SHOCK: Identify the stage of shock, category of shock, and initial action to take for the following patients. 1. An 80-year-old woman admitted with a bowel obstruction has minimal urine output. A nasogastric tube has 1,500 mL of bloody aspirate returned on insertion. She becomes comatose. Vital signs are as follows: blood pressure 78 mm Hg with Doppler stethoscope, pulse 140 bpm and thready, respiration rate 8 breaths per minute, and temperature 94°F (34°C). Stage: _______________________ Category of Shock: _________________ Initial Action: _______________________ 2. A 56-year-old patient with chronic kidney disease who receives hemodialysis is agitated. Her blood pressure is 100/92 mm Hg, pulse 110 bpm, respiration rate 18 breaths per minute, and temperature 102°F (39°C). Stage: _______________________ Category of Shock: __________________ Initial Action: _______________________ 3. A 50-year-old patient who is hypotensive is receiving a fluid challenge of 1,000 mL 0.9% normal saline over 4 hours. Her lung sounds are now crackles in all lung fields. Her heart rhythm is irregular. Jugular vein distention and ankle edema are present. Blood pressure has dropped from 96/50 to 80/40 mm Hg in 1 hour, pulse 108 bpm, respiration rate 24 breaths per minute, and temperature 95°F (35°C). She is confused. Stage: _______________________ Category of Shock: ________________ Initial Action: _______________________ Emergency Response You are called in to help out in the ED where three UPS workers have just arrived by ambulance that was involved in a package being dropped, discharging a white powder into the air. Two of the workers inhaled the powder and got it on their skin and uniforms. Victim 1, who was catching the box tossed when it dropped, is in respiratory distress, coughing, and wheezing. He states he may also have swallowed some of the substance. Victim 2 has a rash with blisters on his face, hands, and arms. He also inhaled some of the white substance when the box broke open. Victim 3 was a little farther away unloading the van and only inhaled the substance. 1. You are to triage these three clients and decide who the physician sees first. What levels would you triage these victims? 2. What is your assessment of victim 1, victim 2, and victim 3? 3. What treatment do you suggest for victim 1? 4. What treatment do you suggest for victim 2? 5. What treatment would you decide for victim 3? 6. What are the three pathogens that can be used by terrorists as biological weapons that are also pathogens that can cause humans disasters?

1. Stage: Progressive Stage

Category of Shock: Hypovolemic Shock

• Hypovolemic shock is a life-threatening condition that results when you lose more than 20 percent (one-fifth) of your body's blood or fluid supply. This severe fluid loss makes it impossible for the heart to pump a sufficient amount of blood to your body. Hypovolemic shock can lead to organ failure.(citation)healthline.com

Initial Action:

• Emergency treatment measures must include prompt and adequate fluid and blood replacement to restore intravascular volume and raise blood pressure.
• Volume expansion. Saline solution or lactated Ringer's solution, then possibly plasma proteins or other plasma expanders, may produce adequate volume expansion until whole blood can be matched.
• Pneumatic antishock garment. A pneumatic antishock garment counteracts bleeding and hypovolemia by slowing or stopping arterial bleeding; by forcing any available blood from the lower body to the brain, heart, and other vital organs; and by preventing return of the available circulating blood volume to the legs.
• Treat underlying cause. If the patient is hemorrhaging, efforts are made to stop the bleeding or if the cause is diarrhea or vomiting, medications to treat diarrhea and vomiting are administered.
• Redistribution of fluid. Positioning the patient properly assists fluid redistribution, wherein a modified Trendelenburg position is recommended in hypovolemic shock. (Citation) www.nurseslabs.com

2. Stage: Compensatory Stage

Category of Shock: Septic Shock

• Sepsis is the result of an infection, and causes drastic changes in the body. It can be very dangerous and potentially life-threatening.
• Septic shock is when you experience a significant drop in blood pressure that can lead to respiratory or heart failure, stroke, failure of other organs, and death.(citation)healthline.com

Initial Action:

• Start adequate antibiotic therapy (proper dosage and spectrum) as early as possible. Identify the source of infection, and treat with antimicrobial therapy, surgery, or both(citation) emedicine.medscape.com

3. Stage: Progressive Stage

Category of Shock: Cardiogenic Shock

• Cardiogenic shock is a condition in which your heart suddenly can't pump enough blood to meet your body's needs. The condition is most often caused by a severe heart attack, but not everyone who has a heart attack has cardiogenic shock. Cardiogenic shock is rare, but it's often fatal if not treated immediately(citation) www.mayoclinic.org

Initial Action:

• Cardiogenic shock treatment focuses on minimizing the damage from lack of oxygen to your heart muscle and other organs.
• Most people who have cardiogenic shock need extra oxygen. If necessary, you'll be connected to a breathing machine (ventilator). You'll receive medications and fluid through an intravenous (IV) line in your arm.attack.(citation) www.mayoclinic.org

