Prehospital Emergency Care Chapter on Shock and Resuscitation

Prehospital: Emergency Care
Eleventh Edition
Chapter 15
Shock and Resuscitation
Copyright © 2018, 2014, 2010 Pearson Education, Inc. All Rights Reserved

Learning Readiness
• EMS Education Standards, text p. 435.
• Chapter Objectives, text p. 435.
• Key Terms, text p. 436.
• Purpose of lecture presentation versus textbook reading
assignments.

Setting the Stage
• Overview of Lesson Topics
– Shock
– Resuscitation in Cardiac Arrest
– Automated External Defibrillation and
Cardiopulmonary Resuscitation
– Recognizing and Treating Cardiac Arrest
– Special Considerations for the AED

Case Study Introduction (1 of 2)
EMTs Tess Price and Steph Bowman are responding to a
report of chest pain, along with the crew from Engine 9.
Their general impression is of a man in his 50s who is
sitting in a recliner, hand on chest, and in apparent
distress. He is pale and extremely sweaty.

Case Study Introduction (2 of 2)
The EMTs confirm a chief complaint of chest pain, and
continue their assessment as they begin treatment. Tess is
immediately concerned with the weak, rapid radial pulse
and labored respirations.

Case Study (1 of 6)
• What is the significance of the weak, rapid pulse and
labored respirations?
• What could explain the the weak, rapid pulse and labored
respirations?
• What should the EMTs do to manage this patient?

Introduction
• Shock is a state of inadequate perfusion of the cells that
can lead to death.
• The body’s attempts to restore homeostasis result in
many signs and symptoms of shock.
• Resuscitation is the emergency care provided to restore
vital body functions.

Shock (1 of 38)
• Defined as inadequate tissue perfusion or hypoperfusion
• Inadequate amounts of oxygen and glucose are available
to cells to meet metabolic needs
• Inadequate waste product removal

Shock (2 of 38)
• Shift from aerobic to anaerobic metabolism results in
decreased energy production and waste product
accumulation.
• Cellular sodium/potassium pump fails, leading to cell
death.
• Cell death results in organ failure.

Shock (3 of 38)
• Treatment of shock is aimed at restoring perfusion to
provide the cells with glucose and oxygen.

Shock (4 of 38)
• Oxygen delivery to the cells is critical, and requires:
– Breathing in an adequate amount of oxygen
– Diffusion of oxygen from alveoli to pulmonary
capillaries
– Oxygen transport to the cellular level
– Release of oxygen at the cellular level

Shock (5 of 38)
• Etiologies of Shock
– Poor tissue perfusion is caused by one or more of
these problems:
▪ Inadequate volume
▪ Inadequate pump function
▪ Inadequate vessel tone

Shock (6 of 38)
– Inadequate Volume
▪ Decreased blood volume decreases preload
▪ Decreased preload causes stroke volume and
cardiac output to fall
▪ Decreased cardiac output causes a drop in systolic
blood pressure
▪ Decreased systolic blood pressure results in
inadequate tissue perfusion

Shock (7 of 38)
▪ May result from loss of whole blood or plasma
volume
– Bleeding
– Vomiting, diarrhea
– Excessive urination
– Increased capillary leakage

Shock (8 of 38)
▪ Patient requires an increase in blood volume
▪ If red blood cells have been lost, there is a
decrease in oxygen-carrying capacity, as well as a
decrease in pressure and perfusion

Shock (9 of 38)
– Inadequate Pump Function
▪ If the heart fails as a pump, regardless of the blood
volume, the delivery of oxygen and glucose to cells
decreases

Shock (10 of 38)
– Inadequate Pump Function
▪ May occur from myocardial infarction or heart
failure, or mechanical obstruction to blood flow
– Pericardial tamponade
– Tension pneumothorax
▪ Giving fluids may worsen the condition

Shock (11 of 38)
– Inadequate Vessel Tone
▪ Blood pressure is a function of cardiac output and
Systemic Vascular Resistance (SVR)
▪ If SVR decreases from vasodilation, blood
pressure decreases

Etiology of Shock: Vasodilation

Shock (12 of 38)
▪ Massive vasodilation can occur from loss of
sympathetic nervous system function or chemicals
released within the body.
▪ Treatment includes vasoconstriction and volume
restoration.

