulse Pressure
- Chemical Compensation
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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
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Describe the Progressive stage of shock
- MAP >20mmHg from baseline
- oxygen demand exceeds supply....leading to MODS
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Describe what you will see when a person is in the progressive stage of shock
- Increased lactic acid
- Increased glucose
- BP<80-90
- HR >150bpm
- Urine less than 20
- Elevated Bun/Creat
- Hypoventilation-respiratory acidosis
- LOC severely depressed
- Absent bowel sounds
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What happens when the liver fails to metabolize drugs and waste
- jaundice
- elevated liver enzymes
- loss of immune function
- Risk for DIC
- Significant bleeding
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What is SIRS?
Systemic Inflammatory Response syndrome
it is a widespread inflammatory response to a variety of severe clinical injuries
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SIRS is clinically indicated by the presence of 2 or more of the following:
- temperature >38 or above <36
- HR >90/min
- RR>20
- PaCO2 <32
- WBC >12 or <4 or with >10% bands
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What is sepsis
the person has the clinical signs of SIRS but with the addition of a definitive infection
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What is Severe sepsis?
- when you have SIRS and an infection that is accompanied by:
- Organ dysfunction
- Hypoperfusion
- Hypotension
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What are the s/s of hypoperfusion?
- lactic acidosis
- oliguria
- acute change in LOC
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Describe septic shock
sepsis with hypotension despite adequate fluid replacement combined with perfusion abnormalities
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Another sign that a person has septic shock
- despite fluid replacement they are also requiring:
- inotropic or vasopressor support
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How do you provide fluid resuscitation for a person in shock?
- IV fluids of 2-3L of crystalloids, and blood admin
- CVP initiated
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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
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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
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2 ways for a patient to get drugs in to a patient with shock
central line or IV
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Vasodilator drugs given for cardiogenic shock
nitroglycerin and nitroprudsside
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Describe how the person in shock will get enteral nutrition
slow continuous drip at 10mL/hr
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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
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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
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What do you assess on a person in shock?
- ABC's!!!
- focused assessment of tissue perfusion
- VS
- Peripheral pulses
- LOC
- Cap Refill
- Skin
- UO
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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
- compensatory-ok
- progressive-SBP<80-90 and MAP<65
- refractory-profound hypotension
-
HR at different stages of shock
- compensatory-101-150
- progressive- >150, irregular
- refractory-severe tachy and dsyrhythmias
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Peripheral pulses and shock
- compensatory-rapid, weak, thready
- progressive-extremely weak, thready, absent?
- refractory-may be absent
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Urine output and different stages of shock
- compensatory-<30mL/hr
- progressive-<20mL/hr
- refractory-anuria
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RR and different stages of shock
- compensatory->20 and TV
- progressive-rapid, shallow, crackles
- refractory-ventilator dependent w/ high FiO2
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Bowel sounds and different stages of shock
- compensatory-hypoactive w/mild distention
- progressive-absent, ileus
- refractory-absent
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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
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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
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The key to recognizing organ dysfunction is by
clinical presentation and lab analysis
-
3 hour bundle
- OMI
- 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
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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
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When performing the 6 hour bundle, what lab test will tell if an antibiotic is working?
procalcitonin
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EBL-
mild
moderate
severe
profound
- mild-750mL
- moderate-1000mL
- severe-1500mL
- profound-2000mL
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What will I infuse for persons with the different amounts of blood loss....
mild
moderate
severe
profound
- mild and moderate -LR, NS or Albumin
- severe-NS and blood
- profound-NS and blood
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Example of colloid IV infusion
ALBUMIN
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When a person has lost a lot of blood how much is transfused back?
1cc for each cc lost
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For a person who has lost a lot of blood how much is transfused back with crystalloids?
3cc for each 1cc of blood lost
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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
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