Medications

• Fluids and plasma, given through an IV, and medications to treat cardiogenic shock, work to increase your heart's pumping ability.
• Inotropic agents. You might be given medications to improve your heart function, such as norepinephrine (Levophed) or dopamine, until other treatments start to work.
• Aspirin. Emergency medical workers might give you aspirin immediately to reduce blood clotting and keep your blood flowing through a narrowed artery. Take an aspirin yourself while waiting for help to arrive only if your doctor has previously told you to do so for symptoms of a heart attack.
• Thrombolytics. These drugs, also called clot busters or fibrinolytics, help dissolve a blood clot that's blocking blood flow to your heart. The sooner you receive a thrombolytic drug after a heart attack, the greater your chances of survival. You'll likely receive thrombolytics, such as alteplase (Activase) or reteplase (Retavase), only if emergency cardiac catheterization isn't available.
• Antiplatelet medication. Emergency room doctors might give you drugs similar to aspirin to help prevent new clots from forming. These include medications, such as oral clopidogrel (Plavix), and platelet glycoprotein IIb/IIIa receptor blockers, such as abciximab (Reopro), tirofiban (Aggrastat) and eptifibatide (Integrilin), which are given through a vein (intravenously).
• Other blood-thinning medications. You'll likely be given other medications, such as heparin, to make your blood less likely to form clots. IV or injectable heparin usually is given during the first few days after a heart attack.(citation) www.mayoclinic.org

1. You are to triage these three clients and decide who the physician sees first. What levels would you triage these victims?

• The physician should see first the victim 1, followed by victim 2 and the last is victim 3.
• Victim 1- Level 2: Emergent
• Conditions that are a potential threat to life, limb or function(citation)
• Victim 2- Level 4: Less urgent 
• Conditions that relate to patient distress or potential complications that would benefit from intervention(citation)
• Victim 3- Level 5: Non-urgent -
• Conditions that are non-urgent or that may be part of a chronic problem(citation)

Reference:

www.hopitalmontfort.com

2. What is your assessment of:

Victim 1- (respiratory distress, coughing, and wheezing.) The patient's signs and symptoms is mostly respiratory.

Inhalation anthrax symptoms can include:

• Fever and chills
• Chest Discomfort
• Shortness of breath
• Confusion or dizziness
• Cough
• Nausea, vomiting, or stomach pains
• Headache
• Sweats (often drenching)
• Extreme tiredness
• Body aches(citation) www.cdc.gov

Victim 2- (rash with blisters on his face, hands, and arms. Inhaled some of the white substance when the box broke open). The patient is presenting signs snd symptoms involving the skin.

Cutaneous anthrax symptoms can include:

• A group of small blisters or bumps that may itch
• Swelling can occur around the sore
• A painless skin sore (ulcer) with a black center that appears after the small blisters or bumps
• Most often the sore will be on the face, neck, arms, or hands(citation) www.cdc.gov

Victim 3- only inhaled the substance

• As of the moment, the patient is not showing any symptoms but should be continuously monitored for potential danger to health.
• The symptoms of anthrax depend on the type of infection and can take anywhere from 1 day to more than 2 months to appear. All types of anthrax have the potential, if untreated, to spread throughout the body and cause severe illness and even death.(citation) www.cdc.gov

3. What treatment do you suggest for victim 1?

• Anthrax is an infectious disease caused by a bacterium called Bacillus anthracis. Infection in humans most often involves the skin, gastrointestinal tract, or lungs.
• Antibiotics are usually used to treat anthrax. Antibiotics that may be prescribed include penicillin, doxycycline, and ciprofloxacin.
• Inhalation anthrax is treated with a combination of antibiotics such as ciprofloxacin plus another medicine. They are given by IV (intravenously). Antibiotics are usually taken for 60 days because it can take spores that long to germinate.(citation)medlineplus.gov

4. What treatment do you suggest for victim 2?

• Cutaneous anthrax is treated with antibiotics taken by mouth, usually for 7 to 10 days. Doxycycline and ciprofloxacin are most often used.(citation)medlineplus.gov

5. What treatment would you decide for victim 3?

• For people who have been exposed to anthrax (but have no symptoms of the disease), providers may prescribe preventive antibiotics, such as ciprofloxacin, penicillin, or doxycycline, depending on the strain of anthrax.(citation)medlineplus.gov

 6. What are the three pathogens that can be used by terrorists as biological weapons that are also pathogens that can cause humans disasters?

1. Bacillus anthracis (Anthrax)

• A biological attack, or bioterrorism, is the intentional release of viruses, bacteria, or other germs that can sicken or kill people, livestock, or crops. Bacillus anthracis, the bacteria that causes anthrax, is one of the most likely agents to be used in a biological attack.(citation) 

2. Clostridium botulinum toxin (Botulism)

• The bacteria that make this toxin are found naturally in many places, but it's rare for them to make people sick. However, the toxin could be used in a biological attack. A biological attack is the intentional release of germs, or the toxins they make, that can sicken or kill people, livestock, or crops(citation)

3. Yersinia pestis (Plague)

• Yersinia pestis used in an aerosol attack could cause cases of pneumonic plague. One to six days after becoming infected with the bacteria, people would develop pneumonic plague. Once people have the disease, the bacteria can spread to others who have close contact with them.(citation)/plague/bioweapon

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