Transcript Shockt

Introduction
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Definition of Shock
Types and Etiology of Shock
Signs and Symptoms of Shock
Case Study
– Body’s Response to Shock
– Treatment of Shock
– Prevention
• How to treat someone in anaphylactic shock
• Management of anaphylaxis in a hospital
setting.
Shock, what is it?
• Shock is a critical condition caused by a
sudden drop in blood flowing through the
body secondary to circulatory system failure
(an inadequate blood flow causing insufficient
delivery of oxygen & nutrients to meet the
metabolic needs of tissue).
• This can damage multiple organs
Types of Shock:
• Cardiogenic Shock
• Hypovolemic Shock
• Vascular/Distributive Shock
– Septic Shock
– Neurogenic - caused by damage to the nervous
system
– Anaphylactic - caused by allergic reactions
Cardiogenic Shock
• This type of shock is associated with heart
problems. It is due to a reduction in cardiac
output caused by a primary cardiac disorder.
• Example: severe myocardial infarction/
Cardiac failure!
Hypovolemic Shock
• This type of shock is caused by deficiency of
intravascular blood volume and the inability to
meet the metabolic needs of tissues.
• Example: Hemorrhage and dehydration
Vascular/Distributive Shock
• This type of shock is characterized by the loss
of blood vessel tone, enlargement of the
vascular compartment, and displacement of
the vascular volume from the systemic
circulation.
• Venous return is decreased in distributive
shock, which leads to a diminished cardiac
output but not a decrease in total volume; this
type of shock is also referred to normovolemic
shock.
• This type of shock is a systemic response to a
severe infection.
Neurogenic Shock
• This type of shock is caused by decreased
sympathetic control of blood vessel tone. This
is due to a defect in the vasomotor center
located in the brain stem.
• Example: Output from the vasomotor center
can be interrupted by brain injury, the
depressant actions of drugs, general
anesthesia, hypoxia, or lack of glucose.
Anaphylactic Shock
• This type of shock is considered the most
severe systemic allergic reaction. It results
from an immunologically mediated reaction in
which vasodilator substances such as
histamine are released into the blood.
• This causes vasodilation or arterioles and
venules along with a marked increase in
capillary permeability.
Causes of anaphylaxis
• Drugs
– Penicillin
• Foods
– Nuts
– Shellfish
• Environmental
– Insect venoms
– Latex
Early signs/symptoms of
Anaphylatic shock:
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Hypotension
High pulse rate: weak and rapid
Dyspnea, coughing, choking, wheezing, and chest tightness
Tachypnea/ hyperventilation
Dry mucous membranes
Burning & warming sensation of the skin, itching, and urticaria
(hives)
Restlessness
Anxiety or agitation
Nausea, abdominal cramps
Thirst
Weakness
WBC - elevated eosinophil count due to allergic reaction
Late symptoms of
Anaphylactic shock:
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Decreased urinary output
Severe fluid and electrolyte imbalance
Confusion
Hypothermia
Drowsiness
Diaphoresis, moist skin
Lethargy, that can lead to coma
Case Study
C.L. is a 35-year-old male
who is admitted to your
floor with a c/c of right
flank pain.
9:00 am The M.D. leaves the following orders:
R/O right renal calculi
V/S q 4 h
BR with BRP
Strain all urine
Strict I & O
CBC, SMAC 20, Chest x-ray, EKG
Intravenous Pylogram (I.V.P.) this AM
D5 2 N/S 300 cc/hr.
Demerol 100 mg IM q 4 h prn for pain
At 9:05 am the nurse clarifies the M.D. orders:
R/O right renal calculi
V/S q 4 h
BR with BRP
Strain all urine
Strict I & O
CBC, SMAC 20, Chest x-ray, EKG
Intravenous Pylogram (I.V.P.) this AM
D5 2 N/S 300 cc/hr.
Demerol 100 mg IM q 4 h prn for pain
10:00 a.m
• You accompany C.L.
for his I.V.P.
