Perfusion

Shock
Disseminated Intravascular Coagulation
 Shock
• Life-threatening condition in which tissue perfusion is inadequate to deliver oxygen
and nutrients to support cellular function
• Affects all body systems
• May develop rapidly or slowly
• Any patient with any disease state may be at risk for developing shock
• Regardless of the initial cause of shock, certain physiologic responses are common
to all types of shock: hypoperfusion of tissues, hypermetabolism, and activation of
the inflammatory response
 Classifications of Shock

• Hypovolemic: shock state resulting from decreased intravascular volume

due to fluid loss
• Cardiogenic: shock state resulting from impairment or failure of
myocardium
• Septic: circulatory shock state resulting from acute infection causing relative
hypovolemia
• Neurogenic: shock state resulting from loss of sympathetic tone causing
relative hypovolemia
• Anaphylactic: circulatory shock state resulting from severe allergic reaction
producing acute systemic vasodilation, relative hypovolemia
 Classifications of Shock
• Hypovolemic
• Cardiogenic
• Obstructive
• Distributive (neurogenic,
anaphylactic, septic)
Compensatory Mechanisms in Shock
 Stages of Shock
• Compensatory
• Progressive
• Irreversible
 Compensatory Stage of Shock

• SNS causes vasoconstriction, increased HR, increased heart contractility

– This maintains BP, CO
• Body shunts blood from skin, kidneys, GI tract, resulting in cool, clammy skin, hypoactive bowel
sounds, decreased urine output
• Perfusion of tissues is inadequate
• Acidosis occurs from anaerobic metabolism
• Respiratory rate increases due to acidosis, may cause compensatory respiratory alkalosis
• Confusion may occur
 Progressive Stage of Shock

• Mechanisms that regulate BP can no longer compensate, BP and

MAP decrease
• All organs suffer from hypoperfusion
• Vasoconstriction continues further compromising cellular
perfusion
• Mental status further deteriorates from decreased cerebral
perfusion, hypoxia
 Progressive Stage of Shock

• Lungs begin to fail, decreased pulmonary blood flow causes further

hypoxemia, carbon dioxide levels increase, alveoli collapse,
pulmonary edema occurs
• Inadequate perfusion of heart leads to dysrhythmias, ischemia
• As MAP falls below 70, GFR cannot be maintained
– Acute kidney injury may occur
• Liver function, GI function, hematologic function are all affected
• Disseminated intravascular coagulation (DIC) may occur as cause or
complication of shock
 Irreversible Stage of Shock

• At this point, organ damage is so severe that the patient does not
respond to treatment and cannot survive
• BP remains low
• Renal, liver function fail
• Anaerobic metabolism worsens acidosis
• Multiple organ dysfunction progresses to complete organ failure
• Judgment that shock is irreversible only made in retrospect
 Question #1

Which stage of shock is characterized by a normal blood pressure?

A. Initial
B. Compensatory
C. Progressive
D. Irreversible
 Answer to Question #1

B. Compensatory
Rationale: In the compensatory stage of shock, the BP remains within normal
limits. In the second stage of shock, the mechanisms that regulate BP can
no longer compensate and the MAP falls below normal limits. Patients are
clinically hypotensive; this is defined as a systolic BP of less than 90 mm Hg
or a decrease in systolic BP of 40 mm Hg from baseline. The irreversible (or
refractory) stage of shock represents the point along the shock continuum
at which organ damage is so severe that the patient does not respond to
treatment and cannot survive. Despite treatment, BP remains low
 For All Types of Shock

• Early identification, timely treatment

• Identify, treat underlying cause
• Sequence of events for different types of shock will vary
– Management, care of patient will vary
Pathophysiology of Hypovolemic Shock
 Hypovolemic Shock

• Medical management
– Treatment of underlying cause
– Fluid, blood replacement
– Redistribution of fluid
– Pharmacologic therapy
• Nursing management
– Administering blood, fluids safely
– Implementing other measures
 General Management Strategies in Shock

• Fluid replacement
– Crystalloid, colloid solutions
– Complications of fluid administration
• Vasoactive medication therapy
• Nutritional support
Pathophysiology of Cardiogenic Shock
 Cardiogenic Shock

• Medical management
– Correction of underlying causes
– Initiation of first-line treatment
• Oxygenation
• Pain control
• Hemodynamic monitoring
• Laboratory marker monitoring
• Fluid therapy
• Mechanical assistive devices
 Cardiogenic Shock: Pharmacologic Therapy

• Dobutamine
• Nitroglycerin
• Dopamine
• Other vasoactive medications
• Antiarrhythmic medications
 Cardiogenic Shock: Nursing Management

• Preventing cardiogenic shock

• Monitoring hemodynamic status
• Administering medications, IV fluids
• Maintaining intra-aortic balloon counter pulsation
• Ensuring safety, comfort
 Circulatory Shock

• Septic shock
• Neurogenic shock
• Anaphylactic shock
Pathophysiology of Circulatory Shock
 Management of All Types of Shock

• Fluid replacement to restore intravascular volume

• Vasoactive medications to restore vasomotor tone, improve
cardiac function
• Nutritional support to address metabolic requirements
 Fluid Replacement

• Crystalloids: 0.9% normal saline, lactated Ringer’s solution,

hypertonic solutions (3% hypertonic saline)
• Colloids: albumin, dextran (dextran may interfere with platelet
aggregation)
• Blood components for hypovolemic shock
• Complications of fluid replacement include fluid overload,
pulmonary edema
 Question #2

Is the following statement true or false?

