Question

K.L., a 25-yr-old Korean American, was not wearing his seat belt when he was the driver involved in a motor vehicle crash. The windshield was broken, and K.L. was found 15 ft from his car. He was face down, conscious, and moaning. His wife and daughter were found in the car with their seat belts on. They sustained no serious injuries, but were upset. All passengers were taken to the emergency department (ED). K.L. states, “I can't breathe” and cries out when abdomen is palpated. BP 80/56 mm Hg; apical pulse 138 but no palpable radial or pedal pulses; carotid pulse present but weak. Lungs: respiratory rate 38 breaths/min; labored breathing with shallow respirations; asymmetric chest wall movement; absence of breath sounds on left side. Trachea deviated slightly to the right. Abdomen: slightly distended and left upper quadrant painful on palpation. Musculoskeletal: open compound fracture of the lower left leg. Chest x-ray: Hemothorax and six rib fractures on left side. Hematocrit: 28%. Left chest tube is draining bright red blood. IV access obtained via one peripheral line and right subclavian central line. Fluid resuscitation started with crystalloids. High-flow O₂ via non-rebreather mask. Surgical procedures to be performed include Splenectomy, Repair of torn intercostal artery, and Repair of compound fracture. ECG shows Sinus Tachycardia.

PLEASE ANSWER ALL QUESTIONS:

1. What types of shock is K.L. experiencing? What clinical manifestations did he display that support your answer?

2. What were the causes of K.L.'s shock states?

3. What are other types and causes of shock?

4. What are the priority nursing responsibilities and ongoing nursing assessment parameters essential for this patient?

5. What are his potential complications?

6. Why are crystalloids used instead of colloids for fluid resuscitation?

Answer 1

1.The patient is suffering from hypovolemic shock.This occurs when there is a loss of intravascular fluid volume.In hypovolemic shock ,the volume is inadequate to fill the vascular space.The volume loss may be either an absolute or a relative volume loss.A patient in hypovolemic shock experience tachypnea.In this situation the patients respiratory rate is 38b/mt which agrees with the above said criteria.Additionally in hypovolemic shock hematocrit value will be decreased.A patient may compensate for a loss of upto 15% of the total blood volume.Further loss of volume will result in a sympathetic nervous system -mediated response .This response result in an increase in heart rate ,CO, respiratory rate and depth.

2 In hypovolemic shock ,the size of the vascular compartment remains unchanged while the volume of blood or plasma decreases.Whether the loss of intravascular volume is absolute or relative,the physiologic consequences are similar.A reduction in intravascular volume results in a decreased venous return to the heart ,decreased preload,decreased stroke volume and decreased CO.The patients response to low blood flow due to acute volume loss is dependent on a number of factors,including extent of injury or insult,age and general state of health.

3.The other types of shock are

• Cardiogenic shock occurs when there is systolic dysfunction,diastolic dysfunction,dysrrhytmias.
• Neurogenic shock :hemodynamic consequence of injury and/or disease to the spinal cord at or above T5.
• Anaphylatic shock:contrast media,blood/blood products,drugs,insect bites,anesthetic agents,food additives,vaccines,environmental agents,latex.
• Septic shock:Infection,at-risk patients.

4

• Identification of patients at risk for the development of shock.
• Integration of the patients history,physical examination and clinical findings to establish a diagnosis.
• Interventions to control or eliminate the cause of the decreased perfusion.
• Protection of target and distal organs from dysfunction.
• Provision of multisystem supportive care.
• Establish and maintain patent airways.
• Administer high flow oxygen by non-rebreather mask.
• Assess for life threatening injuries.
• Treat dysrhythmias

5 The stroke volume and PAWP are decreased because of the decreased circulating blood volume.The patient may appear anxious and urine output will begin to decrease.Loss of auto regulation in the microcirculation and irreversible tissue destruction occurs with more loss of more than 40% of the total blood volume.

6 if hypo volemia is corrected by crystalloid fluid replacement ,tissue dysfunction is generally reversible.