SHOCK

Adalberto Toledo

Javier Rivera

Stephanie Morales

Sheila Prado

Carlos Mendez Gutierrez

What is shock?

Shock is a life-threatening condition that occurs when the body is not getting enough blood flow. The Lack of blood flow means that the cells and organs do not get enough oxygen and nutrients to function properly. Multiple organs can suffer damage as a result.

Types of ShocksCardiogenic Shock Hypovolemic shock

Septic ShockAnaphylactic Shock

Cardiogenic shock

Cardiogenic shock is a condition where the heart has been damaged so much that it is unable to supply enough blood to the organs of the body.

The most common causes are serious heart complications. These complications include: Pressure on the heart due to a buildup of fluid

around it Tear or rupture of the muscles or tendons that

support the heart valves, especially the mitral valve Very slow heart rhythm or problem with the

electrical system of the heart

Symptoms of Cardiogenic Shock

Chest pain or pressure Coma Decreased urination Fast breathing Fast pulse Heavy sweating, moist skin Lightheadedness Loss of alertness and ability to

concentrate Restlessness, agitation,

confusion Shortness of breath Skin that feels cool to the touch Pale skin color or blotchy skin Weak (thready) pulse

Hypovolemic shock

Hypovolemic shock is an emergency condition in which severe blood and fluid loss make the heart unable to pump enough blood to the body.Causes: Losing about a fifth or more of the normal amount of blood in your body causes hypovolemic shock.

Blood loss can be due to: Bleeding from cuts Bleeding from other injuries Internal bleeding, such as in the gastrointestinal tractThe amount of circulating blood in your body may drop when you lose too many other body fluids. This can be due to: Burns Diarrhea Excessive perspiration Vomiting

Symptoms of Hypovolemic shock

Anxiety or agitation Cool, clammy skin Confusion Decreased or no urine

output General weakness Pale skin color (pallor) Rapid breathing Sweating, moist skin Unconsciousness

Anaphylactic shock

Anaphylactic shock is a severe, whole-body allergic reaction to a chemical that has become an allergen.Common anaphylaxis triggers include: (depending what you are allergic to) Certain medications, especially

penicillin Foods, such as peanuts, tree nuts

(walnuts, pecans, almonds, cashews), wheat (in children), fish, shellfish, milk and eggs

Insect stings from bees, yellow jackets, wasps, hornets and fire ants

Septic shock

Septic shock is a serious condition that occurs when a body-wide infection leads to dangerously low blood pressure.Sepsis can be caused by any type of infection: bacterial, fungal, or viral. Sepsis commonly originates from: abdominal or digestive system infections lung infections like pneumonia, bronchitis, or

lower respiratory tract infections, which are responsible for around 25 percent of cases (NHS)

urinary tract infection reproductive system infection

Symptoms of Septic Shock

Cool, pale arms and legs High or very low

temperature, chills Light-headedness Little or no urine Low blood pressure,

especially when standing Palpitations Rapid heart rate Restlessness, agitation,

lethargy, or confusion Shortness of breath Skin rash or discoloration

Shock Management

Overall Goal of Shock management is the restoration of adequate perfusion; to restore perfusion center on achieving an adequate blood pressure, increasing cardiac output, and or optimizing the oxygen content of blood; in order to prevent cellular and organ injury.Restoration of hemodynamic stability should be a priority while simultaneous efforts to treat the cause of shock care implemented.

Common interventions:

Blood Pressure Fluids, vasopressor or vasodilator agent

CardiacPreload

ContractilityAfterload

Fluids, vasodilator agentsInotropic agents Vasopressor or vasodilator agents

Oxygen ContentHemoglobin

Blood Transfusion

Hemoglobin SaturationOxygen demand

Supplemental oxygen, mechanical ventilation Mechanical ventilation, sedation, analgesia, antipyretics

Constant Monitoring is Key

TECHNIQUESElectrocardiographic

BP with an arterial catheterPulse Oximetry

central venous pressurerenal perfusion concentration

of lactate

*Depending on the etiology of the shock will guide you on what specific vital signs to focus on.

Pharmacological Therapy

Vasoactive medications are frequently used in the emergency management of shock to increase mean arterial blood pressure (MAP) and restore organ perfusion and oxygen delivery. Classically, these medications are administered when intravenous fluid resuscitation fails to restore adequate oxygen delivery.

