• perfusion to the cells is inadequate to deliver:
• oxygen
• nutrients - glucose

• sufficient blood volume
• adequate cardiac pump
• effective vasculature tone (SVR) constricture
• Systemic vascular resistance
• if anyone of these fail shock can result
• determines what tmnt is to be done

• hypoperfusion
• hypermetabolism
• inflammatory response

• no oxygen, glucose, atp
• lactic acid
• low ph
• low energy (ATP)
• death

oxygen hemoglobin dissociation curve

• acidosis ↓ oxygen binding to hgb, ↑ oxygen release at the cell (held loosely)
• Alkalosis ↑ oxygen binding to hgb, ↓ oxygen release at the cell(held tight)

1. Hypoperfusion
2. hypermetabolism
3. inflammation

• sympathetic nervous system
• body attemps to deliver more glucose to the cells
• gluconeogenesis
• glycogenolysis
• pt may become hyperglycemic

• lactic acid
• membranes become permeable
• Na, H+, H2O moves into cell
• cells swell, rupture and die
• k+ moves into blood stream
• Na - K pump impairment

• regulate inflammotory response
• wbc release proinflammatory cytokines
• cause endothelial injury
• decrease protein c

• is neccessary to prevent clotting and break up existing clots
• pts with sepsis are deficient in protein c
• clots in the microcirculation lead to DIC and MODS

first responder to shock

• BP drops
• stimulates baroreceptors
• release catecholamines
• results in ↑ HR and vasoconstriction
• BP restored
• SNS attempts to overcome hypoperfusion

• mean arterial pressure
• (SBP + 2DBP)/3 = MAP
• a MAP of >65 mmhg is needed to deliver oxygen /glucose to major organs results in hypoperfusion and shock if <65

a secondary responder

• RAA system
• Renin angiotension aldosterone
• increased Na results in ADH and H2O retention

• release of renin
• converts angiotension I to angiotension II
• results in vasoconstriction
• release of aldosterone
• results in Na and H2O retention
• ↑Na results in release of ADH or vasopressin and H2O retention

• catecholamine improves pump(CO) and tone (SVR)
• glucocorticoids provide energy(glucose)
• C-reactive protein becomes inactive clotting
• anerobic metabolism provides energy(atp)
• kidneys restore tone(angiotensin) and volume (aldosterone and ADH)

• compensatory (early)
• progressive
• Irreversible (late)

• SNS maintains CO
• Normal BP HR>100 RR>20
• PaCO2 <32 mmHg (35-45)
• hyperventilation = Resp Alkalosis = confusion
• ↓ urine(release of ADH)
• cold clammy skin
• start of metabolic acidosis
• ↑Na, glucose

• fluids
• medications

• id and correct underlying cause of shock
• increase oxygen delivery to the cells
• iv fluids
• vasopressors
• prbc
• decrease cellular oxygen demand
• sedating agents, opoids
• prevent shivering

• sublingual capnometry
• near infrared spectroscopy (NIRS)

• stage 2
• mechanisms that maintain BP can no longer compensate
• survival depends on time required to restore tissue perfusion

• SBP <90mmHg
• drop of 40 mmHg below baseline
• MAP falls below 65mmHg
• narrowing pulse pressure
• Lactic acid increase>4 mmol/L

• pulse pressure = SBP - DBP
• Normal Pulse pressure is 30-40 mmHg
• CVP sensor monitors O2 and CO2 levels

• myocardial ischemia and depression
• decreased preload/pump failure
• increased capillary permeability
• interstitial edema,
• prognosis worsens
• inflammatory response continues
• mobilization of energy stores(glucose)

• fatigue leads to hypoventilation, rapid, shallow crackles
• hypoperfused alveoli, atelectasis
• pulmonary edema
• shunting
• decreased PaO2 and increase PaCO2 (50/50 club)
• ARDS
• mechanical ventilation

