insulin shock

shock

[shok] 1. a sudden disturbance of mental equilibrium.2. a condition of acute peripheral circulatory failure due to derangement of circulatory control or loss of circulating fluid. It is marked by hypotension and coldness of the skin, and often by tachycardia and anxiety. Untreated shock can be fatal. Called also circulatory collapse.
Mechanisms of Circulatory Shock. The essentials of shock are easier to understand if the circulatory system is thought of as a four-part mechanical device made up of a pump (the heart), a complex system of flexible tubes (the blood vessels), a circulating fluid (the blood), and a fine regulating system or “computer” (the nervous system) designed to control fluid flow and pressure. The diameter of the blood vessels is controlled by impulses from the nervous system which cause the muscular walls to contract. The nervous system also affects the rapidity and strength of the heartbeat, and thereby the blood pressure as well.

Shock, which is associated with a dangerously low blood pressure, can be produced by factors that attack the strength of the heart as a pump, decrease the volume of the blood in the system, or permit the blood vessels to increase in diameter.Types of Circulatory Shock. There are five main types: Hypovolemic (low-volume) shock occurs whenever there is insufficient blood to fill the circulatory system. Neurogenic shock is due to disorders of the nervous system. Anaphylactic (allergic) shock and septic shock are both due to reactions that impair the muscular functioning of the blood vessels. And cardiogenic shock is caused by impaired function of the heart.Hypovolemic (Low-Volume) Shock. This is a common type that happens when blood or plasma is lost in such quantities that the remaining blood cannot fill the circulatory system despite constriction of the blood vessels. The blood loss may be external, as when a vessel is severed by an injury, or the blood may be “lost” into spaces inside the body where it is no longer accessible to the circulatory system, as in severe gastrointestinal bleeding from ulcers, fractures of large bones with hemorrhage into surrounding tissues, or major burns that attract large quantities of blood fluids to the burn site outside blood vessels and capillaries. The treatment of hypovolemic shock requires replacement of the lost volume.Neurogenic Shock. This type, often accompanied by fainting, may be brought on by severe pain, fright, unpleasant sights, or other strong stimuli that overwhelm the usual regulatory capacity of the nervous system. The diameter of the blood vessels increases, the heart slows, and the blood pressure falls to the point where the supply of oxygen carried by the blood to the brain is insufficient, which can bring on fainting. Placing the head lower than the body is usually sufficient to relieve this form of shock.Anaphylactic (Allergic) Shock. This type (see also anaphylaxis) is a rare phenomenon that occurs when a person receives an injection of a foreign protein but is highly sensitive to it. The blood vessels and other tissues are affected directly by the allergic reaction. Within a few minutes, the blood pressure falls and severe dyspnea develops. The sudden deaths that in rare cases follow bee stings or injection of certain medicines are due to anaphylactic reactions.Septic Shock. This type, resulting from bacterial infection, is being recognized with increasing frequency. Certain organisms contain a toxin that seems to act on the blood vessels when it is released into the bloodstream. The blood eventually pools within parts of the circulatory system that expand easily, causing the blood pressure to drop sharply. Gram-negative shock is a form of septic shock due to infection with gram-negative bacteria.Cardiogenic Shock. This type may be caused by conditions that interfere with the function of the heart as a pump, such as severe myocardial infarction, severe heart failure, and certain disorders of rate and rhythm.

