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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$ering a MCC into a tree =e 1asunhelmete! an! has an obious le#t #emur
#+ =e 1as intubate! #or a 2CS o# in the"el! an! gien 7: NS en route #orh%&otension
/itals; =0 7, BP H7
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(hat kin! o# shock !oes this &atienthae)
A Car!iogenic
B =%&oolemic
C >istributie
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=%&oolemic Shock Shock cause! b% !ecrease! &reloa!
!ue to intraascular olume loss 67iarrhea, omiting, burnsMe!sca&e ::C 3478 6Online access on 33 August 34789
U0:; htt&;
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(hat in#ormation !o %ou hae tosuggest that Mr = has h%&oolemicshock)
A 0ecent trauma
B (BC 738
C =gb ?H
> All o# the aboeE Both A an! C
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.reatment o# =%&oolemic
Shock Ma+imi'e o+%gen !elier%
Control #urther bloo! loss
.ourniuets
Surgical interention
@lui! resuscitationNS Jui! boluses
Bloo! &ro!uct a!ministration
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Case Stu!% Mr S is a 5%o M &resents to E> 1ith
1orsening ab!ominal &ain an! NK/
=e is PO>F s
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(hat kin! o# shock !oes this &atienthae)
A Car!iogenic
B =%&oolemic
C >istributie
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>istributie Shock Shock as a result o# seerel% !iminishe!
S/0
CO is t%&icall% increase! in an e$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&;