Cardiogenic and Septic Shock

By Dominic Wilson-Ing

Student Objectives

• Recapitulate on shock.• Identify the causes of cardiogenic shock.• Describe how a patient in cardiogenic shock

presents.• Describe the basic pathophysiology of

cardiogenic shock.

Objectives Continued

• Identify monitoring that is used for patients in cardiogenic shock.

• List the medical treatments used for cardiogenic shock.

• Using the Mead Model, draw up a nursing care plan for a patient in cardiogenic shock.

Objectives Continued

• Identify the causes of septic shock.• Describe how a patient in septic shock

presents.• Describe the basic pathophysiology of septic

shock.• List the medical treatments of a patient in

septic shock.• Using the mead model, draw up a care plan

for a patient in septic shock.

Objectives Continued

• Describe the differences between cardiogenic and septic shock.

Recapitulation of Shock

Shock – What Is It?

• Shock is when the blood pressure is too low to sustain a supply of oxygen and nutrients; and to remove waste products from body cells, tissues and organs. It may be hypovolaemic, cardiogenic, distributive or obstructive.

The Key Symptoms in Shock

• Hypotension.• Oliguria / Anuria.• Decreased levels of consciousness.• Altered heart rate.• Diaphoresis.

Cardiogenic Shock

What Is Cardiogenic Shock?

• Cardiogenic shock is failure of the heart to pump blood around the body to a degree where life is incompatible.

Causes of Cardiogenic Shock

• Anterior myocardial infarction – most common cause.

• Other myocardial infarctions.• Congenital heart defects such as sever

ventricular septal defects.• Myocardial rupture.• Postoperative cardiac surgery.

Patient Presentation of Cardiogenic Shock

• Severely hypotensive.• Cyanosis.• Cold and clammy.• Dyspnoea.• Elevated central venous pressure.• Tachycardia.• Oliguria.

Basic Pathophysiology of Cardiogenic Shock

• The pump fails e.g. myocardial infarction.• Cardiac output decreases.• Hypotension ensues.• Heart rate increases to compensate for

hypotension.• Oxygen demand exceeds supply.• Peripheral vasoconstriction occurs.• Blood is redirected away from the gut.

Pathophysiology of Cardiogenic Shock Continued

• Chemicals released by dying cells cause further suppression of myocardial function and increase vasoconstriction centrally.

• The work the heart must do is increased thus so is the oxygen demand.

• Vital organs such as the kidneys, brain and liver and lungs are hypoperfused and tissue damage occurs.

• A vicious cycle is then in place and without treatment the patient will die.

The Cycle of Cardiogenic ShockDecreased Cardiac

Output ↓BP

↑ HR

↑SVR↑MVO2↓DO2

↑MyocardialIschaemia

↓ Contractility

↓StrokeVolume

KeyDO2 – Oxygen Supply MVO2 – Myocardial Oxygen Demand SVR – Systemic Vascular Resistance

Monitoring a Patient in Cardiogenic Shock

• Continuous cardiac monitoring – rhythm.• Continuous arterial blood pressure

monitoring.• Hourly urine output.• Hourly nasogastric output.• Strict fluid balance monitoring.• Hourly temperature monitoring.• Continuous central venous pressure

monitoring.

Monitoring Continued

• Respirations.• Arterial blood gas.• Blood sugar.

Medical Management of Cardiogenic Shock

• Initiate monitoring as described above.• Administration of inotropes.• Administration of oxygen.• Initiation of intra-aortic balloon pump

counterpulsation (if not contraindicated).• Administration of diuretics.• May administer GTN.• Active warming.

A Nursing Careplan For Cardiogenic 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.