Shock is a condition when the body is not getting enough blood flow. This condition is life-threatening, so the best option is immediate treatment.
Types of Shock
- Septic shock: is caused by infection
- Hypovolemic shock: due to low blood volume
- Neurogenic shock: caused by a trauma in the nervous system
- Cardiogenic shock: caused by problems of the heart
- Anaphylactic shock: caused by allergic reactions
General Signs and Symptoms of Shock
- Hypotension
- Tachycardia
- Tachypnea
- Obtundation or abnormal mental status
- Colds
- Clammy extremities
- Mottled skin
- Oliguria
- Metabolic acidosis
- Hyperlactatemia
- In hypovolemic shock, there’s also orthostatic hypotension, pallor, and flattened jugular venous pulsations; this may result in a sequelae of chronic liver diseases
- In septic shock, symptoms suggesting infection and infective endocarditis is evident in skin
- Anaphylactic shock includes
- Hypotension
- Flushing
- Urticaria
- Tachypnea
- Hoarseness of voice
- Oral and facial edema
- Hives
- Wheezing
- Inspiratory stridor
Stages of Shock
Initial Stage
- The low cardiac output leads the cells to undergo hypoxia. This may result in a decrease in tissue perfusion, then lead to an inability to support the oxygen demands from the cells.
- Low oxygen causes the cells to perform anaerobic respiration.
Signs and symptoms
- Signs and symptoms from this stage are not immediately obvious as compared to the later stage.
Compensatory Stage
- The body system is trying to compensate using neural, hormonal, and biochemical mechanisms.
- If treated, this stage is reversible.
- Baroreceptors sense the drop in blood pressure. This stimulates the sympathetic nervous system to release epinephrine and norepinephrine, resulting in vasoconstriction, increased blood pressure and heart rate.
Signs and Symptoms
- Cold and clammy skin
- In septic shock, the skin is hot and flushed
- Hyperventilation
Progressive Stage
- The body compensation failed.
- This progresses to many organ dysfunction syndromes.
- The blood stays in the capillaries which can cause fluid and protein leakage in the tissues.
- Depleted blood volume.
Signs and Symptoms
- Slowed speech
- Restlessness
- Agitated
- Anxious
- Does not respond to stimulation
- Fluid in the lungs (crackles)
- Increased respiratory rate
- Decreased oxygen level
- Cardiac dysrhythmia
- Bleeding
- Refractory stage
- The vital organs failed and shock is no longer reversible
- Brain damage and cell death
- Irreversible organ dysfunction
Diagnostic tests
The doctor will assess for the signs and symptoms of shock and will perform laboratory tests. For undifferentiated shock, the laboratory tests include:
- CBC and differential
- Renal and liver function tests
- Serum lactate level
- Cardiac biomarkers
- D-dimer level
- Coagulation profile
- Blood and urine cultures
- Blood gas analysis
- Chest X-rays: determine the source of infection
- CT scan: to know the etiology of shock
- Point of care ultrasonography
Treatment
- The first approach of care is to stabilize the airways and breathing, done through oxygen administration then followed by mechanical ventilation, if necessary
- Peripheral IV or intraosseous infusion (IO)
- Immediate treatment with intravenous (IV) fluid, followed by vasopressor therapy for difficulty in securing peripheral venous access
- There are also specific therapies/treatments needed for specific types of shock:
Septic shock
-
- Fluid resuscitation with IV isotonic crystalloids 30 mL/kg within 3 hours
- Empiric antibiotic therapy within 1 hour
- Vasopressors: Norepinephrine and Vassopresin if refractory
- Hypovolemic shock
- Two large-bore IVs or central line
- Place the patient in Trendelenburg position
- IV fluid resuscitation: 2 to 4 L of isotonic crystalloids
- PRBS transfusion if there’s bleeding
Neurogenic shock
-
- First-line treatment: intravenous fluid resuscitation
- Second-line treatment: Vasopressors and inotropes if hypotension persists
- Epinephrine: used in refractory cases of hypotension
- Surgical intervention for decompression of the spine
Cardiogenic shock
-
- Start ACLS protocol and cardioversion for unstable tachyarrhythmias or bradyarrhythmias
- IV Fluids
- Inotropes and aortic balloon pumps should be considered if there’s refractory shock
- Anaphylactic shock
- IV fluid resuscitation: 4 to 6 L of IV crystalloids
- Intramuscular epinephrine
- Antihistamine
- Corticosteroids
- Nebulize with Albuterol
Nursing Management
- Assess mental status
- Monitor input and output of the patient
- Administer medications as ordered by the physician
- Check laboratories such as BUN and creatinine for kidney status
- Provide nutrition as recommended by the dietician
- Make sure that the patient is rested and does not feel pain
- Check serum glucose levels if the patient is diabetic
- Check skin color, pulses, and warmth for peripheral perfusion; take note and inform the physician if there are changes.
- Ensure DVT and stress ulcer prophylaxis
