SHOCK Trauma

- Condition of profound _______________________________ disturbance

- ____________blood flow and oxygen delivery to the capillaries and tissues of the body

Classification of Shock:

1. Hypovolemic Shock
 _____________ form of shock
 Results from loss of circulating blood volume in the intravascular bed
 Decrease circulating oxygenated blood flow to the body
 Lead to inadequate tissue perfusion causes cellular hypoxia, organ failure and
death
 Causes:
 Hemorrhage – most common
 Vomiting and diarrhea
 GI bleeding
 Trauma/surgery
 DIC – adnormal unrelated clotting in the bloodstream throughout
the body
 Thrombocytopenia
 Hemophilia – bleeding disorder resulting from deficiency in
speficic coagulation proteins, f8 ( A/classic hemophilia), f9 (
B/xmas dse), x-linked recessive, male affected, female carrier
 Renal losses
 DM – hyperglycemic osmotic diuresis
 DI
Pathophysiology:
 ↓ circulating blood volume - ↓ venous return to the right side of the heart
 ↓ cardiac filling - ↓pressure and volume
 ↓ preload – filling volume of the ventricle
 ↓ stroke volume – volume of blood that is ejected during systole
 ____________________ – hypotension, ↓ oxygenated blood flow to organs and
inadequate tissue perfusion
 Anaerobic metabolism to produce ATP for energy – accumulation of lactic acid →
metabolic acidosis
 Respiratory system compensates – increase RR to blow off CO2 and raise blood pH →
_____________________
 ANS stimulation: SNS – adrenal organs (medulla)to release E and NE
 Increase heart rate
 Increase heart contractility to attempt to increase CO
 Vasoconstriction to maintain BP for the blood flow to vital organs specially brain
and heart
 Increase RR
  Kidneys: Renin (angitensinogenase - RAS) – ____________________ converted in the
lungs stimulates adrenal organs (cortex) to produce aldosterone promotes renal
reabsorption of Na and water
 Hypothalamus: ADH/vasopressin renal reabsoprtion of water – decrease urinary output
 Compensatory mechanism fails → hypoxia and decrease tissue perfusion to organs
heart and brain → confused, restless, uncooperative/combative and condition
deteriorates, organ ischemia leading to comatose and death

Clinical Manifestations:
1. Weight loss
2. ____________________ BP / orthostatic / postural hypotension
3. Narrowed pulse pressure
4. ↑RR, PR – rapid, weak, thready pulses – weak and absent pulses
5. Hypoxia
6. Dry/ sticky mucosa
7. ↓ UO – 10 ml/hr
8. Thirst
9. Pale and cool skin
10. Delayed capillary refill
11. Changes in LOC – confusion, restless and anxiousness
12. Cardiac dysrhythmias
13. Diagnostic findings
 Increased Urine Specific Gravity
 Urine tests that measures the ability to concentrate urine
 Normal value _________________
 Increased: more concentrated urine, insufficient fluid intake, decreased renal
perfusion or increased ADH
 Decreased: less concentrated urine, increased fluid intake, DI
 Increased hematocrit (HCT)
 Blood test used to measure the percentage of whole blood made up of RBC
 Increased: DHN, Hypoxia
 Decreased: Overhydration, Anemia
 Increased serum osmolality (hyponatremia, fluid and electrolyte balance
measurement) ______________________________
 Increased BUN
 Serum test measures nitrogeneous urea: byproduct metabolism of CHON in
liver
 Renal clearance of N.U. waste products
 Not always an indication of renal disease
 DHN, poor renal perfusion, high CHON intake, infection, stress,
corticosteroid use
 N:10-20 mg/dl
 Increased Creatinine
  Serum tests measures amount of creatinine: end product of CHON and
muscle metabolism
 Reflects glomerular filtration rate
 Increase means renal disease: 50% renal function is lost
 N:0.5-1.5 mg/dl
14. Hemodynamics results
 Hemodynamic values for Hypovolemic Shock
 Decreased CVP
= CVP: pressure which blood is return in SVC and RA
= Transducer: 0 point at the level of right atrium
= client must be supine: HOB at 45 degrees
=relaxed: coughing/straining will increase intrathoracic pressure: False high
= normal 3-8 mmHg
= increased: excessive fluid
=decreased: decrease circulating blood
 Decreased PAP (10-20 mmHg)
 Decreased PAWP (6-12mmHg)
 Decreased Cardiac Output (4-6 L/min)
= pulmonary artery catheter ports
= inserted in radial/brachial/femoral artery then measured by transducer