Pathogenesis of shock. (ARDS = adult respiratory distress syndrome, GI = gastrointestinal, IL = interleukin, TNF = tumor necrosis factor.) From Damjanov, 2000.anaphylactic shock see anaphylactic shock.cardiogenic shock shock resulting from primary failure of the heart in its pumping function, as in myocardial infarction, severe cardiomyopathy, or mechanical obstruction or compression of the heart; clinical characteristics are similar to those of hypovolemic shock.colloidoclastic shock colloidoclasia.cultural shock feelings of helplessness and discomfort experienced by an outsider attempting to comprehend or effectively adapt to a different cultural group or unfamiliar cultural context.electric shock see electric shock.hypovolemic shock shock resulting from insufficient blood volume for the maintenance of adequate cardiac output, blood pressure, and tissue perfusion. Without modification the term refers to absolute hypovolemic shock caused by acute hemorrhage or excessive fluid loss. Relative hypovolemic shock refers to a situation in which the blood volume is normal but insufficient because of widespread vasodilation as in neurogenic shock or septic shock. Clinical characteristics include hypotension; hyperventilation; cold, clammy, cyanotic skin; a weak and rapid pulse; oliguria; and mental confusion, combativeness, or anxiety.insulin shock a hypoglycemic reaction to overdosage of insulin, a skipped meal, or strenuous exercise in an insulin-dependent diabetic, with tremor, dizziness, cool moist skin, hunger, and tachycardia; if untreated it may progress to coma and convulsions.respirator shock circulatory shock due to interference with the flow of blood through the great vessels and chambers of the heart, causing pooling of blood in the veins and the abdominal organs and a resultant vascular collapse. The condition sometimes occurs as a result of increased intrathoracic pressure in patients who are being maintained on a mechanical ventilator.septic shock shock associated with overwhelming infection, usually by gram-negative bacteria, although it may be produced by other bacteria, viruses, fungi, and protozoa. It is thought to result from the action of endotoxins or other products of the infectious agent on the vascular system causing large volumes of blood to be sequestered in the capillaries and veins; activation of the complement and kinin systems and the release of histamine, cytokines, prostaglandins, and other mediators may be involved. Clinical characteristics include initial chills and fever, warm flushed skin, increased cardiac output, and a lesser degree of hypotension than with hypovolemic shock; if therapy is ineffective, it may progress to the clinical picture associated with hypovolemic shock.shell shock old term for posttraumatic stress disorder.spinal shock the loss of spinal reflexes after injury of the spinal cord that appears in the muscles innervated by the cord segments situated below the site of the lesion.

in·su·lin shock

severe hypoglycemia produced by administration of insulin, manifested by sweating, tremor, anxiety, vertigo, and diplopia, followed by delirium, convulsions, and collapse. Synonym(s): wet shock

insulin shock

n. Acute hypoglycemia usually resulting from an overdose of insulin and characterized by sweating, trembling, dizziness, and, if left untreated, convulsions and coma.

insulin shock

Endocrinology 1. A rare clinical event in which excess insulin is administered, causing profound hypoglycemia to levels below that required for normal brain function, causing anxiety, delirium, convulsions, coma, death.2. Hypoglycemia, see there.

in·su·lin shock

(in'sŭ-lin shok) Severe hypoglycemia produced by administration of insulin, manifested by sweating, tremor, anxiety, vertigo, and diplopia, followed by delirium, convulsions, and collapse.

insulin

(in'su-lin) [L. insula, island + -in]

INSULIN AND GLUCAGON FUNCTIONSA hormone secreted by the beta cells of the pancreas. As a drug, insulin is used principally to control diabetes mellitus. Insulin therapy is required in the management of type 1 diabetes mellitus because patients with this illness do not make enough insulin on their own to survive. The drug also is used in the care of patients with gestational diabetes to prevent fetal complications caused by maternal hyperglycemia (insulin itself does not cross the placenta or enter breast milk). In type 2 diabetes mellitus, its use typically is reserved for those patients who have failed to control their blood sugars with diet, exercise, and oral drugs. See: illustration; diabetes mellitus

Insulin preparations differ with respect to the speed with which they act and their duration and potency following subcutaneous injection. See: table

In the past, insulin for injection was obtained from beef or swine pancreas. These peptides differed from human insulin by a few amino acids, causing some immune reactions and drug resistance. Most insulin now in use is made by recombinant DNA technology and from an immunological perspective is equivalent to human insulin.

Physiology

In health, the pancreas secretes insulin in response to elevations of blood glucose, such as occur after meals. It stimulates cells, esp. in muscular tissue, to take up sugar from the bloodstream. It also facilitates the storage of excess glucose as glycogen in the liver and prevents the breakdown of stored fats. In type 1 diabetes mellitus, failure of the beta cells to produce insulin results in hyperglycemia and ketoacidosis.

Dosage

The insulin dosage should always be expressed in units. There is no average dose of insulin for diabetics; each patient must be assessed and treated individually Doses are titrated gradually to achieve near normal glucose levels, about 90–125 mg/dl.

Storage

The FDA requires that all preparations of insulin contain instructions to keep in a cold place and to avoid freezing.

CAUTION!

