First Aid and Emergency Nursing (Theory) University of Tabuk Faculty of Applied Medical Sciences Department of Nursing First Aid and Emergency Nursing (Theory) (NUR 410)

Curriculum & Course Development Committee Topics Outline Definition CLASSIFICATION OF SHOCK Causes of Shock Sign and Symptoms Medical and Nursing management Outline Pharmacologic Intervention Risks DEPARTMENT OF NURSING Curriculum & Course Development Committee Department of Nursing

SHOCK It is a condition in which systemic blood pressure is inadequate to deliver oxygen and nutrients to support vital organs and cellular function. Is a life threatening condition with variety of underlying causes. It is characterized by inadequate tissue perfusion that, if untreated results in cell death.

CLASSIFICATION OF SHOCK HYPOVOLEMIC SHOCK ANAPHYLACTIC SHOCK Department of Nursing

I. Hypovolemic Shock Occurs when there is a decrease in the intravascular volume. It is the most common type of shock; it is characterized by a decreased intravascular volume of 15% to 25%. This represents a loss of 750 to 1,300 ml of blood in a 70kg person.

Hypovolemic Shock External: Internal: Fluid losses Vomiting Diarrhea Diuresis Diabetic Insipidus Trauma Surgery Fluid Shifts Hemorrhage Burns Ascites Peritonitis Dehydration

Categories of Causes of Hypovolemic Shock Absolute hypovolemia – occurs as a result of external losses of fluid. Relative hypovolemia – occurs as a result of the internal shifting of fluid between the body’s two compartments, which is known as third spacing. “Third spacing is when the fluid of the intravascular space relocates to the extra-vascular space, causing edema”

Sign and Symptoms per Stage Compensatory Stage Occurs with a fluid loss of 15% to 30% or 750 to 1500 ml The goal of this stage is to restore oxygenation and perfusion to the cells

Compensatory Stage Patient may exhibit: Normal BP reading and narrowed pulse pressure (the difference between the systolic and diastolic BP which is normally 40 mmHg Tachycardia Tachypnea Hypoxia Decrease Urinary Output Thirst Pale Cool skin Delayed Capillary refill Changed in LOC (confusion, restlessness, anxiousness)

Sign and Symptoms per Stage Progressive Stage of Shock Occurs with the fluid loss of 30% to 40% or 150 to 200 ml In this stage the compensatory mechanism fail and tissue perfusion becomes ineffective for the body organ to function.

Progressive Stage of Shock Patient may exhibit: Heart rate continues to increase Vasoconstriction Hypotensive Narrowed pulse pressure Oliguria worsen Increasingly lethargic, confused and comatose During this stage, organs become dysfunctional and all body system is affected. As one organ fails, the others eventually become dysfunctional, leading to multi-organ dysfunction syndrome (MODS)

Sign and Symptoms per Stage Refractory or Irreversible Stage of Shock The body organ are no longer responsive to treatment and multi-pre organ failure ensures The compensatory mechanism completely and organ failure occurred

Refractory or Irreversible Stage of Shock The patient exhibit: Severe tachycardia becomes bradycardia Continued hypotension Cardiopulmonary arrest Unresponsive Edema Oliguria at Anuria Failure of other body system, the patient has 90% to 100% mortality rate when only 3 body system fails

GOAL: Restore homeostasis and intra-vascular volume Medical Management Treatment of the underlying cause Fluid and blood replacement Redistribution of fluid Pharmacologic therapy

Nursing Management Ensuring safe administration of prescribed fluids and medications Documenting their administration and effects Monitoring for signs of complication and side effects of treatment Reporting signs early in treatment Administering blood and fluids safely

Anaphylactic Reaction It is also called severe allergic reaction;anaphylaxis; anaphylactic shock. It is an acute systemic hypersensitivity reaction that occurs within seconds or minutes of exposure to various foreign substances, such as medications and other agents such as, insects or foods. Repeated administration of parenteral or oral therapeutic agents may also precipitate an anaphylactic reaction.

Anaphylactic reactions range from mild to severe Anaphylactic reactions range from mild to severe. It can also be sudden or massive. It is a life-threatening situation. If untreated anaphylaxis can be fatal within 5-30 minutes about 60% - 80% of anaphylactic deaths are caused by inability to breathe because swollen airway passages obstruct airflow to the lungs. Another main cause results when blood vessels dilate so blood is deficient in the body.

Risk factors: Penicillin sensitivity Transfusion reaction Insect stings allergy Latex sensitivity

Signs and Symptoms: *Respiratory signs: • Nasal congestion • Sneezing, coughing or wheezing • Dyspnea • Cyanosis • Chest tightness • Tightness or swelling of the throat

*Skin manifestations: • Severe itching, burning, rash or hives on the skin • Swelling of face, tongue and / or mouth *Cardivascular and Neurologic manifestations: • Tachycardia or bradycardia • Pallor • Imperceptible pulse • Decreasing BP • Dizziness • Convulsions • Unconsciousness • Circulatory failure that may lead to death * Gastrointestinal problems: • Nausea and vomiting • Colicky abdominal pains • Diarrhea

Management: 1. Do not mistake anaphylaxis for other reactions such as, hyperventilation, anxiety attacks, alcohol intoxication and hypoglycemia. 2. Check ABCs. 3. Maintaining patent airway and ventilation is essential. 4. Seek medical attention immediately. 5. Early endotracheal tube intubation is essential to avoid loss of airway. 6. Oropharyngeal suctioning may be necessary to remove excessive secretions.

7. First aid for seizures may be necessary. 8 7. First aid for seizures may be necessary. 8. Resuscitative measures are used, especially for patients with stridor and progressive pulmonary edema. 9. If glottal edema occurs, a cricothyroidotomy is used to provide airway. 10. Simultaneously, with airway management, epinephrine is administered as prescribed to provide rapid relief of hypersensitivity reaction. 11. Keeping the conscious victim sitting in an upright position may also help breathing.

References Daniel Limmer ,Michael F. O’keefe. Emergency Care .12 th ed, Pearson Education, Inc., 2011. ISBN-10: 013254380X • ISBN-13: 9780132543804 •Kathleen Sanders Jordan, Emergency Nursing Core Curriculum,5 th ed, Philadelphia, W.B. Saunders company :A division of Harcourt Brace & company,2000. Department of Nursing