Shock (13 of 38)
▪ Treatment of shock depends on underlying cause
▪ Consider requesting ALS, but weigh the benefit
against any potential delay in reaching the hospital

Categories and Types of Shock

Shock (14 of 38)
• Categories of Shock
– Hypovolemic shock is caused by low blood volume
▪ Hemorrhage is the most common cause of
hypovolemic shock
▪ Also caused by burns and dehydration

(a) Hemorrhagic Hypovolemia: Loss of Whole
Blood; (b) Nonhemorrhagic Hypovolemia: Loss of
Plasma

Shock (15 of 38)
– Distributive Shock
▪ Caused by vasodilation leading to a relative
reduction in intravascular volume
▪ Can also involve fluid loss from increased capillary
permeability

Shock (16 of 38)
– Cardiogenic Shock
▪ Caused by inability of heart to contract effectively
▪ Generally occurs with loss of 40 percent or greater
of left ventricular volume
▪ Stroke volume and cardiac output are reduced

Heart Attack as a Cause of Cardiogenic
Shock
Damaged heart muscle results in reduced force of contractions,
reduced stroke volume, and reduced cardiac output

Shock (17 of 38)
– Obstructive Shock
▪ Results from a condition that obstructs forward
blood flow
▪ Causes include pulmonary embolism, tension
pneumothorax, and pericardial tamponade
▪ Treat by relieving the obstruction

Causes of Obstructive Shock
(a) pulmonary embolism; (b) tension pneumothorax; (c)
pericardial tamponade

Shock (18 of 38)
– Metabolic or Respiratory Shock
▪ Some sources list metabolic or respiratory shock
as a fifth category
▪ Dysfunction in the ability of oxygen to diffuse into
the blood, be carried by hemoglobin, off-load at the
cell, or be used effectively by the cell for
metabolism

Shock (19 of 38)
• Specific Types of Shock
– Hemorrhagic Hypovolemic Shock
▪ Loss of whole blood from medical or traumatic
causes
▪ Results in decreased perfusion pressure and
decreased oxygen-carrying capacity
▪ Treat by stopping the bleeding and replacing blood
or blood components

Shock (20 of 38)
– Nonhemorrhagic Hypovolemic Shock
▪ Loss of fluid without loss of red blood cells
▪ Can result from vomiting, diarrhea, sweating
▪ Administration of IV fluids can be helpful

Shock (21 of 38)
– Burn Shock
▪ Is a specific form of nonhemorrhagic hypovolemic
shock resulting from a burn injury
▪ Plasma and plasma proteins leak from damaged
capillaries
▪ Loss of fluid and plasma oncotic pressure leads to
edema

Shock (22 of 38)
– Anaphylactic Shock
▪ Chemical substances released in anaphylactic
reaction cause massive systemic vasodilation and
increased capillary permeability
▪ Epinephrine is the medication of choice

Shock (23 of 38)
– Septic Shock
▪ Septic shock is another type of distributive shock
▪ Bacteria and toxins in the blood lead to
vasodilation and increased capillary permeability
▪ Patient can benefit from ALS treatment

Table 15-1 EMS Screening Tools to Identify
Sepsis
Robson
Screening Tool
Sepsis is suspected if two of the following findings are present with a
suspected active infection:
• Temperature >38.3°C (100.9°F ) or <36°C (96.8°F )
• Heart rate >90 bpm
• Respiratory rate >20 breaths/minute
• Acute altered mental status
• BGL <120 milligram/dL
BAS 90-30-90
Scale
Sepsis is suspected if one or more of the following findings are present in a
patient with a suspected active infection:
• Systolic blood pressure <90 millimeterHg
• Respiratory rate >30 breaths/minute
• SpO2 <90%
qSOFA Score Sepsis is suspected if two or more of the following findings are present
in a patient with a suspected active infection:
•Respiratory rate 22 breaths/minute or greater
•Altered mental status (GCS <13)
Systolic BP 100 millimeterHg or less