Those who use insulin should wear an easily seen bracelet or necklace stating that they have diabetes and use the drug. This helps to ensure that patients with hypoglycemic reactions will be diagnosed and treated promptly.

insulin analog

See: analog

insulin aspart

A rapidly acting insulin administered subcutaneously, with action similar to that of insulin lispro. Aspartic acid replaces proline at a crucial position in the insulin molecule.

biphasic insulin

An insulin preparation that includes two components, typically a rapidly acting insulin, e.g., regular insulin, and an insulin that has a longer duration of action, e.g., NPH insulin.

insulin glargine

A form of insulin that provides basal insulin coverage throughout the day, with little variation in drug levels. It is typically administered as a single injection (often at bedtime) and is usually part of a regimen that includes multiple injections of short-acting insulins or multiple doses of metformin at meal time. It is made by changing the glycine and arginine content of the insulin polypeptide.

human insulin

Insulin prepared by recombinant DNA technology utilizing strains of Escherichia coli. In its effect it is similar to insulins secreted by the human pancreas. Trade names are Humulin and Novolin. Synonym: Novolin 70/30 See: Humulin 50/50; Humulin 70/30; insulin for table

inhaled insulin

Insulin given by inspiration, with the use of an inhaler. It may be composed of liquid droplets or a dry powder. One inhaled insulin product was removed from use in 2008 because of its adverse effects on the lungs.

insulin injection site

See: site

insulin isophane suspension

Intermediate-acting insulin with onset in 1 2 to 1 hr and a duration of 18 to 28 hr. See: insulin for table

insulin lipodystrophy

See: lipodystrophy

insulin lispro

A synthetic insulin with a very rapid onset and short duration of action. Diabetic patients typically use it immediately before meals to prevent postprandial hyperglycemia. Its absorption is more rapid than regular insulin. It is made by reversing the amino acids lysine and proline in the beta chain of the insulin polypeptide (hence its name lispro).

monocomponent insulin

Single-component insulin.

insulin protamine zinc suspension

Long-acting insulin with onset in 6 to 8 hr and a duration of 30 to 36 hr. See: insulin for table

insulin pump

See: pump

insulin shock

Hypoglycemic shock.

single-component insulin

Highly purified insulin that contains less than 10 parts per million of proinsulin, which is capable of inducing formation of anti-insulin antibodies. Synonym: monocomponent insulin

synthetic insulin

Insulin made by the use of recombinant DNA technology.

insulin zinc extended suspension

Long-acting insulin with onset in 5 to 8 hr and duration of more than 36 hr.

insulin zinc prompt suspension

Fast-acting insulin with onset less than 1 hr and a duration of 12 to 16 hr. * These times are estimates and may vary in individual patients. ** Contain NPH plus a rapid-acting insulin (Aspart, Lispro, or Regular); Novolog 70/30 contains 70% NPH, 30% Novolog

Type of Insulin	Generic (Trade Names)	Onset (hr)	Maximum (hr)	Duration (hr)
Very rapid	Aspart (NovoLog)	0.2–0.5	1–3	3–5
Very rapid	Lispro (Humalog)	0.2–0.5	0.5–2.5	3–5
Very rapid	Glulisine (Apidra)	0.2–0.5	1.6–2.8	3–4
Rapid	Regular	0.5–1.0	2.5–5	4–6
Intermediate-acting	NPH (Humulin N, Novolin N)	2–4	4–12	10–18
Fixed-dose combination insulins **	70/30, 50/50, etc.	Variable, depending on mixture used
Very long- acting	Lantus (Glargine)	2–4	none	11–32
Very long- acting	determir (Levemir)	3–4	3–9	6–23 Dose dependent
U 500 regular very concentrated (5 X U100)		0.5–1.0	2.5–5	up to 24 hr

shock

S07-857300 (shok) 1. A clinical syndrome marked by inadequate perfusion and oxygenation of cells, tissues, and organs, usually due to marginal or markedly lowered blood pressure. Synonym: circulatory collapse

Etiology

Shock may be caused by dehydration, hemorrhage, sepsis, myocardial infarction, valvular heart disease, cardiac tamponade, adrenal failure, burns, trauma, spinal cord injury, hypoxia, anaphylaxis, poisoning, and other major insults to the body.

Symptoms

Shock results in failure of multiple organ systems, including the brain, heart, kidneys, lungs, skin, and gastrointestinal tract. Common consequences of shock are confusion, agitation, anxiety, or coma; syncope or presyncope; increased work of breathing; respiratory distress; pulmonary edema; decreased urinary output; and/or acute renal failure. Signs of shock include tachycardia, tachypnea, hypotension, and cool, clammy, or cyanotic skin.

