Apat na Uri ng Shock at ang Unang Oras ng Sepsis

🧠 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, maliban sa right ventricular infarction, kung saan kailangan ng pumapalyang right ventricle ang preload: maingat na fluid boluses at walang nitrates o diuretics. OBSTRUCTIVE (tension pneumothorax, cardiac tamponade, massive pulmonary embolism): pinabababa ng pisikal na bara sa filling o outflow ang cardiac output, madalas na may distended neck veins; alisin ang bara sa pamamagitan ng needle decompression o chest tube, pericardiocentesis, o thrombolysis o embolectomy, dahil hindi ito maaayos ng fluids lang. Ang DISTRIBUTIVE shock ay may tatlong uri. SEPTIC: ang sepsis ay organ dysfunction na dulot ng dysregulated na tugon sa impeksyon; ang septic shock ay sepsis na nangangailangan ng vasopressors para mapanatiling 65 pataas ang MAP at may lactate na higit sa 2 kahit sapat ang fluids; ang bundle sa unang oras ay pagsukat ng lactate (sukatin muli kung higit sa 2), blood cultures na kinuha bago ang antibiotics, broad-spectrum antibiotics sa loob ng isang oras, mabilis na 30 mL/kg ng crystalloid para sa hypotension o lactate na 4 pataas, at vasopressors (norepinephrine muna), na sinisimulan habang o pagkatapos ng fluids, para mapanatiling 65 pataas ang MAP. ANAPHYLACTIC: intramuscular epinephrine muna, saka fluids at airway support. NEUROGENIC (spinal cord injury sa T6 o mas mataas): ang classic na 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, 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.

🏥 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 obstructive ay kailangang maalis ang bara; ang neurogenic ay bradycardicCardiogenic shock gets inotropes and diuretics, not fluid boluses; obstructive needs the block relieved; neurogenic is bradycardic

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