Management:
Goal – ________________________________________

 Oral fluids
 Monitor patient intake and output
 Weigh patient daily
 Massive fluid resuscitation
Two large bore IC catheters
Rapid infusion device
Plasma CHON infusion: albumin
Crystalloids
- ________________ bolus initially
- Evaluate if more than _________ can cause edema
- PNSS
- Avoid dextran - ↓platelet adhesiveness
 Monitor urinary output
 Monitor vital signs
 Blood Transfusion: ___________________, Hbg of 7-8 g/dl, Hct 21 – 24%
 Fresh frozen plasma, platelets, packed RBC
 Administer vasopressors as ordered to maintain BP and increase cardiac contractility
 Dopamine _____________ and Norepinephrine _______________
 Monitor ABG results - Oxygen therapy to ensure tissue perfusion
 100% oxygen : __________________________
  Position the patient:
 mild – HOB elevated 30-60 to maintain pulmonary ventilation
 severe – supine/flat/ legs elevated not higher than a pillow
 avoid t-burg position – mediastinal pressure of abdominal contents against
diaphragm leading to decrease pulmonary compliance

Stages of Hypovolemic Shock

Compensatory Stage
- Fluid loss of __________ / 750-1500ml
- SNS stimulation: release of epinephrine/norepinephrine
- Normal to decrease blood pressure, narrowed pulse pressure,
tachycardia, tachypnea (respiratory alkalosis), hypoxia, decrease U.O.,
thirst, pale and cool skin, delayed capillary refill, changes in LOC
(confusion, restlessness, anxiousness)
Progressive Stage
- Fluid loss of _______________ / 1500 – 2000ml
- Increase CR, cardiac dysrhythmias (irregular heart beat) lead to
myocardial ischemia (lack of blood flow to the heart), hemodynamics
decrease, Systemic Vascular Resistance increase due to peripheral
vasoconstriction (SVR- blood flow, viscosity and lining of the blood
vessel), lead to decrease capillary blood flow to tissues leading to
increase capillary hydrostatic pressure lead to third space fluid shifting-
edema (pulmonary) hypoxemia respiratory/metabolic acidosis,
hypotensive, narrowed pulse pressure, kidneys decrease function –
oliguria, BUN and creatinine increase, LOC deterioration – decrease
cerebral perfusion, lethargic, confused, comatose, Multi-organ
dysfunction syndrome (MODS)
Refractory or Irreversible Stage
- Fluid loss greater than __________ / > 2000ml
- Organ failure, imminent death
- Bradycardia, CP arrest

