💔 New Lesson 31
Shock & Sepsis
Types of shock (hypovolemic, anaphylactic, cardiogenic, neurogenic), SIRS criteria, sepsis management.
Types of Shock
Types of Shock — Comparison
| Type | Cause | Skin | HR | Priority Treatment |
|---|---|---|---|---|
| Hypovolemic | Blood loss, burns, dehydration, vomiting | Cool, clammy, pale | ↑ Tachycardia | IV fluid resuscitation (isotonic) |
| Anaphylactic | Severe allergic reaction (bees, peanuts, penicillin) | Flushed, urticaria | ↑ Tachycardia | EPINEPHRINE FIRST (IM outer thigh) |
| Cardiogenic | MI, heart failure, cardiac tamponade | Cool, clammy | ↑ Tachycardia | Inotropes (dobutamine) — CAUTIOUS with fluids (pulmonary edema risk) |
| Neurogenic | Spinal cord injury above T6 | WARM, FLUSHED | ↓ BRADYCARDIA | Vasopressors, atropine for bradycardia |
| Septic | Systemic infection | Initially warm/flushed, then cool | ↑ Tachycardia | 30 mL/kg IV fluids → vasopressors if MAP <65 |
⭐ Neurogenic Shock UNIQUE Finding:
Unlike ALL other shock types, neurogenic shock presents with BRADYCARDIA and WARM, FLUSHED skin.
Reason: loss of sympathetic tone below the spinal injury = vasodilation (blood pools peripherally)
Unlike ALL other shock types, neurogenic shock presents with BRADYCARDIA and WARM, FLUSHED skin.
Reason: loss of sympathetic tone below the spinal injury = vasodilation (blood pools peripherally)
Shock Stages
Three Stages of Shock
| Stage | BP | HR | Skin | Outcome |
|---|---|---|---|---|
| Compensatory | Normal or slightly ↓ | ↑ Tachycardia | Cool, pale, clammy | Reversible with treatment |
| Progressive | Significantly ↓ (MAP drops >20 mmHg) | ↑↑ Tachycardia | Cool, mottled | Reversible with aggressive treatment |
| Refractory | Severely ↓ | Bradycardia (terminal) | Mottled, cyanotic | Often irreversible — MODS |
⭐ KEY NCLEX FACT:
TACHYCARDIA happens BEFORE significant hypotension in early shock.
A patient with normal BP but HR of 120 = early shock until proven otherwise!
Urine output <30 mL/hr in an adult = inadequate renal perfusion = shock marker
TACHYCARDIA happens BEFORE significant hypotension in early shock.
A patient with normal BP but HR of 120 = early shock until proven otherwise!
Urine output <30 mL/hr in an adult = inadequate renal perfusion = shock marker
Primary Goal of ALL Shock Types:
Correct DECREASED TISSUE PERFUSION and restore adequate CARDIAC OUTPUT
Everything else serves this one goal
Correct DECREASED TISSUE PERFUSION and restore adequate CARDIAC OUTPUT
Everything else serves this one goal
Sepsis
Sepsis — SIRS Criteria
SIRS = 2 or more of:
🌡️ Temperature >38°C (100.4°F) OR <36°C (96.8°F)
❤️ Heart rate >90 bpm
🫁 Respiratory rate >20/min OR PaCO2 <32 mmHg
🩸 WBC >12,000 or <4,000 or >10% bands
SIRS + infection = SEPSIS
Continuum: SIRS → Sepsis → Severe Sepsis → Septic Shock → MODS
🌡️ Temperature >38°C (100.4°F) OR <36°C (96.8°F)
❤️ Heart rate >90 bpm
🫁 Respiratory rate >20/min OR PaCO2 <32 mmHg
🩸 WBC >12,000 or <4,000 or >10% bands
SIRS + infection = SEPSIS
Continuum: SIRS → Sepsis → Severe Sepsis → Septic Shock → MODS
Sepsis Hour-1 Bundle
1. 🩸 Blood cultures x2 (before antibiotics — don't delay antibiotics if cultures can't be drawn in 45 minutes)
2. 🧪 Serum lactate measurement
3. 💧 IV fluids 30 mL/kg isotonic crystalloid
4. 💊 Broad-spectrum antibiotics within 1 hour
5. 💉 Vasopressors (norepinephrine) if MAP <65 mmHg despite fluids
🎯 Target MAP >65 mmHg
2. 🧪 Serum lactate measurement
3. 💧 IV fluids 30 mL/kg isotonic crystalloid
4. 💊 Broad-spectrum antibiotics within 1 hour
5. 💉 Vasopressors (norepinephrine) if MAP <65 mmHg despite fluids
🎯 Target MAP >65 mmHg
⭐ Sepsis in the ELDERLY:
Elderly patients often present ATYPICALLY — NEW-ONSET CONFUSION may be the FIRST and ONLY sign before fever develops.
