Whats is Shock Is Types and Nursing Management
Sepsis And Septic Shock
Septic shock is a systemic response to a serious infection.
The septic shock can cause death or dysfunction of one or more organs. The mortality rate from
septic shock remains high despite advances in treatment.
Definition
The criteria falls under Systemic Inflammatory Response Syndrome (SIRS) when:
Any 2
of the following:
Tachypnea > 20/minute or
PaCO3 < 32 mm Hg on arterial blood gas (ABG)
White blood cell
count (WCC) < 4,000 or > 12,000
Heart rate > 90 bpm Temperature >38 or <36.
Septicemia:
SIRS due to a suspected or proven infectious source, such as
a positive blood culture, CXR, or other findings.
Severe Sepsis:
Signs of end organ dysfunction such as kidney damage, liver
dysfunction, mental changes, increased lactate, coagulation disorders, etc.
Septic Shock:
Refractory hypotension even after adequate fluid intake.
Presentation
Patients will present with hypotension and target organ hypoperfusion. In addition to the systemic features mentioned above, organ damage is manifested by altered mental status, respiratory and cardiovascular instability, liver disorders, acute kidney injury, and impaired coagulation. Lactate levels are increased due to tissue perfusion problems and are used in targeted therapy. Initially warm peripheries due to vasodilation.
This will
present initially with reduced peripheral resistance, increased cardiac index,
tachycardia, and hypotension; but later it can be affected by heart failure.
Sepsis and septic shock are a systemic response to a serious infection. This
can lead to multiple organ dysfunction and death. The mortality rate from
septic shock remains high despite advances in treatment.
Differential Diagnosis
Other types of shock such as hypovolemic, cardiogenic,
obstructive and anaphylactic shock.
Management
Once severe sepsis or septic shock is identified, time is of the essence. Treatment should begin according to the guidelines for survivors of sepsis. Prompt evaluation and initiation of treatment is essential. Blood cultures should be collected along with cultures from suspected sources, and broad-spectrum antibiotics should be started based on local guidelines and suspected organisms. Fluids should be given to correct hypovolemia.
Urine
output should be measured regularly and responsiveness to fluids should be
measured. Lactate levels can be used for targeted therapy. Monitoring of
central venous pressure for fluid requirements and initiation of vasoactive
therapy may be necessary. If hypotension persists, norepinephrine is the drug
of choice. If respiratory failure occurs, ventilatory support may be required.
Vasopressin may be required in resistant cases and renal replacement therapy in
renal failure and acidosis.
Surviving Sepsis Campaign Packs
Ready In 3 Hours:
1. Measure the lactate value
2. Collect blood cultures before administering antibiotics
3. Administer broad spectrum antibiotics
4. Administer 30
mL/kg crystalloids for hypotension or 24 mmol/L lactate.
Ready in 6 hours:
5. Use of vasopressors (for hypotension unresponsive to
initial fluid administration) to maintain a mean arterial pressure (MAP) of 265
mm Hg
6. For persistent
arterial hypotension despite volume replacement (septic shock) or initial
lactate 24 mmol/L (36 mg/dL):
-Measure central venous pressure (CVP)* Measure central
venous oxygen saturation (Scvo2)3
7. Measure lactate again if baseline lactate was elevated.
The targets for quantitative resuscitation included in the guidelines are PVC
of 28 mm Hg: Scvo2 of 270% and lactate normalization.
Cardiogenic Shock
Cardiogenic shock is insufficient tissue perfusion resulting
from a primary heart problem due to myocardial or valvular dysfunction. It
presents with hypotension, cool peripheries, dilated jugular veins, oliguria,
altered mental status, and respiratory failure due to pulmonary edema. The
central venous pressure can be increased with high systemic vascular resistance
and a reduced cardiac index.
Causes
Heart attack
left ventricular failure
cardiomyopathy
heart valve abnormalities trauma.
This must be distinguished from other forms of shock.
Management
Identify and attempt to treat the cause if possible. For myocardial infarction, reperfusion therapy should be initiated as soon as possible. Depending on the volume status and in the case of a right ventricular infarction, patients may require fluids. The pulmonary artery flotation catheter can help guide fluid therapy. Dobutamine can be used for its indicator effect, as can phosphodiesterase inhibitors such as milrinone/enoximon and levosimendan.
Dopamine and norepinephrine can be used with caution in resistant
hypotension. Vasodilators are preferred when blood pressure is more stable.
Diuretics are used for pulmonary edema along with non-invasive ventilation to
relieve strain on the heart. In refractory cases, intra-aortic balloon counterpulsation
and rescue PCI/CABG are used. Patients with recoverable ventricular failure or
patients awaiting transplantation may receive left or right ventricular assist
devices (LVAD/RVAD) and extracorporeal membrane oxygenators (ECMO).
Hypovolemic Shock
Hypovolemia is the result of decreased circulating blood
volume leading to target organ dysfunction or damage. This is also associated
with salt depletion, thus differing from dehydration, which is a predominant
loss of free water. It presents with hypotension, cold periphery, collapsed
veins, impaired capillary refill time, and organ dysfunction such as acute
kidney injury with oliguria, tachycardia, tachypnea, and altered mental status.