• The tech administers
the contrast medium
I.V.
10:05 a.m.
Within minutes C.L. c/o his lips feeling tingly,
his tongue swollen and that he has difficulty
swallowing and breathing. He states, "I feel like
I'm dying." You place him in semi-fowlers and
take his v/s.
R 30 with progressive difficulty and stridor
Wheezes heard on auscultation.
B/P 80/60
P 120 thready
Skin flushed, dry
10:10 a.m.
Epinephrine (1:1000) 1.0 ml S/C
is given STAT
- IV #1 is changed to 0.9% N/S 1000
cc
- A second I.V. is initiated with 0.9%
N.S. Both IV's are rapidly infusing.
- Arterial Blood Gases (ABGs) are
drawn and sent stat.
- Oxygen at 100% via mask is applied.
10:20 a.m.
Vital Signs:
B/P: 84/68
PR: 124 bounding
RR: 26 S.O.B. noted; decreased stridor,
decreased wheezes noted.
Dopamine gtt. is hung - to be titrated to
maintain systolic > 80 to 110 mmHg.
10:30 a.m.
Vital Signs:
BP:92/68
HR:120 Reg.
RR:24
•lungs clear throughout
without wheezing or stridor.
•Patient c/o that he "feels itchy
all over.“ You note urticaria
diffusely over his body.
• Benadryl 75 mg IM is given
STAT with some relief.
10:45 a.m.
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Vital Signs
BP: 108/170
PR: 100 Reg
RR: 22
Patient A & 0 x3. Skin cool,
flushed and dry.
Minimal S.O.B. noted without
diaphoresis, wheezes or
stridor.
Patient states that he is
breathing easier and has
decreased itching.
Cardiac monitor ---> Normal
Sinus Rhythm (NSR).
• IV #1 0.9% N/S rapidly
infusing in the right antecubital
space.
• I.V.#2 0.9% N/S rapidly
infusing in the left antecubital
space.
• Dopamine gtt @ 4
mcq/kg/min infusing.
• ABG results: pH 7.31
PO2 95
CO2 35
HCO2 19
O2Sat 99
• Transferred to
M.I.C.U.
• Dr. Jones in
attendance.
• M.Smith, R.N.
Question 1:
As the primary nurse in charge of C.L’s
care, you check his chart for allergies. You
note that he is only allergic to “shellfish”.
What, if any, is the connection between an
allergy to shellfish and contrast medium?
Differences between a CM allergy
and a Shellfish allergy
Contrast Medium (CM) Allergy
CM is an iodine based substance used in radiology.
CM can cause allergic reaction r/t to either Iodine itself or
the dye component of CM.
Allergy to the IV dye is not a true allergy
• The dye causes the direct release of histamine and other
chemicals from mast cells without the help of allergic
antibodies
Shellfish Allergy
Shellfish contains iodine, but allergy to shellfish is caused
by the protein tropomyosin and NOT the iodine component.
Relation between a Contrast
Medium and Shellfish Allergy
No Correlation btw Allergy to shellfish and CM !
Allergy to Iodine should be tested
independently whether allergy to fish is
present or not.
Contrast Medium
It is generally used to improve the visibility of
internal bodily structures in an x-ray image.
Question 2 & 3:
What is the pathophysiology behind
Anaphylactic Shock?
What chemical mediators are responsible for
vasodilation and increased capillary
permeability?
Pathophysiology of Shock
Immunologic Disorders
There are three levels of immunologic
disorders:
•Hypersensitivity – allergy response
• Autoimmune Disease – body’s response
against self-antigens
• Immunodeficiency – the immune
response is below normal
Hypersensitivity
Hypersensitivity is an immune response
that is beyond normal and is damaging
rather than beneficial
Hypersensitivity
There are 4 classes of hypersensitivity:
• Type I (anaphylactic) reaction
• Type II (cytotoxic) reaction
• Type III (immune complex) reaction
• Type IV (delayed cell-mediated) reaction
Hypersensitivity – Type I
(anaphylactic) reaction
Type I (anaphylactic) reaction can be:
• Localized
• Systemic
Hypersensitivity – Type I
(anaphylactic) reaction
Localized anaphylactic reaction:
• Usually ingested or inhaled allergens
• Symptoms include:
– Hives
– Asthma
– Hay fever
Hypersensitivity – Type I
(anaphylactic) reaction
Systemic anaphylactic reaction
• Usually injected allergens, but can be
ingested
• Very quick response
• Symptoms include:
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coughing
edema
drop in blood pressure
possibly death
Hypersensitivity
• Upon the first exposure to an allergen a person
will not necessarily develop a response.
