1. Dr Lawrence Siamuyoba Senior Registrar Department of Medicine/Haemato- oncology

2.  Mechanisms:  Inadequate oxygen delivery  Release of inflammatory mediators  Further microvascular changes, compromised blood flow and further cellular hypoperfusion  Clinical Manifestations:  Multiple organ failure  Hypotension

3.  Hypovolemic  Obstructive  Cardiogenic  Distributive  Anaphylactic  Septic

4.  Hypovolemic: (classic shock)  THE MOST COMMON CLASS. It is the standard used to compare other forms of shock to differentiate the diagnosis  Hemorrhagic/Blood loss  Dehydration/Fluid loss

6.  What type of shock is it?  Step I: is the cardiac output reduced or elevated  Septic shock is strongly suggested if  High cardiac output hypotension  Widened pulse pressure  Strong apical impulse  Fever or hypothermia  Low cardiac output indicates cardiogenic or hypovolaemic shock  Narrow pulse pressure  Reduced apical impulse  Cool extremities

7.  Step II: if the cardiac output is low, is the heart empty or full  Cardiogenic shock  Volume overload  Findings include  A large heart  Murmurs  Gallop rhythms  JVP  Hypovolaemic shock  Obvious intravascular depletion  Blood loss

10.  Hemorrhage  Severe diarrhea  Vomiting  Excessive perspiration  Third Spacing  Shift of fluid in severe burns can lead to hypovolemic shock  Peritonitis  Intestinal obstruction

11.  Kidneys release antidiuretic hormone which increases vasoconstriction  Signs and symptoms:  Mental status: lethargy, sleepy, combative  Skin: clammy, pale, mottling. Cyanosis around the nose and mouth first, spreads to extremities  Blood pressure: begins to fall, capillary refill delayed  Pulse: rapid and weak  Respirations: rapid and shallow  Other: decreased urination

12.  Signs and symptoms:  Mental status: decreased LOC, to unresponsive  Skin: gray, mottled, cyanotic, waxen, sweating stops  Blood pressure: decreases, becomes undetectable  Pulse: slows then disappears  Respiration: agonal  Other: irritable heart, bradycardia, leads to asystole

13.  Stop the fluid loss – direct pressure, surgery  Replace fluids – blood and blood products, plasma expanders, crystalloid fluids (provide H2O replacement and E-lytes), Colloids (albumin, FF)  Pneumatic antishock garments  Use low dose inotropics

14.  Systemic hypoperfusion secondary to severe depression of cardiac output and sustained systolic arterial hypotension despite elevated filling pressures.

15.  Heart pump failure (40% of myocardium damaged by an MI)  Cardiac trauma  Cardiomyopathy  Congestive heart failure  Cardiac dysrhythmias

16.  Etiologies  Pathophysiology  Clinical/Hemodynamic Characteristics  Treatment Options

17.  Acute myocardial infarction/ischemia  LV failure  VSR  Papillary muscle/chordal rupture- severe MR  Ventricular free wall rupture with subacute tamponade  Other conditions complicating large MIs  Hemorrhage  Infection  Excess negative inotropic or vasodilator medications  Prior valvular heart disease  Hyperglycemia/ketoacidosis  Post-cardiac arrest  Post-cardiotomy  Refractory sustained tachyarrhythmias  Acute fulminant myocarditis  End-stage cardiomyopathyHypertrophic cardiomyopathy with severe outflow obstruction  Aortic dissection with aortic insufficiency or tamponade  Pulmonary embolu  Severe valvular heart disease - Critical aortic or mitral stenosis, Acute severe aortic or MR

20.  Drop in cardiac output  Skin: cyanosis  Pulse: bradycardia, tachycardia, or within normal limits  Respirations: diminishing breath sounds progressing to wheezing and crackles. Patient complains of increasing dyspnea. Coughs white or pink tinged foamy sputum  Other: pulmonary edema and left heart failure  Pitting edema+ right heart failure

21.  Massive pulmonary embolism  Acute dissecting aneurism of the aorta  Acute cardiac tamponade  Acute hemorrhage  Cerebrovascular thrombosis  Diabetic acidosis  Acute pancreatitis  Acute adrenal insufficiency

23.  The priority in treatment of cardiogenic shock is to expand the circulating blood volume with IV fluids-using PWP or CVP as a basic guide.

