Shock

Respiratory Failure: Hypoxemic vs. Hypercapnic

Hypoxemic (O2 Failure)

Hypercapnic (Ventilatory Failure)

o
o
o

PaO2 60 mmHg on 60% O2

PaCO2 <35
Causes: ARDS, Pneumonia, PE, Cardiac
Pulmonary Edema

Clinical Manifestations: Dyspnea,

o
Tachycardia, Nasal Flare, WOB, SpO2
(<80%), Paradoxus Chest
If severe cells shift from aerobic to
anaerobic. Fuel leads to Energy. Waste
product is lactic acid!

o
o
o

PaCO2 >45
pH <7.35
Causes: Asthma, COPD, Cystic Fibrosis,
BSI, OD, HI, Thoracic Trauma, MS, ALS,
Guillain-Barr
Clinical Manifestations: Dyspnea, Tripod
Positioning, Purse-Lipped Breathing,
RR, Tidal Volume

Ventilator, Hemodynamic, and Cardiac Monitoring

BP, CO, O2, ECG, Temperature, Stroke Volume, CVP, ICP, EF, SvO 2
Normal: CVP 2-8mmHg
PAWP 6-12mmHg
MAP 65mmHg
CO 4-8 L/min
SvO2 60-80%
UOP 0.5mL/kg/hr. (Good Rule of Thumb 30mL/hr.)
CVP

PAWP o
MAP

CO
SvO2

In high levels of fluid replacement in septic shock, we want to see CVP 8-12
within 6 hours. **May be first indication that fluid replacement is
successful**
Using a wedged balloon in a pulmonary catheter and inflated within a
pulmonary artery. When inflated, the balloon can measure left ventricular
end diastolic pressure.
Must have a Mean Arterial Pressure (MAP) of at least 60 to perfuse the
coronary arteries, brain, and kidneys.

DBP ( 2 ) + SBP
3

MAP =

o
o

Amount of blood that is pushed through the heart per minute.

Mixed Venous Oxygen Saturation monitoring allows minute-to-minute
assessment of total tissue oxygen balance (oxygenation vs. consumption)
60-80%. Remember pulse ox will not give accurate reading due decreased
blood to peripherals. SVO2 also allows us to monitor clients tolerance to
activity. Example: turning client SvO2/ScvO2 drops as HR increases
1

client isnt tolerating activity well.

Preload (Volume within the ventricle at the end of diastole)

o PAWP & CVP
o with Diuretics, with Fluids
Afterload (Forces opposing ventricular ejection)
o Systemic Vascular Resistance (SVR) = Left ventricular pressure
o Pulmonary Vascular Resistance (PVR) = Right ventricular afterload
o Afterload = Cardiac Output
Contractility
o Increases when preload is unchanged but the heart contracts more forcefully
o Give Positive Inotropes (Dopamine, Norepinephrine, Digoxin)
o Measure PAWP and CO
Pulmonary Artery Catheter
o Right side of the heart
o Complication: Dysthymias
o Monitor: K+, Mg+, and ABG
Shock: 1) Starving Cells 2) O2 out of whack 3) Organ Failure
o Venous Lactic Acid (5-20 mg/dL)
o Arterial Lactic Acid (0.6-2.2 mmol/L) *Know for Testing Purpose*

Key Assessments!! #1 Defense is PREVENTION

o
o
o
o

CRT
LOC
Pulses
CO (4-8L)

o Hgb (M 13-17;
F 11-15)
o Hct (M 39-50%;
F 35-47%)
o UOP (30mL/hr. or
0.5mL/kg/hr.)

o Lactic Acid (4
indicative of organ
damage)
o O2 (<90% BAD)
o MAP (Ideal >65; >60
to sustain organ life)
o Albumin (3.4-5.4)
o SvO2: HR with SvO2 they are not tolerating activity. STOP! Space the care
out.
o > 80: Sepsis, Hypothermia, Anesthesia
o < 60: Anemia, Bleeding, Hyperthermia (Shivering), Hypoxemia, Seizures

Fluid Replacement:
o Monitor: Is&Os, BP, MAP, Lung Sounds, Signs of CO (BP, HR), FVO
o Types: Crystalloid (NS; LR), Colloid (Albumin), Blood Products (PRBC;
Clotting Factors) **Warm Fluids**
o All depends on the type of shock.

o Careful LR with liver patients (Cannot convert lactate to bicarbonate which

Lactic Acid levels, worsening acidosis)

