Download Shock and Burns

Shock and Burns
By: Diana Blum MSN
MCC
NURS 2140
Shock
• Life threatening
• Inadequate tissue perfusion that can lead
to cell death
• Unpredictable
• Definition: condition in which tissue
perfusion is inadequate to deliver oxygen
and nutrients to support vital organs and
cellular function.
Causes
• Death is not a classified as shock but as
multiple organ dysfunction.
Circulatory Homeostasis
Tissue perfusion is driven by blood pressure
BP = CO X PVR
CO – Cardiac Output
PVR – Peripheral Vascular resistance
Cardiac Output
CO = SV X HR
This means that
BP= SV X HR X PVR
Blood Pressure = Stroke Volume X Heart Rate X Peripheral Vascular Resistance
Stroke Volume
• Volume of Blood pumped by the heart
during 1 cycle
What affects Stroke volume?
Blood
Volume
Mechanical
Obstruction
Rhythm Problems
Heart
Muscle
Damage
Stroke
Volume
Mechanical
Obstruction
What makes up blood volume
Plasma
RBCs
Platelets
WBCs
Necessary blood flow components
• Adequate cardiac pump
• Effective circulatory system
• Sufficient blood volume
• If one component compromised cell
starvation and death can occur. This in turn
will cause organ death, and end of life of pt.
Heart Rate
• Heart rate increases as a
compensatory response to Shock
• Rarely you get
High Output failure
Heart rate too fast to allow adequate
refilling of heart between beats
What Alters PVR?
• Circulation cytokines & Inflammatory
mediators (e.g. Histamine)
• Endotoxins
• Drugs (e.g. Nitrates)
Nurses must:
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Be critical thinkers
Be able to act fast
Be able to anticipate orders
Execute orders in a timely yet quickly
manner
Normal cell function
• Metabolism of energy within cell
– Nutrients broken down and stored as ATP
• ATP is used for muscle contraction, active
transport, conduction of electrical
impulses
Patho of Shock
• Cells lack blood supply
• Normal function ceases
• Cell swells and membrane becomes
permeable
– Electrolytes leak out of cell
• Mitochondria become damaged
• Death of cell occurs
Stages
• Compensatory
• Progressive
• Irreversible
Compensatory
• BP WNL
• Body shunts blood from organs in fight or
flight response to the brain and heart
• s/s: cool, clammy, hypoactive bowel sounds,
HR greater than 100, RR greater than 20,
decreased urine output, confusion,
respiratory alkalosis, Na+ is elevated, BGM is
elevated
• If treated here, prognosis good
• Tx: find cause and fix, IVF, monitor vs,
monitor LOC, monitor I/O, promote safety
Pathophysiological Response
• “Flight or fight response”
• Increased Catecholamine release
• Activation of Renin-Angiotensin system
• Increase glucocorticoid and
mineralcorticoid release
• Activation of Sympathetic nervous system
• In stress situations:
– catecholamines, cortisol, glucagons, etc are
released
• Causes hyperglycemia
• Causes insulin resistance
• Promotes gluconeogenesis from proteins and fats
All this leads to organ failure in the end
Progressive
• s/s: Hypotension <90/40, interstitial edema, rapid/shallow
respirations, crackles, desats, pulmonary edema,
dysrhythmias, ischemia, tachycardic, chest pain, agitation,
confusion, low U.O. , lethargic, jaundice, bloody diarrhea,
metabolic acidosis, mottled, petechiae
– Leads to ards
– MI is possible
– DIC may occur
• Overworked heart causes ischemia and myocardial depression
leading to heart failure
• Prognosis worsens
• DX: BNP, CMP, CBC, ABG
• TX: mechanical vent, enteral support, Insulin, careful
assessments, ICU, Neuro checks, balloon pump, meds,
dialysis, infection prevention, family support
Irreversible
• Organ damage severe
• Death imminent
• s/s: low BP, necrosis to liver and kidneys,
respiratory system fails even on vent,
unresponsive
• Dx: based on failure to respond to tx
• Tx: palliative care, experimental tx,
monitor pt, provide comfort, pastoral care
Treatment of Shock
• IVF and or blood products
• Blood if related to this
• LR or NS
• Intial amount 2-3 liters for an adult with unknown cause
• Monitor client closely
• Beta and alpha adrenergic receptors
– NIPRIDE, levaphed, vasopressin
• Pain management
• Sympathomimetics
– Dopamine, dobutamine, adrenalin, milrinone,
amrinone
• Nutritional support
– Parenteral or enteral
• http://www.youtube.com/watch?v=9a7N9
