SHOCK

Definition Shock is a medical emergency in which the organs and tissues of the body are not receiving an adequate flow of blood. This deprives the organs and tissues of oxygen (carried in the blood) and allows the buildup of waste products. Shock can result in serious damage or even death. Description There are three stages of shock: Stage I (also called compensated, or non-progressive), Stage II (also called decompensated or progressive), and Stage III (also called irreversible). In Stage I of shock, when low blood flow (perfusion) is first detected, a number of systems are activated in order to maintain/restore perfusion. The result is that the heart beats faster, the blood vessels throughout the body become slightly smaller in diameter, and the kidney works to retain fluid in the circulatory system. All this serves to maximize blood flow to the most important organs and systems in the body. The patient in this stage of shock has very few symptoms, and treatment can completely halt any progression. In Stage II of shock, these methods of compensation begin to fail. The systems of the body are unable to improve perfusion any longer, and the patient's symptoms reflect that fact. Oxygen deprivation in the brain causes the patient to become confused and disoriented, while oxygen deprivation in the heart may cause chest pain. With quick and appropriate treatment, this stage of shock can be reversed. In Stage III of shock, the length of time that poor perfusion has existed begins to take a permanent toll on the body's organs and tissues. The heart's functioning continues to spiral downward, and the kidneys usually shut down completely. Cells in organs and tissues throughout the body are injured and dying. The endpoint of Stage III shock is the patient's death. Causes and symptoms Shock is caused by three major categories of problems: cardiogenic (meaning problems associated with the heart's functioning); hypovolemic (meaning that the total volume of blood available to circulate is low); andseptic shock (caused by overwhelming infection, usually by bacteria). Cardiogenic shock can be caused by any disease, or event, which prevents the heart muscle from pumping strongly and consistently enough to circulate the blood normally. Heart attack, conditions which cause inflammation of the heart muscle (myocarditis), disturbances of the electrical rhythm of the heart, any kind of mass or fluid accumulation and/or blood clot which interferes with flow out of the heart can all significantly affect the heart's ability to adequately pump a normal quantity of blood. Hypovolemic shock occurs when the total volume of blood in the body falls well below normal. This can occur when there is excess fluid loss, as in dehydration due to severe vomiting or diarrhea, diseases which cause excess urination (diabetes insipidus, diabetes mellitus, and kidney failure), extensive burns, blockage in the intestine, inflammation of the pancreas (pancreatitis), or severe bleeding of any kind. Septic shock can occur when an untreated or inadequately treated infection (usually bacterial) is allowed to progress. Bacteria often produce poisonous chemicals (toxins) which can cause injury throughout the body. When large quantities of these bacteria, and their toxins, begin circulating in the bloodstream, every organ and tissue in the body is at risk of their damaging effects. The most damaging consequences of these bacteria and toxins include poor functioning of the heart muscle; widening of the diameter of the blood vessels; a drop in blood pressure; activation of the blood clotting system, causing blood clots, followed by a risk of uncontrollable bleeding; damage to the lungs, causing acute respiratory distress syndrome; liver failure; kidney failure; and coma.

Initial symptoms of shock include cold, clammy hands and feet; pale or blue-tinged skin tone; weak, fast pulse rate; fast rate of breathing; low blood pressure. A variety of other symptoms may be present, but they are dependent on the underlying cause of shock. Diagnosis Diagnosis of shock is based on the patient's symptoms, as well as criteria including a significant drop in blood pressure, extremely low urine output, and blood tests that reveal overly acidic blood with a low circulating concentration of carbon dioxide. Other tests are performed, as appropriate, to try to determine the underlying condition responsible for the patient's state of shock. Treatment The most important goals in the treatment of shock include: quickly diagnosing the patient's state of shock; quickly intervening to halt the underlying condition (stopping bleeding, re-starting the heart, giving antibiotics to combat an infection, etc.); treating the effects of shock (low oxygen, increased acid in the blood, activation of the blood clotting system); and supporting vital functions (blood pressure, urine flow, heart function). Treatment includes keeping the patient warm, with legs raised and head down to improve blood flow to the brain, putting a needle in a vein in order to give fluids or blood transfusions, as necessary; giving the patient extra oxygen to breathe and medications to improve the heart's functioning; and treating the underlying condition which led to shock. Prognosis The prognosis of an individual patient in shock depends on the stage of shock when treatment was begun, the underlying condition causing shock, and the general medical state of the patient. Prevention The most preventable type of shock is caused by dehydration during illnesses with severe vomiting or diarrhea. Shock can be avoided by recognizing that a patient who is unable to drink in order to replace lost fluids needs to be given fluids intravenously (through a needle in a vein). Other types of shock are only preventable insofar as one can prevent their underlying conditions, or can monitor and manage those conditions well enough so that they never progress to the point of shock. Major classes of Shock: HYPOVOLEMIC SHOCK Hypovolemic shock is an emergency condition in which severe blood and fluid loss makes the heart unable to pump enough blood to the body. This type of shock can cause many organs to stop working. Causes Losing about 1/5 or more of the normal amount of blood in your body causes hypovolemic shock. Blood loss can be due to:

Bleeding from cuts Bleeding from other injuries Internal bleeding, such as in the gastrointestinal tract

The amount of circulating blood in your body may drop when you lose too many other body fluids, which can happen with:

Burns Diarrhea Excessive perspiration Vomiting

Symptoms

Anxiety or agitation Cool, clammy skin Confusion Decreased or no urine output General weakness Pale skin color (pallor) Rapid breathing Sweating, moist skin Unconsciousness

The greater and more rapid the blood loss, the more severe the symptoms of shock. Exams and Tests An examination shows signs of shock, including:

Low blood pressure Low body temperature Rapid pulse, often weak and thready

Tests that may be done include:

Blood chemistry, including kidney function tests Complete blood count (CBC) CT scan, ultrasound, or x-ray of suspected areas Echocardiogram Endoscopy Right heart (Swan-Ganz) catheterization Urinary catheterization (tube placed into the bladder to measure urine output)

Treatment Get immediate medical help. In the meantime, follow these steps:

Keep the person comfortable and warm (to avoid hypothermia). Have the person lie flat with the feet lifted about 12 inches to increase circulation. However, if the person has a head, neck, back, or leg injury, do not change the person's position unless he or she is in immediate danger. Do not give fluids by mouth. If person is having an allergic reaction, treat the allergic reaction, if you know how. If the person must be carried, try to keep him or her flat, with the head down and feet lifted. Stabilize the head and neck before moving a person with a suspected spinal injury.

The goal of hospital treatment is to replace blood and fluids. An intravenous (IV) line will be put into the person's arm to allow blood or blood products to be given.

Medicines such as dopamine, dobutamine, epinephrine, and norepinephrine may be needed to increase blood pressure and the amount of blood pumped out of the heart (cardiac output). Other methods that may be used to manage shock and monitor the response to treatment include:

Heart monitoring, including Swan-Ganz catheterization Urinary catheter to collect and monitor how much urine is produced

Outlook (Prognosis) Hypovolemic shock is always a medical emergency. However, symptoms and outcomes can vary depending on:

Amount of blood volume lost Rate of blood loss Ilness or injury causing the loss Underlying chronic medication conditions, such as diabetes and heart, lung, and kidney disease

In general, patients with milder degrees of shock tend to do better than those with more severe shock. In cases of severe hypovolemic shock, death is possible even with immediate medical attention. The elderly are more likely to have poor outcomes from shock. Possible Complications

Kidney damage Brain damage Gangrene of arms or legs, sometimes leading to amputation Heart attack

Prevention Preventing shock is easier than trying to treat it once it happens. Quickly treating the cause will reduce the risk of developing severe shock. Early first aid can help control shock.

CARDIOGENIC SHOCK Cardiogenic shock is a state in which the heart has been damaged so much that it is unable to supply enough blood to the organs of the body. Causes Shock occurs whenever the heart is unable to pump as much blood as the body needs. The most common causes are serious heart complications. Many of these occur during or after a heart attack(myocardial infarction). These complications include:

A large section of heart muscle that no longer moves well or does not move at all Breaking open (rupture) of the heart muscle due to damage from the heart attack Dangerous heart rhythms, such as ventricular tachycardia, ventricular fibrillation, or supraventricular tachycardia Tear or rupture of the muscles or tendons that support the heart valves, especially the mitral valve

Tear or rupture of the wall (septum) between the left and right ventricles (lower heart chambers) Very slow heart rhythm (bradycardia) or problem with the electrical system of the heart (heart block)

Symptoms

Chest pain or pressure Fast breathing Fast pulse Heavy sweating, moist skin Restlessness, agitation, confusion Shortness of breath Skin that feels cool to the touch Pale skin color or blotchy skin Weak (thready) pulse Decreased mental ability o Loss of ability to concentrate o Loss of alertness Coma (loss of consciousness)

Exams and Tests An examination will show:

Low blood pressure (usually less than 90 systolic) Blood pressure drop of more than 10 points when you stand up after lying down (orthostatic hypotension) Weak (thready) pulse

To diagnose cardiogenic shock, a catheter (tube) may be placed in the lung artery (right heart catheterization). Tests may show that blood is backing up into the lungs and the heart is not pumping properly. Tests include:

Cardiac catheterization Chest x-ray Coronary angiography Echocardiogram Electrocardiogram Nuclear scans