Treatment

Attempts to restore normal blood pressure and tissue perfusion include fluid resuscitation (in hypovolemic shock); control of hemorrhage (in shock caused by trauma or bleeding); administration of corticosteroids (in adrenal failure); pressor support (in cardiogenic or septic shock); the administration of epinephrine (in anaphylaxis); antibiotic administration with the drainage of infected foci (in sepsis); pericardiocentesis (in cardiac tamponade); transfusion; and oxygenation. Oral or parenterally administered sugars (typically glucose) can treat hypoglycemia caused by insulin, oral hypoglycemic drugs, or insulinomas.

Critical Care

The shock syndrome is a life-threatening medical emergency and requires very careful therapy and monitoring. If the patient does not respond at once, treatment and monitoring in the best facility available (such as intensive care unit) are essential. It is important that the ECG, arterial and central venous blood pressures, blood gases, core and skin temperatures, pulse rate, blood volume, blood glucose, hematocrit, cardiac output, urine flow rate, and neurological status be monitored on an ongoing basis (for example, hourly).

Patient care

Patients at risk for shock include, but are not limited to, those with severe injuries, external or suspected internal hemorrhage, profound fluid loss or sequestration (severe vomiting, diarrhea, burns), allergen exposures, sepsis, impaired left ventricular function, electrical and thermal injuries (including lightning strikes), and diabetes (if receiving supplemental insulin).

One, two, or more large-bore intravenous catheters are inserted, and prescribed fluid therapy is initiated. External monitoring of vital signs is instituted; a pulmonary artery catheter may be placed or impedance cardiography instituted for precise hemodynamic monitoring; and an indwelling urinary catheter is inserted to track urine output hourly. Prescribed oxygen therapy is provided; SaO₂, arterial blood gas levels (ABGs), and ventilatory function are monitored to determine the need for ventilatory support. If occult bleeding is suspected, stools and gastric fluids are tested, and injured tissues and spaces are carefully assessed or imaged. Routine measures are taken to reduce the risk of decubitus ulcers, muscular atrophy, deep venous thrombosis, delirium, and contractures. The patient is maintained in a normothermic environment for comfort. Radiant warmers are useful in preventing hypothermia in patients who cannot be kept clothed or covered during assessment and treatment. The environment is kept as calm and controlled as possible. Procedures and treatments are explained to the patient in a simple, clear, easily understandable manner.

Positioning is based on the particular shock type. Although hypovolemic shock states respond best to supine positioning, or even elevation of the feet and lower legs, cardiac and anaphylactic shock states require head elevation to ease ventilatory effort. Correct body alignment should be maintained, whatever the necessary position. Oral fluids are often withheld to prevent vomiting and aspiration. Oral care and misting are provided frequently to prevent dryness, stomatitis, sordes, and salivary obstructions. The patient's sensorium is closely assessed, and sensory overload is prevented as much as possible. Regular assessments are conducted for acute organ dysfunction, e.g., urine output below 0.5 ml/kg/hr, hypotension, hypoxemia, lactic acidosis, and low platelet count. While providing comfort measures and emotional support, the health care professional acts as a liaison to family members or significant others, providing them with information about the patient's status and the treatment regimen. If shock is irreversible, the family must prepare for the patient's death; family members are encouraged to be with, talk to, and touch the patient, and social work and mental health consultations or spiritual measures may be obtained for the patient and family as determined by their beliefs and desires.

2. An electrical shock, e.g., a discharge of electricity from a cardioverter or defibrillator.

anaphylactic shock

Rapidly developing systemic anaphylaxis that produces life-threatening acute airway obstruction followed by vascular collapse within minutes after exposure to an antigen. See: allergy; anaphylaxis

Etiology

The condition is the result of a type I allergic or hypersensitivity reaction during which the allergen is absorbed into the blood directly or through the mucosa. The most common agents are bee or wasp venoms, drugs (such as penicillins), and radiographic contrast media. It also can be triggered by severe food allergies (shellfish, peanuts) and by latex exposure. Individuals with a history of asthma, eczema, or hay fever are at increased risk. Chemical mediators released during the reaction cause constriction of the bronchial smooth muscle, vasodilation, and increased vascular permeability.

