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Shock

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CMSgt John Jonckers, RN, NREMT-P …

CMSgt John Jonckers, RN, NREMT-P
Superintendent 141st MDG
SMEE - Thailand

Published in: Health & Medicine, Business

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  • 1. Hemorrhage & Shock CMSgt John Jonckers, RN, NREMT-P Superintendent 141 st MDG SMEE - Thailand
  • 2. Review of Hemorrhage
    • Location
    • Anatomical Type & Timing
    • Coagulation
    • Fibrinolysis
    • Assessment
    • Management
  • 3. Review of Hemorrhage
    • Location
      • External
      • Internal
        • Traumatic
        • Non-Traumatic
    • Examples?
  • 4. Review of Hemorrhage
    • Anatomical Type
      • Arterial
      • Venous
      • Capillary
    • Timing
      • Acute
      • Chronic
  • 5. Management of Hemorrhage
    • Airway and Ventilatory Support
    • Circulatory Support
      • From nose or ears after head trauma = loose drsg
      • Control bleeding
        • direct pressure, elevation, pressure points
        • tourniquet
        • packing of large wounds
        • splinting
        • PASG
        • transport to appropriate facility
  • 6. Shock Inadequate peripheral perfusion leading to failure of tissue oxygenation  may lead to anaerobic metabolism
  • 7. Shock
    • Homeostasis
      • cellular state of balance
      • perfusion of cells with oxygen and glucose is one of its cornerstones
      • Transfer of waste materials from the cell to blood for elimination
  • 8. Fick Principle Air’s gotta go in and out. Blood’s gotta go round and round. Any variation of the above is not a good thing!
  • 9. Shock
    • Inadequate oxygenation or perfusion causes:
      • Inadequate cellular oxygenation
      • Shift from aerobic to anaerobic metabolism
  • 10. AEROBIC METABOLISM Glycolysis: Inefficient source of energy production; 2 ATP for every glucose; produces pyruvic acid Oxidative phosphorylation: Each pyruvic acid is converted into 34 ATP 6 O 2 GLUCOSE METABOLISM 6 CO 2 6 H 2 O 36 ATP HEAT (417 kcal)
  • 11. ANAEROBIC METABOLISM Glycolysis: Inefficient source of energy production; 2 ATP for every glucose; produces pyruvic acid GLUCOSE METABOLISM 2 LACTIC ACID 2 ATP HEAT (32 kcal)
  • 12. Anaerobic Metabolism
    • Occurs without oxygen
      • oxydative phosphorylation can’t occur without oxygen
      • glycolysis can occur without oxygen
      • cellular death leads to tissue and organ death
      • can occur even after return of perfusion
        •  organ or organism death
  • 13. Maintaining perfusion requires:
    • Volume = blood
    • Pump = heart
    • Container = Vessels
    • Failure of one or more of these causes shock
  • 14. Shock Classifications
    • Hypovolemic
    • Cardiogenic
    • Vasogenic (Distributive)
    • Neurogenic
  • 15. Shock
    • Hypovolemic Shock = Low Volume
    • A leak in the vessel
      • Trauma
      • Non-traumatic blood loss
        • Vaginal
        • GI
        • GU
      • Burns
      • Diarrhea
      • Vomiting
      • Diuresis
      • Sweating
      • Third space losses
        • Pancreatitis
        • Peritonitis
        • Bowel obstruction
  • 16. Shock
    • Cardiogenic Shock = Pump Failure
    • Pump not working efficiently
      • Acute M I
      • CHF
      • Bradyarrhythmias
      • Tachyarrhythmias
      • Mechanical obstruction (“distributive shock”)
        • Cardiac tamponade
        • Tension pneumothorax
        • Pulmonary embolism
  • 17. Shock
    • Vasogenic Shock = Low Resistance
    • Container got larger or holds more
      • Spinal cord trauma
        • neurogenic shock
      • Depressant drug toxicity
      • Simple fainting
  • 18. Shock
    • Mixed Shock