Shock (24 of 38)
– Neurogenic Shock
▪ Spinal cord injury can cause loss of sympathetic
nerve fiber functions responsible for maintaining
blood vessel tone
▪ Loss of systemic vascular resistance

Shock (25 of 38)
– Cardiogenic Shock
▪ Causes include acute myocardial infarction,
congestive heart failure, abnormal cardiac rhythm,
and overdose on certain drugs
▪ Patients can benefit from ALS interventions

Click on the Term That Best Describes the Type of
Shock That Occurs When There is Massive Systemic
Vasodilation
A. Obstructive
B. Metabolic
C. Distributive
D. Cardiogenic

Shock (26 of 38)
• The Body’s Response to Shock
– The body attempts to compensate to return perfusion
to normal
– Many signs and symptoms of shock are related to
compensatory mechanisms
– Sympathetic nervous system stimulation and the
release of hormones are the two major compensatory
mechanisms

Shock (27 of 38)
– Direct Nerve Stimulation
▪ The effects of sympathetic stimulation are
immediate
– Increase in heart rate
– Increase in force of ventricular contraction
– Vasoconstriction
– Stimulation of the release of epinephrine and
norepinephrine from the adrenal gland

Shock (28 of 38)
– Release of Hormones
▪ The effects of hormones are more sustained
– Epinephrine has alpha and beta effects that
cause vasoconstriction and increased cardiac
output
– Norepinephrine has alpha effects that cause
vasoconstriction
– Other hormones are also released

Table 15-2 Effects of Alpha and Beta
Stimulation
Receptor Stimulatory Effect Sign or Symptom
Alpha 1 Contraction of the muscles controlling the iris Dilated pupils
Contraction of vascular smooth muscle causing
vasoconstriction
Pale, cool skin, narrow pulse
pressure
Stimulation of sweat glands Localized sweating, clammy skin
Beta 1 Increased heart rate Tachycardia
Increased speed of impulse through conduction
system
Tachycardia
Increased force of contraction Pounding heart
Beta 2 Bronchial smooth muscle dilation Decreased resistance in airway
Skeletal muscle contractility Tremors

Table 15-3 Effects of Hormones Released in
Shock (1 of 2)
Hormone Effect on Body Sign or Symptom
Epinephrine Increased heart rate (beta 1) Tachycardia
Increased contractility (beta 1) Pounding heart
Vasoconstriction (alpha 1) Pale, cool skin
Sweat gland stimulation (alpha 1) Clammy skin
Decreased insulin secretion (alpha 2) Increased blood glucose level
Conversion of stored glucose in liver to blood
glucose
Conversion of noncarbohydrates into sugar
Iris muscle contraction (alpha 1) Pupillary dilation
Norepinephrine Vasoconstriction (alpha 1) Pale, cool skin
Sweat gland stimulation (alpha 1) Clammy skin
Increased heart rate (beta 1) Tachycardia

Table 15-3 Effects of Hormones Released in
Shock (2 of 2)
Hormone Effect on Body Sign or Symptom
Antidiuretic Hormone
(Vasopressin)
Increased sodium reabsorption in the
kidneys
Decreased urine output
Vasoconstriction Increased blood pressure
Angiotensin II Vasoconstriction Pale, cool skin
Sodium reabsorption in the kidney Decreased urine output
Aldosterone Sodium reabsorption in the kidney Decreased urine output
Glucagon Conversion of stored glucose in liver to
blood glucose
Increased blood glucose level
Conversion of noncarbohydrates into
sugar
Increased heart rate and contractility Tachycardia

Shock (29 of 38)
• Stages of Shock
– The stages of shock are:
▪ Compensatory
▪ Decompensatory

