Complex 1

• Initial
• Compensatory
• Progressive
• Refactory (Irriversible)

• Progression of physiologic effects as shock ensues:
• Cardiac depression
• Respiratory distress
• Renal Failure
• Dic

End result is organ failure

• Monitor for reactions (especially to new meds)
• Remove allergen
• Administer epi if needed
• Benadryl for antihistamine
• Albuterol to help airway
• *Maintain airway

• ABC"s
• urticaria
• rash
• tickle in throat
• SOB 
• lightheaded

• Defined as SBP <90, PCWP >18
• Cool, mottled skin
• Tachypnea
• Hypotension
• Altered mental status
• NARROWED PULSE PRESSURE
• Rales, murmur

• Goal is airway stability and improving myocardial pump function:
• Cardiac monitor, pulse oximetry
• Supplemental O2, IV access
• Intubation will decrease preload and result in hypotension
• *Be prepared to give fluid bolus
• MONA
• Monitor urine output, BUN and serum creatinine levels to detect decreased renal function secondary to effects of cardiogenic shock or tx

• Goals are to limit further myocardial damage, preserve healthy myocardium, and improve cardiac function by increasing cardiac contractility, decreasing ventricular afterload, or both
• Achieved by increasing O2 supply to heart muscle while reducing O2 demands

• Aspirin, beta blocker, morphine heparin
• If no PE, IV fluid challenge
• If PE:
• Dopamine & Dobutamine = Improve contractility, increase stroke volume, increase cardiac output. BUT also increased O2 demand on heart
• Combination therapy may be more effective
• PCI or thrombolytics

• To achieve max effectiveness, metabolic acidosis must be first corrected.
• Doses of 2 to 8 μg/kg/min improve contractility (inotropic action), slightly increase the heart rate (chronotropic action), and may increase cardiac output.

• Doses higher the 8 ug/kg/min predominantly
• cause vasoconstriction, which increased afterload and also cardiac workload. As this is undesirable in cardiogenic shock, dopamine doses must be carefully titrated

• Sequence of events in hypovolemic begins with decreased intravascular volume
• Results in decreased venous return of blood to heart and subsequent decreased ventricular filling
• Decreased ventricular filling results in decreased stroke volume (amt blood ejected from heart) and decreased cardiac output
• This caused drop in BP and tissues not being adequately perfused
• Occurs when reduction in intravascular volume by 15-30%
• Can be caused by trauma orinternal fluid shift

• trauma
• dehydration
• burns
• internal bleeding

Non-hemorrhagic: N/V, diarrhea, bowel obstruction, pancreatitis, burns, dehydration

Hemorrhagic: GI bleed, major hemoptysis, AAA, ectopic preg, postpartum bleeding

• continue tx
• monitor pt, provide comfort
• Communicate to pt about what's happening even if you dont think they can here
• Family communication is important, let them touch and talk to them
• *essential to explain the equipment and treatments are being provided are intended for pt comfort and do not suggest pt will recover

• Finger in rectum
• recent traum
• Low BP and low HR
• decreased sympathetic tone = warm and dry skin
• results in hypotension and bradycardia

• spinal cord injury decrease sympathetic response and unopposed vagal tone leads low cardiac output
• Injury above T1 disrupts entire sympathetic system

Trauma causes sudden loss of background sympathetic stimulation to blood vessels - this causes them to relax (vasodilation) resulting in sudden decrease in BP

• Leading death in noncoronary ICU pt
• Most common type of circulatory shock
• More than 18 mil cases yr, 1400 daily worldwide
• Common in elderly
• increasing #'s of resistant bacteria and use of invasive procedures contribute to septic shock

• Body is making minor corrections.
• HR and respirations may go up a bit
• BP may go up a bit
• Blood shunted to vital organs so extremities become cool

• still reverible if you act now
• Things are starting to shut down... lungs, heart, liver, kidneys

• determine underlying cause
• Obtain 2 large bore IV 
• anticipate labe and meds
• frequent assessments to detect changes from baseline
• Supplemental oxygen 
• Fluids: crystalloids (NS or LR)

• support resp system with supplemental O2 and/or mechanical vent
• Support vascular with fluids
• Vasoactive meds restore vasomotor tone and improve cardiac function
• Nutritional support to address metabolic requirements that often dramatically increase in shock

• Increased metabolic rates during shock increase energy requirements and therefore caloric requirements
• May need over 3000 calories a day
• Release of catecholamines early in the shock continuum causes depletion of glycogen stores in about 8 to 10 hours
• Nutritional energy requirements are then met by breaking down lean body mass. In this catabolic process, skeletal muscle mass is broken down even when the patient has large stores of fat or adipose tissue. Loss of skeletal muscle greatly prolongs the patient’s recovery time.

• Vital signs must be monitored frequently (at least every 15 until stable)
• Should be administered through central venous line, because infiltration and extravasation of some vasoactive drugs can cause tissue necrosis and sloughing-ASSESS FOR THIS!
• Watch for vasodilators to drop cause hypotension
• Vasopressors can shunt blood from skin, gi tract, kidneys - WATCH FOR THIS
• Vasoactive drugs should be tapered with frequent monitoring

• Disseminated intravascular coagulation
• widespread clotting and bleeding occur simultaneously. Bruises (ecchymoses) and bleeding (petechiae) may appear in the skin.
• Coagulation time is prolonged
• Clotting factors and platelets are consumed and require replacement therapy to achieve hemostasis.

• treat underlying cause
• correct tissue ischemia by improving oxygenation, replacing fluids, correct electrolyte imbalances, administer vasopressor meds
• rep

• Avoid procedures/activities that can increase intracranial pressure (e.g., coughing, straining to have a bowel movement).
• Monitor vital signs closely, including neurologic checks:
• Avoid medications that interfere with platelet function if possible (e.g., aspirin, nonsteroidal anti-inflammatory drugs, beta-lactam
• Avoid rectal probes, rectal medications, and IM injection
• Monitor amount of external bleeding carefully

Multiple Organ Dysfunction Syndrome

• Fever, Tachycardia, dyspnea, altered mental status, hypermetabolic state...
• Lungs show signs first, with progressive dyspnea and resp failure 
• After 7-10 days, hepatic and renal failure
• Soon cardiac

• PREVENTION IS BEST!!
• Early recognition
• If preventive measures fail, treatment measures to reverse MODS are aimed at
• (1) controlling the initiating event,
• (2) promoting adequate organ perfusion,
• (3) providing nutritional support, and
• (4) maximizing patient comfort.

• Arterial line enables accurate and continuous monitoring of BP
• Provides port from with to obtain frequent arterial blood samples

Stroke volume x Hr

• Afterload is pressure in wall of left ventricle during ejection (Systole)
• Vasodilators (Nitro) reduce afterload, reduce O2 demands, lower BP
• Vasopressors (Norepi and Dopamine) increase afterload, BP, cardiac workload, but compromises perfusion to skin, kidneys, lungs and gi

• Central venous pressure - Blood pressure in venae cavae, near right atrium of hear
• Normal is 2-6
• reflects amount of blood returning to heart and ability of heart to pump blood back to arterial system
• Can be attached to transducer and monitor to read pressures

• Pulmonary artery pressure
• Used for pts with :
• labile BP
• titration of vasoactive drugs
• frequent blood sampling for ABG
• Hemodynamic monitoring for shock
• Trauma

• Cardio is changing conduction pattern with "synchronized shock, pt is sedated. Done on QRS complex
• Defib is shock anytime to get conduction pattern

• an acute MI, "STEMI"
• elevation due to ventricles not totally depolarizing - cardiac ischemia