SHOCK CARE AND INTERVENTIONS DIAGNOSTIC STUDIES No single diagnostic study Medical and surgical history and history or recent events and injuries Laboratory changes that reflect anaerobic metabolism lactate and base deficit elevation 12 lead EKG continuous cardiac monitoring chest x ray continuous pulse oximetry hemodynamic monitoring arterial pressure CVP PAP SvO2 ScvO2 COLLABORATIVE CARE Early recognition and treatment is critical Successful management includes o identification of patients at risk for developing shock o Integration of the patients history physical examination and clinical findings to establish a diagnosis o Interventions to control or eliminate the cause of the decreased perfusion o Protection of target and distal organs from dysfunction o Provision of multisystem supportive care Establish patent airway natural or with ETT administer oxygen maintain SaO2 90 and PaO2 60 fluid replacement and drug therapy optimize mean and circulating blood volume Oxygen and ventilation o Oxygen delivery is dependent on CO available hemoglobin and arterial oxygen saturation o Need to increase supply and decrease demand o Supply is increased by Optimizing the CO with fluid replacement and drug therapy Increasing hemoglobin by the transfusion of whole blood or packed RBC Increasing the arterial oxygen saturation with supplemental oxygen and mechanical ventilation o Monitor ScvO2 by central venous catheter SvO2 via PA catheter CO hemoglobin and oxygen consumption o Space care that will increase oxygen demand Fluid resuscitation o Based on patients clinical status and type volume of fluid loss GOAL restore tissue perfusion o Cardiogenic and neurogenic does not involve a decrease in circulating blood volume o Obstructive shock repair the obstruction o Septic hypovolemic and anaphylactic volume expansion with administration of fluid o 2 large bore 14 16 gauge IV into antecubital veins ideal o Monitoring If cryst2 3 L of crystalloids do not work blood administration CVP or PAP Serial BPs or arterial catheter to monitor patient response Indwelling bladder catheter will help monitor fluid status o Potential complications Hypothermia and coagulopathy Warm fluids if massive fluid resuscitation is needed Remember packed RBCs do not contain clotting factors Hypotension despite normalized CVP 8 12 Add vasopressor norepinephrine Levophed dopamine Intropin Add inotrope dobutamine Dobutrex Nutritional Therapy o Protein calorie malnutrition due to hypermetabolism o Enternal nutrition should be started within 24 hours if not immediately Eventually the GI system will not be working so you need to get as much nutrients into them as possible while you still can Parenteral nutrition if not meeting 80 of caloris needs o Weigh daily on the same scale at the same time of day Significant weight loss may be dehydration or deficient calorie intake Weight gain is common due to third spacing o Assess nutritional status Serum protein albumin BUN Glucose and electrolytes FLUID THERAPY IN SHOCK Crystalloids o Isotonic 0 9 NaCl or Lactated Ringers LR Fluid primarily remains in the intravascular space increase intravascular volume Used for initial volume replacement in most types of shock Monitor patient closely for circulatory overload Do not use LR in patients with lover failure LR may be used if hyperchloremic acidosis develops from use of NaCl Lactated ringers is rarely used because liver cannot convert lactate to bicarbonate increase in serum lactate o Hypertonic 1 8 3 5 NaCl Fluid remains in the intravascular space rapid volume expansion May be used for initial volume expansion in hypovolemic shock Monitor patient closely for signs of hypernatremia disorientation convulsions Central line is preferred for infusing 3 or greater percent NaCl caustic Blood blood products o Packed RBC Fresh frozen plasma platelets Replaces blood loss increases oxygen carrying capacity Replaces coagulation factors Help control bleeding causes by thrombocytopenia Used in all types of shock Same precautions need to be used as during regular blood administration Colloids o Hetastarch Hespan Made from starch and acts as volume expander is as effective as albumin can exert osmotic effect for up to 36 hours All types of shock expect cardiogenic and neurogenic May be 50 less costly than albumin Use cautiously in patients with heart failure renal failure or bleeding disorders Antiplatelet effects o Human serum albumin 5 plasma protein fraction 5 albumin in 500 ml NaCl Can increase plasma colloid osmotic pressure rapid volume expansion All types of shock except cardiogenic and neurogenic shock Monitor for circulatory overload Mild side effects of chills fever and urticarial may develop More expansive then other colloids o Dextran 40 or 70 Hyperosmotic glucose polymer Similar degrees of volume expansion with 40 and 70 but 70 has longer duration of action Limited use because of side effects including reducing platelet adhesion diluting clotting factors Increased risk of bleeding Important to monitor patient for allergic reaction and acute renal failure Drug Therapy o IV or central line o Dobutamine Dobutrex Mechanism of action Myocardial contractility Ventricular fillinf pressures SVR PAWP CO stroke volume CVP HR Type of shock to 70 if Hb 7 or Hct 30 Nursing implications Used in cardiogenic shock with severe systolic dysfunction Used in septic shock to increase oxygen delivery and raise SvO2 ScvO2 Administer via central line infiltration sloughing Do not administer in same line as NaHCO3 Monitor HR BP hypotension may worse need to increase med Stop if tacydysrhythmias develop o Dopamine Inotropin Mechanism of action Positive inotropic effects o Myocardial contractility o Automaticity o Atrioventricular conduction HR CO BP and MAP MVO2 High dose progressive vasoconstriction Low dose blood flow to renal mesenteric and cerebral circulation Type of shock Cardiogenic shock Nursing Implications Administer via central line infiltration sloughing Do not administer in same line as NaHCO3 Monitor for tachydysrhythmias Monitor for peripheral vasoconstriction at moderate high doses o Paresthesia and cold extremities o Drotrecogin alfa Xigris Mechanism of action Type of shock Anticoagulant effect Profibinolytic and anti inflammatory properties Septic shock in patients with high risk of death 2 or more failed organs and no contraindications Nursing implications Monitor for signs of bleeding Monitor Hb PLT PT PTT o Epinephrine Adrenalin Mechanism of