SEMINAR ON SHOCK

Introduction:-

shock is life threatening with variety underlying causes. It is characterized by

inadequate tissue perfusion that, if untreated, results in cell death. The progression
of shock is neither linear nor predictable, and shock states, especially septic shock,
compromise a current area of aggressive clinical research. Nurse caring for patient
with shock and for those at risk for shock.

Definition of shock:-

A condition in which tissue perfusion is inadequate to deliver O2 and nutrients to

support vital organs and cellular functions (Hameed, Aired, and Cohan). Adequate
blood flow to the tissues and cells requires the following component adequate
cardiac pump, effective vasculature or circulatory system, and sufficient volume. If
one component is impaired, perfusion to the tissue is threatened or compromised.
Without treatment, inadequate blood flow of tissues result in poor delivery of
oxygen and nutrient to the cells, cellular starvation, cell death, organ dysfunctions
progressing to organ failure and eventual death

CONDITION PRECIPITATING SHOCK

Conventionally, the primary underlying pathophysilogic process and the

underlying disorder are used to classify the shock state. Several definitions of
shock state are found in the literature. In this chapter,the following shock states
will be described;
 Hypovolemic shock: Which occur when there is decrease in the intra
vascular volume.
 Cardiogenic shock: which occurs when the heart has an impaired pumping
ability it may be of coronary or non coronary event origin.
 Septic shock: which caused by infection.
 Neurogenic shock: which is cause by alteration in vascular smooth muscle
tone, caused by either nervous system injury or complications associated
with medication such as epidural anesthesia.
 Anaphylactic shock: which caused by a hypersensitivity reaction.

STAGES OF SHOCK
Compensatory stage
In Stage I of shock, when low blood flow (perfusion) is
first detected, a number of systems are activated in order to maintain/restore
perfusion. The result is that the heart beats faster, the blood vessels throughout
the body become slightly smaller in diameter, and the kidney works to retain
fluid in the circulatory system. All this serves to maximize blood flow to the
most important organs and systems in the body. The patient in this stage of
shock has very few symptoms, and treatment can completely halt any
progression.

Progressive stage
In Stage II of shock, these methods of compensation begin
to fail. The systems of the body are unable to improve perfusion any longer,
and the patient's symptoms reflect that fact. Oxygen deprivation in the brain
causes the patient to become confused and disoriented, while oxygen
deprivation in the heart may cause chest pain. With quick and appropriate
treatment, this stage of shock can be reversed.

Irreversible stage
In Stage III of shock, the length of time that poor perfusion has
existed begins to take a permanent toll on the body's organs and tissues. The
heart's functioning continues to spiral downward, and the kidneys usually shut
down completely. Cells in organs and tissues throughout the body are injured
and dying. The endpoint of Stage III shock is the patient's death.
 SEPTIC SHOCK
Septic shock is a very serious medical condition caused by decreased tissue
perfusion and oxygen delivery as a result of infection and sepsis, though the
microbe may be systemic or localized to a particular site[1]. It can cause
multiple organ failure and death [1]. Its most common victims are children,
immunocompromised individuals, and the elderly, as their immune systems
cannot deal with the infection as effectively as those of healthy adults. The
mortality rate from septic shock is approximately 50% [1].

PATHOPHYSIOLOGY OF SEPTIC SHOCK

PRECIPITATING EVENT

VASODILATION

ACTIVATION OF INFLAMMATORY RESPONSE

MALDISTURBUTION OF BLOOD VOLUME

DECREASED VENOUS RETURN

DECREASED CARDIC OUT PUT

DECREASED TISSUE PERFUSION

 Symptoms:
 Cool, pale extremities
 High or very low temperature, chills
 Lightheadedness
 Low blood pressure, especially when standing
 Low urine output (due to kidney failure)
 Palpitations
 Rapid heart rate
 Restlessness, agitation, lethargy, or confusion
 Shortness of breath

Signs and tests:

Blood tests may be done to check for infection, low blood oxygen level,
disturbances in the body's acid-base balance, or poor organ
function or organ failure.

A chest x-ray may show pneumonia or pulmonary edema.

MEDICAL MANAGEMENT:
Septic shock is a medical emergency. Patients are usually admitted to the
intensive care unit of the hospital.