Medications:
o Antibiotics (Cultures first)
o Bicarbonate
o Vasodilators (Sodium Nitroprusside, Nitroglycerin, Vasopressin)
o Vasoconstrictors (Dopamine, Norepinephrine)
o Fluid Replacement before Vasoconstrictors (You have to have that fuel in
the tank)
o Mimics SNS ( SVR = Workload; shunts blood to vital organs)
o Goal is to maintain MAP >65
o Usually get 3L of fluid with shock!
o Enteral Feedings started within 24 hr. ( blood flow to the gut to maintain
GI tract)
o TPN (Protein, Calorie) (Prevent Stress Ulcers with IV Protonix)
Care:
o Daily Weight (Same Clothing, Same Time, No Extra Pillows)
o Increase in weight could be due to 3rd Spacing which is BAD.
o Frequent Mouth Care
o Proper Skin Care
o Monitor IV Site (Infiltration can occur)
o Dopamine and Norepinephrine causes blood to shut to vital organs which
can cause necrosis of the extremities. Check peripheral Pulses, Color, and
Temperature. If Necrosis occurs use Phentolamine (Regitine) to reverse.
o Bed Rest
o Labs: Glucose, Albumin (3rd Spacing), BUN, Creatinine, H&H, WBC,
Platelets, Protein, Electrolytes, ABG (1. Respiratory Alkalosis 2. Metabolic
Acidosis)

Stages of Shock
o May or may not have symptoms.
o Aerobic to Anaerobic (Lactic Acid Level Monitoring)
o Glucose related to release of glycogen
2. Compensatory o The body recognizes the problem and shunts fluid to the organs by
activating SNS response. Renin activated and releases Angiotensin.
Aldosterone to retain sodium and water. ADH increasing water
resorption.
o Clinical Manifestations: Restless, Tachycardia (Need O2), Tachypnea
(Need O2), Renal Flow (UOP NOT affected), Cool/Pale Skin
o Failure Begins. (1st Lungs, 2nd Kidneys, 3rd GI)
3. Progressive
o Leads to MODS, ARDS
o Clinical Manifestations: Perfusion, Respiratory Distress (Use of
accessory muscles), O2, Crackles/Cyanosis (EARLY), Agitation,
BP (40 from baseline), Pulses, UOP (LATE), GI (Ulcers), ECG
Changes (PVC, Dysrhythmias), Metabolic Acidosis, Lactic Acid,
Edema (3rd Spacing), Cold/Clammy, Bleeding (DIC)
o No Recovery. All Organs Failing.
4. Refractory
o Signs and Symptoms to differentiate.
o Clinical Manifestations: BP, Lactic Acid Levels, GI Function,
Kidney Failure, Hypoglycemis, Cerebral Ischemia, DIC, Tachycardia
leading to Bradycardia, Hypothermic, Cyanosis, Unresponsive

1. Initial

Shock Classification
Type

Cause

Cardiogenic
Shock
(Low Blood
Flow)

MI,
Cardiomyopathy,
systemic and
pulmonary HTN
and cardiac
tamponade

Clinical
Manifestations
o
o
o
o
o
o
o
o

Anxious
Cool/Clammy
Tachycardia
Hypotension
Tachypnea
Crackles or
Rhonchi
Increased PAWP
(FVO)
Decreased urine
output

Treatment
o
o
o
o
o
o

Thrombolytic therapy
Angioplasty w/wo stenting
IABP ( Ventricle Workload)
Nitrates ( Workload)
Diuretics (If PAWP,
Preload)
Beta blockers (HR &
Contractility; Contraindicated
for EF <40%)
Positive Inotropes
(Dobutamine, Dopamine)
Cardiac Output
Careful fluid replacement due
4

o
Hypovolemic
Shock
(Low Blood
Flow)
Goal is Stop
fluid loss (e.g.
trauma and
blood loss)

Septic Shock
(Maldistribution
of Blood Flow)

Hemorrhage, GI
loss, Diuresis,
Ascites, Third
spacing

o
o
o
o
o

o
o
o

o
o

Anaphylactic
Shock
(Maldistribution
of Blood Flow)
Goal is
Prevention
(know pts
allergies)

Systemic
inflammatory
response to an
infection=sepsis
1. bacteria
enters
bloodstream
from source (e.g.
abscess)
2. bacteria
release toxins
causing
inflammatory
response
3. response
becomes
systemic=tissue
hypoxia
Life threatening
situation due to
allergic reaction
(from inhalation,
topical, oral, or
parenteral
exposure to
allergen)

Neurogenic
Shock
(Maldistribution

Trauma to 5th
thoracic
vertebrae or

o
o
o

o
o
o
o
o
o

Anxious
Tachycardia
Tachypnea
Hypotension
Hypoactive or
Absent Bowel
Sounds
Decrease UOP
Cool/Clammy
Decreased H&H
(LATE)

