SHOCK, SEPSIS, and MULTIPLE ORGAN DYSFUNCTION MEDICAL MANAGEMENT:

SYNDROME
▪ Identify the cause of the shock.
SHOCK ▪ Correcting the underlying disorder.
• Shock
- A life-threatening condition. NURSING MANAGEMENT:
- A syndrome characterized by decreased tissue ▪ Tissue Perfusion Monitoring
perfusion and impaired cellular metabolism ▪ Reducing Anxiety
imbalance between the supply of and demand for ▪ Clarifying Advance Directives
oxygen and nutrients. ▪ Promoting Safety
- If shock is not effectively treated multiple organ
dysfunction syndrome (MODS)

CLASSIFICATION OF SHOCK:

Four Main Categories of Shock:

❖ Cardiogenic TISSUE PERFUSION MONITORING:

❖ Hypovolemic
❖ Distributive ▪ Hemodynamic status (measure PULSE
❖ Obstructive PRESSURE)
➢ Narrowing or pulse pressure early
indicator of shock.
▪ Continuous central venous oximetry (ScO2)
monitoring
▪ Sedatives (lowers metabolic demands)
▪ Supplemental oxygen and mechanical ventilation
▪ Administration of IV fluids 7 PRBC transfusion

STAGES OF SHOCK:

▪ STAGE 1: Compensatory
▪ STAGE 2: Progressive
▪ STAGE 3: Irreversible
▪ Passive Leg Raising (PLR)
• Compensatory Stage − Used to determine which patients will or will not
− BP remains within normal limits. respond to IV fluid bolus challenges.
− Vasoconstriction, HR, and contractility of the heart − Involves raising the patient’s leg to 30- to 40- degree
= to maintain CO (from SNS stimulation and release angle to increase venous return and thus cardiac
of catecholamines) output.
− Patient display the often-described “fight-or-flight” − If the blood pressure improves with PLR, the patient
response. will respond to additional fluids.
− Body shunts blood from organs such as the skin,
kidneys, and gastrointestinal (GI) tract to the brain,
heart, and lungs to ensure adequate blood supply to
these vital organs cool and pale, bowel sounds
are hypoactive, and urine output decreases in
response to the release of aldosterone and ADH.

• Progressive Stage
- Mechanisms that regulate BP can no longer
compensate.
- MAP falls below normal limits.
- CLINICALLY HYPOTENSIVE + DECLINING
MENTAL STATUS

Edited by : Hinimi Ho | 1
MEAN ARTERIAL PRESSURE: • Irreversible Stage
− Irreversible (or refractory) stage.
▪ The average pressure of the arteries.
− Represents the point along the shock continuum at
▪ NORMAL RANGE: 70-110 mmHg
which organ damage is so severe that the patient
FORMULA: does not respond to treatment and cannot survive.
− Despite treatment, BP remains low.
(2 𝑥 𝐷𝐵𝑃) + 𝑆𝐵𝑃 − Anaerobic metabolism contributes to a worsening
3 lactic acidosis.
− Reserves of ATP are almost totally depleted.
MAP is multiplied by 2 because diastolic phase last longer
− Multiple organ dysfunction progressing to organ
than the systolic phase.
failure death.

MEDICAL MANAGEMENT:

▪ Same with other stages of shock.

▪ Experimental strategies (investigational
medications)

HYPOVOLEMIC SHOCK

• Hypovolemic Shock
- Most common type of shock.
- Characterized by decreased intravascular volume.

PHYSIOLOGY AND PATHOPHYSIOLOGY:

EXERCISE PROBLEMS:

1. Patient’s blood pressure is: 155/98. What is the

patient’s MAP?
2. Patient’s blood pressure is: 76/28. What is the
patient’s MAP?
3. Patient’s blood pressure is: 220/118. What is the
patient’s MAP?
4. Patient’s blood pressure is: 160/102. What is the
patient’s MAP?