      • Septic Shock
        • Overwhelming infection
        • Inflammatory response occurs
        • Blood vessels
          • Dilate (loss of resistance)
          • Leak (loss of volume)
  • 19. Shock
    • Mixed Shock
      • Septic Shock
        • Fever
          • Increased O 2 demand
          • Increased anaerobic metabolism
        • Bacterial toxins
          • Impaired tissue metabolism
  • 20. Shock
    • Mixed Shock
      • Anaphylactic Shock
        • Severe allergic reaction
        • Histamine is released
        • Blood vessels
          • Dilate (loss of resistance)
          • Leak (loss of volume)
  • 21. Shock
    • Mixed Shock
      • Anaphylactic Shock
        • Histamine release
        • Extravascular smooth muscle spasm
          • Laryngospasm
          • Bronchospasm
  • 22. Compensated Shock
    • Presentation
      • Restlessness, anxiety
        • Earliest sign of shock
      • Tachycardia
        • ?Bradycardia in cardiogenic, neurogenic
  • 23. Compensated Shock
    • Presentation
      • Normal BP, narrow pulse pressure
      • Falling BP = late sign of shock
      • Mild orthostatic hypotension (15 to 25 mm Hg)
      • “ Possible” delay in capillary refill
  • 24. Compensated Shock
    • Presentation
      • Pale, cool skin
        • Cardiogenic
        • Hypovolemic
      • Flushed skin
        • Anaphylactic
        • Septic
        • Neurogenic
  • 25. Compensated Shock
    • Presentation continued
      • Slight tachypnea
      • Respiratory compensation for metabolic acidosis
  • 26. Compensated Shock
    • Presentation
      • Nausea, vomiting
      • Thirst
      • Decreased body temperature
      • Feels cold
      • Weakness
  • 27. Decompensated Shock
    • Presentation
      • Peripheral effects
        • Relaxation of precapillary sphincters
        • Continued contraction of postcapillary sphincters
        • Peripheral pooling of blood
        • Plasma leakage into interstitial spaces
  • 28. Decompensated Shock
    • Presentation
      • Peripheral effects
        • Continued anaerobic metabolism
        • Continued increase in extracellular potassium
        • Cold, gray, “waxy” skin
  • 29. Decompensated Shock
    • Presentation
      • Listlessness, confusion, apathy, slow speech
      • Tachycardia; weak, thready pulse
      • Decreased blood pressure
      • Moderate to severe orthostatic hypotension
      • Decreased body temperature
      • Tachypnea
  • 30. Irreversible Shock
    • Presentation
      • Confusion, slurred speech, unconscious
      • Slow, irregular, thready pulse
      • Falling BP; diastolic goes to zero
      • Cold, clammy, cyanotic skin
      • Slow, shallow, irregular respirations
      • Dilated, sluggish pupils
      • Severely decreased body temperature
  • 31. Irreversible Shock
    • Irreversible shock leads to:
      • Renal failure
      • Hepatic failure
      • Disseminated intravascular coagulation (DIC)
      • Multiple organ systems failure
      • Adult respiratory distress syndrome (ARDS)
      • Death
  • 32. Shock Classifications
    • Hypovolemic Causes
      • Hemorrhage
      • Plasma
      • Fluid & Electrolytes
      • Endocrine
  • 33. Shock Classifications
    • Cardiogenic Causes
      • Contractility
      • Rate
      • Obstructive (Preload/Afterload)
        • Tension pneumothorax
        • Pericardial tamponade
        • Pulmonary embolism
        • Severe Hypertension
  • 34. Shock Classifications
    • Vasogenic (distributive)
      • Increased venous capacitance
      • low resistance, vasodilation
        • anaphylaxis
        • sepsis
  • 35. Shock Classifications
    • Neurogenic (spinal shock)
      • loss of spinal cord function below site of injury
      • loss of sympathetic tone