2. Cardiogenic Shock
 Failure of the heart to pump adequately
 Results from decrease cardiac output and compromising tissue perfusion
 40% of the left ventricle necrosis: occlusion of major coronary vessels
 Decreased blood flow to coronary arteries leading to cardiac hypoxia
 Causes:
- Most common: dysrhythmias: Heart attack/Myocardial infarction
- CHF
- cardiac tamponade
 accumulation of fluid in the pericardium
 pericarditis
  pericardial effusion
 restrict ventricular filling – decrease cardiac output
 muffled heart sounds
 pericardiocentesis
 Assessment:
 Hypotension: ___________________________- lower than the client’s
baseline
 U.O. < 30 ml/hr
 Cold clammy skin
 Poor peripheral pulses : weak and thready
 Tachycardia
 Tachypnea
 Pulmonary congestion: blood backs up the pulmonary system, fluid leaks
out the pulmonary capillaries into lung tissue and alveoli causes
pulmonary edema: Crackles
 Altered LOC: disorientation, restlessness and confusion
 Chest discomfort: pain and tightness
 Changes in ECG: ST depression, T inversion, ST elevation, PVC
 Decrease capillary refill
 Interventions:
 Adm _____________________
- Opioid analgesics: suppress pain but can suppress respiration and
coughing reflex
- decrease pulmonary congestion and relieve pain
- avoid for gall bladder surgery: spasm of sphincter of the oddi: mascular
valve that controls flow of digestive juices (bile and pancreatic juices
- Avoid for respiratory disorders, head injuries, increased ICP, seizures
 Adm O2 as prescribed
 Prepare for intubation and mechanical ventilation
 Administer vasopressors and positive inotropics to maintain organ
perfusion
 Vasopressors: Dopamine (Intropin) and Norepinephrine (Levophed)
 Positive Inotropics: Dobutamine, Digoxin (cardiac glycoside): stimulate
myocardial contractility – increase cardiac output – improve blood flow to
kidneys and peripherys – increase organ perfusion
 Monitor apical pulse: 60 b/m withheld the medication
 Monitor K level: causes hypokalemia: Toxicity: therapeutic digoxin range:
0.5-2 ng/ml
 Nitroglycerin: dilate coronary artery to decrease angina pain
 Na nitroprusside (Nipride): ________________________________
 Preload: filling volume of the ventricle at the end of the diastole
 Afterload: amount of resistance against which the left ventricle pumps:
influenced by blood viscosity, flow patterns: Increase resistance more
 myocardium has to work to overcome the resistance. Determine by the
blood pressure.
 Monitor arterial blood gas level and prepare to treat imbalances
 Monitor urinary output
 Prepare client for insertion of Intraaortic Balloon Pump: improve coronary
artery perfusion and improve cardiac output
 Diastole: Inflate to increase blood flow to the coronary arteries to increase
Oxygen delivery to heart muscle
 Systole: deflate to reduce afterload to decrease the workload of the heart
 Assist insertion of pulmonary artery catherter (Swan-Ganz) to assess
degree of heart failure
 Monitor distal pulses and CVP

3. Distributive Shock or Vasogenic Shock

 Massive vasodilation

 Neurogenic/ Spinal Shock

 generalized ___________________due to conditions affecting the
medulla oblongata and SNS
 sudden depression of reflex activity in the spinal cord occurs below the
level of injury (peripheral vasomotor tone loss)
 disruption of SNS impulses transmission
 eg. SCI, Head injury, general anesthesia, overdose of downers /
autonomic blocking medications, pain/stress, CNS dysfunction
 occurs within the first hour of injury and can last days to months

 Assessment:
o Flaccid paralysis
o Loss of reflex activity below the level of the lesion
o Bradycardia
o Hypotension
o Decreased cardiac output
o Decreased hemodynamics
o Hypothermic
o Paralytic ileus

 Interventions:
 Monitor signs of shock following an injury
 Assess for reflex activity and bowel sounds
 Administer IV fluids for volume replacement
 Administer ____________as ordered to control the BP to promote tissue
perfusion and manage cardiovascular instability
  Administer ____________________________________________ that will
increase the patient’s heart rate to improve tissue perfusion
 Provide rewarming measures such as covering patient with warm blankets
 Place the patient on continues pulse oximeter for respiratory assessment
 ___________________ the airway, if necessary
 Pulse Oximetry
= non-invasive that registers oxygen saturation of the client’s hemoglobin
= Sa02= 95 to 100%
= sensor place on finger, toe, earlobe
= maintain transducer at heart level
= do not select extremity with an impending blood flow
= < 91% necessitates immediate treatment
= < 85% oxygenation to body tissues is compromised
= < 70% life threatening: Endotracheal tube to maintain patent airway