MEDICAL MANAGEMENT:

▪ Early enteral nutritional support

▪ Targeted hyperglycemic control with IV insulin.
▪ Use of antacids, histamine-2 (H2) blockers, or anti-
peptic medications/

NURSING MANAGEMENT:

▪ Preventing complications
▪ Promoting rest and comfort
▪ Supporting family members

Edited by : Hinimi Ho | 2
 CLINICAL MANIFESTATIONS:

✓ Pain of Angina
✓ Arrythmias
✓ Complain of Fatigue
✓ Express feelings of doom
✓ Hemodynamic Instability Signs

DIAGNOSTICS:

▪ Biomarkers for Ventricular Dysfunction (B-type

natriuretic peptide)
▪ Cardiac Enzyme Levels
▪ Biomarkers (cTn-1)
▪ Serum lactate
▪ Transthoracic Echocardiography
▪ 12-lead Electrocardiograms

MEDICAL MANAGEMENT:

▪ Correction of Underlying Causes (ACS, CMP)

First-Line Treatment:

▪ Oxygenation (2-6 LMP) via 30 minutes

▪ Pain Control (IV morphine)
▪ Hemodynamic Monitoring
▪ Fluid Therapy
▪ Pharmacologic Therapy (vasoactive medications)
▪ Mechanical Assistive Devices &IABP

MEDICAL MANAGEMENT:

▪ Treatment of the Underlying Cause (e.g. stop

active bleeding)
▪ Fluid Resuscitation and Blood Replacement:
➢ Crystalloids (PLR, PNSS)
➢ Colloids (5% or 25% Albumin)
➢ Blood products (plasma, packed red blood
cells, and platelets)
▪ Redistribution of Fluid (passive leg raising)
▪ Pharmacologic Therapy (vasoactive medications)

NURSING MANAGEMENT:

▪ Administering Blood and Fluids Safely

➢ Cardiovascular overload & DOB
➢ Fluid intake and output (I&O) monitoring
➢ WOF: Hypothermia due to rapid fluid resuscitation
➢ Monitoring jugular venous pressure JVD
Other MEASURES:
▪ Oxygen Therapy
CARDIOGENIC SHOCK:
• Cardiogenic Shock
- Occurs when the heart’s ability to contract and to
pump blood is impaired and the supply of oxygen is
inadequate for the heart and the tissues.
PATHOPHYSIOLOGY:
NURSING MANAGEMENT:
▪ Preventing Cardiogenic Shock
▪ Monitoring Hemodynamic Status
▪ Administering Medications and Intravenous Fluids
▪ Maintaining Intra-Aortic Balloon Counterpulsation.
▪ Enhancing Safety and Comfort.
DISTRIBUTIVE SHOCK
• Distributive Shock
- Occurs when intravascular volume pools in
peripheral blood vessels.
- Can be caused by either a loss of sympathetic tone
or a release of biochemical mediators from cells that
causes vasodilation.

SUBCLASSIFICATION:

▪ Septic Shock
▪ Neurogenic Shock

Edited by : Hinimi Ho | 3
 ▪ Anaphylactic Shock

PATHOPHYSIOLOGY:

SEPTIC SHOCK

• Septic Shock
- A systemic inflammatory response to an infection
- Life-threatening organ dysfunction caused by a
dysregulated host response to infection. THREE MAJOR PATHOPHYSIOLOGIC EFFECTS:

• Septic Shock ▪ Vasodilation

- The presence of sepsis with hypotension despite ▪ Maldistribution of blood flow
adequate fluid resuscitation, along with inadequate ▪ Myocardial depression
tissue perfusion resulting in tissue hypoxia.
MEDICAL MANAGEMENT:

▪ Correcting of Underlying Causes (rapid

identification and elimination of the cause of
infection) – critical element in managing sepsis.
➢ Diagnostics: (all cultures should be obtained prior to
antibiotic administration)
▪ Preventive Measures
➢ IV Lines are removed and reinserted at alternate
sites.
➢ Urinary catheters are removed or charged.

