Types of Shock

Obstructive shockCaused by an obstruction that interferes with return of blood to the heart such as a PE, cardiac tamponade, tension pneumothorax.
Distributive shockcaused by an abnormal distribution and return of blood resulting from vasodilation, vasopermeability or both as in neurogenic, anaphylactic shock, or septic shock.
Fluid bolus for shockHypovolemic is indicated, contraindicated for cardiogenic shock with pulmonary edema.

Cardiogenic shockShock caused by insufficient cardiac output; inability for the heart to pump enough blood to perfuse all parts of the body.
Usually a result of severe left ventricular failure secondary to AMI or CHF.
Reduced BP aggravates this situation even more by lowering the coronary artery perfusion.
Ultimately results in complete heart failure.
Common cause of cardiac ShockSevere left ventricular failure is the most common. Others: cardiomyopathy, rupture pf the papillary heart muscles or intraventricular septum and end-stage valvular disease ( Mitral stenosis or aortic regurgitations.
Hypovolemic cardiogenic shock PtsAlthough most PTs with cardiogenic shock will have normal blood volume, those PTs who use excessive use of prescribed diuretics or severe diaphoresis (common in some acute cardiac events) may have low blood volume. essay

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Pts may have relative hypovolemia from the vasodilatory effects of Nitroglycerin.
Recognizing Cardiogenic shockA major difference from this type of shock compared to others is the presence of pulmonary edema, pts may complain of difficulty breathing.
Possible diminished lung sounds as fluid enters the interstitial spaces of the lungs
As fluid levels rise: Wheezes, crackles/rales may be heard.
Productive cough with white or pink tinged foamy sputum.
Cyanosis is typical.
Other signs: Altered mental status (due to lack of brain perfusion, oliguria (diminished urination from compensatory mechanisms with holding water to increase volume)
Treatment of cardiogenic shockTreatment for this shock: Ensure open airway, administer oxygen if pt is hypoxic and assist with ventilations if needed.
Keep pt warm dues to impaired cellular metabolism no longer producing enough energy to keep up temperature.
With hold fluid due to pulmonary edema
Hypovolemic shockShock caused by a loss of intravascular fluid volume.
Possible causes: internal or external hemorrhage, traumatic injury, long bone or open fractures, Severe dehydration, plasma loss from burns, excessive sweating, and DKA with resultants osmotic diuresis
Osmotic diuresisGreatly increased uriniation and hydration due to high levels of glucose that cannot be reabsorbed into the blood from the kidney tubules causing water into the urine
Recognizing Hypovolemic shock.Signs of this shock are the classic sings; Altered mental status, anxiety to lethargy or combativeness to unresponsiveness, pale/cool/clammy skin, BP may be normal during compensated shock but will begin to fail, pulse normal then will become rapid finally slowing and disappearing.
As kidneys continues to reabsorb water, urination decreases.
Cardiac arrhythmias may develop in late shock deteriorating to asystole .
Treatment of hypovolemic shock.Treatment for this shock includes: It is accepted to administer crystalloid or colloid solution to replace fluids lost via vomiting, diarrhea, burns, excessive sweating, or osmotic diuresis.
In Trauma pts its quite controversial to administer fluids.
Premissive hypotensionIt has been demonstrated that natural compensation for low flow states when the systolic pressure is maintained between 70 and 85 mmHg, a BP greater than 85 mmHg has shown to have worsened outcomes. (Due to the fact that aggressive fluid resuscitation, before the source of bleeding is repaired)
Many surgeons and EMS medical directors are now recommending fluid only to the 70-85 mark.
Neurogenic shockShock resulting from the brain or spinal cord injury that causes an interruption of nerve impulse to the arteries with loss of arterial tone, dilation and relative hypoventilation.
Most commonly caused by severe spinal cord injury or total transection of the cords (spinal shock) or deprivation of oxygen or glucose to the medullar of the brain.
Sympathetic nerve impulses in neurogenic shockImpulses to the adrenal glands are lost. which prevents the release of catecholamines and there compensatory effects.
Injury high in the cervical spineThere may be interruption of impulses to the peripheral nervous system, causing paralysis and loss of sensation. Respiratory and cardiac centers of the brain may also be affected.
Recognizing Neurogenic shockThis type of shock will present in contrast to hypovolemic shock: warm, red skin and dry skin from vasodilation.
Because of lack of compensatory release of catecholamine release: low blood pressure and a slow pulse even in early stages.
Spinal shock is characterized by hypotension, reflex bradycardia, and warm/dry skin.
Treatment of neurogenic shock or spinal shockTreatment of this shock is similar to other types of shock: Airway, oxygenation, ventilation, maintenance of body temperature and IV access.
Anaphylaxis or anaphylactic shockA life threatening allergic reaction. Generally speaking the faster the reaction the more severe it is likely to be, death can occur before the pt can get to the hospital. The most rapid reaction happen when the substance is injected right to the blood stream
Skin S&S in anaphylactic shockFlushing Itching Hives Swelling and Cyanosis
Respirs S&S in anaphylactic shockBreathing difficulty, sneezing, coughing, Wheezing, stridor, Laryngeal edema, laryngospasm
Cardiovascular system S&S in anaphylactic shockVasodilation, increased heart rate, decreased blood pressure,
GI system S&S in anaphylactic shockNausea, Vomiting, abdominal cramping, diarrhea,
Nervous system S&S in anaphylactic shockAltered mental status, dizziness, headache, seizures, tearing
anaphylactic shock altered mental statusCan progress to unresponsiveness, so gather a brief Hx asap, including: previous allergic reactions and any info about the or may have ingested or been exposed to. Be sure the pt is no longer in contact with the allergen; if stinger is in the skin scrape it awat with scalpel blade.
Treatment for Anaphylactic shockProtecting the airway is the first concern, administer oxygen as necessary, by endotracheal intubation.
Due to depletion of circulatory volume by promoting capillary permeability/leaking fluid into the interstitial spaces. so establish an IV (NS or LR) for volume support.
Pharmacological treatment of Anaphylactic shockThe primary treatment for this shock. EPI is usually given (If the pt has Hx of anaphylaxis), Antihistamines, (Diphenhydramine) corticosteriods (methyl-pred-nis-o-lone, hydrocortisone, dexamethasone) and vasopressors (dopamine, norepi or epi)
Occasionally inhaled beta agonist (albuterol) may be required.
Septic shockShock that develops as a result of infection carried by the bloodstream eventually causing dysfunction of multiple organ systems.
Recognizing Septic shockThe signs and symptoms of this shock are progressive. Beginning: cardiac input is increased, but toxins may prevent increase in BP, pt may seem sick but not alarmingly so.
Last stages: Toxins have increased permeability of the blood vessels to the point where great amounts of fluid are lost from the vasculature and blood pressures falls drastically.
Signs and symptoms of Septic shockHigh fever, other especially elderly and young children may be afebrile or even hypothermic,
Skin can be flushed if fever is present or very pale and cyanotic in late stages.
The most susceptible to this is the respiratory system, pts my present with difficulty breathing and altered lung sounds.
Brain may be infected resulting in altered mental status
Suspicion of this shock if based on Hx of recent infection or illness.
Multiple organ dysfunction syndrome (MODS)progressive impairment of two or more organ system resulting from an uncontrolled inflammatory response to a severe illness or injury.
Sepsis and septic shock are the most common causes.
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