Other studies may be done to find out why the heart is not working properly. Lab tests include:

Arterial blood gas Blood chemistry (chem-7, chem-20, electrolytes) Cardiac enzymes (troponin, CKMB) Complete blood count (CBC)

Treatment Cardiogenic shock is a medical emergency. You will need to stay in the hospital, usually in the Intensive Care Unit. The goal of treatment is to find and treat the cause of shock to save your life. You may need medicines to increase blood pressure and improve heart function, including:

Dobutamine Dopamine Epinephrine Norepinephrine

These medicines may help in the short-term, but they should not be used over the longterm. When a heart rhythm disturbance (dysrhythmia) is serious, urgent treatment may be needed to restore a normal heart rhythm. This may include:

Electrical "shock" therapy (defibrillation or cardioversion) Implanting a temporary pacemaker Medications given through a vein (intravenous)

You may receive pain medicine if needed. Bed rest is recommended to reduce demands on the heart. Getting oxygen by a nasal tube or mask worn over the mouth lowers the workload of the heart helping the tissue of the body need less blood. You may receive intravenous fluids, including blood and blood products, if needed. Other treatments for shock may include:

Cardiac catheterization with coronary angioplasty and stenting Heart monitoring to guide treatment Heart surgery (coronary artery bypass surgery, heart valve replacement, left ventricular assist device) Intra-aortic balloon counter pulsation (IABP) to improve heart and blood vessel function Pacemaker

Outlook (Prognosis) In the past, the death rate from cardiogenic shock ranged from 80 - 90%. In more recent studies, this rate has decreased to 50 - 75%. When cardiogenic shock is not treated, the outlook is poor. Possible Complications

Brain damage Kidney damage Liver damage

Prevention You may reduce the risk of developing cardiogenic shock by:

Quickly treating its cause (such as heart attack or heart valve problem) Preventing and treating the risk factors for heart disease, such as diabetes, high blood pressure, high cholesterol and triglycerides, or tobacco use

ANAPHYLAXIS Anaphylaxis is a life-threatening type of allergic reaction. Causes Anaphylaxis is a severe, whole-body allergic reaction to a chemical that has become an allergen. After being exposed to a substance such as bee sting venom, the person's immune system becomes sensitized to it. On a later exposure to that allergen, an allergic reaction may occur. This reaction happens quickly after the exposure, is severe, and involves the whole body. Tissues in different parts of the body release histamine and other substances. This causes the airways to tighten and leads to other symptoms. Some drugs (morphine, x-ray dye, and others) may cause an anaphylactic-like reaction (anaphylactoid reaction) when people are first exposed to them. Aspirin may also cause a reaction. These reactions are not the same as the immune system response that occurs with "true" anaphylaxis. However, the symptoms, risk for complications, and treatment are the same for both types of reactions. Anaphylaxis can occur in response to any allergen. Common causes include:

Drug allergies Food allergies Insect bites/stings

Pollens and other inhaled allergens rarely cause anaphylaxis. Some people have an anaphylactic reaction with no known cause. Anaphylaxis is life-threatening and can occur at any time. Risks include a history of any type of allergic reaction. Symptoms Symptoms develop rapidly, often within seconds or minutes. They may include the following:

Abdominal pain or cramping Abnormal (high-pitched) breathing sounds Anxiety Confusion Cough Diarrhea Difficulty breathing Difficulty swallowing

Fainting, light-headedness, dizziness Hives, itchiness Nasal congestion Nausea, vomiting Palpitations Skin redness Slurred speech Wheezing

Exams and Tests Signs include:

Abnormal heart rhythm (arrhythmia) Fluid in the lungs (pulmonary edema) Hives Low blood pressure Mental confusion Rapid pulse Skin that is blue from lack of oxygen or pale from shock Swelling (angioedema) in the throat that may be severe enough to block the airway Swelling of the eyes or face Weakness Wheezing

The health care provider will wait to test for the specific allergen that caused anaphylaxis (if the cause is not obvious) until after treatment. Treatment Anaphylaxis is an emergency condition requiring immediate professional medical attention. Call 911 immediately. Check the person's airway, breathing, and circulation (the ABC's of Basic Life Support). A warning sign of dangerous throat swelling is a very hoarse or whispered voice, or coarse sounds when the person is breathing in air. If necessary, begin rescue breathing and CPR. 1. Call Medical Health Care Team. 2. Calm and reassure the person. 3. If the allergic reaction is from a bee sting, scrape the stinger off the skin with something firm (such as a fingernail or plastic credit card). Do not use tweezers -squeezing the stinger will release more venom. 4. If the person has emergency allergy medication on hand, help the person take or inject the medication. Avoid oral medication if the person is having difficulty breathing. 5. Take steps to prevent shock. Have the person lie flat, raise the person's feet about 12 inches, and cover him or her with a coat or blanket. Do NOT place the person in this position if a head, neck, back, or leg injury is suspected, or if it causes discomfort. DO NOT:

Do NOT assume that any allergy shots the person has already received will provide complete protection. Do NOT place a pillow under the person's head if he or she is having trouble breathing. This can block the airways. Do NOT give the person anything by mouth if the person is having trouble breathing.