Symptoms

Initial symptoms include anxiety, tingling, itching, or warm feelings and skin rash, a metallic taste, swelling of lips and tongue, dyspnea, wheezing, vomiting, abdominal cramps, diarrhea, light-headedness, dizziness, and chest pain. Severe symptoms include acute respiratory distress, hypotension, edema, rash, tachycardia, pale cool skin, convulsions, and cyanosis. If no treatment is received, unconsciousness and death may result. Tissue swelling can be life-threatening if the larynx is involved, since air flow is obstructed with even minimal swelling.

Prevention

A history of past allergic reactions, particularly to bee stings, drugs, blood products, or contrast media, is obtained. The at-risk patient is observed for reaction during and immediately after administration of any of these agents.

Patient care

At the first sign of life-threatening respiratory distress, an airway is established, the appropriate physician is notified, and oxygen is administered by non–rebreather mask. Venous access is established. Epinephrine is administered, and diphenhydramine and corticosteroids are administered per protocol. Drugs should be administered intravenously if the patient is unconscious or hypotensive, and subcutaneously or intramuscularly if the patient is conscious and normotensive. Airway patency is maintained, and the patient should be observed for early signs of laryngeal edema, e.g., stridor, hoarseness, and dyspnea. Endotracheal intubation or a surgical airway may be necessary. In addition to high-concentration oxygen for all patients in shock, cardiopulmonary resuscitation and defibrillation, as indicated, are initiated if the patient becomes pulseless. The patient is assessed for hypotension and shock; circulatory volume is maintained with prescribed volume expanders, and blood pressure is stabilized with prescribed vasopressors. Blood pressure, central venous pressure, and urinary output are monitored in the hospital setting. Once the initial emergency has subsided, prescribed drugs for long-term management and inhaled bronchodilators for bronchospasm may be considered. The patient is taught to identify and avoid common allergens and to recognize an allergic reaction. Sensitivity testing may be advised to help determine offending allergens. If a patient is unable to avoid exposure to allergens and requires medication, an emergency kit should be kept readily available. Typically, this contains epinephrine in an auto-injector and liquid diphenhydramine. Both patient and family are instructed in its use. The patient with known serious allergies should wear an identifying bracelet or carry a card in his/her wallet. Patients with food allergies should be advised to read labels and to ask about food preparation and content when eating out. Individuals with insect sting allergies should avoid wearing bright-colored clothing, scented cosmetics, hairsprays, or perfumes that attract insects and should use insect repellant and wear closed shoes outdoors.

anesthesia shock

Shock due to an overdose of a general anesthetic. The anesthetic should be immediately withheld and oxygen, mechanical ventilation, and vapor drugs should be given.

cardiogenic shock

Failure of the heart to pump an adequate supply of blood and oxygen to body tissues. The most common cause of cardiogenic shock is acute myocardial infarction, but other causes include failure or stenosis of heart valves (such as aortic or mitral stenosis or regurgitation), cardiomyopathies, pericardial tamponade, and sustained cardiac rhythm disturbances, among others. Cardiogenic shock is often fatal; only about 20% of affected persons survive. Its incidence has declined as the care of patients with acute myocardial infarction has incorporated thrombolytic drugs and emergency percutaneous coronary intervention.

Patient care

The patient is assessed for a history of any cardiac disorder that severely decreases left ventricular function, for anginal pain, dysrhythmias, reduced urinary output, respiratory effort and rate, blood pressure, pulse, dizziness, alterations in mental status, and perfusion of the skin. Signs of poor tissue perfusion include cold, pale, clammy skin; cyanosis; restlessness, mental confusion and obtundation; tachycardia; tachypnea; systolic blood pressure 30 mm Hg below baseline or below 80 mm Hg; and oliguria (urine output below 20 ml/hr). Heart sounds are auscultated for a gallop rhythm and murmurs, the lungs are checked for crackles and wheezes, and neck veins are assessed for distention.

Arterial blood gas values, electrolyte levels, cardiac rhythms, and hemodynamic values (pulmonary artery pressures, wedge pressures, and cardiac output) are monitored intensively. Echocardiography helps to determine left ventricular function and valve abnormalities. Treatment goals include enhancing cardiovascular status by increasing cardiac output, improving myocardial perfusion, and decreasing cardiac workload. Combinations of various cardiovascular drugs and mechanical assist techniques are used. Prescribed intravenous fluids are administered via a large-bore intravenous catheter (14 G to 18 G) according to hemodynamic patterns and urine output. Oxygen is administered by face mask or artificial airway to ensure adequate tissue oxygenation. Prescribed inotropic agents and vasopressors are administered and evaluated for desired effects and any adverse reactions.

