Shock + Sepsis & DIC

38 flashcards

What is shock?: A systemic condition where tissue perfusion is inadequate to deliver oxygen and nutrients to support vital organs and cellular function.
Shock Pathophysiology: Inadequate tissue perfusion ’ cells switch from aerobic to anaerobic metabolism ’ lactic acid production ’ cells swell ’ membrane becomes more permeable ’ electrolytes & fluids seep in & out of cell ’ Na+/K+ pump impaired ’ cell death
What effect does shock have on organs?: Heart: “ CO and hypotension Lung: “ gas exchange ’ tachypnea and pulmonary edema Endocrine: ‘ ADH ’ reabsorption of water CNS: “ perfusion ’ drowsy Blood: coagulation abnormalities ’ DIC Renal: “ GFR ’ “ urine output Gl: mucosal ischemia ’ bleeding & ‘ hepatic enzymes
What are the signs of shock if it's compensated?: 1. Vasoconstriction, tachycardia, ‘ heart contractility 2. The body shunts blood away from the skin, kidneys, and GI tract to maintain vital organ function 3. Clammy skin, hypoactive bowel sounds, “ urine output 4. Hyperventilation ’ compensatory respiratory alkalosis 5. Feeling of impending doom: anxiety, restlessness, confusion
What are the signs of the progressive stage of shock?: 1. “ BP and MAP ’ all organs suffer from hypoperfusion 2. Cardiac dysrhythmias and ischemia 3. Acute renal failure 4. Mental status further deteriorates from decreased cerebral perfusion and hypoxia ’ lethargy 5. Disseminated intravascular coagulation (DIC)
What is the refractory/decompensated stage of shock?: Irreversible organ failure and severe hypotension, with a SpO2 usually falling below 70%.
What is the general management strategy for shock?: Fluid replacement to restore intravascular volume Vasoactive medications to restore vasomotor tone, improve cardiac function Nutritional support to address metabolic requirements
What is septic shock?: A circulatory shock state resulting from overwhelming infection, causing organ dysfunction and hypotension.
What is the difference between septic shock and sepsis?: Sepsis develops into septic shock after vasopressor therapy. The patient is hypotensive but maintains a MAP of at least 65 and/or has a serum lactate greater than 3 mmol/L, despite adequate fluid resuscitation
What are the phases of septic shock?: Warm shock phase (compensated) and cold shock phase (decompensated).
What is the difference between warm septic shock vs cold septic shock?: Warm Shock Phase/Compensated Stage - Warm extremities - Reduction in capillary refill/flash capillary refill (< 1sec) Cold Shock Phase/Decompensated Stage The later phase is characterized by: - Cold extremities - Delayed capillary refill (> 3sec)
What is SIRS, and what is its criteria?: A syndrome resulting from an overwhelming inflammatory response by the body caused by various stressors ’ could be anything, not always infection, while sepsis is an infection Criteria - Two or more of the following 1. Temperature greater than 38 °C or less than 36 °C 2. HR greater than 90 bpm 3. RR greater than 20 breaths/min or PaCO2 less than 32 mmHg 4. WBC count greater than 12,000 or less than 4,000, or greater than 10% immature band forms
What are nursing interventions for septic shock?: 1. 1-hour sepsis bundle 2. Vasopressors for hypotension - Titrate norepinephrine to meet MAP goals, usually > 65 3. Inotropic Therapy - Dobutamine ’ ‘ CO without vasodilation (perfect for this, as vasoconstriction is needed to maintain perfusion)
What is cardiogenic shock?: Shock state resulting from impairment or failure of the myocardium ’ direct pump failure (40% necrosis of the left ventricle)
What are common signs of cardiogenic shock?: 1. Chest discomfort 2. Tachycardia & tachypnea ’ hypotension 3. Urine output < 0.5 - 1 mL/kg/hr 4. Cold, clammy skin with poor peripheral pulses & prolonged capillary refill 5. Pulmonary congestion ’ crackles, pulmonary edema 6. Agitation, restlessness, or confusion
What is a common device that is used to treat cardiogenic shock?: Since cardiogenic shock is a direct heart pump failure, using an IABP can reduce the workload of the heart and allow proper rest and healing
What are common medications used to treat cardiogenic shock?: Dobutamine Nitroglycerin Dopamine Other vasoactive medications Antiarrhythmic medications
What is hypovolemic shock?: Shock resulting from decreased intravascular volume due to fluid loss, leading to decreased cardiac output and perfusion
What are the signs of hypovolemic shock?: 1. Hypotension 2. Tachycardia 3. Cool, clammy skin (pallor), diaphoresis 4. Rapid and shallow breathing 5. Behavioral changes ’ confusion, extreme anxiety, agitation, etc. 6. Little to no urine
What are nursing interventions for hypovolemic shock?: 1. Treatment of the underlying cause 2. Administering replacement blood, medications, and fluids (crystalloids) safely 3. Redistribute fluids through positioning, temperature of the room, and decreasing anxiety - Modified Trendelenburg ’ similar to trendelenburg but only legs are raised - Uses gravity to increase blood flow to the brain and heart ’ ‘ CO