Treatment may include:

 Drugs to treat low blood pressure, infection, or blood clotting

 Fluids by a vein (intravenously)
 Oxygen
 Surgery
 Support for any poorly functioning organs

There are new drugs that act against the hyperinflammatory response seen in
septic shock. These may help limit the damage to vital organs.
Antibiotics and doses recommended in SEPTIC SHOCK patients

Drug Dosage Route Freq Gram Spectrum

Ampicillin 20-40 mg/kg IV TID G+, G-, some anaerobes

Penicillin G, 20,000- 100,000 IV, IV, SC TID G+, G-, anaerobes

Aqueous U/kg

Cefazolin1 20 mg/kg IV TID G+, some G-, some anaerobes

Cephalothin1 20-30 mg/kg IV QID G+, some G-, some anaerobes

Cefotaxime3 20-80 mg/kg IV, IM TID G+, some G-, some anaerobes

Cefoxitin2 20 mg/kg IV TID some G+, some G-, some

anaerobes

Trimethoprim- 15 mg/kg IV, IM BID some G+, G-, some anaerobes

sulfa

Enrofloxacin 5-10 mg/kg IV SID some G+, G-

5-20 mg/kg IV

Ciprofloxacin 5-15 mg/kg PO SID some G+, G-

10-20 mg/kg PO

Amikacin 10-15 mg/kg IV SID few G+, good G-

Gentamicin 6-9 mg/kg IV, IM, SID few G+, good G-

SC BID

Tobramycin 2-4 mg/kg IV TID few G+, good G-

Clindamycin 10-12 mg/kg IV BID some G+, few G-, anaerobes

Metronidazole 10 mg/kg IV as CRI TID

Hemodynamic monitoring -- the evaluation of the pressures in the heart and

lungs -- may be required. This can only be done with specialized equipment
and intensive care nursing.

Expectations (prognosis):
Septic shock has a high death rate. The death rate depends on the cause of
the infection, how many organs have failed, and how quickly and
aggressively medical therapy is started.

Complications:
Respiratory failure

cardiac failure

any other organ failure can occur.

 HYPOVOLEMIC SHOCK

Definition of Hypovolemic shock:

Hypovolemic shock is an emergency condition in which severe blood and

fluid loss makes the heart unable to pump enough blood to the body. This
type of shock can cause many organs to stop working.

Causes, incidence, and risk factors:

Losing about 1/5 or more of the normal amount of blood in your body
causes hypovolemic shock.

Blood loss can be due to bleeding from cuts or other injury or internal
bleeding such as gastrointestinal tract bleeding. The amount of blood in your
body may drop when you lose too many other body fluids, which can
happen with diarrhea, vomiting, burns, and other conditions.

The greater and more rapid the blood loss, the more severe the shock
symptoms.
Path physiology of hypovolemic shock:

Decreased blood volume

Decreased venous return

Decreased stoke volume

Decreased cardiac output

Decreased tissue perfusion

Symptoms:

Rapid pulse

Pulse may be weak (thready)

Rapid breathing

Anxiety or agitation

Cool, clammy skin

Weakness

Pale skin color (pallor)

Sweating, moist skin

Decreased or no urine output

Low blood pressure

Confusion

Unconsciousness

Signs and tests:

An examination indicates the presence of shock. There is usually low blood

pressure, rapid pulse, and low body temperature.

Tests that may be done include:

CBC

CT scan or an x-ray of suspected areas

Endoscopy

Echocardiogram (heart ultrasound)

Right heart (Swan-Ganz) catheterization -- can help tell the difference

between hypovolemic and another type of shock called cardiogenic shock

MEDICAL MANAGEMENT:
 Obtain professional medical care immediately! Limited measures to
help include:

Keep the victim comfortable and warm (to avoid hypothermia).

Have the victim lie flat with the feet elevated about 12 inches to increase
circulation. However, if the victim suffers from a head, neck, back, or leg
injury, leave the victim in the position in which they were found unless
doing so poses other immediate danger.

Do not give fluids by mouth.

If victim is stung or suffering an allergic reaction, treat the allergic reaction.

If the victim must be carried, try to maintain the flat, head down, feet
elevated position. Stabilize the head and neck before moving a victim with a
suspected spinal injury.

Hospital treatment focuses on replacing blood and fluid volume. Treatment

may also include determination of the cause of blood loss and control of bleeding
to prevent recurrence of hypovolemic shock.

fluids, which may include blood or blood products, are used to

Intravenous
maintain volume in the circulatory system.

Dopamine,
dobutamine, epinephrine, norepinephrine, and other medications may be
required to increase blood pressure and cardiac output.

