Multisystem Study Guide for the CCRN

Shock and Sepsis

Two important conditions to know in critical care nursing are shock and sepsis. While these two diagnoses often occur together or because of each other, they can also occur independently. Sepsis is the result of harmful microorganisms in the blood. Shock is associated with a drop in blood pressure due to serious events such as sepsis, blood loss, neurogenic injury, and other illnesses. Both will be reviewed in the next section of this guide.

Sepsis Continuum

Many infectious conditions are called sepsis; however, sepsis occurs on a continuum starting from less-severe bacteremia all the way to septic shock. Sepsis should be identified and treated as early as possible to prevent patient complications. It may develop over the course of several days or within several hours and can range in severity.

The difference between bacteremia and septicemia is that in bacteremia, there is just the presence of bacteria in the blood without systemic infection. When the bacteria in the blood causes systemic infection, it then develops into septicemia. Septicemia generally occurs due to bacterial or fungal infection. The infection may need to be treated with antibiotics or antifungal medications while other bodily responses are managed, including blood pressure, fever, and pain.

Systemic inflammatory response syndrome (SIRS)— As sepsis continues on the spectrum, septicemia can develop into systemic inflammatory response syndrome (SIRS). SIRS is the multiorgan inflammation that can occur due to systemic infection. It may also occur in the event of burns, trauma, adrenal insufficiency, drug overdose, and pulmonary embolism. To diagnose SIRS, a patient must have at least two of the four following symptoms: rectal temperature greater than 38 or less than 36 degrees Celsius, \(PaCO_2\) less than 32 mmHg or tachypnea, tachycardia, and/or leukocytosis represented by a number greater than 12,000 WBC per \(mm^3\) or leukopenia less than 4000 WBC per \(mm^3\).

Sepsis— Sepsis develops when patients have identified local or systemic bacteremia with presence of SIRS and an additional symptom of either changes in mental status, hypoxemia, elevated plasma lactate, or decreased urinary output (<5 mL/kg/hr for >1 hr).

Severe sepsis— Patients with severe sepsis experience all the symptoms of bacteremia, SIRS, and all the symptoms of sepsis described above. Patients with severe sepsis also experience inadequate perfusion, hypotension, and organ dysfunction.

Septic shock— Sepsis can develop into septic shock when infection and symptoms progress to refractory hypotension despite treatment of sepsis. Patients with septic shock will often experience abnormal lab values, including electrolyte imbalances, increased WBC count, and lactic acidosis.

Shock States

Shock occurs when there is a significant decrease in tissue perfusion due to hypotension that is caused by a triggering event. The insufficient tissue perfusion leads to decreased oxygen flow to the cells, ultimately causing tissue injury. Symptoms of shock include hypotension, decreased urinary output, metabolic acidosis, peripheral/cutaneous vasoconstriction/vasodilation, and changes in level of consciousness. All types of shock have varying impacts on the cardiovascular system.

Several types of shock exist but all have similar bodily responses. The primary types of shock are septic, distributive, cardiogenic, and hypovolemic.

Septic Shock

Septic shock develops due to the toxins released in the body by bacteria and cytokines in response to infection. Patients with septic shock may experience elevated or lowered body temperature, tachycardia, increased pulse pressure, hypotension, hyperventilation, respiratory alkalosis, increased lactic acid, unstable blood pressure, dehydration, decreased mental status, and initially increased urine output.

As the shock progresses, myocardial depression, dysrhythmias, and acute respiratory distress syndrome can occur. The initial response of the body to have increased urine output with dehydration quickly turns into decreased urine output, acute kidney injury (from the toxin load), and increased BUN. Patients may develop jaundice, liver dysfunction, and stress ulcerations on the mucosal tissue that could result in blood loss. Patients should be monitored for hyperglycemia as well.

The patients at highest risk for septic shock are newborns, patients older than 50 years, and immunocompromised patients. Septic shock is a diagnosis of several positive lab markers. The labs drawn when shock is considered include CBC, lactic acid, electrolyte panel, liver function tests, blood glucose, ABG, urinalysis, DIC panel, and BUN. Patients additionally should have blood and urine cultures performed and radiologic imaging.

Treatment of septic shock focuses on supportive measures to reduce tissue injury. Early identification and removal or treatment of causative agents (e.g., catheter, abscess, wound) is important to reduce complications of shock. Broad-spectrum antibiotics are generally started to treat any infection in the event of septic shock. Patients should be provided with supplemental oxygen or mechanical ventilation as needed. Patients should have large bore IV access in at least two locations to provide access for medications and fluids. Rapid fluid bolus should be administered at 0.5 L of NS or isotonic crystalloid every 5-10 minutes up to 4-6 liters to bolster body fluid volume. Inotropic or vasoconstrictive agents may be used to support blood pressure when fluid administration is not sufficient.