•Antibodies (Immunoglobins (Ig) will be formed
after the first exposure to fight off the same
allergen upon a second exposure.
Mechanism of Type I
(anaphylactic) Hypersensitivity
• Specifically Immunoglobin E (IgE) is found
floating around the cell and also bound to
basophils and mast cells
• When an allergen enters the body the
allergen will bind with IgE on
the basophils and mast cells
Mechanism of Type I
(anaphylactic) Hypersensitivity
• A signal transduction
pathway will tell the cell
to degranulate and
release chemical
mediators such as
histamines, leukotrines,
and prostaglandins
Mechanism of Type I
(anaphylactic) Hypersensitivity
• Chemical mediators
cause dilation and
leakage of plasma
from capillaries,
airway constriction,
and increased mucus
production
• This, in turn, can
cause itching,
swelling, and pain
Chemical Mediators
• Many chemical mediators of inflammation are released by
Human Mast Cells and Basophils including:
Mediator
Chemical Characteristics
Histamine
Simple Amine
Prostaglandin
Simple Amine
Platelet-activating factor (PAF)
Phospholipid
Leukotrienes
Acid lipid
Neutral Proteases
Small protein enzymes
Acid Hydrolases
Fairly large proteins
Heparin
Peptide chain bearing longchain sulfated amino sugars
Superoxide dismutase
Enzymatic protein
The three most responsible for
vasodilation and increased capillary
permeability are:
1) Histamine
2) Prostaglandin
3) Leukotrienes
Histamine
 Once histamines are released
into the tissues, they exert a
variety of effects:
 Contracts visceral smooth
muscle
 Causes inflammation
 Increases permeability of
capillaries
 Increases respiratory
mucous gland activity
 Produces sensation of
itching
 Dilate Blood Vessels
 Stimulate gland secretion
 Prompt the release of
proteins from cells
 These effects, in turn, help the
body rid itself of foreign
invaders
 Dilation of blood vessels
increases circulation to the
injured area, washing away
harmful bacteria
 Proteins also attract other
immune cells to the area, such
as macrophages.
Leukotrienes
• Leukotrienes are inflammatory mediators
that cause vasodilation and mucosal
swelling, which results in inflammation and
congestion.
• Leukotrienes are also responsible for:
– Prolonged visceral smooth muscle spasm
– Increased permeability of venules
Prostalglandin
• Prostalglandins are mediators that have
strong physiological effects:
– Vasodilation
– Bronchodilation
– GI tract smooth muscle contraction
– stimulates constriction and clotting of platelets
– Increases mediator release by basophils
Chemical Mediators
Inflammation
• Caused by the release of histamine from
basophil or mast cells
• Directly effects epithelial cells of vessel wall
– Pulls the epithelial cells apart from each other
– Installs cell adhesion molecules (CAM) on the
surface of the vessel wall
• Causes leukocytes to stick to the CAM on the
sides of the vessel wall
• Leukocytes then squeeze through the gaps
created by the epithelial cells
Inflammation
• When leukocytes reach their target, they
secrete more cytokines, which recruit more
neutrophils and macrophages
• Leukocytes secrete colony stimulating factor,
which causes the bone marrow to create more
leukocytes
Inflammation
07/31/08
Inflammation
Inflammation
Question 4:
How is the Cardiovascular System
affected by anaphylaxis?