 Septic/Toxic Shock
 ____________________ present in the blood
 Results from severe infection commonly caused by gram-negative
organism
 Endotoxins release in the bloodstream causes massive vaodilation
 Hemophilus, escherechia, pseudomonas, klebsiella, neisseria
 Risk: very young children, older adults, immunocompromised individuals,
chronically ill patients, patients with malignancies

 Signs and symptoms:

 Compensatory stages
 Tachycardia: respiratory alkalosis: fatigue of breathing: Decreased carbon dioxide:
triggers CNS to decreased respiratory rate: ARDS
 Leukocytosis
 Hyperthermia
 Hypotension – blood volume is adequate but misplaced, vasodilation occurs, increase
capilliary permeability – fluid lost interstitial spaces. Edema, pulmonary edema - hypoxia
 Compromised CO – decreased
 Decreased tissue perfusion – organ ischemia
 Acute tubular necrosis (ATN): decreased blood supply to the kidneys and released of
endotoxins – renal failure
 Lesion/Rashes/ localized or generalized: DIC and TSS: staph aureus
 Hyperglycemia: endotoxins – insulin resistance
 Septic encephalopathy – confused, lethargy, disoriented, unarousable

Interventions:
 Maintaning patent airway – respiratory failure – intubation
 Initial intervention oxygen delivery 5-6L/min
  SF – lung expansion
 Pulse oximetry and ABG monitoring
 Administartion of IV fluids as prescribed
 Monitor V/S
 Monitor hemodynamics status
 Administer inotropic agents/ vasoactive agents
 Monitor UO for adequacy of renal perfusion
 Adm antipyretic as prescribed
 Obtain cultures
 Administer appropriate antibiotic therapy

Anaphylactic Shock
 Results from _________________________
 Systemic serious and immediate hypersensitivity reaction
 Mediated release of histamine, bradykinin, leukotrienes, prostaglandin
 Deposition in vessels and tissue walls – inflammation of affected organ
 Immune mediated: anaphylactic, Chemically mediated – anaphylactoid

Causes:
 Antigen-antibody reaction usually result from allergies
 Allergen
 Foods, environmental agents (pollens, molds, animal danders)
 Medication
 Blood products
 Venoms

Responses: self – limiting (5-10 minutes) but could be fatal if not promptly treated.
 Primary Immune Response: IgE – formation of antibody from allergen, antibody
accumulate and attach themselves in the plasma with large amounts of
histamine/basophils
 Secondary Immune Response – rupture of cells – degranulation, release of histamine,
leukotrines, platelet activating factors, prostaglandins - increased capilliary permeability

Assessment:
 Hypotension, tachycardia, arrhythmias cardiac arrest
 Chest and on the face - Pruritus, erythema, urticaria, redness, warm and swelling
 Headache, dizziness, paresthesia
 Angioedema – swelling in the face, oral cavity and lower pharynx and larynx
 Hoarseness, coughing, narrowed airway, chest tightness/wheezing/stridor, dysnea,
dysphagia bronchoconstriction / pulmonary edema - respiratory arrest
 Restless, dizziness, anxious and apprehensive with complaint of sense of impending
doom
 Smooth muscle constriction – vomiting, abdominal cramping, urinary incontinence
  Decreased hemodynamics

Interventions:
o Establish patent airway
o Remove the client from the causative agent/ source
o 1st step: Hallmark management for anaphylaxis: Prepare for administration of
epinephrine (adrenalin) cardiac stimulation and bronchodilation, inhibits the release of
secondary immune response, SQ .3-.5ml every 5-10 mins or IV 3 ml of via ET tube 3-
5ml.
o 2nd step: ABC - Provide Oxygen
o Consider ET intubation in severe cases with mechanical ventilation
o 3rd Step: Administer antihistamines as prescribed. Diphenhydramine (Benadryl) -
anticholinergic or corticosteroids – anti-inflammation
o Provide measures to control shock
o Provide emotional support