Causes
trauma and bleeding diarrhea and vomiting
bad burns
Surgical blood loss.
heatstroke
Fast.
This must be distinguished from other causes of shock.
Management
Prompt detection is essential for treatment of this
condition. If fluid treatment is started early, any abnormalities can be
corrected early. Assess airway and breathing, followed by fluid estimation and
recovery. Blood and colloids are used judiciously based on blood loss and
volume status. Vital signs are checked regularly for response and adequacy of
resuscitation. Surgical advice should be obtained early to locate and control
the source of bleeding.
Obstructive Shock
Extracardiac obstruction of blood flow can lead to obstructive shock, in which effective circulatory flow is restricted. It can present as cardiogenic shock with hypotension, tachycardia, cold peripheries, dilated jugular veins, pulsus paradoxus, reduced heart sounds, kidney damage, and altered mentality. The ECG may show tachycardia and reduced amplitude.
Causes
Impaired diastolic filling (reduced preload) Direct venous
obstruction (vena cava obstruction) due to intrathoracic tumors
Increased intra-thoracic pressure
tension pneumothorax
Positive pressure mechanical ventilation asthma
Decreased cardiac compliance
cardiac
tamponade constrictive pericarditis
Impaired systolic contraction (increased afterload)
Right ventricle
pulmonary embolism,
acute
pulmonary hypertension
Left ventricle
saddle
embolism
Aortic dissection (rare).
Diagnosis begins with suspicion of the disease. CXR can
diagnose pneumothorax and pulmonary embolism in some cases. The echocardiogram
will diagnose tamponade and distention of the right heart in pulmonary
embolism. The tamponade may be due to infection (tuberculosis), uremia, trauma,
malignancy, or an idiopathic cause. This must be distinguished from
constrictive pericarditis, restrictive cardiomyopathy, left ventricular
failure, and right ventricular failure.
Management
Once the problem is diagnosed, appropriate treatment should be instituted. Liquids should be used with caution. Many of the conditions are life-threatening if not treated promptly. In the case of tension pneumothorax, a needle thoracotomy followed by insertion of an intercostal drain can immediately improve hemodynamics. PE can be treated with thrombolysis and cardiac tamponade as described above. In appropriate cases, surgical advice should be obtained as soon as possible.
Neurogenic Shock
Neurogenic shock is a type of distributive shock that causes
hypotension along with bradycardia. This is due to a failure of the autonomic
system as a result of a spinal cord injury. This leads to a reduction in
sympathetic tone in the blood vessels with accumulation of blood in the
periphery. If the injury is above T6, loss of thoracic sympathetic tone results
in bradycardia with hypotension; whereas when lower, unimpeded sympathetic tone
causes and increases contractility. The extremities are hot above the level of
injury and cold below the level of injury. Hypotension is severe and
occasionally treatment-resistant. This must be differentiated from other causes
of shock.
Causes
Brain Damage
Injury to the cervical or upper thoracic spine.
Management
The site of the injury should be examined. Fluids are the initial treatment for such spinal shock. Fluid resuscitation may be followed in selected cases by vasopressor support with norepinephrine or dopamine. Vasopressin can also be used in resistant cases. If bradycardia persists, atropine can also be used. Ventilation support may be required if the injury is higher and spinal stabilization is required in such cases.
Anaphylactic shock
An anaphylactic reaction is an IgE-mediated allergic reaction that can result in shock and death if not recognized and treated promptly. Symptoms commonly include a rash, swelling of the throat, wheezing, and hypotension. It appears between 5 and 30 minutes after exposure, although this can last for several hours. This leads to the sudden release of immune mediators from mast cells and basophils.
This causes a general condition of the
system leading to skin rashes, angioedema, bronchospasm, tachycardia,
hypotension, arrhythmia, convulsions, diarrhea, seizures and coma. This can be
caused by foods such as peanuts and fish, medications, toxins, latex, aspirin,
X-ray contrast media, and antibiotics, among others. If the following symptoms
appear within minutes of exposure to an allergen, there is a high likelihood of
anaphylaxis: Skin or mucosal surface involvement
Difficulty Breathing
Cardiovascular Collapse
Gastrointestinal Symptoms.
This must be differentiated from cardiogenic shock, sepsis,
poisoning and epilepsy.
Types
Anaphylactic shock: Occurs within minutes of exposure to the allergen.
Delayed Anaphylaxis: Occurs up to days after initial exposure. It has
the same mechanism and is treated in the same way?
Anaphylactoid reactions: occur due to mast cell
degranulation and do not involve the allergy pathway.
Management
`Assess and manage airway and breathing. In severe cases,
intubation and ventilation may be required. Intravenous fluids are required for
volume expansion. In suspected cases, epinephrine should be given in doses of
0.3-0.5 mg IM as soon as possible. or 0.1 mg IV in repeated doses titrated for
effect. Histamine antagonists are used in conjunction with them to block HI and
H2 receptors (often chlorpheniramine and ranitidine). Steroids are also used
for delayed reactions. The use of vasopressors may be necessary. Tryptase
levels can be sent to diagnose mast cell degranulation. Detected early and
treated properly, it has a very good prognosis.
Give your opinion if have any.