Other interventions that may be used to manage shock include:

cardiac monitoring, including Swan-Ganz (used to guide treatment)

placement of a urinary catheter to monitor urine output Expectations

(prognosis):

Hypovolemic shock is always a medical emergency, but there is wide

variation in both symptoms and outcomes depending upon the amount of
blood volume lost, the rate of loss, the underlying illness or injury causing
the loss, and other factors.
In general, patients with milder degrees of shock tend to do better than those
with more severe shock. However, in cases of severe hypovolemic shock,
death is possible even with immediate medical attention. The elderly are at
increased risk of having poor outcomes from shock.

Complications:

>Kidney damage

>Brain damage

Prevention:

Preventing shock is easier than trying to treat it once it happens. Prompt

treatment of the underlying cause will reduce the risk of developing severe
shock. Early first aid can help control shock.

CARDIOGENIC SHOCK
.Cardiogenic shock is based upon an inadequate circulation of blood due to
primary failure of the ventricles of the heart to function effectively.[1]
[2] [3] [4] [5]

Since this is a category of shock there is insufficient perfusion of tissue (i.e.

the heart) to meet the required demand for oxygen and nutrients. This
leads to cell death from oxygen starvation, hypoxia. Because of this it
may lead to cardiac arrest (or circulatory arrest) which is an acute
cessation of cardiac pump function.[4]

Cardiogenic shock is defined by sustained hypotension with tissue

hypoperfusion despite adequate left ventricular filling pressure. Signs
of tissue hypoperfusion include oliguria (<30 mL/h), cool extremities,
and altered mentation

Etiology
Cardiogenic shock is caused by the failure of the heart to pump effectively. It
can be due to damage to the heart muscle, most often from a large
myocardial infarction. Other causes include arrhythmia,
cardiomyopathy, cardiac valve problems, ventricular outflow
obstruction (i.e. aortic valve stenosis, aortic dissection, systolic
anterior motion (SAM) in hypertrophic cardiomyopathy),
ventriculoseptal defects or medical error.

Pahophysiology of cardiogenic shock

Decreased cardiac
contractility

Decreased stroke
volume & cardiac out
put

Pulmonary congestion Decreased systematic Decreased coronary

tissue perfusion artery perfusion

Signs and symptoms

Anxiety, restlessness, altered mental state due to decreased cerebral

perfusion and subsequent hypoxia.

Hypotension due to decrease in cardiac output.

A rapid, weak, thready pulse due to decreased circulation combined with

tachycardia.

Cool, clammy, and mottled skin (cutis marmorata), due to vasoconstriction

and subsequent hypoperfusion of the skin.
Distended jugular veins due to increased jugular venous pressure.

Oliguria (low urine output) due to insufficient renal perfusion if condition

persists.

Rapid and deep respirations (hyperventilation) due to sympathetic nervous

system stimulation and acidosis.

Fatigue due to hyperventilation and hypoxia.

Absent pulse in tachyarrhythmia.

Pulmonary edema, involving fluid back-up in the lungs due to insufficient

pumping of the heart.

Diagnosis evalution

Electrocardiogram

An electrocardiogram helps establishing the exact diagnosis and guides

treatment, it may reveal:

Cardiac arrhythmias

Signs of cardiomyopathy

Radiology

Echocardiography may show poor ventricular function, signs of PED,

ventricular septal rupture (VSR), an obstructed outflow tract or
cardiomyopathy.

Swan-ganz catheter

The Swan-ganz catheter or Pulmonary artery catheter may assist in the

diagnosis by providing information on the hemodynamics.

Biopsy
In case of suspected cardiomyopathy a biopsy of heart muscle may be
needed to make a definite diagnosis.

Medical management:

In cardiogenic shock: depending on the type of myocardal infarction one can

infuse fluids or in shock refractory to infusing fluids inotropica. In
case of cardiac arrhythmia several anti-arrhythmic agents may be
administered, i.e. adenosine, verapamil, amiodarone, β-blocker.
Positive inotropic agents, which enhance the heart's pumping
capabilities, are used to improve the contractility and correct the
hypotension. Should that not suffice an intra-aortic balloon pump
(which reduces workload for the heart, and improves perfusion of the
coronary arteries) can be considered or a left ventricular assist device
(which augments the pump-function of the heart). [1] [2] [3]

Cardiogenic shock may be treated with intravenous dobutamine, which acts

on β1 receptors of the heart which causes increased power and heart
rate. [8]

NEUROGENIC SHOCK
Neurogenic shock, sometimes called vasogenic shock, results from the
disruption of autonomic nervous system control over vasoconstriction.
Under normal conditions, the autonomic nervous system keeps the muscles
of the veins and arteries partially contracted. At the onset of most forms of
shock, further constriction is signaled. However, the vascular muscles cannot
maintain this contraction indefinitely. A number of factors, including
increased fluid loss, central nervous system trauma, or emotional shock, can
override the autonomic nervous system control. The veins and arteries
immediately dilate, drastically expanding the volume of the circulatory
system, with a corresponding reduction of blood pressure.