• myocardial ischemia/infarction dysrythmias
• tachycardia
• chest pain
• ck-mb monitor troponins
• BNP b-type natriuretic peptide

• decreased cerebral perfusion
• behavior changes
• agitation
• confusion
• lethargy
• coma

• ARF if MAP <65
• ↑ BUN, ↑creatinine
• F/E imbalances
• loss of renal / hormonal BP control
• Urine output <0.5ml/kg/hr

• ↓metabolism of meds and waste products
• ↑ammonia levels
• ↑lactic acid
• failure of gluconeogenesis/glycogenolysis
• increased risk of infection
• ↑alt ast ldh bilirubin
• jaundice

• cool clammy dry
• flushed / mottling

• stress ulcers - gi bleeding
• ischemic intestines- bloody diarrhea
• intestional bacteria migrate via lymphatics to blood stream

• activation of clotting cascade (cytokines)
• microclots/DIC
• bleeding/petechiae
• increased PT aPTT
• increased d-dimer
• leukocytosis(↑wbc)
• bands - immature neutrophil

• ICU hemodynamic monitoring
• mechanical ventilation
• IV fluids - replace volume
• vasopressors - replaces tone and pump
• antibiotics
• enteral feeds with glycemic control
• GIB prevention(h2 blockers)
• dialysis
• intra aortic balloon pumps

• cyrstalloids
• isotonic - 0.9% NaCl, LR
• colloids
• albumin
• prbc
• platelets
• fresh frozen plasma
• dextran

• assess fluid overload
• pulmonary edema - crackles wheezes
• urine output
• mental status
• peripheral edema skin perfusion
• abdominal compartment syndrome(acs)

• obtain and monitor labs, abg
• maintian iv access lines
• admin iv fluids and meds
• prevent VAP
• normothermia
• decrease pt / family anxiety

• multiple organ dysfunction syndrome(MODS)
• Refractory organ damage- death
• continue progressive stage of treatment
• advanced directives
• support family with grave prognosis

• hypovolemic - volume
• cardiogenic - pump
• circulatory(distributive) - tone
• septic shock
• neurogenic shock
• anaphylactic shock

• volume problem
• decreased intravascular volume
• 15-30% or 750-1500 ml

• trauma-burns, surgery, hemorrhage, GIB
• dehydration - vomiting, diarrhea, Diuresis
• Diabetes insipidus, DKA, addisons crisis
• ascites peritonitis
• ruptured ectopic pregnancy

• LR is proinflammatory
• too rapid infusion may destabilize clot

• excessive bleeding
• massive bleeding

• oozing from tubes IVs orifices
• >2000ml /24 hrs
• 100-200 ml/hr for 4hrs

• up to 100 ml/min
• external bleeding is easy to see
• internal bleeding is insidious
• can settle in chest, abdomen, retroperitoneum, pelvis

• Hgb abrupt drop 2 gm
• ↑PTT INR - coagulopathy cascade
• ↓platelets
• early use of plasma
• lactic acid level
• restlessness
• subtle respiratory rate ↑
• orthostasis(hr 20 beats up SBP 20 down)

• radial 80
• femoral 70
• carotid 60

• correct underlying cause
• start 2 large bore iv sites
• iv fluid replacement
• type and crossmatch
• 3:1 guideline for blood transfusions
• pressors after fluid resuscitation
• modified trendelenberg position
• oxygen
• assess for fluid overload, hypothermia, JVD
• NG, foley

• pump problem
• hearts ability to contract/pump blood is impaired
• CO falls - BP falls - tissue perfusion is reduced (shock)

• coronary
• acute MI
• non coronary stressors to the myocardium
• hypo - xemia/glycemia/calcemia
• acidosis
• tension pneumothorax/tamponade
• cardiomyopathies/dysrthymias

• preload
• pressure stretch from blood volume in ventricles at end of diastole

• Resistance against which the ventricles have to pump
• SVR for left ventricle
• pulmonary vascular resistance for right ventricle

