CARDIOGENIC SHOCK

Cardiovascular System

Tachycardia

↓ BP

↓ Capillary refill

↑ MVO2

Chest pain may or may not be present

HYPOVOLEMIC SHOCK

Cardiovascular System

↓ Preload

↓ Stroke volume

↓ Capillary refill

NEUROGENIC SHOCK

Cardiovascular System

↓ BP

↓/↑ Temperature

Bradycardia

ANAPHYLACTIC SHOCK

Cardiovascular System

Chest pain

Third spacing of fluid

SEPTIC SHOCK

Cardiovascular System

↓/↑ Temperature

Myocardial dysfunction

Biventricular dilation

↓ Ejection fraction

OBSTRUCTIVE SHOCK

Cardiovascular System

↓ Blood pressure

↓ Preload

CARDIOGENIC SHOCK

Pulmonary System

Tachypnea

Crackles

Cyanosis

Rhonchi

HYPOVOLEMIC SHOCK

Pulmonary System

ANAPHYLACTIC SHOCK

Pulmonary System

Shortness of breath

Edema of larynx and epiglottis

Wheezing

Stridor

Rhinitis

SEPTIC SHOCK

Pulmonary System

Hyperventilation

Respiratory alkalosis → respiratory acidosis

Hypoxemia

Respiratory failure

ARDS

Pulmonary hypertension

Crackles

OBSTRUCTIVE SHOCK

Pulmonary System

Tachypnea → bradypnea (late)

Shortness of breath

CARDIOGENIC SHOCK

Renal System

Skin

↑ Na+ and H2O retention

↓ Renal blood flow

↓ Urine output

Pallor

Cool, clammy

HYPOVOLEMIC SHOCK

Renal System

Skin

↓ Urine output

Pallor

Cool, clammy

NEUROGENIC SHOCK

Renal System

Skin

Bladder dysfunction

↓ Skin perfusion

Cool or warm

Dry

ANAPHYLACTIC SHOCK

Renal System

Skin

Incontinence

Flushing

Pruritus

Urticaria

Angioedema

SEPTIC SHOCK

Renal System

Skin

↓ Urine output

Warm and flushed → cool and mottled (late)

OBSTRUCTIVE SHOCK

Renal System

Skin

↓ Urine output

Pallor

Cool, clammy

CARDIOGENIC SHOCK

Neurologic System

Gastrointestinal System

↓ Cerebral perfusion:

•Anxiety

•Confusion

•Agitation

↓ Bowel sounds

Nausea/vomiting

HYPOVOLEMIC SHOCK

neuro

Gi

↓ Cerebral perfusion:

•Anxiety

•Confusion

•Agitation

Absent bowel sounds

neurogenic shock

neuro

Gi

Flaccid paralysis below the level of the lesion

Loss of reflex activity

Bowel dysfunction

anaphylactic shock

neuro

GI

Anxiety

Feeling of impending doom

Confusion

↓ LOC

Metallic taste

Swelling of lips and tongue

Cramping

Abdominal pain

Nausea

Vomiting

Diarrhea

septic shock

neuro

Gi

Alteration in mental status (e.g., confusion)

Agitation

Coma (late)

GI bleeding

Paralytic ileus

obstructive shock

gi 

neuro

↓ Cerebral perfusion:

•Anxiety

•Confusion

•Agitation

↓ to absent bowel sounds

COMPENSATORY STAGE

Neurologic System

Cardiovascular System

Oriented to person, place, time

Restless, apprehensive, confused

Change in level of consciousness

Sympathetic nervous system response

•Release of epinephrine/norepinephrine, which promotes vasoconstriction

↑ MVO2  ↑ Contractility  ↑ HR

Coronary artery dilation

Narrowed pulse pressure

↓ BP but adequate to perfuse vital organs (heart, brain)

compensatory stage 

respiratory 

GI

↓ Blood flow to the lungs

•↑ Physiologic dead space

•↑ Ventilation-perfusion mismatch

•Hyperventilation

•↑ Minute ventilation (VE)

↓ Blood supply

↓ GI motility

Hypoactive bowel sounds

↑ Risk for paralytic ileus

compensatory

renal 

skin

↓ Renal blood flow

↑ Renin resulting in release of angiotensin (vasoconstrictor)

↑ Aldosterone resulting in Na+ and H2O reabsorption

↑ Antidiuretic hormone resulting in H2O reabsorption

Pale and cool

Warm and flushed (early onset of septic shock)

progressive

neuro

cardiovascular

↓ Cerebral perfusion pressure

↓ Cerebral blood flow

Listless or agitated

↓ Responsiveness to stimuli

↑ Capillary permeability → systemic interstitial edema

↓ Cardiac output → ↓ BP and ↑ HR

MAP <60 mm Hg (or 40 mm Hg drop in BP from baseline)

↓ Coronary perfusion → dysrhythmias, myocardial ischemia, myocardial infarction

↓ Peripheral perfusion → ischemia of distal extremities, diminished pulses, ↓ capillary refill

progressive 

respiratory

Gi

Acute respiratory distress syndrome (ARDS)

•↑ Capillary permeability

•Pulmonary vasoconstriction

•Pulmonary interstitial edema

Alveolar edema    Diffuse infiltrates

↑ Respiratory rate      ↓ Compliance

•Moist crackles

Vasoconstriction and ↓ perfusion → ischemic gut (e.g., stomach, small and large intestines, gallbladder, pancreas)