The Cycle of Hemorrhagic Shock

Shock (30 of 38)
• Stages of Shock
– Compensatory Shock
▪ The body is able to maintain near-normal blood
pressure and perfusion of vital organ
▪ Blood is shunted away from non-vital areas, such
as the skin and gastrointestinal tract
▪ Pulse pressure may be narrowed

Shock (31 of 38)
• Stages of Shock
– Decompensatory Shock
▪ Compensatory mechanisms are overwhelmed
▪ The body can no longer maintain a blood pressure
and perfusion of the vital organs
▪ Anaerobic metabolism is occurring
▪ Vital organs are not perfused

Shock (32 of 38)
• Stages of Shock
– Multiple Organ Dysfunction Syndrome (MODS)
▪ The stage in which multiple organs begin to fail
throughout the body from extreme and prolonged
hypoxia, altered metabolism, and elevated carbon
dioxide and acid levels
▪ Sometimes referred to as irreversible shock

Shock (33 of 38)
• Shock Assessment
– Signs may be subtle or profound, but rapid
recognition of shock is key to treatment
– Consider history findings, physical assessment
findings, signs of perfusion disturbance, and vital
signs
– Do not rely on one finding, sign, or symptom

Shock (34 of 38)
– History
▪ Chief complaint
▪ Sample history
▪ Beta blockers and calcium channel blockers can
alter the response to shock

Shock (35 of 38)
– Physical exam
▪ Vital signs can appear normal in compensatory
shock
▪ Look for signs of poor perfusion

Table 15-5 Physical Assessment Indicators
of Hypovolemic Shock
Vital Signs Signs of Poor Perfusion
Decreasing blood pressure Anxiety, anxiousness that Progresses to a decreased
mental status
Narrowing pulse pressure Pale, cool, clammy skin
Tachycardia Delayed capillary refill
Tachypnea Weak or absent peripheral pulses
Pale, cool, and clammy skin Decreased urine output
Unobtainable or poor SpO2
reading

of Cardiogenic Shock
Decreasing blood pressure Anxiety, anxiousness that progresses to a
decreased mental status
Narrowing pulse pressure Pale, cool, clammy skin; cyanotic or mottled
skin
Tachycardia or bradycardia; may
be irregular
Jugular venous distention and peripheral
edema (right-sided heart failure)
Pale, cool, and clammy skin;
cyanotic or mottled skin
Decreased SpO2 reading Other sign: Crackles or rales upon
auscultation (left-sided heart failure)

of Distributive Shock
Decreasing blood pressure Anxiety, anxiousness that progresses to a decreased
mental status
Tachycardia (anaphylactic and septic shock)
Relative bradycardia or normal heart rate (shock associated with
a spinal cord injury)
Mottled, cyanosis (late—sepsis, anaphylactic and
neurogenic)
Tachypnea with respiratory distress and wheezing (anaphylactic
shock)
Weak or absent peripheral pulses
Tachypnea (septic)
Normal respiratory rate (neurogenic)
Normal to flushed (early sepsis)
Warm, flushed skin (neurogenic)
Warm, flushed skin with hives, possible cyanosis (anaphylactic)
Mottled, cyanosis (late: sepsis, anaphylactic, and neurogenic)
Severely decreased SpO2 reading (anaphylactic) Other signs:
Fever (sepsis)
Loss of motor/sensory function (neurogenic due to
spinal cord injury)
Edema (anaphylactic)

of Obstructive Shock
Decreasing blood pressure
Pulsus paradoxus (tension pneumothorax
and pericardial tamponade)
Anxiety, anxiousness that progresses to a decreased
mental status
Narrowing pulse pressure Pale, cool, clammy skin; cyanotic or mottled skin
Tachycardia Jugular venous distention (pericardial tamponade and
tension pneumothorax)
Pale, cool, and clammy skin; cyanotic or
mottled skin
Decreased SpO2 reading Severely
decreased SpO2 reading
(tension pneumothorax and massive
pulmonary embolism)
Other sign: Severely decreased to absent breath sounds
of one hemithorax (tension pneumothorax)

Shock (36 of 38)
• Age Considerations in Shock
– Age may influence the development, presentation,
management, and recovery from shock.
– Children can compensate well, but deteriorate
quickly.
– Geriatric patients do not compensate well.

