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🫀 Adaptasyon Fizyolojik · Leson 8 sou 10 · 7 min

Kat Kalite Chòk ak Premye Èdtan Sepsis

Four Kinds of Shock and the First Hour of Sepsis

🩸 Chòk ipovolemik vle likid. Chòk kadyojenik nwaye ladan li. Toudè gen tansyon ba. Egzamen an mande ki sak ou pann, epi move repons lan se yon repons trè posib.

🩸 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.

💡 Ide prensipal

Konpansasyon kache chòk dèyè yon tansyon nòmal: veye batman kè, presyon puls, po ak pipi. Likid pou ipovolemik ak septik; pa pou kadyojenik, eksepte enfaktis vantrikil dwat, ki bezwen likid pou preload epi pa nitrat; obstriktif bezwen blokaj la soulaje. Chòk newojenik se sa ki dousman, cho a.

Compensation hides shock behind a normal blood pressure: watch heart rate, pulse pressure, skin and urine. Fluids for hypovolemic and septic; not for cardiogenic, except right ventricular infarction, which needs fluids for preload and no nitrates; obstructive needs the block relieved. Neurogenic shock is the slow, warm one.

🧠 Poukisa sa enpòtan

Chòk se pèfizyon tisi ensifizan. Etap KONPANSATWA: takikadi, presyon puls k ap retresi, po frèt mouye, anksyete, pipi diminye; tansyon an ka toujou parèt nòmal. Etap PWOGRESIF ak REFRAKTÈ: ipotansyon (MAP anba 65), konfizyon, oliguri, asidoz metabolik ak lactate k ap monte, ak echèk ògan. IPOVOLEMIK (emoraji, boule, dezidratasyon): likid izotonik ak san, sispann pèt la. KADYOJENIK (MI masif, ensifizans kadyak): ponp lan echwe, kidonk likid agrave konjesyon poumon; inotropes, dyiretik epi pafwa sipò mekanik, eksepte nan enfaktis vantrikil dwat, kote vantrikil dwat ki echwe bezwen preload: bolus likid pridan epi pa nitrat oswa dyiretik. OBSTRIKTIF (pneumothorax tansyon, tamponad kadyak, anboli poumon masif): yon blokaj fizik pou ranplisaj oswa soti bese pwodiksyon kadyak, souvan ak venn kou distandi; soulaje blokaj la ak dekonpresyon zegwi oswa yon tib pwatrin, pericardiocentesis, oswa thrombolysis oswa embolectomy, paske likid sèlman pa pral repare li. Chòk DISTRIBITIF gen twa kalite. SEPTIK: sepsis se disfonksyon ògan yon repons deregile a enfeksyon lakòz; chòk septik se sepsis ki bezwen vasopresseurs pou kenbe MAP 65 oswa plis epi li gen yon lactate anwo 2 malgre likid adekwa; pake premye èdtan an se mezi lactate (remezire si anwo 2), kilti san pran anvan antibyotik, antibyotik laj spectre nan yon èdtan, 30 mL/kg crystalloid rapid pou ipotansyon oswa yon lactate 4 oswa plis, ak vasopresseurs (norepinephrine anvan), kòmanse pandan oswa apre likid, pou kenbe MAP 65 oswa plis. ANAFILAKTIK: epinephrine entramiskilè anvan, apre sa likid ak sipò wout respiratwa. NEWOJENIK (lesyon mwal epinyè a oswa anwo T6): chòk klasik ak BRADIKADI ak po cho sèk, soti nan ton senpatik pèdi; trete ak likid, vasopresseurs ak atropine. Swen enfimyè inivèsèl: oksijèn, de IV gwo kalib, pipi chak èdtan omwen 0.5 mL/kg/hr (anviwon 30 mL/hr nan granmoun), kontwòl kontini, epi kenbe pasyan an cho.

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, except in right ventricular infarction, where the failing right ventricle needs preload: cautious fluid boluses and no nitrates or diuretics. OBSTRUCTIVE (tension pneumothorax, cardiac tamponade, massive pulmonary embolism): a physical block to filling or outflow drops cardiac output, often with distended neck veins; relieve the block with needle decompression or a chest tube, pericardiocentesis, or thrombolysis or embolectomy, because fluids alone will not fix it. DISTRIBUTIVE shock has three types. SEPTIC: sepsis is organ dysfunction caused by a dysregulated response to infection; septic shock is sepsis that needs vasopressors to keep MAP 65 or higher and has a lactate above 2 despite adequate fluids; the first hour bundle is lactate measurement (remeasure if above 2), blood cultures drawn before antibiotics, broad-spectrum antibiotics within one hour, rapid 30 mL/kg of crystalloid for hypotension or a lactate of 4 or more, and vasopressors (norepinephrine first), started during or after fluids, to keep MAP 65 or higher. ANAPHYLACTIC: intramuscular epinephrine first, then fluids and airway support. NEUROGENIC (spinal cord injury at or above T6): the classic 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.

🏥 Nan lavi reyèl

🧊 Yon pasyan k ap senyen apre operasyon gen yon tansyon 118/88 ak yon batman kè 126, ak po frèt ak 15 mL pipi nan dènye èdtan an. Yon nouvo enfimyè li presyon an kòm byen. Enfimyè ki gen eksperyans la li yon presyon puls 30, takikadi ak oliguri kòm chòk emorajik konpanse, epi pasyan an retounen nan sal operasyon anvan presyon an janm tonbe. Tansyon an se dènye chif ki deplase.