Paramedics or physicians may place a tube through the nose or mouth into the airways (endotracheal intubation) or perform emergency surgery to place a tube directly into the trachea (tracheostomy or cricothyrotomy). The person may receive antihistamines, such as diphenhydramine, and corticosteroids, such as prednisone, to further reduce symptoms (after lifesaving measures and epinephrine are given). Outlook (Prognosis) Anaphylaxis is a severe disorder that can be life-threatening without prompt treatment. However, symptoms usually get better with the right therapy, so it is important to act right away. Possible Complications

Airway blockage Cardiac arrest (no effective heartbeat) Respiratory arrest (no breathing) Shock

Prevention

Avoid triggers such as foods and medications that have caused an allergic reaction (even a mild one) in the past. Ask detailed questions about ingredients when you are eating away from home. Also carefully examine ingredient labels. If you have a child who is allergic to certain foods, introduce one new food at a time in small amounts so you can recognize an allergic reaction. People who know that they have had serious allergic reactions should wear a medical ID tag. If you have a history of serious allergic reactions, carry emergency medications (such as a chewable form of diphenhydramine and injectable epinephrine or a bee sting kit) according to your health care provider's instructions. Do not use your injectable epinephrine on anyone else. They may have a condition (such as a heart problem) that could be negatively affected by this drug.

SEPTIC SHOCK Septic shock is a serious condition that occurs when an overwhelming infection leads to life-threatening low blood pressure. Causes Septic shock occurs most often in the very old and the very young. It also occurs in people who have other illnesses. Any type of bacteria can cause septic shock. Fungi and (rarely) viruses may also cause the condition. Toxins released by the bacteria or fungi may cause tissue damage, and may lead to low blood pressure and poor organ function. Some researchers think that blood clots in small arteries cause the lack of blood flow and poor organ function. The body also produces a strong inflammatory response to the toxins. This inflammation may contribute to organ damage. Risk factors for septic shock include:

Diabetes Diseases of the genitourinary system, biliary system, or intestinal system Diseases that weaken the immune system such as AIDS Indwelling catheters (those that remain in place for extended periods, especially intravenous lines and urinary catheters and plastic and metal stents used for drainage) Leukemia Long-term use of antibiotics Lymphoma Recent infection Recent surgery or medical procedure Recent use of steroid medications

Symptoms Septic shock can affect any part of the body, including the heart, brain, kidneys, liver, and intestines. Symptoms may include:

Cool, pale extremities High or very low temperature, chills Lightheadedness Low blood pressure, especially when standing Low or absent urine output Palpitations Rapid heart rate Restlessness, agitation, lethargy, or confusion Shortness of breath Skin rash or discoloration

Exams and Tests Blood tests may be done to check for infection, low blood oxygen level, disturbances in the body's acid-base balance, or poor organ function or organ failure. A chest x-ray may show pneumonia or fluid in the lungs (pulmonary edema). A urine sample may show infection. Additional studies, such as blood cultures, may not become positive for several days after the blood has been taken, or for several days after the shock has developed. Treatment Septic shock is a medical emergency. Patients are usually admitted to the intensive care unit of the hospital. Treatment may include:

Breathing machine (mechanical ventilation) Drugs to treat low blood pressure, infection, or blood clotting Fluids given directly into a vein (intravenously) Oxygen Surgery

There are new drugs that act against the extreme inflammatory response seen in septic shock. These may help limit organ damage.

Hemodynamic monitoring -- the evaluation of the pressures in the heart and lungs -- may be required. This can only be done with special equipment and intensive care nursing. Outlook (Prognosis) Septic shock has a high death rate. The death rate depends on the patient's age and overall health, the cause of the infection, how many organs have failed, and how quickly and aggressively medical therapy is started. Possible Complications Respiratory failure, cardiac failure, or any other organ failure can occur. Gangrene may occur, possibly leading to amputation. Prevention Prompt treatment of bacterial infections is helpful. However, many cases of septic shock cannot be prevented.

UNIVERSITY OF ILOILO PHINMA EDUCATION NETWORK RIZAL ST., ILOILO CITY

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN ONCOLOGY

Submitted by: Leana Rae B. Siel BSN IV-C

Submitted to: Mrs. Michelle Jagunap, R.N. LECTURER

September 28, 2011