Some patients will undergo emergent cardiac catheterization, coronary angioplasty, coronary stents, bypass surgery, or placement of intra-aortic balloon pumps, turbine pumps, or temporary or permanent ventricular assist devices. The ICU setting, special procedures, and equipment are explained to the patient and family to reduce their anxiety; a calm environment with as much privacy as possible and frequent rest periods are provided; and frequent family visits are permitted. All invasive sites are assessed for infection and/or hematomas. When the patient’s hemodynamic stability is restored, he/she is gradually weaned from supportive mechanical devices and drug therapies. The family is prepared for the possibility of a fatal outcome and assisted to find effective coping strategies.

compensated shock

The early phase of shock in which the body's compensatory mechanisms (such as increased heart rate, vasoconstriction, increased respiratory rate) are able to maintain adequate perfusion to the brain and vital organs. Typically, the patient is normotensive in compensated shock.

cryptic shock

Shock without hypotension.

culture shock

The emotional trauma of being exposed to the culture, mores, and customs of a culture that is vastly different from the one to which one has been accustomed.

decompensated shock

The late phase of shock in which the body's compensatory mechanisms (such as increased heart rate, vasoconstriction, increased respiratory rate) are unable to maintain adequate perfusion to the brain and vital organs. Typically, the patient is hypotensive in decompensated shock.

deferred shock

Shock occurring several hours to a day after an injury or illness. Synonym: secondary shock

distributive shock

Shock in which there is a marked decrease in peripheral vascular resistance and consequent hypotension. Examples are septic shock, neurogenic shock, and anaphylactic shock.

electric shock

Injury from electricity that varies according to type and strength of current and length and location of contact. Electric shocks range from trivial burns to complete charring and destruction of skin and injury to internal organs, including brain, lungs, kidneys, and heart. Approximately 1000 people are electrocuted accidentally each year in the U.S., and another 4000 are injured. Five percent of admissions to burn centers are related to electrical injury.

Whether or not an electric shock will cause death is influenced by the pathway the current takes through the body, the amount of current, and the skin resistance. Thus, a very small amount of electrical energy applied directly to the heart may be enough to stop it from beating or to trigger ventricular fibrillation.

Symptoms

Burns, loss of consciousness, and/or cardiac arrest are symptoms of electrical injury.

First Aid

Rescuers of any electrical shock victim who is unconscious should immediately call for emergency assistance. See: cardiopulmonary resuscitation; electrocution; lightning safety rules

Treatment

The patient should be freed carefully from the current source by first shutting off the current. Prolonged support in a critical care unit may be needed.

endotoxic shock

Septic shock due to release of endotoxins by gram-negative bacteria. Endotoxins are lipopolysaccharides in the cell walls that are released during both reproduction and destruction of the bacteria. They are potent stimulators of inflammation, activating macrophages, B lymphocytes, and cytokines and producing vasodilation, increased capillary permeability, and activation of the complement and coagulation cascades. See: endotoxin; septic shock

hemorrhagic shock

Shock due to loss of blood.

hypoglycemic shock

Shock produced by extremely low blood sugars (less than 40 mg/dl), usually caused by an injection of an excessive amount of insulin, failure to eat after an insulin injection, or rarely by an insulin-secreting tumor of the pancreas. Insulin-related hypoglycemic shock may be intentionally induced in the treatment of certain psychiatric conditions. Synonym: insulin shock See: hypoglycemia

Patient care

All unconscious patients should be treated for presumptive hypoglycemia with an injection of D₅₀. Once the patient is conscious, glucose is given by mouth to attain the desired glucose level. The rescue therapy is followed by a carbohydrate and protein snack to maintain the desired level.