AU1GiQ&feature=related
5 types
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Hypovolemic
Cardiogenic
Septic
Neurogenic
Anaphylactic
HYPOVOLEMIC
Hypovolemic Shock Caused by Body Fluid Loss
Site of Fluid Loss
Mechanism of Loss
Skin
Thermal or chemical burn, sweating
from excessive heat exposure
GI tract
Vomiting or diarrhea
Kidneys
Diabetes mellitus or insipidus, adrenal
insufficiency, “salt-losing” nephritis,
the polyuric phase after acute tubular
damage, and use of potent diuretics
Intravascular fluid lost to the
extravascular space
Increased capillary permeability
secondary to inflammation or traumatic
injury (eg, crush), anoxia, cardiac
arrest, sepsis, bowel ischemia, acute
pancreatitis
Causes
• External fluid loss
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Trauma
Surgery
Vomiting
Diarrhea
Diuresis
Diabetes insipidus
• Internal fluid shift
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Burns
Hemorrhage
Ascites
Peritonitis
Dehydration
Treatment
• Treat underlying cause
• Replace fluid and/or blood
• Place in modified tredelenburg (legs
elevated)
• Meds depending on cause
• Blood
• Oxygen
CARDIOGENIC
• Impaired oxygen
• 2 types: coronary and non coronary
– Coronary: LV damage, MI=greatest risk
– Non-coronary: Stress on myocardium (heart
disease, acidosis, etc.)
– Manifestations: angina, dysrythmia
– Dx: cardiac enzymes, ekgs,
– Tx: correct underlying cause, O2, pain control,
IVF, balloon pump, ICU, CABG, nitro,
dobutamine, dopamine, levophed,
antiarrythmics, vent
Mechanisms of Cardiogenic and Obstructive Shock
Type
Mechanism
Obstructive
Mechanical interference Tension pneumothorax,
with ventricular filling cava compression,
cardiac tamponade,
atrial tumor or clot
Cardiogenic
Cause
Interference with
ventricular emptying
Pulmonary embolism
Impaired myocardial
contractility
Myocardial ischemia or
MI, myocarditis, drugs
Abnormalities of cardiac Tachycardia,
rhythm
bradycardia
Cardiac structural
disorder
Acute mitral or aortic
regurgitation, ruptured
interventricular septum,
prosthetic valve
malfunction
Circulatory shockaka Distributive
• Occurs with abnormally placed blood
volume
• 3 types
– Septic
– Neurogenic
– anaphylactic
SEPTIC
Management
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Antibiotics
rhAPC
Aggressive nutritional support
Aseptic technique for procedures
Monitor IV lines, indwelling lines, and
wounds
Monitor LOC
Monitor vs—keep temp in check
IVF
Vasoactive agents like other shocks
NEUROGENIC
• Vasodilatation occurs
– Results of balance loss b/w sympathetic and
parasympathetic stimulation
• Sympathetic: vascular smooth muscles constrict
• Parasympathetic: causes smooth muscle to relax or
dilate
• In neurogenic shock, the lean is to
parasympathetic
ANAPHYLACTIC
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Occurs rapidly
Life threatening
Caused by severe allergic reaction
Tx: remove agent, antihistamine,
epinephrine, nebulizers, CPR, intubate,
IVF, assess allergies, educate about meds
and treatment if exposure
Treatment of Shock
ABC
Multisystem organ dysfunction
• Complication of SIRS/Sepsis/tissue injury
• Unknown trigger
• Begins in lungs usually, then liver, GI, and
kidneys
• s/s: respiratory failure, hyperglycemia,
hyperlacticacidemia, polyuria, infection,
jaundice,
• Tx: intubation, ICU, dialysis
BURNS
Causes
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Thermal: electricity
chemicals
scalds
Radiation
inhaled
http://www.youtube.com/watch?v=Gj4GgioI5CM&feature=related
Superficial partial thickness
• Epidermis destroyed
• Parts of dermis injured
• s/s: pain, appears red/dry
– Example: sunburn
Deep partial thickness
• Destruction of epidermis and upper
dermis
• Injury to deeper portions of dermis
• s/s: painful wound that appears red and
exudes fluid…cap refill follows tissue
blanching
• Hair follicles are intact
• May result in scars
Full thickness
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Destroyed epidermis
Destroyed dermis
Appears white, red, brown, or black
No pain
Wound appears leathery
Hair follicles and sweat glands destroyed
Classifying Burns
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How did injury occur
Causative agentscald or chemical
Temp of burn agent
