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🫀 Physiological Adaptation (Pisikal na Pag-angkop) · Aralin 8 sa 10 · 7 min

Apat na Uri ng Shock at ang Unang Oras ng Sepsis

Four Kinds of Shock and the First Hour of Sepsis

🩸 Ang hypovolemic shock ay nangangailangan ng fluid. Ang cardiogenic shock ay nalulunod dito. Parehong mababa ang blood pressure. Itinatanong ng exam kung aling bag ang isasabit mo, at ang maling sagot ay napaka-kapani-paniwala.

🩸 Hypovolemic shock wants fluid. Cardiogenic shock drowns in it. Both have low blood pressure. The exam asks which bag you hang, and the wrong answer is a very plausible one.

💡 Pangunahing ideya

Itinatago ng compensation ang shock sa likod ng normal na blood pressure: bantayan ang heart rate, pulse pressure, balat at ihi. Fluids para sa hypovolemic at septic; hindi para sa cardiogenic. Ang neurogenic shock ay ang mabagal at mainit.

Compensation hides shock behind a normal blood pressure: watch heart rate, pulse pressure, skin and urine. Fluids for hypovolemic and septic; not for cardiogenic. Neurogenic shock is the slow, warm one.

🧠 Bakit mahalaga

Ang shock ay hindi sapat na tissue perfusion. COMPENSATORY stage: tachycardia, sumisikip na pulse pressure, malamig at malagkit na balat, anxiety, bumababang urine output; maaari pa ring mukhang normal ang blood pressure. PROGRESSIVE at REFRACTORY stages: hypotension (MAP na mababa sa 65), pagkalito, oliguria, metabolic acidosis na may tumataas na lactate, at organ failure. HYPOVOLEMIC (hemorrhage, burns, dehydration): isotonic fluids at dugo, pigilan ang pagkawala. CARDIOGENIC (malaking MI, heart failure): pumapalya ang pump, kaya pinalalala ng fluids ang pulmonary congestion; inotropes, diuretics at minsan mechanical support. Ang DISTRIBUTIVE shock ay may tatlong uri. SEPTIC: suspected na impeksyon na may hypotension at organ dysfunction; ang bundle sa unang oras ay blood cultures, broad-spectrum antibiotics sa loob ng isang oras, 30 mL/kg ng crystalloid para sa hypotension o lactate na 4 pataas, pagsukat ng lactate, at vasopressors (norepinephrine muna) kung nananatiling mababa sa 65 ang MAP pagkatapos ng fluids. ANAPHYLACTIC: intramuscular epinephrine muna, saka fluids at airway support. NEUROGENIC (spinal cord injury sa T6 o mas mataas): ang tanging shock na may BRADYCARDIA at mainit at tuyong balat, dahil sa nawalang sympathetic tone; gamutin ng fluids, vasopressors at atropine. Pangkalahatang nursing care: oxygen, dalawang large-bore IV, hourly urine output na hindi bababa sa 0.5 mL/kg/hr (mga 30 mL/hr sa mga adult), tuloy-tuloy na monitoring, at pagpapanatiling mainit ang pasyente.

Shock is inadequate tissue perfusion. COMPENSATORY stage: tachycardia, narrowing pulse pressure, cool clammy skin, anxiety, decreased urine output; the blood pressure can still look normal. PROGRESSIVE and REFRACTORY stages: hypotension (MAP below 65), confusion, oliguria, metabolic acidosis with rising lactate, and organ failure. HYPOVOLEMIC (hemorrhage, burns, dehydration): isotonic fluids and blood, stop the loss. CARDIOGENIC (massive MI, heart failure): the pump fails, so fluids worsen pulmonary congestion; inotropes, diuretics and sometimes mechanical support. DISTRIBUTIVE shock has three types. SEPTIC: suspected infection with hypotension and organ dysfunction; the first hour bundle is blood cultures, broad-spectrum antibiotics within one hour, 30 mL/kg of crystalloid for hypotension or a lactate of 4 or more, lactate measurement, and vasopressors (norepinephrine first) if MAP stays below 65 after fluids. ANAPHYLACTIC: intramuscular epinephrine first, then fluids and airway support. NEUROGENIC (spinal cord injury at or above T6): the only shock with BRADYCARDIA and warm dry skin, from lost sympathetic tone; treat with fluids, vasopressors and atropine. Universal nursing care: oxygen, two large-bore IVs, hourly urine output of at least 0.5 mL/kg/hr (about 30 mL/hr in adults), continuous monitoring, and keeping the client warm.

🏥 Sa totoong buhay

🧊 Ang isang pasyenteng dumudugo pagkatapos ng operasyon ay may blood pressure na 118/88 at heart rate na 126, malamig ang balat at 15 mL lang ng ihi sa nakaraang oras. Binasa ng bagong nurse ang pressure bilang ayos lang. Binasa ng bihasang nurse ang pulse pressure na 30, tachycardia at oliguria bilang compensated hemorrhagic shock, at bumalik ang pasyente sa operating room bago pa bumagsak ang pressure. Ang blood pressure ang huling numerong gumagalaw.