What are the signs of fluid overload?: Edema, crackles, bounding pulse, respiratory distress, HTN, anxiety
What is neurogenic shock?: Shock resulting from loss of sympathetic tone, causing relative hypovolemia, often due to spinal cord injury above T6 Results in disruption in communication pathways between upper motor neurons and lower motor neurons
What are the signs of neurogenic shock?: 1. Symptomatic bradycardia ’ HR < 60 bpm 2. Warm, pink & dry skin 3. Hypotension ’ SBP < 90 or MAP <65 mmHg 4. Reduced LOC and “ urine output 5. SpO2 <95% or symptoms of aspiration (stridor, garbled speech, inability to clear airway) 6. Poikilothermic - Neuron damage leads to inability to regulate temperature ’ patients can have a fever or be hypothermic (more common)
What interventions are critical in neurogenic shock?: 1. Rapid response ’ ICU 2. Raise the HOB 30 degrees 3. IV Fluids & vasopressors ’ increase BP 4. Dextran - plasma expander 5. Atropine - increases heart rate 6. Assess for autonomic dysreflexia, as it's common for it to follow neurogenic shock
How is sepsis diagnosed?: S/S of severe infection manifested by 2 or more of the SIRS criteria as a consequence of documented or presumed infection
What clinical tool is used to assist in the early identification of sepsis?: Modified Early Warning System (MEWS) Chart/Score - A bedside clinical tool used to identify early signs of patient deterioration by tracking vital signs If the score is >4, then 30-minute rounding is needed to avoid further deterioration
What is procalcitonin used for?: Lab test used to see if the infection is bacterial - This can be used to see if antibiotics are needed Not always used for sepsis to avoid unnecessary antibiotic resistance
What complications can arise from shock?: Organ dysfunction, multiple organ dysfunction (MODS), disseminated intravascular coagulation (DIC), and acute renal failure.
What characterizes severe sepsis?: Sepsis accompanied by organ dysfunction or tissue hypoperfusion.
What is serum lactate?: A byproduct of anaerobic metabolism, with normal levels < 2 mmol/L; Elevated levels indicate poor oxygenation and sepsis
What are the signs and symptoms of sepsis (S.E.P.S.I.S)?: Shivering, fever, or feeling very cold. Extreme pain or discomfort. Pale, discolored, or clammy/sweaty skin. Sleepy, difficult to wake up, or confused. Impending doom ’ I feel like I might die. Shortness of breath.
What is the treatment for sepsis?: Sepsis Bundle (Initial Resuscitative Therapy) ’ should be completed in 1 hour 1. Usually, isotonic crystalloids, 30 mL/kg, started within the first hour and completed within 3 hours 2. Labs drawn ASAP: CBC, serum lactate, blood culture, ABGs, procalcitonin - CBC, serum lactate, and blood culture are sepsis bundle-specific and need to be drawn and processed first 3. Broad-spectrum antibiotic therapy within the first hour - Start ABX before procalcitonin is processed, then stop it if it's negative or low 4. Antifungals can also be started within the first hour
Why is glucose management important in sepsis?: Hyperglycemia is more common as the body tries to overproduce glucose for stress-induced compensation ’ eventually glucose will run out, leading to hypoglycemia
What is DIC?: Disseminated Intravascular Coagulation, a condition characterized by hyperactive clotting and bleeding at the same time, leading to systemic blood clot formation.
Why do you bleed and clot at the same time in DIC?: Hyperactive clotting uses up the available platelets and clotting factors inside the body (a process called consumption coagulopathy) ’ no way to sustain normal clotting processes ’ hemorrhage risk
What are the signs of DIC?: 1. Bleeding: petechiae, ecchymoses (bruising), and blood coming from sites of wounds, IV lines, catheters, or mucosa 2. Renal Dysfunction: AKI, low CBC, hematuria, etc. 3. Low clotting factors (factor V & VIII, fibrinogen, and platelet counts) 4. Low O2 saturation and PaO2 from bleeding leading to anemia
What interventions are needed for DIC?: 1. Address the underlying cause - Ex. if DIC is related to sepsis, administer aggressive broad-spectrum antibiotic treatment and other sepsis bundle interventions 2. Initiation or increase of oxygen and/or ventilatory support 3. Foley for urine output monitoring from fluid resuscitation & blood replacement 4. Replace blood components - RBC transfusion for severe bleeding - Low-dose heparin to stop active hyperactive clotting, once severe bleeding stops - Coagulation factor replacement therapy
What is the role of isotonic crystalloids in sepsis treatment?: To increase stroke volume and cardiac output by staying in the vein.