Simple fainting (syncope) is a variation of neurogenic shock. It often is the

result of a temporary gravitational pooling of the blood as a person stands
up. As the person falls, blood again rushes to the head, and the problem is
solved. Neurogenic shock may also be induced by fear or horror, which will
override the autonomic nervous system control.

Etiology:
Spinal cord injury, spinal anesthesia, depressant action of medication and
lack of glucose.

Sign/symptoms;

>dry warm skin

>eye dull or lackluster pupils dilated

>shallow, labored breathing

>nausea,vomit thurst.

>syncope, fainting

>Pulse weak,rapid

>skin pale to brush.

Medical management:

 Restoreing symathatic tone through stabilization of spinal cord injury

if injured
 If due to hypoglycemia glucose is rapidly administered

 specific treatment depends on cause of shock.

ANAPHYLACTIC SHOCK:
Anaphylactic shock occurs rapidly and is life threatening. Because
anaphylactic shock occurs in patient already exposed to antigen and who
developed antibodies to it, can often prevented. Patient with known allergies
should understand the consequences of subsequent exposure to the antigen
and should wear medical identification that lists their sensitivities.

Causes and pathophysiology:

It is caused by a severe allergic reaction when patients who have already

produced antibodies to foreign substances(antigen) develop a systematic
antigen antibody reaction. Antigen antibody reaction provokes mast cells to
release potent vocative substances, such as histamine or bradykinin, causing
widespread vasodilatation and capillary permeability.

Medical management :

o Required removing the causative antigen (Discontinuous an antibiotic

agent)
o Administered medication that restore vascular tone & providing
emergency support of basic life function

o Epinephrine is given for vasocontrictive action

o Benadryl is administered to reverse the effect of histamine

o Nebulize medication such as albutrol

o Patent I/V line

 NURSING MANAGMENT OF SHOCK
Respiratory

•Dyspnoea.

•Hypoxia.

•Oxygen administration –

–Facemask.

–CPAP.

–Ventilator.

•Blood gas analysis.

Cardiovascular

•Rhythm –tachycardia.

•Blood pressure.
•Fluid management.

•Temperature.

•Clotting studies.

•Electrolytes.

Neurological

•Altered level of consciousness.

•Uraemic seizures.

•Confusion / disorientation.

Pain and Sedation

•Pain from ischaemic myocardium.

•Pain from ischaemic tissues.

•Pain from insertion of monitoring lines.

•Level of consciousness.

•Administration of sedation if ventilated.

Nutrition and Hydration

•Strict fluid balance monitoring.

•Variable blood sugar.

•Paralytic ileus.

•Increased nutritional requirements.

 Elimination

•Oliguria / anuria.

•Bowels.

•Inability of cells to rid themselves of toxins –acidic blood.

Mobility, Hygiene and Wounds

•Reduced mobility –reduced skin integrity.

•Assistance with maintaining hygiene needs.

•Surgical wounds / line sites.

Psychological

•Fear of dying.

•Explanations of treatments to patient.

•Support of patient/Support of family / significant others.

SUMMARY

TODAY WE HAVE SEEN THE SEMINAR UNDER THE

FOLLOWING HEADS:

- DEFINATION OFF SHOCK & ITS SIGNIFICANCE

- STAGES OF SHOCK

COMPANSATORY STAGE (STAGE 1ST)

PROGRESSIVE STAGE (STAGE 2ND)

IRREVERSIBLE STAGE (STAGE 3RD)

CLASSIFICATION OF SHOCK
 ETIOLOGY OF VARIOUS TYPE OF SHOCK

PATHOPHOSIOLOGY OF VARIOUS TYPE OF SHOCK

SIGN & SYMTOMS OF VARIOUS TYPE OF SHOCK

MEDICAL & NURSING MANAGEMENT OF VARIOUS TYPE OF

SHOCK

COMPLICATION & PREVENTION OF VARIOUS TYPE OF

SHOCK

CONCLUSION:

The seminar on SHOCK has given knowledge about SHOCK and its occur.
By this seminar we all will be able to provide proper nursing care to the
client having SHOCK & prevention of SHOCK.
DR. DY PATIL COLLEGE OF NURSING PUNE 18

SEMINAR ON SHOCK