Edited by : Hinimi Ho | 4
 ▪ Other tool, Modified Early Warning System (MEWS)
– MEWS score greater than 4 is suggestive of the
▪ Fluid Replacement Therapy development of sepsis.
➢ Aggressive fluid resuscitation (crystalloids infusions
of 30 mL/kg of crystalloids over 30 minutes)
▪ Pharmacologic Therapy
➢ Broad-Spectrum Antibiotic Agents (unknown agent;
no C/S result yet)
➢ Vasopressor agents/inotropes (norepinephrine or
dopamine)
➢ Sedatives & DVT prophylaxis

NURSING MANAGEMENT:

▪ Strict aseptic technique practices

▪ For ICU patients with infection, use Sepsis-Related
Organ Failure Assessment Score (Sequential Organ
Failure Assessment [SOFA] Score)
▪ SOFA Score
- A drop of 2 points or more in a patient’s SOFA score
from baseline is suggestive of organ dysfunction.

▪ Hyperthermia (raises metabolic demands)

➢ Acetaminophen or hypothermia blanket.
▪ Shivering (raises oxygen demand)
➢ Comfort measures
▪ Administer Prescribed IV fluids and medications.
➢ Monitor for liver and kidney function (antibiotics)
▪ Close monitoring of serum albumin and pre-
albumin levels.

NEUROGENIC SHOCK

• Neurogenic Shock
- Is a hemodynamic phenomenon that can occur
within 30 minutes of a spinal cord injury at the fifth
NURSING MANAGEMENT: thoracic (TV) vertebrae or above.
- It can last up to 6 weeks.
▪ For non-ICU patients with infection, use Quick SOFA - Injury results in massive vasodilation without
(qSOFA) scale be used to screen for the compensation because of the loss of SNS
development of sepsis. vasoconstrictor tone leads to a pooling of blood
in the blood vessels, tissue hypoperfusion, and
ultimately impaired cellular metabolism.

Most important CLINICAL MANIFESTATIONS:

✓ Hypotension (from the massive vasodilation)

✓ Bradycardia (from unopposed parasympathetic
stimulation)

Edited by : Hinimi Ho | 5
Later, the patient’s skin may be cool or warm depending on
the ambient temperature (poikilothermia – taking on the
temperature of the environment)

• Spinal Shock
- Occurs with neurogenic shock (in most cases)
- A transient condition that is present after an acute
spinal cord injury
- Patient experiences absence of all voluntary and
reflex neurologic activity below the level of the injury.
MANAGEMENT:
▪ Removing the causative antigen.
▪ Intramuscular epinephrine (vasoconstrictive action)
▪ Diphenhydramine IV (reverses histamine action)
▪ Nebulization (albuterol) – reverse histamine-induced
bronchospasm.

OBSTRUCTIVE SHOCK

• Obstructive Shock
- A rare type of shock.
- Refers to the anatomical obstruction of the great
vessels of the heart (e.g. superior vena cava, inferior
vena cava, and pulmonary vessels) the leads to
decreased venous return and/or excessive afterload
(i.e. the force that the left ventricle has to overcome
MEDICAL MANAGEMENT:
to eject blood through the aortic valve), resulting in
▪ Restoring sympathetic tone (stabilization of a spinal decreased cardiac output.
cord injury or, in the instance of spinal anesthesia, by
positioning the patient properly)
▪ Specific treatment depends on the cause of the
shock.