🧊 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.

📌 Sa pou retni

  • Chòk bonè: takikadi, presyon puls retresi, po frèt, pipi ba, BP nòmalEarly shock: tachycardia, narrow pulse pressure, cool skin, low urine, normal BP
  • Premye èdtan sepsis: kilti, antibyotik, likid 30 mL/kg, lactate, norepinephrine si MAP anba 65Sepsis hour one: cultures, antibiotics, 30 mL/kg fluids, lactate, norepinephrine if MAP under 65
  • Chòk kadyojenik resevwa inotropes ak dyiretik, pa bolus likid; obstriktif bezwen blokaj la soulaje; newojenik se bradikadikCardiogenic shock gets inotropes and diuretics, not fluid boluses; obstructive needs the block relieved; neurogenic is bradycardic

📖 Tèm nan leson sa a

Chòk kadyojèn (Cardiogenic shock): Chòk yon ponp kè ki defaye lakòz, yo trete l ak inotrop olye gwo bolus likid.

Chòk septik (Septic shock): Sepsis ki mande vazopresè pou kenbe MAP nan 65 mmHg oswa plis, ak laktat pi wo pase 2 mmol/L malgre likid yo; premye èdtan: laktat, kilti, antibyotik, 30 mL/kg kristaloyid ak vazopresè.

Pwodiksyon pipi minimòm (Minimum urine output): Granmoun ta dwe fè omwen 30 mL/hr (0.5 mL/kg/hr) epi timoun omwen 1 mL/kg/hr; mwens pandan de èdtan vle di move pèfizyon ren, tankou nan chòk, dezidratasyon oswa toksisite magnesium, epi yo rapòte sa anvan kreyatinin lan monte.

Epinephrine: Premye medikaman pou anafilaksi, 0.3 a 0.5 mg IM (1 mg/mL) nan deyò kwis la, epi 1 mg IV chak 3 a 5 minit nan arè kadyak; atann takikadi ak ipètansyon, epi tcheke konsantrasyon an de fwa paske de fòs yo diferan dis fwa.

✅ Teste tèt ou

Ki rezilta pasyan ki endike etap konpansatwa chòk ipovolemik?Which client findings indicate the compensatory stage of hypovolemic shock?
  1. Tansyon 80/40, batman kè 140, konfizyon epi pa gen pipiBlood pressure 80/40, heart rate 140, confusion and no urine output
  2. Batman kè 124, tansyon 112/88, po frèt, pipi 20 mL/hrHeart rate 124, blood pressure 112/88, cool skin, urine 20 mL/hr
  3. Batman kè 56, po cho sèk, tansyon 90/60Heart rate 56, warm dry skin, blood pressure 90/60
  4. Lafyèv, po wouj, pulsasyon fò, batman kè 110, tansyon 96/50Fever, flushed skin, bounding pulses, heart rate 110, blood pressure 96/50

Repons: B · Batman kè 124, tansyon 112/88, po frèt, pipi 20 mL/hr

Takikadi, presyon puls retresi, po frèt ak pipi diminye ak yon presyon pre nòmal se konpansasyon; premye seri a se chòk ta, twazyèm nan se newojenik, epi katriyèm nan, ak lafyèv, po wouj ak pulsasyon fò, se chòk septik cho bonè.

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, and the fourth, with fever, flushed skin and bounding pulses, is early warm septic shock.

Yon pasyan ki gen chòk septik gen yon MAP 58 apre li resevwa 30 mL/kg crystalloid. Ki entèvansyon enfimyè a prevwa apre?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. Antibyotik pa bouch yon fwa kilti yo retounenOral antibiotics once cultures return
  2. Dyiretik pou anpeche surchaj likidDiuretics to prevent fluid overload
  3. Yon perfusion norepinephrineA norepinephrine infusion
  4. Yon lòt bolus crystalloid 30 mL/kgAnother 30 mL/kg crystalloid bolus

Repons: C · Yon perfusion norepinephrine

Ipotansyon pèsistan apre likid adekwa mande vasopresseurs, ak norepinephrine kòm premye chwa. Yon lòt bolus 30 mL/kg repete yon etap ki deja echwe pou mennen MAP a 65 epi li ajoute risk surchaj likid.

Persistent hypotension after adequate fluids calls for vasopressors, with norepinephrine as the first choice. Another 30 mL/kg bolus repeats a step that has already failed to bring the MAP to 65 and adds the risk of fluid overload.

Poukisa yo evite gwo bolus likid nan chòk kadyojenik?Why are large fluid boluses avoided in cardiogenic shock?
  1. Volim anplis agrave èdèm poumonExtra volume worsens pulmonary edema
  2. Pasyan an pa ipotansifThe client is not hypotensive
  3. Likid lakòz ipèkalemiFluids cause hyperkalemia
  4. Likid entèfere ak medikaman inotropikFluids interfere with inotropic medications

Repons: A · Volim anplis agrave èdèm poumon

Nan chòk kadyojenik pwoblèm nan se ponp lan, pa volim; likid ajoute retounen nan poumon yo. Likid pa entèfere ak medikaman inotropik; yo souvan itilize toude ansanm, kidonk limit sou volim se konjesyon, pa yon entèaksyon medikaman.

In cardiogenic shock the problem is the pump, not volume; added fluid backs up into the lungs. Fluids do not interfere with inotropic medications; the two are often used together, so the limit on volume is congestion, not a drug interaction.

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