The stabilized patient's immediate past history should be reviewed, looking for triggering factors. The patient and family can then be taught ways to avoid such situations in the future or to manage them before hypoglycemia again becomes this serious. If insulin levels need to be adjusted, the patient's preprandial glucose levels for the preceding 24 hr must be reviewed. The patient and family are assisted in processing the event. Their treatment actions are given positive reinforcement, correcting any errors such as inability to recognize early symptoms of insulin shock, overcorrection of insulin deficiency, or use of food products that are absorbed too slowly.

hypovolemic shock

Shock occurring when there is an insufficient amount of fluid in the circulatory system. This is usually due to bleeding, diarrhea, or vomiting. Synonym: oligemic shock

insulin shock

Hypoglycemic shock.

irreversible shock

Shock of such intensity that even heroic therapy cannot prevent death.

neurogenic shock

A form of distributive shock due to decreased peripheral vascular resistance. Damage to either the brain or the spinal cord inhibits transmission of neural stimuli to the arteries and arterioles, which reduces vasomotor tone. The decreased peripheral resistance results in vasodilation and hypotension; cardiac output diminishes due to the altered distribution of blood volume.

obstructive shock

Circulatory collapse caused by conditions that block the flow of blood into or out of the heart, such as cardiac tamponade, cardiac tumors, massive pulmonary embolism, or tension pneumothorax. Obstructive shock is characterized by very low cardiac output and increased systemic vascular resistance.

oligemic shock

Hypovolemic shock.

protein shock

Shock reaction resulting from parenteral administration of a protein.

psychic shock

Shock due to excessive fear, joy, anger, or grief.

psychogenic shock

Shock due to emotional stress or to seeing an injury or accident. See: psychic shock

refractory shock

Shock that does not respond to standard treatments, e.g., with oxygenation and ventilation, fluid resuscitation and the restoration of perfusion, and identification and treatment of infection. It typically requires high doses of vasopressors, e.g., more than 15 mcg/kg/min of dopamine to maintain a blood pressure of 60 mm Hg.

secondary shock

Deferred shock.

septic shock

Hypotension and inadequate blood flow to organs resulting from sepsis. The most common organisms are gram-negative and gram-positive bacteria, but fungi and other organisms may also be responsible. See: sepsis

Etiology

Organisms and released endotoxins or exotoxins initiate a systemic inflammatory response. Chemical mediators of inflammation and the cell-mediated immune response (esp. tumor necrosis factor and interleukin 1) cause the physiological changes to septic shock. Initially, vasodilation, increased capillary permeability, and movement of plasma out of blood vessels produce hypovolemia and hypotension. Compensatory vasoconstriction occurs in an effort to maintain blood flow to vital organs. As sepsis progresses, secondary inflammatory mediators are released, increasing vascular endothelial damage.

Selective vasoconstriction produces tissue hypoxia and single or multiple organ dysfunction. Tissue hypoxia is increased by abnormal stimulation of the coagulation and kinin cascades in the capillaries, which produce microthrombi. Within the lung, damage to the capillary endothelium may cause adult respiratory distress syndrome. Septic shock often progresses to multiple organ dysfunction syndrome (MODS), which is the most common cause of death in surgical intensive care units.

Symptoms

Confusion and other alterations of consciousness are common symptoms. Signs include hypotension, fever, tachypnea, tachycardia, decreased urinary output, and cold, clammy skin. Laboratory studies reveal acidosis and, sometimes, renal failure or coagulopathies.

Treatment

Empiric therapy with an extended-spectrum penicillin (such as ticarcillin/clavulanate, piperacillin/tazobactam) or third-generation cephalosporin (such as ceftriaxone), plus clindamycin or metronidazole, provide antibiotic coverage until an organism from the primary site of infection is positively identified. Intravenous resuscitation and if necessary, vasopressors such as dopamine or norepinephrine are used to stabilize blood pressure. Activated drotecogin alfa, a recombinant form of human activated protein C (Xigris) is occasionally effective. Oxygen and other supportive interventions are used to minimize organ damage. Maintaining blood glucose levels between 80 and 110 mg/dl improves chances of survival significantly. Use of corticosteroids is not supported by research.

Patient care

Intensive care measures are instituted to monitor blood pressure, fluid and electrolyte balance, renal function, and changes in neurological status. Assessment of progressive agitation or confusion should emphasize the possibility of hypoxia. Routine measures to reduce the risk of decubitus ulcers, muscle atrophy, and contractures are needed. Repeated teaching is necessary for family members to understand the severity of the infection, the purpose of interventions, signs of improvement, and the possibility of death.

serum shock

Shock occurring as part of a reaction to the injection of serum. See: anaphylactic shock

spinal shock

Immediate flaccid paralysis and loss of all sensation and reflex activity below the level of injury in acute transverse spinal cord injury. Arterial hypotension may be present in this condition.