Distributive Shock

Septic shock is one of the most common causes of distributive shock. Two other types of distributive shock exist, anaphylactic and neurogenic. These types of shock occur because there is an inadequate intravascular volume due to arterial or venous dilation from neurogenic or allergic bodily responses. Patients with distributive shock often have adequate blood volume but may experience decreased cardiac and vascular function due to the shock response.

Symptoms of these types of distributive shock are similar to septic shock. Patients will experience hypotension, tachypnea, tachycardia, changes in cognition, decreased urinary output, temperature variability, and initially warm but later hypoperfused skin temperature.

Patients who experience distributive shock will need to be stabilized and have any underlying causes treated. Oxygen therapy and intubation may be needed. Fluid resuscitation could be performed at 0.25-0.5 L of NS or isotonic crystalloid every 5-10 minutes up to 2-3 L. Vasoconstrictive and inotropic medications may additionally be used to help correct hypotension.

Anaphylactic— Patients with severe allergies may experience anaphylaxis and anaphylactic shock. This can be potentially deadly if not corrected quickly. Symptoms of anaphylactic shock include sudden onset of weakness, dizziness, and confusion; severe edema and/or angioedema; urticaria; loss of vascular tone due to increased permeability of the vascular system; laryngospasm or bronchospasm; and nausea, vomiting, and diarrhea.

Patients experiencing anaphylactic shock will need to have a secured, patent airway with 100% oxygen administration. Administration of epinephrine should be performed to help block the progressive allergic reaction. Albuterol may also be used for bronchospasm. Diphenhydramine and methylprednisolone may be administered if reaction is not reduced with epinephrine. Vital signs should be monitored closely and hypotension and bradycardia reversed when indicated. Patients may require IV fluid resuscitation to treat hypotensions.

Neurogenic— Neurogenic shock occurs when injury to the central nervous system disrupts the autonomic nervous system which in turn disrupts the cardiovascular system. Injury to the CNS can occur due to acute spinal injury from trauma, neurologic disease, drugs, or anesthesia.

Symptoms of neurogenic shock include hypotension with warm, dry skin. Patients may also experience bradycardia. Treatment of neurogenic shock includes supporting the basic functions of life, fluid resuscitation, and inotropic agents. Patients with neurogenic shock may need placement of a pulmonary artery catheter to monitor fluid overload.

Hypovolemic Shock

Hypovolemic shock results due to insufficient vascular volume. Insufficient volume levels can be a result of external fluid loss (bleeding, diarrhea, vomiting, etc.) or internal fluid shift. It can be related to vasodilation, decreased osmotic pressure, or increased capillary permeability.

There are several classes of hypovolemic shock signifying the severity of the fluid loss. Class I is diagnosed when fluid loss is less than 750 mL or less than or equal to 15% of the total circulating volume. In Class II, fluid loss ranges from 750-1000 mL or 15-30% of total circulating volume. Class III progresses to 1500-2000 mL or 30-40% of loss and Class IV is identified as greater than 2000 mL or greater than 40% of fluid loss.

Patient with extensive fluid loss will experience cardiac involvement due to lowered circulating fluid volume. It can be expected that patients will have a decrease in ventricular filling and preload. This will decrease the right atrial pressure (RAP) and pulmonary artery occlusion pressure (PAOP). Decreased pressure leads to decreased stroke volume and cardiac output. Vasoconstriction develops, which decreases tissue perfusion and can cause cellular injury.

Symptoms of hypovolemic shock include cold, clammy skin, pallor, anxiety, cyanosis, hypotension, increased respirations, and weakened pulse. Treatment of hypovolemic shock includes treating underlying causes; replacing fluid loss with blood, crystalloids fluids, or colloids depending on the primary fluid deficit; oxygen support; and vasopressors or dopamine as needed for fluid-resistant hypotension.

Toxin-Related Illnesses

Some critical care patients will have illnesses relating to exposure to a toxin or environmental hazard. Understanding the nature of the patient’s exposure and severity of their reaction is important to navigating their treatment course. Remember that regardless of a patient’s condition, priority care revolves around securing and maintaining the patient’s airway and circulation.

Toxin/Drug Exposure

Several medications and illicit drugs can cause severe reactions in patients. These reactions may be caused by an allergy, adverse side effects, or by medication overdose. The severity of the reaction depends on the offending medication or drug and the length of exposure. Patients with severe reactions may develop metabolic acidosis due to tissue hypoperfusion and lactic acidosis. Patients are also at risk for shock, organ damage/failure, and death if the toxicity is not treated.

