Cardiovascular Shock is a life-threatening condition characterized by FIGURE 1. TYPES OF SHOCK hypotension Inadequate perfusion and oxygenation of vital organs Shock type is classified based on its underlying cause (FIGURE 1): y Hypovolemic: Fluid or blood loss (hemorrhage, burns) y Distributive: Widespread vasodilation (sepsis, anaphylaxis, neurogenic shock) y Cardiogenic: Inadequate cardiac output from pump failure (MI, heart failure) y Obstructive: Physical obstruction to blood flow (PE, cardiac tamponade) Stages of shock y If not treated early, shock progressively decompensates until it becomes irreversible: y Compensatory stage (normal BP) Progressive stage (symptomatic hypotension) Refractory stage (organ damage is irreversible, even with treatment) Early intervention is a priority to prevent progression to 3. Hypovolemic Shock refractory hypoperfusion and irreversible organ damage. Hypovolemic shock occurs when fluid or blood loss leads to insufficient organ perfusion. 2. Priority Interventions Causes Priorities when caring for a client with any type of shock y Blood loss (trauma, GI bleed) include (see TABLE 1): y Fluid loss (burns, dehydration, vomiting) 1. Early recognition: Monitor for hypotension, altered Assessment findings mental status, andurine output. y Hypotension 2. Supporting oxygenation: Administer oxygen; y Tachycardia, weak pulses intubate if necessary. y Cold, clammy skin 3. Hemodynamic monitoring: Frequently assess y urine output BP, mean arterial pressure (MAP), and tissue perfusion (capillary refill, lactate levels). Interventions Stop volume loss (control bleeding, administer antiemetics). Fluid resuscitation: y Administer isotonic IV fluids. y Administer blood products for hemorrhage.
Signs of shock: Detect shock early by monitoring Hypovolemic shock: The priority in hypovolemic for hypotension, decreased urine output, and shock is to stop the source of bleeding or fluid loss altered mental status. and then administer IV fluids to restore fluid volume.
Cardiovascular y Start antibiotics within 1 hr to prevent SIRS + confirmed infection = sepsis. Sepsis can progression. progress to septic shock and multi-organ failure. 2. Support perfusion: Assessment findings y Continue to administer IV fluids. Early sepsis (compensated, “warm” phase): y Aggressive fluid resuscitation is typically y Fever, chills, or hypothermia needed with septic shock. Tachycardia, tachypnea y Closely monitor BP, MAP, CVP, and urine output. Altered mental status (confusion) y Goal MAP for adequate perfusion = >65 mmHg. y Warm, flushed skin due to early vasodilation If BP does not improve with IV fluids alone, start Normal BP or mild hypotension vasopressors (norepinephrine) to achieve a Septic shock (decompensated, “cold” phase): MAP >65 mmHg. Persistent hypotension despite receiving IV fluids y Clients receiving vasopressors may require y Cool, mottled skin invasive hemodynamic monitoring (CVP, y Signs of organ dysfunction: arterial line). y urine output y Monitor lactate levels to assess perfusion. y lactate levels y lactate = tissue hypoxia. y Respiratory failure (dyspnea, hypoxemia) 3. Monitor for life-threatening complications: Diagnostics y Disseminated intravascular coagulation lactate levels (indicates tissue hypoperfusion) (DIC) occurs when sepsis activates the clotting y Positive blood cultures cascade, causing widespread clot formation, y procalcitonin levels (marker for bacterial infection) which depletes clotting factors and causes WBCs severe bleeding. Interventions y Monitor for bleeding, bruising, and petechiae. y Acute respiratory distress syndrome (ARDS) Priorities for a client with signs of septic shock include: is a type of respiratory failure that causes fluid 1. Initiating IV fluids and identifying and treating buildup in the alveoli. infection y Monitor for signs of hypoxemia 2. Supporting perfusion (dyspnea, cyanosis). 3. Monitoring for life-threatening complications y Multi-organ dysfunction syndrome (MODS) is the failure of ≥2 organ systems (renal, respiratory). y Assess for worsening organ dysfunction (urine output,creatinine).
Septic shock: The priority in septic shock Vasopressors: If IV fluids fail to correct is administering an IV fluid bolus of hypotension from septic shock, use 30 mL/kg and collecting blood cultures vasopressors (e.g., norepinephrine) to achieve before giving antibiotics. a MAP >65 mmHg.
Cardiovascular Urticaria (hives) y Monitor for fluid overload (crackles, edema). Angioedema (FIGURE 2) y Administer vasopressors (phenylephrine) to Stridor, wheezing, respiratory distress counteract vasodilation. y Hypotension y Administer atropine for bradycardia. y Tachycardia 5. Cardiogenic Shock FIGURE 2. ANGIOEDEMA Cardiogenic shock occurs when the heart fails to pump adequately. y cardiac output Poor perfusion and fluid backup in the lungs. Causes y Heart failure caused by: y Myocardial infarction (MI) y Ventricular dysrhythmias y Cardiac tamponade Assessment findings y Hypotension y Weak pulses, FIGURE 3. JVD cool extremities y Pulmonary edema Interventions (crackles in #1 priority = immediately administer epinephrine IM lungs) or IV. y Jugular vein y Causes vasoconstriction and bronchodilation distention (JVD) y Provide supportive care: (FIGURE 3) Prepare for endotracheal intubation if needed. Administer IV diphenhydramine. Interventions y Administer IV corticosteroids to reduce y Administer inflammation. oxygen for hypoxemia. c. Neurogenic Shock y If client Spinal cord injury Loss of sympathetic nervous has signs of MI, prepare for emergent cardiac system tone Vasodilation and bradycardia catheterization to restore coronary perfusion. Assessment findings Administer inotropes (e.g., dobutamine) to improve Bradycardia (unique to this type of shock) cardiac output. y Warm, dry skin y Administer diuretics (furosemide) to treat y Hypotension fluid overload.
Anaphylactic shock: The priority in anaphylactic shock is to immediately administer IM epinephrine.
Cardiovascular Assessment findings y Isotonic IV fluids Jugular vein distention (JVD) y Blood products for hemorrhage y Sudden hypotension y Tachycardia, tachypnea Septic y Aggressive IV fluid resuscitation and norepinephrine Interventions as needed to achieve MAP >65 mmHg y #1 priority = treat the underlying y Blood cultures before antibiotics cause. y Broad-spectrum antibiotics y PE: Administer thrombolytics or anticoagulants. Anaphylactic y Epinephrine IM or IV y Tension pneumothorax: y Diphenhydramine Anticipate needle decompression. Neurogenic y Vasopressors (phenylephrine) y Cardiac tamponade: Prepare for y Atropine for severe bradycardia pericardiocentesis. y Administer IV fluids to maintain BP Cardiogenic y Inotropes (dobutamine) and cardiac output. y Diuretics
Obstructive y Treat underlying cause:
y PE: thrombolytics y Tension pneumothorax: Needle decompression y Cardiac tamponade: Pericardiocentesis
Signs of shock include hypotension, decreased If IV fluids fail to correct hypotension from septic _____ output, and altered _____ status. shock, use ________ (which medication class?) What is the priority intervention for hypovolemic to achieve a MAP of >_____ mmHg. shock? What is the priority intervention for anaphylactic In septic shock, which intervention must be completed shock? before administering antibiotics? To treat hypotension from septic shock, administer an IV fluid bolus of _____ mL/kg. Answers: 1. urine, mental status 2. Stop bleeding/fluid loss and then administer IV fluids 3. Collect blood cultures; 30 4. vasopressors, >65 mmHg 5. Administer epinephrine