        • cutaneous vasodilation
        • relative bradycardia
  • 36. Key Issues In Shock
    • Tissue ischemic sensitivity
      • Heart, brain, lung: 4 to 6 minutes
      • GI tract, liver, kidney: 45 to 60 minutes
      • Muscle, skin: 2 to 3 hours
    Resuscitate Critical Tissues First!
  • 37. Key Issues In Shock
    • Recognize & Treat during compensatory phase
    Best indicator of resuscitation effectiveness = Level of Consciousness Restlessness, anxiety, combativeness = Earliest signs of shock
  • 38. Key Issues In Shock
    • Falling BP = LATE sign of shock
    • BP is NOT same thing as perfusion
    • Pallor, tachycardia, slow capillary refill = Shock, until proven otherwise
  • 39. Key Issues In Shock Isolated head trauma does NOT cause shock (“possible” in peds)
  • 40. General Shock Management
    • Airway
      • Open, Clear, Maintained
      • Consider Intubation
  • 41. General Shock Management
    • High concentration oxygen
      • Oxygen = Most Important Drug in Shock
    • Assist ventilation as needed
      • When in Doubt, Ventilate
        • BVM
    • Decompress Tension Pneumothorax
  • 42. General Shock Management
    • Establish venous access
      • Replace fluid
      • Give drugs, as appropriate
      • Don’t delay definitive therapy
    • Maintain body temperature
      • Cover patient with blanket if needed
      • Avoid cold IV fluids
  • 43. General Shock Management
    • Monitor
      • Mental Status
      • Pulse
      • Respirations
      • Blood Pressure
      • ECG
  • 44. Hypovolemic Shock
    • Control severe external bleeding
    • Elevate lower extremities
    • Avoid Trendelenburg
    • Pneumatic anti-shock garment – if your protocols dictate
  • 45. Hypovolemic Shock
    • Two large bore IV lines
      • Infuse Lactated Ringer’s solution
      • Titrate BP to 90-100 mm Hg
  • 46. Hypovolemic Shock
    • Do NOT delay transport – scoop & run.
    • Start IVs enroute to hospital
    Where does stabilization of critical trauma occur?
  • 47. Cardiogenic Shock
    • Supine, or head and shoulders slightly elevated
    • Do NOT elevate lower extremities
  • 48. Cardiogenic Shock
    • Keep open line, TKO
    • Fluid challenge based on cardiovascular mechanism and history
      • Titrate to BP ~ 90 mm Hg
  • 49. Cardiogenic Shock
    • Obstructive Shock
      • Treat the underlying cause
        • Tension Pneumothorax
        • Pericardial Tamponade
      • Isotonic fluids titrated to BP w/o pulmonary edema
      • Control airway
        • Intubation
  • 50. Shock Management
    • Avoid vasopressors until hypovolemia ruled out, or corrected
  • 51. Vasogenic Shock
    • Consider need to assist ventilations
    • Patient supine; lower extremities elevated
    • Avoid Trendelenburg
  • 52. Vasogenic Shock
    • Infuse isotonic crystalloid
      • “ Top off tank”
    • Consider possible hypovolemia
    • Consider vasopressors
  • 53. Vasogenic Shock
    • Maintain body temperature
    • Hypothermia may occur
  • 54. Vasogenic Shock
    • Anaphylaxis
      • Suppress inflammatory response
        • Antihistamines
        • Corticosteroids
      • Oppose histamine response
        • Epinephrine
          • bronchospasm & vasodilation
      • Replace intravascular fluid
        • Isotonic fluid titrated to BP ~ 90 mm
  • 55. Shock in Children
    • Small blood volume
      • Increased hypovolemia risk
    • Very efficient compensatory mechanisms
      • Failure may cause “sudden” shock
    • Pallor, altered LOC, cool skin = shock UPO
  • 56. Shock in Children
    • Avoid massive fluid infusion
      • Use 20 cc/kg boluses
    • High surface to volume ratio
      • Increased hypothermia risk

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