Any new confusion in an elderly patient with a urinary catheter = rule out sepsis FIRST.
Elderly patients often present ATYPICALLY — NEW-ONSET CONFUSION may be the FIRST and ONLY sign before fever develops.
Any new confusion in an elderly patient with a urinary catheter = rule out sepsis FIRST.
📖 Notes for Dummies
📖 Shock & Sepsis Explained Simply
💉 Why Neurogenic Shock Is Unique in Plain English:
Every other shock type: the body panics and squeezes the blood vessels tight (vasoconstriction) → skin gets cold and clammy → heart beats fast. Neurogenic shock: the spinal cord injury cuts the signal to the blood vessels → they go limp (vasodilation) → blood pools in the legs → skin is WARM and FLUSHED. The heart has no signal to speed up either → BRADYCARDIA. It's the opposite of everything else.
💧 Cardiogenic Shock Fluid Caution in Plain English:
Hypovolemic shock needs fluids because there's not enough blood. Cardiogenic shock = the heart pump is broken. Pouring more fluid into a broken pump is like filling a clogged sink — it overflows into the lungs (pulmonary edema). Give fluids VERY carefully and watch lung sounds closely.
🦠 Sepsis in the Elderly in Plain English:
Young people with sepsis get fevers and look sick. Elderly people often can't mount a fever response — their only sign might be that they seem confused or "not themselves." A patient who was fine this morning and is suddenly disoriented may have an infection in their blood. CAUTI is the most common source. When in doubt — check cultures, get lactate, give antibiotics.
⏰ The Shock Timeline in Plain English:
The body compensates first — it speeds up the heart and constricts the vessels to maintain blood pressure. BP looks normal, but the heart is racing. THAT is your warning sign. Once BP drops, the body is in the progressive stage. Once organs start failing — refractory. Each stage is harder to reverse. Catch it in the compensatory stage every time.
Every other shock type: the body panics and squeezes the blood vessels tight (vasoconstriction) → skin gets cold and clammy → heart beats fast. Neurogenic shock: the spinal cord injury cuts the signal to the blood vessels → they go limp (vasodilation) → blood pools in the legs → skin is WARM and FLUSHED. The heart has no signal to speed up either → BRADYCARDIA. It's the opposite of everything else.
💧 Cardiogenic Shock Fluid Caution in Plain English:
Hypovolemic shock needs fluids because there's not enough blood. Cardiogenic shock = the heart pump is broken. Pouring more fluid into a broken pump is like filling a clogged sink — it overflows into the lungs (pulmonary edema). Give fluids VERY carefully and watch lung sounds closely.
🦠 Sepsis in the Elderly in Plain English:
Young people with sepsis get fevers and look sick. Elderly people often can't mount a fever response — their only sign might be that they seem confused or "not themselves." A patient who was fine this morning and is suddenly disoriented may have an infection in their blood. CAUTI is the most common source. When in doubt — check cultures, get lactate, give antibiotics.
⏰ The Shock Timeline in Plain English:
The body compensates first — it speeds up the heart and constricts the vessels to maintain blood pressure. BP looks normal, but the heart is racing. THAT is your warning sign. Once BP drops, the body is in the progressive stage. Once organs start failing — refractory. Each stage is harder to reverse. Catch it in the compensatory stage every time.