Shock (37 of 38)
• General Goals of Prehospital Management of Shock
– Secure and maintain a patent airway.
– Establish and maintain adequate ventilation.
– Establish and maintain adequate oxygenation.
– Do not hyperventilate the shock patient.
– Stop bleeding as quickly as possible.

Shock (38 of 38)
• General Goals of Prehospital Management of Shock
– Splint fractures, don’t delay transport.
– Do not remove an impaled object.
– Maintain the body temperature.
– Keep the patient supine.
– Apply PASG, according to protocol.
– Rapid transport.
– Consider ALS intercept.

Case Study (2 of 6)
Finding that the patient is confused, the EMTs complete a
rapid secondary assessment and obtain a history from the
patient's wife, as the engine crew helps them prepare the
patient for transport.

Case Study (3 of 6)
Tess finds that the patient’s respirations are 28 and
labored, and that he has crackles in his lungs. His heart
rate is 116, with a blood pressure of
92 percent.
100
,
72
and an SpO2 of

Case Study (4 of 6)
• Is this patient in shock? Explain your answer?
• What interventions should the patient be receiving?
• What are the potential consequences of failing to
intervene appropriately or in a timely manner?

Resuscitation in Cardiac Arrest (1 of 12)
• Resuscitation means bringing a patient back from a
potential or apparent death.
• Resuscitation focuses on management of the airway,
ventilation, and oxygenation, and restoring adequate
circulation.

• Cardiac arrest occurs when the ventricles of the heart are
not contracting or cardiac output is ineffective and no
pulses can be felt.
– Brain cells begin to die within four to six minutes
following cardiac arrest.
– Cardiac arrest patients are described as having
suffered sudden death when the patient dies within
one hour of the onset of the signs and symptoms.

• A common cause of cardiac arrest is ventricular
fibrillation.
• Ventricular fibrillation can be treated with defibrillation.

• Pathophysiology of Cardiac Arrest
– The patient goes through three phases of cardiac
arrest that lead to biological death
▪ Electrical phase
▪ Circulatory phase
▪ Metabolic phase

– Electrical Phase
▪ First four minutes.
▪ The heart still has a supply of oxygen and glucose.
▪ Conditions are favorable for resuscitation.
▪ The heart is prepared to respond to defibrillation.

– Circulatory Phase
▪ Four through ten minutes after cardiac arrest.
▪ Oxygen stores are exhausted; myocardial cells
switch to anaerobic metabolism.
▪ CPR is needed to restore a supply of oxygen and
glucose to enhance the possibility of successful
defibrillation.

– Metabolic Phase
▪ Begins ten minutes after cardiac arrest.
▪ The heart muscle is acidic and ischemic, and
begins to die.
▪ Chances of resuscitation are unfavorable.

• Terms Related to Out-of-Hospital Cardiac Arrest (OHCA)
Resuscitation
– Downtime
– Total downtime
– Return of spontaneous circulation (ROSC)
– Survival
– Witnessed cardiac arrest
– Unwitnessed cardiac arrest

• Withholding a Resuscitation Attempt
– Do not resuscitate orders
– Physician orders for life-sustaining treatment
– Medical orders for life-sustaining treatment
– Injuries incompatible with life

• The 2015 AHA Chain of Survival
– Successful resuscitation depends on a sequence of
events
▪ The Chain of Survival is slightly different for
pediatric patients.

– AHA 2015 OHCA Adult Chain of Survival
▪ Immediate recognition and activation.
▪ Immediate high-quality CPR.
▪ Rapid defibrillation.
▪ Basic and advanced emergency medical services.
▪ Advanced life support and post-arrest care.

– AHA 2015 OHCA Pediatric Chain of Survival
▪ Prevention of arrest.
▪ Early high-quality CPR.
▪ Rapid activation of EMS.
▪ Effective advanced life support and rapid transport.
▪ Integrated post-cardiac-arrest care.

