Identification of Shock States

Here's how to understand SHOCK and the different types of manifestations and pathophysiology for each problem.
  1. 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
  2. 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
  3. 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
  4. 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>2000 1500-2000 750-1500 <750ml>40 30-40 15-30 <15%>
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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
  15. Identification of Shock
    • Type and degree of shock?
    • Initial intervention?
    • What signs of improvement will you see with treatment?
  16. 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.

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