Erosive ulcers  Gl bleeding

Translocation of Gl bacteria  Impaired absorption of nutrients

progressive 

renal 

hepatic

Renal tubules become ischemic → acute tubular necrosis

↓ Urine output

↑ BUN/creatinine ratio

↑ Urine sodium

↓ Urine osmolality and specific gravity

↓ Urine potassium

Metabolic acidosis

Failure to metabolize drugs and waste products

Cell death (↑ liver enzymes)

Jaundice (decreased clearance of bilirubin)

↑ NH3 and lactate

progressive

blood 

temp 

skin

DIC

•Thrombin clots in microcirculation

•Consumption of platelets and clotting factors

Hypothermia

Sepsis: hypothermia or hyperthermia

Cold and clammy

irreversible stage

neuro

cardiovascular

↓ Cerebral blood flow

Listless or agitated

↓ Responsiveness to stimuli

Unresponsive

Areflexia (loss of reflexes)

Pupils nonreactive and dilated

Profound hypotension

↓ Cardiac output

Bradycardia; irregular rhythm

↓ BP inadequate to perfuse vital organs

irreversible

respiratory

GI

Severe refractory hypoxemia

Respiratory failure

Ischemic gut

irreversible stage

renal

hepatic

hematological

Anuria

Metabolic changes from accumulation of waste products

(e.g., NH3, lactate, CO2)

DIC progresses

emergency management shock

INITIAL 

ONGOING

Initial

•Assess ABCs.

•Stabilize cervical spine as appropriate.

•Administer high-flow oxygen (100%) by non-rebreather mask or bag-valve-mask.

•Anticipate need for intubation and mechanical ventilation.

•Establish IV access with two large-bore catheters (14-16 gauge) and begin fluid resuscitation with crystalloids (e.g., normal saline solution).

•Draw blood for laboratory studies (e.g., blood cultures, lactate, WBC)

•Control any external bleeding with direct pressure or pressure dressing.

•Assess for life-threatening injuries (e.g., pericardial tamponade, liver laceration, tension pneumothorax).

•Consider vasopressor therapy if hypotension persists after fluid resuscitation.

•Insert an indwelling bladder catheter and nasogastric tube.

•Administer antibiotic therapy if sepsis is suspected.

•Treat dysrhythmias.

Ongoing Monitoring

•Vital signs, including pulse oximetry; peripheral pulses, capillary refill, skin color and temperature

Respiratory status  Cardiac rhythm

Urine output     Level of consciousness

cardiogenic shock 

collaborative care

oxygenation

circulation

•Provide supplemental O2 (e.g., nasal cannula, non-rebreather mask)

•Intubation/mechanical ventilation, if necessary

•Monitor SvO2 or ScvO2

•Restore blood flow with thrombolytics, angioplasty with stenting, emergent coronary revascularization

•Reduce workload of the heart with circulatory assist devices: IABP, VAD

cardiogenic shock

collaboritive care

drug therapiies

supportive therapies

•Nitrates (e.g., nitroglycerin)

•Inotropes (e.g., dobutamine)

•Diuretics (e.g., furosemide)

•β-Adrenergic blockers (contraindicated with ↓ ejection fraction)

supportive

Correct dysrhythmias

hypovolemic shock

collaboritive care

oxygenation

circulation

•Provide supplemental O2

•Monitor SvO2 or ScvO2

•Restore fluid volume (e.g., blood/blood products, crystalloids)

•Rapid fluid replacement using two large-bore (14-16 gauge) peripheral IV lines

•End points of fluid resuscitation:

•CVP 15 mm Hg

•PAWP 10-12 mm Hg

hypovolemic shock

use warmed fluids

septic shock

collaborative care

oxygenation

circulation

•Provide supplemental O2

•Intubation/mechanical ventilation, if necessary

•Monitor SvO2 or ScvO2

•Aggressive fluid resuscitation

•End points of fluid resuscitation:

•CVP 15 mm Hg

•PAWP 10-12 mm Hg

septic shock

collaborative care

drug therapy

supportive therapy

•Antibiotics as ordered

•Vasopressors (e.g., dopamine)

•Inotropes (e.g., dobutamine)

•Anticoagulants (e.g., low-molecular-weight heparin)

•Drotrecogin alfa (Xigris) for patients with high risk of death

•Obtain cultures (e.g., blood, wound) before beginning antibiotics

Monitor temperatureControl blood glucose

•Stress ulcer prophylaxis

neurogenic shock

collaboritive care

oxygenation 

circulation

•Maintain patent airway

•Provide supplemental O2

•Intubation/mechanical ventilation, if necessary

•Cautious administration of fluids

neurogenic shock

collaboritive care

drug therapy

supportive therapy

•Vasopressors (e.g., phenylephrine)

•Atropine (for bradycardia)

•Minimize spinal cord trauma with stabilization

•Monitor temperature

anaphylactic shock

collaboritive care

oxygenation

circulation

•Maintain patent airway

•Optimize oxygenation with supplemental O2

•Intubation/mechanical ventilation, if necessary

•Aggressive fluid resuscitation with colloids

anaphylactic shock

collaboritive care

drug therapy

supportive therapy

•Antihistamines (e.g., diphenhydramine)

•Epinephrine (subcutaneous, IV, nebulized)

•Bronchodilators: nebulized (e.g., albuterol)

•Corticosteroids (if hypotension persists)

•Identify and remove offending cause

•Prevention via avoidance of known allergens

•Premedication with history of prior sensitivity (e.g., contrast media)

obstructive shock

collaboritive therapy

oxygenation

circulation

•Maintain patent airway

•Provide supplemental O2

•Intubation/mechanical ventilation, if necessary

•Restore circulation by treating cause of obstruction

•Fluid resuscitation may provide temporary improvement in CO and BP