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Shock
• Shock is characterized by an inadequate
supply of oxygen and nutrients to cells from impaired tissue perfusion and, if untreated, results in death. Adequate blood flow to the tissues and cells requires the following components: – Adequate cardiac pump – Effective vasculature of circulatory system – Sufficient blood volume • When one component is impaired, blood flow to the tissues is threatened or compromised. • Without treatment, inadequate blood flow to the tissues results in poor delivery of oxygen and nutrients to the cells, cellular starvation, cell death, organ dysfunction progressing to organ failure and eventual death. Normal Cellular Function • Energy metabolism occurs within the cell, where nutrients are chemically broken down and stored in the form of adenosine triphosphate (ATP). • Cells use stored energy to perform necessary functions, such as active transport and muscle contraction. • ATP can be synthesized aerobically or anaerobically. • Aerobic metabolism use bigger amounts of ATP than anaerobic metabolism and thus is a more efficient and effective way of producing energy. • Anaerobic metabolism results in the accumulation of the toxic end product lactic acid, which must be removed from the cell and transported to the liver for conversion into glucose and glycogen. Pathophysiology
• When the body is in shock, cells do not receive enough
oxygen or nutrients and must produce energy through anaerobic metabolism. • Energy production is lower and acidotic, because of these changes normal cell function ceases. • The cell start to swell and the cell membrane is more permeable, allowing electrolytes and fluids to seep out of and into the cell. • cell structures, primarily the mitochondria, are damaged; and death of the cell results. Vascular Responses
• Oxygen attaches to hemoglobin in red blood cells and is
carried to the body cells. The amount of oxygen that is delivered to cells depends on blood flow to a specific area and on blood oxygen concentration. • This process of circulation is facilitated through a vasculature consisting of arteries, arterioles, capillaries, veins and venules. The vasculature can dilate or constrict based on central and local regulatory mechanisms. • Local regulatory mechanisms (autoregulation) stimulate vasodilation or vasoconstriction in response to biochemical mediators released by the cell. • Blood Pressure Regulation
• An adequate blood pressure is necessary for effective
tissue perfusion. • Blood pressure is regulated through a complex interaction of neural, chemical and hormonal feedback systems that affect cardiac output and peripheral resistance. • Cardiac output is determined by stroke volume (the amount of blood ejected at systole) and heart rate. • Peripheral resistance is determined by the diameter of the arterioles. This relationship is expressed in the following equation: Formula for Estimating Mean Arterial Pressure (MAP) MAP = systolic BP = 2(diastolic BP) 3
Example: Patient’s BP = 125/75 mm
Hg
MAP = 125 + (2 x 75) 3 The MAP is the average MAPpressure at which blood = 92 (rounded to moves nearestthrough the vasculature. 1/10) MAP should exceed 70 to 80 mm Hg for cells to receive enough oxygen and nutrients to live. Stages of Shock
• In this stage the client’s blood pressure remains within
normal limits. • Vasoconstriction, increased heart rate and increased contractility of the heart contribute to maintain adequate cardiac output as result of epinephrine and norepinephrine release. • The “fight or flight” response is activated and shunts blood from organs such as the skin, kidneys and gastrointestinal tract to the brain and heart to ensure adequate blood supply to the vital organs. • The client’s skin is cold and clammy, bowel sounds are hypoactive and urine output decreases in response to the release of aldosterone and ADH. Clinical Manifestations
• The client shows numerous clinical signs indicating inadequate
organ perfusion. • The result is anaerobic metabolism and a build up of lactic acid, producing metabolic acidosis. • The respiratory rate facilitates removal of excess carbon dioxide but raises the blood pH and often causes a compensatory respiratory alkalosis. • The alkalotic state causes mental status change, such as confusion. • If treatment begins in this stage of shock, the prognosis for the client is good. Management
• Identify the cause of shock.
• Correct the underlying disorder. • Initiate fluid replacement and medication therapy to maintain an adequate blood pressure. • Reestablish and maintain adequate tissue perfusion. • Early intervention is needed to improve the client’s prognosis therefore the nurse should recognize clients at risk for shock. Management
• In the compensatory state of shock, serum sodium and
blood glucose levels are elevated in response to the release of aldosterone and catecholamines. Nursing Management
• Monitor the client’s hemodynamic status and report
abnormalities to the physician. • Administer prescribed fluids and medications and promote client safety. • Vital signs are key indicators of the client’s hemodynamic status. • Pulse pressure correlates well to stroke volume and is calculated by subtracting the diastolic measurement from the systolic measurement; the difference is the pulse pressure. • The pulse pressure should be 30 to 40 mm Hg and a narrowing or decreased pulse pressure is an earlier indicator of shock. Progressive Stage • In this stage the mechanisms that regulate blood pressure can no longer compensate and the MAP falls below normal limits. • The heart is overworked and becomes dysfunctional and the body is unable to meet increased oxygen requirements which result in ischemia and myocardial depression. This leads to failure of the cardiac pump; even of the underlying cause of the shock is not of cardiac origin. • Capillary perfusion is further compromised by arteriolar and venous constriction. Fluid starts to leak from the capillaries, creating interstitial edema and less fluid return to the heart. The client’s prognosis worsens. Clinical manifestations
decompensation in the organ systems. • Use of appropriate intravenous fluids and medications to restore tissue perfusion by (1) optimizing intravascular volume, (2) supporting the pumping action of the heart and (3) improving the competence of the vascular system. • close monitoring -Hemodynamic monitoring,ECG,ABG, Evaluating serum electrolyte levels,Physical and mental status changes • Intervention with supportive technologies, such as mechanical ventilation, dialysis and intra-aortic balloon pump. • Irreversible Stage
• The irreversible (or refractory) stage of shock -organ
damage is so severe that the client does not respond to treatment and cannot survive. Despite treatment, blood pressure remains low. • Complete renal and liver failure creates an overwhelming metabolic acidosis. • Anaerobic metabolism contributes to a worsening lactic acidosis. • Multiple organ dysfunction progressing to complete organ failure has occurred and death is imminent. Management
• Medical management during the irreversible stage of
shock is usually the same as for the progressive stage. • The nurse focuses on carrying out prescribed treatments, monitoring the client, preventing complications, protecting the client from injury and providing comfort. • Families should be encouraged to express their wishes concerning the use of life-support measures. Clinical Findings in Stages of Shock ASSESSMENT
(<1 yr and >65 yr) reaction Malnourishment Bee sting allergy Depressant action of medications Chronic illness Latex sensitivity Glucose deficiency
Invasive procedures Sepsis Pathogenesis of Sepsis
Nguyen H et al. Severe Sepsis and Septic-Shock: Review of the Literature and Emergency Department Management Guidelines. Ann Emerg Med. Treatment Algorithm
Rivers E et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock N Engl J Med.
