Shock का चार प्रकार र Sepsis को पहिलो घण्टा

🧠 यो किन महत्त्वपूर्ण छ

Shock भनेको तन्तुमा अपर्याप्त perfusion हो। COMPENSATORY चरण: tachycardia, pulse pressure साँघुरिनु, चिसो र पसिनाले भिजेको छाला, चिन्ता, पिसाब घट्नु; blood pressure अझै सामान्य देखिन सक्छ। PROGRESSIVE र REFRACTORY चरण: hypotension (MAP 65 भन्दा कम), भ्रम, oliguria, बढ्दो lactate सहित metabolic acidosis, र अङ्ग फेल। HYPOVOLEMIC (hemorrhage, burns, dehydration): isotonic fluids र रगत, नोक्सानी रोक्नुहोस्। CARDIOGENIC (ठूलो MI, heart failure): पम्प फेल हुन्छ, त्यसैले fluids ले pulmonary congestion बिगार्छ; inotropes, diuretics र कहिलेकाहीँ mechanical support, right ventricular infarction मा बाहेक, जहाँ फेल हुँदै गरेको right ventricle लाई preload चाहिन्छ: सावधानीपूर्वक fluid boluses र nitrates वा diuretics नदिने। OBSTRUCTIVE (tension pneumothorax, cardiac tamponade, massive pulmonary embolism): filling वा outflow मा भौतिक अवरोधले cardiac output घटाउँछ, प्रायः distended neck veins सहित; needle decompression वा chest tube, pericardiocentesis, वा thrombolysis वा embolectomy ले अवरोध हटाउनुहोस्, किनभने fluids मात्रले यो ठीक हुँदैन। DISTRIBUTIVE shock का तीन प्रकार हुन्छन्। SEPTIC: sepsis भनेको infection प्रतिको अनियन्त्रित प्रतिक्रियाले हुने अङ्ग dysfunction हो; septic shock भनेको पर्याप्त fluids हुँदा पनि MAP 65 वा बढी राख्न vasopressors चाहिने र lactate 2 भन्दा माथि भएको sepsis हो; पहिलो घण्टाको bundle मा lactate मापन (2 भन्दा माथि भए फेरि नाप्नुहोस्), antibiotics भन्दा पहिले लिइएका blood cultures, एक घण्टाभित्र broad-spectrum antibiotics, hypotension वा 4 वा बढी lactate का लागि छिटो 30 mL/kg crystalloid, र MAP 65 वा बढी राख्न fluids दिँदा वा पछि सुरु गरिने vasopressors (पहिले norepinephrine) हुन्छन्। ANAPHYLACTIC: पहिले intramuscular epinephrine, त्यसपछि fluids र airway सहयोग। NEUROGENIC (T6 वा माथिको spinal cord injury): यो क्लासिक shock हो जसमा BRADYCARDIA र तातो सुख्खा छाला हुन्छ, sympathetic tone हराएका कारण; fluids, vasopressors र atropine ले उपचार गर्नुहोस्। सबैका लागि नर्सिङ हेरचाह: oxygen, दुई ठूला-bore IVs, कम्तीमा 0.5 mL/kg/hr (वयस्कमा करिब 30 mL/hr) को प्रति घण्टा पिसाब, निरन्तर निगरानी, र बिरामीलाई न्यानो राख्नु।

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.

🏥 वास्तविक जीवनमा

🧊 सर्जरी पछि रक्तस्राव भइरहेको बिरामीको blood pressure 118/88 र heart rate 126 छ, छाला चिसो छ र पछिल्लो एक घण्टामा 15 mL पिसाब आएको छ। नयाँ नर्सले pressure ठीकै ठान्छे। अनुभवी नर्सले 30 को pulse pressure, tachycardia र oliguria लाई compensated hemorrhagic shock को रूपमा पढ्छे, र pressure खस्किनुअघि नै बिरामी फेरि operating room मा जान्छ। Blood pressure सबैभन्दा पछि सर्ने अंक हो।

🧊 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.

📌 सम्झनुहोस्

• सुरुवाती shock: tachycardia, साँघुरो pulse pressure, चिसो छाला, कम पिसाब, सामान्य BPEarly shock: tachycardia, narrow pulse pressure, cool skin, low urine, normal BP
• Sepsis को पहिलो घण्टा: cultures, antibiotics, 30 mL/kg fluids, lactate, MAP 65 भन्दा कम भए norepinephrineSepsis hour one: cultures, antibiotics, 30 mL/kg fluids, lactate, norepinephrine if MAP under 65
• Cardiogenic shock मा inotropes र diuretics दिइन्छ, fluid boluses होइन; obstructive मा अवरोध हटाउनु पर्छ; neurogenic मा bradycardia हुन्छCardiogenic shock gets inotropes and diuretics, not fluid boluses; obstructive needs the block relieved; neurogenic is bradycardic

✅ आफूलाई जाँच्नुहोस्