24. 1. Position the patient 2. Make certain that there is adequate airway 3. Mainatain adequate oxygenation 4. Start an IV infusion of 5% Dextrose Water using 5. Insert CVP or swan-Ganz catheter into the pulmonary artery 6. Draw the necessary blood samples 7. Insert urinary catheter for purposes of obtaining adequate measurement of the urine output. 8. Monitor patient continuously 9. Relieve any pain 10. Relieve any agitation 11. Take portable Chest X-rays

25.  Hemodynamic monitoring  IV fluids  Intra-aortic balloon pump  Cardiac transplant  Inotropics/cardiotonics  Digoxin, Amrinone, Primacor  Vasodilators  Diuretics  If from obstructive may need surgical repair, chest tube, pacemaker, needle aspiration of fluid

26.  Can be classed as a type of cardiogenic shock  Pulmonary embolism/Blocked pulmonary circulation  Tension pneumothorax/Increased intrathoracic pressure  Cardiac tamponade/Pressure on myocardium. Decreased preload

27.  Mental status :  anxiety,  feeling of impending doom  Skin :  pallor to cyanosis around the mouth and the nose  Other :  chest pain,  lung sounds may be clear,  possible syncope,  cardiac dysrhythmias can lead to sudden cardiac arrest

28.  Anaphylactic Shock  Mechanism: severe allergic reaction  Skin:  hives,  possible petechia.  Urticaria,  pallor,  cyanosis  Blood pressure:  abrupt fall in cardiac output  Respiration:  rapid shallow,  dyspnea with stridor,  wheezes,  crackles,  leading to respiratory arrest  Other: swelling of mucus membranes/pulmonary edema

29.  Maintain airway  Ice to site of injection or sting  Gastric lavage  Isotonic IV fluids – D5W, NACL, LR  Epinephrine and theophylline  Antihistamines (H2 blockers)  Steroids  Vasopressors to constrict blood vessels and raise BP

30.  Mechanism: overwhelming infection  Skin: varies form flushed pink (if fever is present) to pale and cyanotic. Purple blotches possible, peeling skin, general or on palms and soles of feet  Blood pressure: early—cardiac output increases but toxins prevent increase in BP. Late --- drop in BP, hypotension  Respiratory: dyspnea with altered lung sounds  Other: high fever, (except in elderly and very young), Late sign is pulmonary edema

31.  C & S for infective site  IV fluids with NS  Medications and other treatment  Vancomycin  Penicillin  Cephalosporin  Cardiotonics and inotropics  Vasopressors  Heparin  Blood products

32.  Remember your ABC’s  Administer airway  100% O2 via a non- re-breather mask  Assist ventilations if necessary  Position patient to assist perfusion  Keep patient warm  Perform focused assessment  Monitor and adjust O2, gain IV access, cardiac monitor, pulse oximetry  Fluid replacement of LR or NS  Need 3 liter of fluid to replace I liter of blood loss  Apply pressure to IV or blood to facilitate faster infusion

33.  Ineffective Tissue Perfusion  Decreased Cardiac Output  Anxiety  Fluid Volume Deficit  Risk for Injury  Risk for Infection

34.  Defined as when generalized inflammation occurs and threatens vital organs  Causes: multiply transfusions, massive tissue injury, burns, and pancreatitis, severe infections or sepsis  Effects: endothelium is damaged and allows fluid to leak into the body tissues, results in poor perfusion of blood to organs  Body is in a hypermetabolic state

35.  Diagnosis made when 2 or more of the following are seen:  Temperature less than 97 or greater than 100.4  Heart rate more than 90  Respiratory rate more than 20 or PaCO2 less than 32mm Hg  WBC count less than 4000 cells or more than 12,000  Sepsis is used if patient has SIRS with and infection

36.  Defined: when 2 or more organ systems are failing at one time  Is caused by the immune system’s uncontrolled response to severe illness or injury  Common cause of death of patients in the ICU, with mortality of 50%  Identifying and acting quickly can help survival  Can develop quickly following surgery, trauma, or severe burns or slowly in the case of an infection

37.  Critical care nursing  Goals  Prevent and treat infections  Maintain tissue oxygenation  Provide nutritional and metabolic response  Support failing organs