In anaphylaxis, the cardiovascular
symptoms are:
-Hypotension
-Vasodilation occurs when the muscular walls of the
arteries dilates and relaxes causing the cardiac
output to decrease and peripheral vascular
resistance.
-Increased capillary permeability leads to the leakage
of fluid through the epithelium from the blood to the
interstitial fluid.
-Vasodilation and increased capillary permeability
causes hypovolemia
-Tachycardia
- is a result to compensate for the low blood volume
circulating through the body
Question 5:
How is the Pulmonary System affected by
anaphylaxis?
The Effects of Shock on the Pulmonary System
The Effects of Shock on the Pulmonary System
Question 6:
What are some complications that can
result from Anaphylactic Shock?
Complications of Anaphylactic
Shock
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Airway Blockage
Cardiac or respiratory arrest
Arrhythmias
Laryngeal edema
Myocardial ischemia
Hypoxia
-Prolonged hypoxia [possibly leading to brain injury
• Death
Multiple Organ Failure
• Brain:
- Ischemia encephalopathy: Decrease of tissue perfusion in the brain.
• Heart:
-Coagulation necrosis: Decrease of tissue perfusion in the brain.
-Subendocardial hemorrhage: large amount of blood loss in inner layer of
myocardium.
-Contraction band necrosis: inability of myocardial cells to contract.
• Kidneys:
-Tubular ischemia injury causing oliguria: decreased urine output.
-Anuria: absence of urine
-Electrolyte disturbances
Multiple Organ Failure Continued
• Lungs:
-Shock lung: edema, impaired
perfusion, reduction in alveolar
space causing atelectasis and
impaired breathing.
• Adrenals:
-Cell lipid depletion
• GI:
-hemorrhagic enteropathy:
hemorrhage and necrosis of
intestinal lining
• Liver:
-fatty deposits or central
hemorrhagic necrosis
Widespread Tissue Hypoxia
Oxygen deficit from
decreased
respiration rate
This lowers the pH of
tissues and organs
and causes
vasodilatation
Vasodilatation
debilitates cardiac
output
Causes intracellular
aerobic respiration to
cease
Lactic acid is
produced and causes
the pH of the blood to
decrease
With decreased
cardiac output the
tissues are at risk for
hypoxic injury
Anaerobic respiration
produces lactic acid
If not corrected
immediately,
irreversible damage
can take place and
death can ensue.
Anaerobic respiration
takes over
Question 7:
How do the following affect hemodynamic
stabilization?
A- Rapid Infusion of IV fluids.
(2-3 L in 20-30 min)
B- Epinephrine
C- Dopamine
Hemodynamic Stabilization:
Restoring the Rate and Rhythm of the Heart
• Rapid Infusion:
 2-3 Liters of fluid in 20-30 minutes.
-This increases blood volume.
-Isotonic solution is used (e.g. 0.9% saline)
Hemodynamic Profile:
Characteristic of Shock State
• Systolic arterial pressure less than 90 mm Hg or 30 to 60 mm Hg below
the previous baseline level.
• Evidence of decreased blood flow to major organ systems:
- Urine output less than 20 ml/hour, usually with decreased sodium
content
- Peripheral vasoconstriction associated with cold, clammy skin
- Impaired mental function
• Cardiac index less than 2.1 L/min/m2
• Evidence of left-sided heart failure with LVEDP/pulmonary capillary
wedge pressure (PCWP) greater than 18 to 21 mm Hg.
Hemodynamic Stabilization:
Epinephrine and Dopamine
• Vasopressor agents
-Stimulate alpha receptors to vasoconstrict, which increases arterial
blood pressure and resistance to ventricular ejection.
-Stimulate beta receptors to increase contractility.
• Both effects are beneficial to the stabilizing of circulation.
-Possibility of danger because both effects increase need for oxygen
increasing myocardium infarction.
• Use of Vasopressor usually limited to extreme
hypotension that no other therapy will have an effect.
