Shock
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| 🇬🇧 | 🇬🇧 |
| Shock | A state of inadequate tissue perfusion, transition between hemostasis and death |
| What would you expect the pulse of a patient with acute hemorrhagic, distributive or occlusive shock to be ? | Weak and slow |
| What is the first step for hemorrhage management ? | Direct pressure |
| What is the third step for hemorrhage management | Arterial pressure points |
| What is the last step for hemorrhage management | Tourniquet application |
| If you have a patient that is showing S&S of shock, why would you perform the tilt test on your patient | To determine the presence of orthostatic hypotension |
| Orthostatic hypotension | Decrease in BP when PT moves from a supine position to sitting or upright position |
| First step in the body's response to local hemorrhage? | Vascular phase |
| Second step in the body's response to local hemorrhage? | Platelet phase |
| What happens in the vascular phase | Smooth muscle contracts, lumen size reduced, arterial BP is primarily regulated by vasoconstriction and vasodilation |
| What happens in the platelet phase | Tunica intima is damaged, turbulent blood flow, platelets then stick to collagen on vessel's surface (weak clot) and aggregate |
| What happens in the coagulation phase | Enzymes released into bloodstream, triggers a series of reactions resulting in the form and release of fibrin, forming clot |
| What are the medications that affect clotting | ASA, Heparin, Warfarin |
| Best indicators of shock | MOI, Local S&S of injury, Early S&S of shock |
| Epistaxis | Nose bleed |
| Outward signs of internal hemorrhage | Hemoptysis, esophageal varices, melena, chronic hemorrhage |
| Esophageal varices | Enlarged and engorged esophageal veins |
| Melena | Bowel hemorrhage, blood is. digested before release causing it to look black and tarry |
| Stage one of hemorrhage | Compensation, blood loss up to 15%, body can accommodate for loss, no affect on BP, pulse pressure, renal output, catecholamine release, PT may display some anxiety, elevated HR, cool skin |
| Stage two of hemorrhage | Early decompensation, blood loss 15 - 25%, can no longer maintain BP, catecholamine release , increase peripheral vascular resistance, cool clammy skin, restlessness and thirst |
| Stage three of hemorrhage | Late decompensation, blood loss between 25- 35%, compensatory mechanisms unable to cope, classic signs of shock, tachycardia, decrease BP, urine output, pulse pressure narrows |
| Stage four of hemorrhage | Irreversible, blood loss greater than 35%, pulse may or may not be palpable, PT lethargic, confused moving towards unconscious |
| The release of accumulated lactic acid, carbon dioxide (carbonic acid), potassium, and rouleaux into the venous circulation is called | Capillary washout |
| What is the best explanation for the patient's decreasing level of consciousness as it pertains to the increased respiratory rate | The patient goes into respiratory alkalosis constricting the cerebral blood vessels |
| If the patient's O2 Sats are <92% and they are thought to be in shock, they should receive supplemental oxygen by | Nonrebreather at 15 liters per minute |
| An IV solution with an osmotic pressure greater than that of the body's cells is a | Hypertonic solution |
| As the body compensates for shock with peripheral vasoconstriction, oxygen delivery to the capillaries decreases, causing | Anaerobic metabolism to replace aerobic metabolism |
| In compensatory shock, the body secretes which of the following hormones to prolong the "fight of flight" response | Catecholamines, glucocorticoids, aldosterone |
| Hypovolemic shock | Acute blood volume loss resulting from dehydration and hemorrhage (loss of vascular fluid) |
| What is the most common type of hypovolemic shock | Hemorrhagic shock |
| Distributive shock | Occurs when peripheral vasodilation without proportional increase in fluid volume. |
| Cardiogenic shock | Failure of the hearts pumping action, may be intrinsic or extrinsic, may present with hypotension, tachycardia and JVD |
| Obstructive shock | Impaired blood return to heart, pericardial tamponade, tension pneumothorax, pulmonary embolus (from previous fracture, recent surgery, use on "pill" in older women) |
| Psychogenic shock | Is a type of distributive shock. vasovagal, syncope, fainting |
| Neurogenic shock | Is a type of distributive shock. triad of decreased BP, HR and temp, PT may be LOAx3 |
| Septic shock | Is a type of distributive shock. altered LOA, Tachycardia, Delayed cap refill, Hyperventilation to respiratory arrest, hypoglycaemia due to fever production |
| When should the IV bag be changed | When there is approx. 150 mLs of solution remaining |
| Macro drip | 10, 15, or 20 drops/cc |
| Micro drip | 60 drops/cc |
| Crystalloids IV fluids | Saline, lactated ringers, dextrose |
| Hypotonic solutions | Less solutes than intracellular fluid, fluid shifts INTO cells, used for cellular hydration. lower serum osmolality within the vascular space by causing fluid to shift out of the blood into the cells and tissue spaces. Typically used to treat conditions causing intracellular dehydration, such as diabetic ketoacidosis and hyperosmolar hyperglycemic states. |
| Isotonic solutions | Same tonicity as intracellular fluid, no fluid shift, used for fluid and lyte replacement. These fluids remain within the extracellular compartment and are distributed between intravascular (blood vessels) and interstitial (tissue) spaces, increasing intravascular volume. They are used primarily to treat fluid volume deficit |
| Hypertonic solution | More solutes than intracellular fluid, fluid shifts OUT of cells, used for hypovolemia/vascular expansion, increase urine output (post op), DKA. higher solute concentration causes the osmotic pressure gradient to draw water out of cells, increasing extracellular volume. These fluids are often used as volume expanders and may be prescribed for hyponatremia (low sodium). They may also benefit patients with cerebral edema. |
| Crystalloid solutions | Are distinguished by the relative tonicity (before infusion) in relation to plasma and are categorized as isotonic, hypotonic, or hypertonic. |
| Colloid solutions | Also known as volume/plasma expanders. Less total volume is required compared to IV fluids. are indicated for patients in malnourished states and patients who cannot tolerate large infusions of fluid. |
| Effects of catecholamines during shock | Aggravate hypermetabolism by promoting hyperglycemia and hyperlactatemia, and further increase oxygen demands, which can contribute to further organ damage. |
| Secondary treatment to be considered post epinephrine administration | Diphenhydramine IM/IV |
| What is the ratio for Epinephrine | 1:1000 (1 mg/ml) |
| Vasopressors | Support blood pressure in prolonged cases |
| Beta agonists | Help reverse some of the bronchspasm |
| Corticosteroids | Important in treatment and prevention for inflammation, little benefit initially |
| The intercostal artery, vein, and nerve are found: | Along the bottom of the rib |
| Shelby has sustained a laceration to the left side of her neck from a figure skate, In addressing this injury, you should | Apply an occlusive dressing |
| Muffled heart sounds, JVD, and narrowing pulse pressures describe the clinical findings that make up: | Beck's triad |
| Hypotension due to spinal shock | Decreased venous return, decreased afterload, decreased preload |
| As blood volume is lost due to a traumatic injury, the body's response is to: | Increase heart rate and constrict precapillary sphincters |
| A patient who complains of dizziness when sitting up or standing up and who demonstrates a significant increase in pulse rate or decrease in blood pressure is: | Orthostatically hypotensive |
| What are some of the indications for saline | Increase intravascular volume, Irrigation and cooling for burns, Used to treat DKA, septic shock, crush injuries, HHNK |