NURSING MANAGEMENT:

▪ Elevate and maintain the HOB at least _____ to

prevent neurogenic shock when a patient receives
spinal or epidural anesthesia.
➢ R: Elevation of the head helps prevent the spread of
the anesthetic agent up the spinal cord.
▪ For suspected SCI, maintain complete
immobilization of cervical spine.
▪ Avoid VTE (high risk due to immobility)
▪ Monitor for internal injuries (loss of sensation)

ANAPHYLACTIC SHOCK

• Anaphylactic Shock
- An acute, life-threatening hypersensitivity (allergic)
reaction to sensitizing substance (e.g. drug,
chemical, vaccine, food, insect venom)
- Reaction quickly causes massive vasodilation,
release of vasoactive mediators, and an increase in
capillary permeability fluid leaks from the vascular
space into the interstitial space EDEMA,
SEVERE, BRONCHOSPASM & LARYNGOSPASM.

Edited by : Hinimi Ho | 6
MEDICAL MANAGEMENT:

OXYGENATION:

▪ Maintain patent airway

▪ Provide supplemental O2
▪ Intubation and mechanical ventilation, if necessary.

CIRCULATION:

▪ Restore circulation by treating cause of obstruction.

▪ Fluid resuscitation may provide temporary
improvement in CO and BP.

TYPES OF SHOCK: HYPOTENSIVE PATIENTS AND GAS

PUMPS

Edited by : Hinimi Ho | 7
 ▪ The metabolic rate may be 1.5 to 2 times the basal
metabolic rate.
MULTIPLE ORGAN DYSFUNCTION SYNDROME ▪ At this time, is a severe loss of skeletal muscle mass
• Multiple Organ Dysfunction Syndrome (MODS) (auto-catabolism) to meet the high energy demands
- Altered organ function in acutely ill patients that of the body.
requires medical intervention to support continued
organ function.
- Is the failure of two or more organ systems in an
acutely ill patient such that homeostasis cannot be
maintained without intervention.

PATHOPHYSIOLOGY:

EXACT ETIOLOGY: Unknown

• Sepsis
- Majority is due to SEPSIS because of INADEQUATE
TISSUE PERFUSION. After approximately 7 to 10 days:
- Septic shock tissue perfusion not restored
MODS. ▪ Signs of HEPATIC DYSFUNCTION (elevated
bilirubin and liver function tests)
SEQUENCE: Usually begins in the lungs, and cardiovascular ▪ Signs of RENAL DYSFUNCTION (elevated
instability, as well as failure of the hepatic, GI, renal creatinine and anuria)
immunologic, and central nervous systems, follows.
▪ As the lack of tissue perfusion continues, the
hematologic system becomes dysfunctional, with
worsening immunocompromise, increasing the risk
of bleeding.
▪ Cardiovascular system becomes unstable and
unresponsive to vasoactive agents, and the patient’s
neurologic response progresses to a state of
unresponsiveness or coma.

MEDICAL MANAGEMENT:

▪ Prevention remains the top priority in managing

MODS.
CLINICAL MANIFESTATIONS:
OLDER PATIENTS:
CLINICAL SEVERITY ASSESSMENT TOOLS
▪ Older adult patients are at increased risk for MODS
✓ APACHE (Acute Physiology and Chronic Health because of the lack of physiologic reserve and the
Evaluation) natural degenerative process, especially immune
✓ SAPS (Simplified Acute Physiology Score) compromise.
✓ PIRO (Predisposing factors, Infection, Host ▪ Early detection and documentation of initial signs of
response, & Organ dysfunction) infection are essential in managing MODS in older
✓ SOFA score adult patients.
▪ Typically, the lungs are the first organs to show signs
If preventive measures fail, treatment to reverse MODS are
of dysfunction.
aimed at:
Progressive dyspnea and respiratory failure that are
▪ Controlling the initiating event.
manifested as ALI or ARDS.
▪ Promoting adequate organ perfusion.
▪ Hypermetabolic State: ▪ Providing nutritional support.
✓ Hyperglycemia (Increase blood glucose level) ▪ Maximizing patient comfort.
✓ Hyperlactic acidemia (Increase lactic acid)
✓ Increased BUN

Edited by : Hinimi Ho | 8