🧊 A client bleeding after surgery has a blood pressure of 118/88 and a heart rate of 126, with cool skin and 15 mL of urine in the last hour. A new nurse reads the pressure as fine. The experienced nurse reads a pulse pressure of 30, tachycardia and oliguria as compensated hemorrhagic shock, and the client goes back to the operating room before the pressure ever falls. The blood pressure is the last number to move.

📌 Tandaan

  • Maagang shock: tachycardia, makitid na pulse pressure, malamig na balat, mababang ihi, normal na BPEarly shock: tachycardia, narrow pulse pressure, cool skin, low urine, normal BP
  • Unang oras ng sepsis: cultures, antibiotics, 30 mL/kg na fluids, lactate, norepinephrine kung mababa sa 65 ang MAPSepsis hour one: cultures, antibiotics, 30 mL/kg fluids, lactate, norepinephrine if MAP under 65
  • Ang cardiogenic shock ay binibigyan ng inotropes at diuretics, hindi fluid boluses; ang neurogenic ay bradycardicCardiogenic shock gets inotropes and diuretics, not fluid boluses; neurogenic is bradycardic

📖 Mga term sa araling ito

Cardiogenic shock: Shock na dulot ng pagpalya ng pump ng puso, ginagamot ng inotropes sa halip na malalaking fluid bolus.

Septic shock: Sepsis na may mababang presyon ng dugo na nananatili kahit pagkatapos ng fluids; sa unang oras ay lactate, cultures, antibiotics, 30 mL/kg na fluid at vasopressors kung kailangan.

Minimum urine output: Dapat umihi ang adults ng hindi bababa sa 30 mL/hr (0.5 mL/kg/hr) at ang mga bata ng hindi bababa sa 1 mL/kg/hr; ang mas kaunti sa loob ng dalawang oras ay mahinang perfusion ng bato, tulad sa shock, dehydration o magnesium toxicity, at ini-report ito bago tumaas ang creatinine.

Epinephrine: Ang unang gamot sa anaphylaxis, 0.3 hanggang 0.5 mg IM (1 mg/mL) sa labas ng hita, at 1 mg IV kada 3 hanggang 5 minuto sa cardiac arrest; asahan ang tachycardia at hypertension, at dalawang beses i-check ang concentration dahil sampung beses ang pagkakaiba ng dalawang strength.

✅ Subukan ang sarili mo

Aling mga finding ng pasyente ang nagpapahiwatig ng compensatory stage ng hypovolemic shock?Which client findings indicate the compensatory stage of hypovolemic shock?
  1. Blood pressure 80/40, heart rate 140, pagkalito at walang ihiBlood pressure 80/40, heart rate 140, confusion and no urine output
  2. Heart rate 124, blood pressure 112/88, malamig na balat, ihi na 20 mL/hrHeart rate 124, blood pressure 112/88, cool skin, urine 20 mL/hr
  3. Heart rate 56, mainit at tuyong balat, blood pressure 90/60Heart rate 56, warm dry skin, blood pressure 90/60
  4. Lagnat, namumulang balat, malakas na pulso, heart rate 110, blood pressure 96/50Fever, flushed skin, bounding pulses, heart rate 110, blood pressure 96/50

Sagot: B · Heart rate 124, blood pressure 112/88, malamig na balat, ihi na 20 mL/hr

Ang tachycardia, makitid na pulse pressure, malamig na balat at bumabang urine output na may halos normal na pressure ay compensation; ang unang set ay huling shock, ang ikatlo ay neurogenic.

Tachycardia, narrowed pulse pressure, cool skin and reduced urine output with a near-normal pressure are compensation; the first set is late shock, the third is neurogenic.

Ang isang pasyenteng may septic shock ay may MAP na 58 pagkatapos tumanggap ng 30 mL/kg ng crystalloid. Aling intervention ang inaasahan ng nurse sa susunod?A client with septic shock has a MAP of 58 after receiving 30 mL/kg of crystalloid. Which intervention does the nurse anticipate next?
  1. Oral antibiotics kapag lumabas na ang culturesOral antibiotics once cultures return
  2. Diuretics para maiwasan ang fluid overloadDiuretics to prevent fluid overload
  3. Isang norepinephrine infusionA norepinephrine infusion
  4. Isa pang 30 mL/kg na bolus lamangAnother 30 mL/kg bolus only

Sagot: C · Isang norepinephrine infusion

Ang patuloy na hypotension pagkatapos ng sapat na fluids ay nangangailangan ng vasopressors, na norepinephrine ang unang pagpipilian.

Persistent hypotension after adequate fluids calls for vasopressors, with norepinephrine as the first choice.

Bakit iniiwasan ang malalaking fluid boluses sa cardiogenic shock?Why are large fluid boluses avoided in cardiogenic shock?
  1. Pinalalala ng sobrang volume ang pulmonary edemaExtra volume worsens pulmonary edema
  2. Hindi hypotensive ang pasyenteThe client is not hypotensive
  3. Nagdudulot ng hyperkalemia ang fluidsFluids cause hyperkalemia
  4. Nakakasagabal ang fluids sa mga inotropic na gamotFluids interfere with inotropic medications

Sagot: A · Pinalalala ng sobrang volume ang pulmonary edema

Sa cardiogenic shock, ang problema ay ang pump, hindi ang volume; ang dagdag na fluid ay bumabalik sa baga.

In cardiogenic shock the problem is the pump, not volume; added fluid backs up into the lungs.

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