Pharmacological Therapy

Inotropic agent any of a class of agents affecting the force of muscle contraction, particularly a drug affecting the force of cardiac contraction; positive inotropic agents increase, and negative inotropic agents decrease the force of cardiac muscle contraction.

Norepinephrine

Norepinephrine is similar to adrenaline. It works by constricting (narrowing) the blood vessels and increasing blood pressure and blood glucose (sugar) levels.Norepinephrine is used to treat life-threatening low blood pressure (hypotension) that can occur with certain medical conditions or surgical procedures. This medication is often used during CPR (cardio-pulmonary resuscitation).

Things to Know

Norepinephrine is injected into a vein through an IV.

Norepinephrine is usually given for as long as needed until your body responds to the medication. Some people must receive norepinephrine for several days.

Your blood pressure, breathing, and other vital signs will be watched closely while you are receiving norepinephrine.

Epinephrine

Epinephrine is a chemical that narrows blood vessels and opens airways in the lungs. These effects can reverse severe low blood pressure, wheezing, severe skin itching, hives, and other symptoms of an allergic reaction.Epinephrine injection is used to treat severe allergic reactions (anaphylaxis) to insect stings or bites, foods, drugs, and other allergens. Epinephrine is also used to treat exercise-induced anaphylaxis.

Dobutamine Dobutamine stimulates heart muscle and improves blood flow by helping

the heart pump better. Dobutamine is used short-term to treat cardiac decompensation due to

weakened heart muscle. Dobutamine is usually given after other heart medicines have been tried

without success.

Dobutamine is injected into a vein through a catheter. You will receive this medicine in a hospital or clinic setting to quickly treat any serious side effects that occur. While using dobutamine, you may need frequent medical tests. Your heart function may need to be checked using an electrocardiograph or ECG (sometimes called an EKG).

Dopamine

Dopamine injection (Intropin) is used to treat certain conditions, such as low pressure, that occur when you are in shock, which may be caused by heart attack, trauma, surgery, heart failure, kidney failure, and other serious medical conditions. Dopamine injection is injected into a vein through an IV. Your breathing, blood pressure, oxygen levels, kidney

function, and other vital signs will be watched closely while you are receiving dopamine.

Intravenous/Fluid therapy

Intravenous therapy is used to correct electrolyte imbalances, to deliver medications, for blood transfusion or as fluid replacement to correct, for example, dehydration.

Volume expandersThere are two main types of volume expander; crystalloids and colloids. Crystalloids are aqueous solutions of mineral salts or other water-soluble molecules. Colloids contain larger insoluble molecules, such as gelatin. Blood is a colloid. Colloids preserve a high colloid osmotic pressure in the blood, while, on the

other hand, this parameter is decreased by crystalloids due to hemodilution. Crystalloids generally are much cheaper than colloids. (blood, albumin, plasma, etc.)

The most commonly used crystalloid fluid is normal saline, a solution of sodium chloride at 0.9% concentration, which is close to the concentration in the blood (isotonic). Lactated Ringer's (also known as Ringer's lactate) and the closely related Ringer's acetate, are mildly hypotonic solutions often used in those who have significant burns (normal saline, ringer lactate, dextrose, etc.)

Safety Precautions

Dextrose 5% in waters should not used to treat hypovolemic shock.

0.45% saline is not appropriate for volume expansion

Smaller bolus amounts are indicated for patients with suspected or known cardiogenic shock.

Fresh frozen plasma should be used only for correction of coagulopathy and not for volume replacement.

Oxygen demand should also be decreased when possible.

CASE STUDYA 25-year old woman presents to the emergency department complaining of a cough productive of tenacious greenish yellow mucus. Vital Signs are temperature 101.8 F, Heart rate 129/min, respiratory rate 27/min, and blood pressure 112/68 mm Hg.

What information is needed to determine if this patient has shock?

Vital Signs - heart rate high, temperature high, respiratory rate high

Laboratory tests – Blood work up

Infection around the body Low blood oxygen level Disturbances in the

body's acid-base balance Poor organ function or

organ failure Oxyhemoglobin

saturation test

What initial interventions are needed to stabilize the patient? Start adequate antibiotic therapy (proper

dosage and spectrum) as early as possible Fluids given directly into a vein

(intravenously) Oxygen as needed