Fever (+ or -)
Warm and Flushed
(EARLY)
Confusion
Tachycardia
Hypotension
Tachypnea
GI Dysfunction
Cold/Clammy Skin
(BAD)

o
o

o
o

o
o
o
o
o
o

o
o
o

o
o
o
o
o
o

Face swelling
Bronchospasm
Hypotension
Wheezing/Stridor
Skin Flushing
Tachycardia

o
o
o
o
o

Hypotension
Bradycardia
Hypothalamic

o
o

to heart failure (NS/LR)

Vasopressors [e.g. Dopamine,
Norepinephrine (Levophed)]
Fluid Replacement (NS Bolus)
3L
Blood Transfusions
Monitor CVP (upper & little
higher (12-14) with fluid
resuscitation)
STOP the Cause!!
Replacement is just a bandage
fix!
Surgery
After fluids CVP 12-15 and
PAWP >12
Fluid replacement with
crystalloids and colloids
Norepinephrine (Levophed)
Positive Inotropes
(Dobutamine)
Antibiotics (start with broad
then specific)
Insulin Drip
Low-molecular Heparin
H2 antagonists (Pepcid,
Protonix) to prevent stress
ulcers
CVP 8-12 in 6 hr.
With Vent patients CVP 11-14
Maintain MAP >65

Maintain Patent Airway

Epinephrine (1st choice) IV
1:10,000; SQ/IM 1:1,000
Diphenhydramine (Benadryl)
IV 50mg
Corticosteroids IV 125mg (If
BP has not dropped in 2 hr.)
Fluid replacement colloids
(Albumin)
Maintain Spinal Stability
Restore Fluid Volume carefully
b/c Hypotension is not r/t to
5

of Blood Flow)
Goal is to
correct
hypotension
and control
body
temperature

above,
o
Anesthesia
given improperly,
Drugs that affect
o
the autonomic
nervous system

Obstructive
Shock
(Physical
obstruction
impending the
filling or
outflow of
blood causing
reduced CO)

Cardiac
Tamponade,
Tension
Pneumothorax,
Superior Vena
Cava Syndrome,
Abdominal
Compartment
Syndrome, PE

o
o
o

o
o
o
o
o

Dysfunction
Warm r/t
Vasodilation; then
Cool
Poikilothermic (at
risk for
Hypothermia)
Dry Skin
Hypotension
Tachypnea leading
to Bradypnea
(LATE)
Pulsus Paradoxus
Decreased UOP
Pallor
Cool/Clammy
Decreased/Absent
Bowel Sounds

o
o
o
o
o
o

fluid loss
a-Adrenergic Agonist
(peripheral vasoconstriction)
NeoSynephrine (increases HR
and BP)
Atropine (0.5mg) if Bradycardic
Neurovascular Checks (CRT,
Extremity Pulse & Color)
Needle Decompression
Chest Tube
Pericardiocentesis
Fluid Resuscitation

SIRS & MODS

Type

Cause

Systemic
Inflammatory
Response
Syndrome
(SIRS)

Infection,
Pancreatitis,
Ischemia, Multiple
Trauma with tissue
injury, hemorrhagic
shock, Immunemediated organ
injury, aspiration of
gastric contents,
massive
transfusions, client
defense
mechanisms
(Hemolytic
Reaction)
Usually develops
from SIRS
Outcome is poor

Multiple
Organ
Dysfunction
Syndrome
(MODS)

Clinical
Manifestations

Treatment

Have to exhibit at least 2 oKey Assessments (LOC,

or more
VS q 15 min, Lung
o TEMP > 38C or < 36C
Sounds, Heart Sounds,
o HR > 90
UOP, Pulses, Bowels,
o RR > 20 BPM
Fluids, Skin)
o PaCo2< 32 mmHg
oGoals:
1)
o WBC > 12,000 cells/mm
O2 Supply Demand
OR < 4,000 cell/mm
2) Support Failing
Organs (Dialysis, Vent)
3) Prevent & Treat
Infection
4) Nutrition (Cal &
Protein)
5) Find Source & Treat
oManage: Routine Mouth
Have to exhibit 2 or more
Care, HOB 30, Space
o Respiratory Changes
Activity, Passive ROM,
o Mental Changes
Family Support, Orient,
o Acute Renal Failure r/t
Talk to patient, Glucose
Hypoperfusion
(140-180)
o GI Failure r/t decreased
shunting and motility
6

and depletion of
glycogen stores