Patients with severe allergy to a toxin or drug will have allergic symptoms such as urticaria, pruritus, generalized trunk pain, facial flushing, edema, difficulty breathing, and wheezing. Patients with specific drug exposure may have different effects. Patients with amphetamine, cocaine, ephedrine, and pseudoephedrine exposure may experience diaphoresis, hypertension, pupil dilation, and tachycardia. This is otherwise known as the beta- and alpha-adrenergic response.

Diagnosis of drug/toxin exposure can be obtained with thorough patient history, toxicology screen, and allergy testing. Treatment of this condition is focused on eliminating any continued exposure to the offending substances. Antidotes to medications may be used when available. Activated charcoal may also be used to absorb toxins from ingested substances. For patients with severe metabolic acidosis, patients may need sodium bicarbonate to reverse the acidosis. Injected epinephrine and diphenhydramine (Benadryl®) should be used for patients with severe allergic reactions.

Toxic Ingestions/Inhalations

In some cases, patients may experience toxicity due to toxic ingestion or inhalation. Patients may not always be forthcoming with information regarding the events leading up to their critical care admission, so careful assessment is needed. If it becomes suspect that the patient is experiencing toxicity from either ingested or inhaled substances, several treatment modalities may be considered.

Common substances that cause toxicity in excess amounts include illicit drugs, alcohol, acetaminophen, salicylates, household cleaners, and benzodiazepines. Remember to review these common ingestions and specific treatment measures for each.

Several antidote medications are currently available for patients with toxicity from specific substances. Naloxone (Narcan®) may be used in the event of an opiate overdose. N-acetylcysteine works to inactivate acetaminophen. Calcium channel blockers can be reversed with calcium chloride, while beta-blockers can be reversed with glucagon. Sodium bicarbonate can be used to negate tricyclic antidepressants. Deferoxamine does the same for iron.

In patients where antidotes are not readily available, activated charcoal, dosed at 1 g/kg, should be given within an hour of ingestion. This helps to deactivate the ingested substance and enhance elimination. It can be redosed every 4-6 hours as needed. In some cases, dialysis may be needed to clear toxins from the bloodstream while supporting kidney healing and function.

Other Multisystem Issues

Critically ill patients are often plagued by several conditions that complicate their hospital stay. These can affect several bodily systems and be difficult to manage. Understanding the conditions discussed previously and how they can affect the body as a whole is a critical part of intensive care nursing.

Multiple Organ Dysfunction Syndrome (MODS)

Multiple organ dysfunction syndrome (MODS) usually develops in conjunction or as a result of sepsis. Patients with MODS are at high risk for sepsis-related death. When MODS occurs, the patient experiences decreases in cardiac, liver, and kidney function. The kidneys may suffer acute tubular necrosis or cortical necrosis as a result of the inflammation and infection associated with the patient’s condition. Patients may need interventions implemented for acute respiratory distress syndrome (ARDS). Patients are also at acute risk for coagulation disorders such as thrombocytopenia and disseminated intravascular coagulation (DIC).

Treatment of MODS revolves around treatment of the underlying infection and inflammation. Patients will also need correction of any electrolyte and blood gas imbalances. While patients are receiving antibiotics or antifungal medications, they may also need supportive therapies such as fluid resuscitation, vasopressor medications, supportive or mechanical ventilation, and dialysis.

Multisystem Trauma

In the event of a multisystem trauma, nurses must prioritize patient care to treat the most critical events first. Proper management of a trauma greatly increases the patient’s chance for survival. By the time trauma patients present to the hospital setting, several interventions are likely to have been implemented. Common prehospital interventions include frequent neurologic assessments, neck/spine immobilization, managing bleeding, and preventing shock.

Upon arriving at the hospital, trauma patients will need a quick, but thorough, assessment and critical interventions. Generally, hospitals have a designated trauma team consisting of physicians, nurses, respiratory therapists, and other staff trained in these types of patient scenarios. The trauma team can determine which injuries/conditions are the most life-threatening. They will ensure the patient has a secure and patent airway, or place one if the patient has an airway compromise.

Secondly, the trauma team will assess the patient’s cardiovascular and hemodynamic status to determine the need for fluid resuscitation or blood product. The patient’s temperature will also be monitored to watch for hypothermia. During the acute phase of trauma evaluation, patients will also undergo several tests, including EKG, several laboratory levels, and radiologic imaging.

Trauma patients should be monitored closely for several complications that may develop in the acute phase of injury. The complications may be directly related to the traumatic event or be secondary to the treatments of the event. A list of potential complications is printed below:

• Acute respiratory distress syndrome (ARDS)
• Renal failure
• Infection
• Compartment syndrome
• Sepsis
• Dysrhythmias
• Disseminated intravascular coagulopathy