18_ ShockPPT Final (Turning Point)

7/26/2019 18_ ShockPPT Final (Turning Point)

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Shock Management

Erin Burrell, ACNP-BC

Surgical ICU Nurse

Practitioner


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Objecties Un!erstan! the !e"nition o# the

three !i$erent t%&es o# shock

Be able to recogni'e the !i$erentt%&es o# shock in &atient scenarios

Un!erstan! an! a&&l% treatmentgui!elines #or the !i$erent t%&es o#shock


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(hat is Shock)

Shock is the *&h%siologic statecharacteri'e! b% signi"cant re!uction o#

s%stemic tissue &er#usion, resulting in!ecrease! tissue o+%gen !elier%

.issue &er#usion is !e&en!ent on S/0 an!CO

Imbalance bet1een o+%gen !elier% an!o+%gen consum&tion 1hich lea!s to cell!eath, en! organ !amage, multi-s%stemorgan #ailure, an! !eath2aieski et al 3445 6Online accesse! 33 August 34789

U0:; htt&;


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.hree .%&es o# Shock Car!iogenic

=%&oolemic >istributie

Se&tic

Ana&h%lactic Neurogenic

Combine!


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Case Stu!% Mrs C is a ?7%o @ 1ho &resents to E>

com&laining o# #atigue an! SOB She hassigni"cant PM=+; >M, obesit%, =.N

=usban! also states she has becomeslightl% con#use!

/itals; =0 ?, BP ?


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(hat kin! o# shock !oes this &atienthae)

A Car!iogenic

B =%&oolemic

C >istributie


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Car!iogenic Shock Shock cause! as a result o# car!iac

&um& #ailure

0esults in a !ecrease in CO

S/0 is increase! in an e$ort tocom&ensate to maintain organ &er#usion

Causes; M%ocar!ial In#arction

Arr%thmias 6Atrial "brillation, entriculartach%car!ias, bra!%car!ias, etc9

Mechanical abnormalities 6alular !e#ects9

E+tracar!iac abnormalities 6PE, &ulm =.N, tension

&neumothora+9Me!sca&e 0e#erence 755 6Online accesse! 33 August 34789U0:; htt&;


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(hat in#ormation !o %ou hae tosuggest that Mrs C has car!iogenicshock)A =%&otension

B Ei!ence o# MI

C Altere! MentalStatus

> All o# the aboe

E Both A an! B


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.reatment o# Car!iogenicShock

Correct h%&otension;

@lui! resuscitation to correct h%&oolemia

Inotro&ic or /aso&ressor su&&ort; >obutamine

Milrinone

Nore&ine&hrine >o&amine

E&ine&hrine

O+%genation

I# MI G ASA, =e&arin, an! 0easculari'ation

I# arrth%mia G correct arrth%mia

I# e+tracar!iac abnormalit% G reerse or treatcause


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Case Stu!%

Mr = is a 7%o M 1ho &resents to E> a#tersu$ering a MCC into a tree =e 1asunhelmete! an! has an obious le#t #emur

#+ =e 1as intubate! #or a 2CS o# in the"el! an! gien 7: NS en route #orh%&otension

/itals; =0 7, BP H7


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A Car!iogenic

B =%&oolemic

C >istributie


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=%&oolemic Shock Shock cause! b% !ecrease! &reloa!

!ue to intraascular olume loss 67iarrhea, omiting, burnsMe!sca&e ::C 3478 6Online access on 33 August 34789

U0:; htt&;


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(hat in#ormation !o %ou hae tosuggest that Mr = has h%&oolemicshock)

A 0ecent trauma

B (BC 738

C =gb ?H

> All o# the aboeE Both A an! C


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.reatment o# =%&oolemic

Shock Ma+imi'e o+%gen !elier%

Control #urther bloo! loss

.ourniuets

Surgical interention

@lui! resuscitationNS Jui! boluses

Bloo! &ro!uct a!ministration


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Case Stu!% Mr S is a 5%o M &resents to E> 1ith

1orsening ab!ominal &ain an! NK/

=e is PO>F s


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A Car!iogenic

B =%&oolemic

C >istributie


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>istributie Shock Shock as a result o# seerel% !iminishe!

S/0

CO is t%&icall% increase! in an e$ort tomaintain &er#usion

Subt%&es;

Se&tic G secon!ar% to an oer1helming in#ection

Ana&h%lactic G secon!ar% to a li#e-threateningallergic reaction

Neurogenic G secon!ar% to a su!!en loss o# theautonomic nerous s%stem #unction

2aieski et al 3445 6Online accesse! 33 August 34789

U0:; htt&;


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(hat in#ormation !o %ou hae tosuggest Mr S has !istributie shock)

A S&O3 5D on

: NCB Anastamotic

leak on C. scan

C (BC 347> All o# the aboe

E Both B an! C


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.reatment o# Se&tic Shock 0esuscitate

84ccellinger, 0 et al Suriing Se&sis Cam&aign; International 2ui!elines#or Management o# Seere Se&sis an! Se&tic Shock;3473, 7; 4-?8H,

3478


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.reatment o# Ana&h%lacticShock

0emoe o$en!ing agent

Establish an air1a% an! return circulation

Pharmacologic su&&ort;