Epinephrine
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Vasopressor
Antagonizes the effects of Histamine
Relaxes smooth muscle of bronchi
Positive chronotropic and inotropic effects on heart
Raises blood sugar
Rapid IV infusion: direct stimulation of heart and increases
systolic blood pressure
• Slow IV infusion: increase in systolic pressure and decrease
in diastolic
Dopamine
• Vasopressor
• Increases pumping strength and function of heart and kidney
blood supply.
• Selective vasodilator by redirecting blood flow to critical
organs.
• Increases cardiac output
• Causes vasoconstriction which increases the systemic
vascular resistance.
• Dopamine is typically used in septic shock or cardiogenic
shock.
Question 8:
What is the rationale for giving Benadryl 75 mg
IM stat to C.L.?
Why Benadryl?
Benadryl has “antihistamine and
antipruritic effects” Benadryl is
given to "competitively block the
effects of histamine at H1 receptor
sites." Benadryl therefore works to
combat the increase of histamines
that his body produced in response
to the allergy.
So is the dosage correct?
75mg IM of Benadryl is an appropriate dose
to administer to CL because Benadryl can be
administered “10-50mg IV or deep IM up to
100mg if required”
Question 9:
Interpret C.L.’s ABGs?
What is normal?
pH
7.35-7.45
pO2
80-100
HCO222-26
CO2
35-45
SaO2
95-100%
Clients ABG Results
pH
7.31
low
pO2
95
Normal
CO2
35
Normal
HCO2 -
19
low
SaO2
99
Normal
ABG Interpretation
Question 10:
List, in priority order, three nursing diagnoses
Prioritized Nursing Diagnosis
1
• Ineffective Airway Clearance
R/T constricted airways
2
• Decreased cardiac output R/T
insufficient blood volume
3
• Decreased peripheral tissue
perfusion R/T vascular dilation
Question 11:
Before C.L. is discharge from the
hospital, what needs to be taught
to him in terms of patient
education, re: his allergic
reaction?
Education
Foods that may cause an allergic response
When dining out, ask the chef if foods may
contain minor traces of shellfish
Environmental allergies
How to react to anaphylactic shock
When diagnostic testing make sure patient
has not prior allergies to contrast medium
Education
Educate about the use and importance of
EpiPens and Epinephrine pumps
Medical I.D. bracelets or watches could be
purchased for ease of allergy recognition.
These bracelets states the person’s name,
medical condition, specific allergens that
cause anaphylatic shock.
Epinephrine
• EpiPen is a prescribed medication by a physician
who will educate the proper technique of using this
device.
• Patients are encourage to use the medication before
the device’s expiration date.
• However, it has no adverse affects if used after the
expiration date
EpiPen
Adult: one adult auto-injector (0.3 mg)
Infant and child: one infant/child auto-injector
(0.15 mg)
Question 12:
How might this incident have been avoided?
Prevention
• Learn about situations that can trigger a
response or increase risk of exposure
• Participate in precautionary measures such
as skin tests and use of antihistamines or
corticosteroids prior to exposure of possible
triggers
• Wear a tag that identifies any allergies
• Always look at labels and be aware of
ingredients
Emergency Plan
• Despite using all possible preventative
measures, it is not always possible to avoid
an allergic reaction.
• Have a written emergency plan and make it
available to places frequently visited such as
school and work
• If at high risk, carry an EpiPen
What to do if you find someone is
in anaphylatic shock?
• Call 911
• Check ABC
• Ask bystanders the events leading up to anaphylatic
reaction
• Continuously check the rate of breathing
• Place the patient in shock position if conscious and
without injuries.
[ Lie flat, elevate legs/ high-flow oxygen, support
airway and assist ventilation as required.]
What to do if you find someone in
anaphylatic shock?
• Continuously check the
rate of breathing
• Place the patient in
shock position if
conscious and without
injuries.
• Keep the patient warm
and comfortable
Management of Anaphylaxis in a
hospital setting:
• http://video.aol.com/video-detail/anaphylacticshock-when-allergies-are-deadly/2165467462