The most common colloid solution used to treat
hypovolemic shock is 5% albumin
 Answer to Question #2

True
Rationale: The most common colloid solution used
to treat hypovolemic shock is 5% albumin
 Question #3

Is the following statement true or false?

The primary goal in treating cardiogenic shock is to
limit further myocardial damage
 Answer to Question #3

False
Rationale: The primary goal in treating cardiogenic shock is not to
limit further myocardial damage. The primary goal in treating
cardiogenic shock is to treat the oxygenation needs of the heart
muscle
 Question #4

When caring for a patient in hypovolemic shock who is receiving

large volumes of IV isotonic fluids, the nurse should monitor for
symptoms of:
A. Hyperthermia
B. Pain
C. Pulmonary edema
D. Tachycardia
 Answer to Question #4

C. Pulmonary edema
Rationale: The nurse should monitor for circulatory
overload and pulmonary edema when large
volumes of fluids are administered
intravenously. Hypothermia may occur with
large volumes of fluid that are not warmed. Pain
would not be seen in hypovolemic shock but
may occur with cardiogenic shock. Tachycardia
would be expected in hypovolemic shock
 Vasoactive Medications

• Used when fluid therapy alone does not maintain MAP

• Support hemodynamic status; stimulate SNS
• Check vital signs frequently; continuous monitoring of vital signs
every 15 minutes or more often
• Give through central line if possible
o Extravasation may cause extensive tissue damage
• Dosages usually titrated to patient response
 Nutritional Therapy

• Nutritional support needed to meet increased metabolic and

energy requirements to prevent further catabolism due to
depletion of glycogen
• Support with parenteral or enteral nutrition
• GI system should be used to support its integrity
• Administration of glutamine
• Administration of H2 blockers or proton pump inhibitors
 Psychological Support of Patients and Families

• Anxiety
• Support of coping
• Patient, family education
• Communication
• End-of-life issues
• Grief processes
Disseminated Intravascular Coagulation
• Disseminated intravascular coagulation
(DIC) may occur either as a cause or as a
complication of shock.
• In this condition, widespread clotting and
bleeding occur simultaneously.
• Bruises (ecchymoses) and bleeding
(petechiae) may appear in the skin.
• Coagulation times (e.g., prothrombin time,
activated partial thromboplastin time) are
prolonged.
• Clotting factors and platelets are
consumed and require replacement
therapy to achieve hemostasis.
 DIC

• Not a disease but a sign of an underlying disorder

• Severity is variable; may be life threatening
• Triggers may include sepsis, trauma, shock, cancer, abruptio placentae, toxins, and
allergic reactions
• Altered hemostasis mechanism causes massive clotting in microcirculation. As
clotting factors are consumed, bleeding occurs. Symptoms are related to tissue
ischemia and bleeding
• Laboratory tests
• Treatment: treat underlying cause, correct tissue ischemia, replace fluids and
electrolytes, maintain blood pressure, replace coagulation factors, use heparin or
LMWH
Pathophysiology of DIC
 Assessment

• Be aware of patients who are at risk for DIC and assess for signs
and symptoms of the condition
• Assess for signs and symptoms and progression of thrombi and
bleeding
Common Lab Values of DIC
 Diagnoses

• Risk for fluid volume deficiency

• Risk for impaired skin integrity
• Risk for imbalanced fluid volume
• Ineffective tissue perfusion
• Risk for injury
• Death anxiety
 Collaborative Problems and
Potential Complications

• Kidney injury
• Gangrene
• Pulmonary embolism or hemorrhage
• Acute respiratory distress syndrome
• Stroke
 Planning

• Major goals may include maintenance of hemodynamic status,

maintenance of intact skin and oral mucosa, maintenance of
fluid balance, maintenance of tissue perfusion, enhanced
coping, and absence of complications
 Interventions

• Assessment and interventions should target potential sites of

organ damage
• Monitor and assess carefully
• Avoid trauma and procedures that increase the risk of
bleeding, including activities that would increase intracranial
pressure
 Pharmacology and Coagulation

• Unfractionated heparin therapy

– Thrombosis prevention
– Maintain therapeutic aPTT
– Heparin-induced thrombocytopenia
• Low--molecular-weight heparin therapy
• Warfarin (Coumadin) therapy
– Impact of vitamin K
– INR
• Dabigatran (Pradaxa), rivaroxaban (Xeralto), apixiban (Eliquis), endoxaban (Savaysa),
Aspirin
 Question #3

Is the following statement true or false?

Disseminated intravascular coagulation is not a

disease but a sign of an underlying condition
 Answer to Question #3

True

Disseminated intravascular coagulation is not a

disease but a sign of an underlying condition