shell shock

A term used during World War I to designate a wide variety of psychotic and neurotic disorders associated with the stress of combat. See: post-traumatic stress disorder

stacked shock

In emergency cardiac care, defibrillation repeated immediately without resuming basic life support or cardiopulmonary resuscitation between the electrical discharges.

surgical shock

Shock following operations and including traumatic shock. See: traumatic shock

traumatic shock

Shock due to injury or surgery. In the abdomen, it may result from hemorrhage and/or peritonitis secondary to a disrupted or perforated viscus. Additional causes of traumatic shock include the following:

Cerebral injury: Shock from concussion of the brain secondary to cranial contusion or fracture or spontaneous hemorrhage. The shock may be evident immediately or later due to edema or delayed intracranial hemorrhage. Chemical injury: Shock due to physiological response to tissue injury, such as fluid mobilization, toxicity of the agent, and reflexes induced by pain due to the effect of chemicals, esp. corrosives. Crushing injury: Shock caused by disruption of soft tissue with release of myoglobulins, hemorrhage, and so forth, generally proportional to the extent of the injury. Fracture (esp. open fracture): Shock due to blood loss, fat embolism, and the physiological effects of pain. Heart damage: Shock caused by myocardial infarction, myocarditis, pericarditis, pericardial tamponade, or direct trauma with ensuing cardiovascular effects. Inflammation: Shock caused by severe sepsis, for example, peritonitis due to release of toxins affecting cardiovascular function and significant fluid mobilization. Intestinal obstruction: Shock caused by respiratory compromise due to distention, fluid mobilization, release of bacterial toxins, and pain. Nerve injury: Shock caused by injury to the area controlling respirations (e.g., high cervical cord injury) or to highly sensitive parts, such as the testicle, solar plexus, eye, and urethra, or secondary to cardiovascular reflexes stimulated by pain. Operations: Shock that may occur even after minor operations and paracentesis or catheterization due to rapid escape of fluids resulting in abrupt alteration of intra-abdominal pressure dynamics and hemorrhage. Perforation or rupture of viscera: Shock resulting from acute pneumothorax, ruptured aneurysm, perforated peptic ulcer, perforation of appendicial abscess or colonic diverticulum, or ectopic pregnancy. Strangulation: Shock resulting from strangulated hernia, intussusception, or volvulus. Thermal injury: Shock caused by burn, frostbite, or heat exhaustion secondary to fluid mobilization due to the physiological effects of pain. Torsion of viscera: Shock caused by torsion of an ovary or a testicle secondary to the physiological effects of pain.

insulin shock

1. HYPOGLYCAEMIA resulting from excessive insulin in the blood. 2. An outmoded treatment for psychiatric disorders in which hypoglycaemia is deliberately induced and then terminated with intravenous glucose.

in·su·lin shock

(in'sŭ-lin shok) Severe hypoglycemia produced by administration of insulin, manifested by sweating, tremor, anxiety, vertigo, and diplopia, followed by delirium, convulsions, and collapse.

insulin shock

insulin shock

in′sulin shock`

insulin shock

insulin shock:

insulin shock

insulin shock

shock

in·su·lin shock

insulin shock

insulin shock

in·su·lin shock

insulin

Physiology

Dosage

Storage

CAUTION!

insulin analog

insulin aspart

biphasic insulin

insulin glargine

human insulin

inhaled insulin

insulin injection site

insulin isophane suspension

insulin lipodystrophy

insulin lispro

monocomponent insulin

insulin protamine zinc suspension

insulin pump

insulin shock

single-component insulin

synthetic insulin

insulin zinc extended suspension

insulin zinc prompt suspension

shock

Etiology

Symptoms

Treatment

Critical Care

Patient care

anaphylactic shock

Etiology

Symptoms

Prevention

Patient care

anesthesia shock

cardiogenic shock

Patient care

compensated shock

cryptic shock

culture shock

decompensated shock

deferred shock

distributive shock

electric shock

Symptoms

First Aid

Treatment

endotoxic shock

hemorrhagic shock

hypoglycemic shock

Patient care

hypovolemic shock

insulin shock

irreversible shock

neurogenic shock

obstructive shock

oligemic shock

protein shock

psychic shock

psychogenic shock

refractory shock

secondary shock

septic shock

Etiology

Symptoms

Treatment

Patient care

serum shock