Shock States (Anaphylactic, Hypovolemic)

Definition/Etiology:

• Definition
  • Circulatory failure
    • Poor Perfusion = tissue/organ ischemia = Anoxia
    • Impaired cellular metabolism = organ dysfunction
    • Death
• Etiology – Think of a gas station
  • Anaphylactic – Vascular loses fluid (Leaking Gas Hose)
    • Contrast media
    • Medication reactions
    • Blood transfusion reactions
    • Food allergies
    • Insect bites or stings
    • Snake bites
  • Hypovolemic Shock = Fluid loss (No Gasoline)
    • Bleeding
    • Vomiting
    • Diarrhea
    • Burns
    • Third-Spacing

Pathophysiology:

• Anaphylactic Shock
  • Impaired tissue perfusion resulting from antigen-antibody reaction that releases histamine into the bloodstream.
  • Capillary permeability increases, and arteriolar dilatation occurs.
  • SVR falls. Blood return to the heart is decreased dramatically. Hypotension results
• Hypovolemic Shock
  • Impaired tissue perfusion resulting from severely diminished circulating blood volume
  • SVR increases to TRY to return blood to the heart, but there is no blood/fluid there.

Noticing: Assessment & Recognizing Cues:

• All Shock leads to MODs from lack of Perfusion
  • ↑HR, ↓BP,
  • ↓ Cardiac Output + ↓ urine output
• Anaphylactic Shock
  • Brain
    • ↓ LOC
  • Skin
    • Rash/hives, itching, flushed, warm skin
  • Lungs
    • Bronchospasm: Stridor wheezing
• Hypovolemic Shock
  • Brain
    • Syncope
  • Skin
    • Pale Cool and Clammy
  • Signs of Bleeding
    • Poor capillary refill
    • Collapsed neck veins

Interpreting: Analyzing & Planning:

• Labs – Reflect Shock + Organ damage
  • ABGS
    • Metabolic Acidosis
      • anaerobic metabolism by hypoxia
    • Respiratory Alkalosis
      • Compensation from breathing fast
  • Serum Lactate
    • Greater than 4
  • Blood Count & Fibrinogen – Hemorrhage
  • BUN/creatinine – Kidney damage
• Diagnostics
  • ECG – Electricity
    • Arrhythmias
  • CXR
    • Pulmonary Edema/Effusion

Responding: Patient Interventions & Taking Action:

• ABCs Shock Stabilization
  • Optimize 02 delivery
    • Mask → Ventilator
    • Keep Normothermic
      • Shivering ↑ 02 demand
  • Non-invasive Hemodynamics (PCCN Level)
    • MAP
      • Keep >60
    • CVP
      • Normal 2-6
      • Should increase with fluids
  • Anaphylactic Shock
    • Epinephrine
    • Bronchodilators
    • Steroids
  • Hypovolemic Shock
    • Volume Replacement
      • Massive Transfusion Protocol
        • plasma, platelets, and clotting factors
        • Prevents clotting issues

Reflecting: Evaluating Patient Outcomes:

• Airway/Breathing
  • Sufficient oxygenation is provided
  • Pulmonary congestion is decreased
• Hemodynamics/Circulation
  • MAP is increased to adequately perfuse tissues and vital organs.
  • BP and pulse are within normal limits for the patient.
  • Fluid and electrolyte balances are maintained
  • Intake and output are balanced

Linchpins (Key Points):

• Notice -Objective/Subjective Cues ↓ Perfusion
• Interpret – Labs/Diagnostic (Anaphylaxis vs Hypovolemia)
  • Labs can differentiate (CRP vs H/H)
• Respond
  • Hemodynamics
  • Treating underlying cause
    • Wheezes = Bronchospasms
    • Bleeding = Fluids
• Reflect
  • MAP & Urine Output