Duration of contact
Thickness of skin
Rules of nine
Lund Browdner Formula
Parkland Formula
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Parkland Burn Formula: 4 cc. per kg. body weight per % deep burn during
the first 24 hours
1. To calculate: multiply 4 X kg. X % burn ˜ total fluid requirement
2. Give half of this amount during the first 8 hours from the time of
injury
3. In most cases, this will work out to 2 large bore IV’s wide open until
hospital arrival
a. Monitor and record the exact amounts given, and provide hospital
personnel with this information
4. Lactated Ringer’s is the preferred fluid, if available
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Electrical Burns
• Worst to get
• Will cause lifelong neurovascular problems
• High voltage (>1000 volts) cause bone and
tissue destruction
– Leads to amputations and death
• There is usually an entrance and exit wound
– Travels from least resistance to ground
• Clothes catch fire
Compli cations
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HypoVolemia
Decreased cardiac output
Hypotension
Edema
Obstruction of blood flow
Hyponatremia
Hyperkalemia
Inhalation injury
Sepsis
Ileus
• REMEMBER
CAB
• http://www.youtube.com/watch?v=BB8k
Tdbzzpo&feature=related
TX
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Current immediately contracts muscles
Dysrhythmias and spinal injuries occur
EKG Monitoring
Spinal collar
IVF LR
Monitor urine output Prone to RF
Frequent Neuro Checks
ET tube
ICU or Burn Center
Stages Of Burn Care
• Emergent
• Acute
• Rehab
Emergent Care
• From onset of injury to end of fluid
resuscitation
– Remove from harm/extinguish flames on
victim
– Establish airway
– Cool wound with cool water
– O2
– Large bore IV
– Immobilize cervical spine
At hospital
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Airway
O2
Chest x-rays
CMP,CBC, Blood alcohol, ABG
Clean sheets under and over pt
Tetanus
Photos taken
Catheter placement
Xfer to burn center
Acute
• From the beginning of diuresis to wound
closure
– Remove restrictive objects
– Irrigate chemical burns/Cover wound
– Nutritional support
– Prevent complications
• Priority is airway, pain control, wound
care, and maintaining balance
• Bronchial lavage may need to be done
• May be placed on vasoactive meds,
diuretics, and fluid restriction
• ICU with Art line
Infection prevention
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Asepsis
Antibx as ordered
Wound cleaning
Baths are painful
Topical antibacterials
Loose dressings
Debridment
Grafts
• Autograft
• Homograft
• Biograft and synthetic dressings
Care of graft site
• Occlusive dressing initially
• First dressing change 2-5 days after
surgery
• Monitor drainage
• Position carefully
• Exercise 5-7 days after surgery
Care of donor site
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Pain management
Moist gauze at surgery
Vaseline gauze
Heals in 7-14 days
Nutritional support
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Control stress and pain
Protein requirements: 1.5-4.0g per kg
Include lipids
Carbs good
5000 calories/day
Or
– Enteral feeding
Scars
• Hypertrophic cause contractures on joints
• Ace wraps are helpful to promote
circulation
• rehab
keloids
• Mass of scar tissue
• Mostly in dark skin individuals
• Monitor healing process
• Monitor contractures
Rehab
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Prevent scars and contractures
PT,OT, Speech
Reconstructive Surgery
Counseling
Research
• Nutrition
• Artificial skins
SHOCK
Clinical Scenarios
• 1) A 26 year old man with a comminuted closed
fracture of the femur shaft undergoes
intramedullary nail fixation. Two days post
operatively, he develops a pyrexia, shortness of
breath and tachycardia.
• Discuss the emergency management?
• 2) A 72 year old man develops sudden
back pain and is brought to the emergency
department with a swollen ,tense
abdomen. He is tachycardic ,with a low
volume pulse and low BP.
• Discuss the emergency management?
• 3) A 72 year old man with an underlying prostate
carcinoma sustains a femoral shaft fracture .He
undergoes intramedullary nail fixation. At post
operative day 7 he develops a shortness of breath
,hypotension and a tachycardia
• Discuss the emergency management?
Questions