• oxygen
• thrombolytic therapy
• valve replacements/mechanical assistive devices
• antidysrhytmia and inotropic medications
• Beta blockers may mask tachycardia
• correct acidosis / f/e imbalances
• PCI CABG IABP
• pain control
• vasopressors
• hemodynamic monitoring
• arterial lines
• cvp

• intra aortic balloon pump
• rapidly shuttles helium gas in and out of the balloon, which is located in the descending aorta.
• the balloon is inflated at the onset of cardiac diastole and deflated at the onset of systole.
• mechanical device that increases myocardial oxygen perfusion while at the same time increasing cardiac output

• limb ischemia
• bleeding from site
• infection/sepsis
• aortic valve rupture/dissection
• thrombosis/embolism
• renal failure
• balloon rupture

• central venous pressure
• placed in superior vena cava
• measures pressure and blood return to right atrium
• right sided heart preload
• estimation of preload
• normal CVP is 2-6 mmHg
• low cvp signals hypovolemia

increase BP

• dopamine
• dobutamine
• norepinephrine
• neosynephrine
• vasopressin

• decrease BP
• goal to decrease preload and afterload
• morphine
• nitroglycerine

• goal to increase contractility and cardiac output and regular rhythm

• alpha 1 - constriction of blood vessels
• beta 1 - stimulates heart rate and contractility
• beta 2 - causes bronhodilation and vasodilation heart skeletal vessels

• dilates renal vasculature
• improves urine output

• vasodilators
• vasoconstrictors
• rn titrates to vital signs parameters
• high alert drugs - dosing errors risk in harm

• dopaminergic 1-4mcg/kg/min increases U.O.
• beta 5-10mcg/kg/min increase HR contractility
• Alpha 1 10-20mcg/kg/min increases SVR/BP

• dobutrex
• increases stroke volume
• improves cardiac output
• less tachycardia than with dopamine
• manages CHF when an increase in HR is not desired
• positive ionotrope, little chronotrope

• levophed
• alpha 1 and beta 1
• potent vasoconstrictor
• increases bp and cardiac output
• monitor bp q 2-5min when titrating
• cautious use in veins with occlusive disease
• assess for mottling

• neosynephrine
• used to tx hypotension without raising HR
• potent alpha adrenergic
• little effect on beta 1
• vasoconstriction
• increased SBP / DBP

• Antidiuretic hormone ADH
• causes vasoconstriction
• increases BP
• hypovolemic/hemorrhagic shock
• code drug

• low dose - venous dilator - reduces preload
• high dose - arterial dilator - reduces afterload
• can cause hypotension
• RN assess for refractory tachycardia
• consider for pump problem

• tone problem
• blood volume pools in peripheral blood vessels causing relative hypovolemia
• loss of sympathetic tone
• aka distributive septic anaphylatic neurogenic shock

• most common type of circulatory shock
• widespread infection
• hypotension/hypoperfusion despite fluid replacement
• Sepsis = infection + inflammation
• severe sepsis = sepsis +↓bp(<90)
• Septic shock = severe sepsis +↓bp+fluids

• bacteria in blood
• from respiratory urine abdominal wound infections

three simultaneous responses occur:

• inflammation
• coagulation
• impaired fibrinolysis

low serum protein c may be a screening tool for early sepsis

• immune response
• cytokines/inflammation
• bacteria release endotoxins
• leaky membranes
• vasodilation
• hypotension
• inadequate oxygen/nutrients
• hypermetabolism
• acidosis
• hypercoagulation
• impaired fibrinolysis
• low protein c
• end organ damage MODS

• fever, tachycardia
• skin-flushed/dry or cool/pale
• hypotension, blood shunting
• MODS
• hypoxia
• ↓UO
• liver(bilirubin, NH3)
• metabolic acidosiss