E&ine&hrine G reerses &eri&heral aso!ilation,

!ilates bronchial air1a%s, increases m%ocar!ialcontractilit%, an! su&&resses histamine< leukotrienerelease

Antihistamine 6bena!r%l9 G ma% hel& counterhistamine-me!iate! aso!ilation an!bronchoconstriction

Corticosteroi!s 6h%!rocortisone9 G ma% hel& shortenreaction

Broncho!ilatorsSoar, L et al 3478 6Online Accesse! on 33 August 34789

U0:; htt&;


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.reatment o# NeurogenicShock

Establish an air1a% to maintaina!euate o+%genation an! entilation

@lui! resuscitation #or MAP?mm=g Inotro&ic su&&ort

>obutamine

>o&amine

Atro&ine #or seere bra!%car!ia

=igh !ose meth%l&re!nisolone thera&%Emergenc% Me!icine 3445 6Online Accesse! on 33 August 34789

U0:;htt&;


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All three t%&es o# shock canoccur at the same time to

hae a combine! shock&icture


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Case Stu!%

Mrs > is a H7%o @ 1ho &resente! toE> a#ter a 8 !a% h4 s


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Case Stu!% cont .he Surgical ICU team &laces a MAC

1ith PAC to obtain #urther !ata about

the &atients hemo!%namic status PAC numbers; PAP 7


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(hat t%&e o# shock !oes this &atienthae)

A Car!iogenic

B =%&oolemic

C >istributie

> All o# the Aboe


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(hat in#ormation lea!s %ou to belieeMrs > has a com&onent o# car!iogenicshock)

A BP 3


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(hat in#ormation !emonstrates acom&onent o# h%&oolemic shock)

A C/P 7 mm=gB PC(P 3 mm=g

C S/0 ?7

!%nes


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(hat in#ormation in!icates a !egree o#!istributie shock)

A PC(P 3 mm=gB S/0 ?7

!%nes


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Mrs S is su$ering #rom !istributiese&tic shock along 1ith car!iogenican! h%&oolemic shock

A .rue

B @alse


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Case Stu!% cont

.he Surgical ICU team starts b% giing MrsS a 3: NS bolus an! 7: D Albumin bolus

/itals; =0 77, BP 5


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Mrs S continues to hae a combine!shock o# h%&oolemic, !istributie, an!

car!iogenic shockA .rue

B @alse


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Mrs S continues to su$er #romcar!iogenic an! !istributie se&ticshock as ei!ence b% the #ollo1ing;

A CI 7 :


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As an intensiist, 1hat treatmentshoul! be im&lemente! ne+t)

A More Jui!resuscitation

B Initiate aso&ressorsu&&ort

C Initiate inotro&ic

su&&ort> No change in

current thera&%

E Both B an! C


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Case stu!% cont A#ter initiating milrinone an!

leo&he! thera&%, Mrs S im&roes

/itals; =0 58, BP 733


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Case stu!% cont .he Surgical ICU team !eci!es to attem&t

to 1ean aso&ressor su&&ort "rst

Mrs S is success#ull% 1eane! o$ leo&he!su&&ort a#ter a&&ro+imatel% 73 hours

/itals; =0 H, BP 77H


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Case Stu!% cont A#ter an a!!itional 73 hours, Mrs S is

success#ull% 1eane! o$ milrinonesu&&ort as 1ell

She is e+tubate! the ne+t !a% an!&rogressing 1ell

On =O> ?, Mrs S is com&laining o# a =A

an! 1oul! &re#er not to take narcotics

Ibu&ro#en 344mg ?h P0N is a!!e! to=A &ain


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Case Stu!% cont

A#ter a&&ro+imatel% 7 min o# her "rst!ose o# Ibu&ro#en, Mrs S starts tocom&lain o# !icult breathing,Jushing, an! air1a% e!ema

.he be!si!e 0N notices a ne1 onset o#hies aroun! Mrs Ss neck an! mouth

/itals; =0 7H, BP


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(hat kin! o# shock is Mrs Se+hibiting)

A Car!iogenic

B =%&oolemic

C >istributie


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(hat 1oul! %ou inclu!e in %ourtreatment &lan)

A Bena!r%l 3 mg

I/B 0eintubation

C =%!rocortisone

744 mg I/> E&ine&hrine 4

mcg I/

E All o# the aboe


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Case Stu!% cont

Mrs S is success#ull% intubate! an!a!ministere! treatment #or her

ana&h%la+is A#ter a&&ro+imatel%73hours, her s%m&toms haeresole! She is again e+tubate! an!

&rogressing 1ell Mrs S goes on to rehab an!

eentuall% homeQ


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Summar%

Surial an! outcomes

im&roe 1ith earl% &er#usion,a!euate o+%genation, an!i!enti"cation 1ith a&&ro&riatetreatment o# the cause o#shock


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Ruestions)


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0e#erences >ellinger, 0 et al Suriing Se&sis Cam&aign; International

2ui!elines #or Management o# Seere Se&sis an! Se&ticShock;3473, 7; 4-?8H, 3478

Emergenc% Me!icine 3445 6Online Accesse! on 33 August 34789U0:; htt&;

Documents

18_ ShockPPT Final (Turning Point)