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.