• bacteremia
• change loc
• hypotension <90 or ↓40, not responsive to fluids
• MAP <65
• RR>20
• UO <0.5/kg/hr
• WBC lactic acid LFT, coagulopathies
• insulin resistance
• mottling

• fluid replacement
• antipyretics - for each 1º = 10 additional beats
• vasopressors agents
• pan culture
• eliminate infection
• antibiotics
• mechanical ventilation
• transfue if Hgb<7g/dl
• enteral feeds with glycemic control
• consider steroids sedation protein c

• first 3 hours
• draw lactic acid level
• draw blood cultures
• admin antibiotics
• admin 30ml/kg crystalloid for hypotension or lactate levels =>4mmol/l

• increases map thru vasoconstriction (alpha 1)
• used first
• phenylephrine - reserved for salvage therapy

• wounds
• burn patiens
• intravascular urinary catheters
• elderly >65
• infants <1yr
• malnourished
• invasive procedures
• chronic illness - diabetes,  liver disease, cancer

• bacteremia
• osteomyelitis
• endocarditis/pericarditis
• meningitis
• diverticulitis, appendicitis, perforated or ischemic bowel
• pneumonia
• surgical wounds
• urinary / kidney infections

• imbalance of SNS and PSNS
• predominate parasympathetic stimulation leads to vasodilation and hypotension
• hypotension without tachycardia or vasoconstriction

• spinal cord injury
• spinal anesthesia
• depressant action of medications
• glucose deficiency

• hypotension without tachycardia or vasoconstriction
• consider head/spinal cord injury in patient that does not respond to fluid resusitation
• dry warm skin
• hypotension with bradycardia

severe potentially fatal systemic allergic reaction that occurs suddenly after contact with an allergy causing substance

becomes worse with each occurence

• food - peanuts, shell fish
• medications PCN, nsaids
• environmental - venom, bees, latex

• Respiratory - cough throat tightness wheezing
• integumentary - rash / hives
• vascular - compensatory tachycardia, capillary leakage, hypotension
• gastrointestinal - N/V

• angioedema
• astham
• panic attack
• epiglottis
• tracheal FB
• PE
• MI
• urticaria
• msg poisoning

• large bore IV
• O2 - pulse ox
• epinephrine - 0.3-0.5 mg in lateral thigh q5-15min
• antihistamines
• corticosteroids
• beta agonists
• H1 recepter blockers
• H2 receptor blockers
• Beta blockers
• vasopressin

• systemic inflammatory response syndrome
• clinically similar to sepsis - infection may be absent or hidden
• severe insult initiates inflammatory response
• defined as two or more of the following :
• core temp <96.8 or >100.4 (<36-38>)
• HR>90
• RR>20 or PaCO2 <32mmHg
• WBC>12000 or <4000 or 10%bands

• disseminated intravascular coagulation
• primarily a thrombotic process
• systemic process resulting in both clotting and hemorrhage
• aka consumption coagulopathy
• increased PT PTT d-dimer, fibrin degradation products
• decreased platelets and fibrinogen

• prolongation/increase of PT aPTT
• d/t consumption and inhibition of clotting factors
• thrombocytopenia
• d-dimer increases
• dic is enchanced by the comorbidity of liver disease

• ID cause - all other therapies are temp
• asymptomatic pts have only lab abnormalities - no tx
• transfusions of platelets - improves thrombocytopenia
• fresh frozen plasma FFP
• large volumes of plasma in servere cases
• drotrecogin alfa (xigris)

• multiple organ dysfunction syndrome
• altered function of one or more organs, requiring medical intervention to support organ function
• dysfunction of one organ = 20% mortalitiy
• dysfunction of >4organs = 70% mortality

• lungs-dyspnea-resp failure -ards - ventilation
• cardiac-BP support - iv fluids/vasopressors
• hyperglycemia acidosis increased bun
• loss of skeletal muscle mass
• hepatic dysfunction elevated bilirubin
• bleeding
• coma
• treatment is prevention