Automated External Defibrillation and
CPR (1 of 9)
• Rationale for early defibrillation
– The most frequent initial rhythm in sudden cardiac
arrest is ventricular fibrillation.
– The most effective treatment for ventricular fibrillation
is defibrillation.
– The probability of successful defibrillation decreases
over time.

CPR (2 of 9)
• Rationale for early defibrillation
– Successful defibrillation depends on effective CPR;
interruptions in chest compressions for defibrillation
must be minimized.
– Without intervention, ventricular fibrillation
degenerates into asystole.

CPR (3 of 9)
• “Push hard and push fast” to provide effective chest
compressions in CPR.
– Compressions at a rate of at least 100/minute.
– Compression-to-ventilation ratio of 30:2.
– Minimize interruptions for defibrillation.
– Avoid excess ventilation.

CPR (4 of 9)
• Types of Defibrillators
– Manual defibrillators require extensive training to use.
– Automated defibrillators are simpler to use.

CPR (5 of 9)
– Advantages of AEDs
▪ Speed of operation
▪ Safer, more effective shock delivery
▪ More efficient monitoring

CPR (6 of 9)
– Types of AEDs
▪ Fully automated
▪ Semiautomated
– AEDs may use a monophasic or biphasic waveform

Physio-Control Lifepak® 1000 Defibrillator
(© Physio-Control, Inc.)

Infant/Child Pads for Physiocontrol Lifepak® 1000

CPR (7 of 9)
• Analysis of Cardiac Rhythms
– Ventricular fibrillation
– Ventricular tachycardia
– Asystole
– Pulseless electrical activity

Ventricular Fibrillation is Associated with
Chaotic Electrical Discharge in the Ventricles

Ventricular Tachycardia Originates in the
Conduction System of the Ventricle

Asystole, or “Flatline,” is the Complete
Absence of Electrical Activity in the Heart

CPR (8 of 9)
• Analysis of Cardiac Rhythms
– No one should touch the patient during AED rhythm
analysis or shock delivery
▪ Movement interferes with rhythm analysis.
▪ The electrical energy can be transmitted to anyone
touching the patient.

CPR (9 of 9)
• When and When Not to Use the AED
– AEDs can be used in patients of all ages.
– Manual defibrillation is preferred for those less than
one year of age.
– A dose attenuating system is preferred for use in
children.
– Use adult pads with children greater than eight years
of age.

AED Pads Applied to a Pediatric Patient

AED Pads Applied to an Infant

Recognizing and Treating Cardiac
Arrest (1 of 16)
• Assessment-Based Approach: Cardiac Arrest
– Scene Size-Up and Primary Assessment
▪ If a patient appears unresponsive without signs of
life, quickly check for breathing and carotid pulse.
▪ Assess for no longer than ten seconds.
▪ If the patient is apneic or has agonal respirations,
begin CPR with a C-A-B approach.

Arrest (2 of 16)
– Patients less than one year of age
▪ If heart rate is >60 with inadequate ventilation,
assist or provide ventilations at 12–20 per minute.
▪ If heart rate is <60 or pulse is absent, begin chest
compressions.

Arrest (3 of 16)
– Patients less than one year of age
▪ 30 compressions: two ventilations for one EMT
performing CPR.
▪ 15 compressions: two ventilations for two EMTs
performing CPR.

Arrest (4 of 16)
– Patients one year of age to puberty
▪ 30 compressions: two ventilations for one EMT
performing CPR.
▪ 15 compressions: two ventilations for two EMTs
performing CPR.

Arrest (5 of 16)
– Adolescents with signs of puberty and adults
▪ 30 compressions: two ventilations
▪ Rate of at least 100/minute.
▪ Compression depth of at least two inches
▪ For an obviously pregnant patient, displace the
uterus laterally.

Arrest (6 of 16)
– Secondary Assessment
▪ Attempt to obtain a history from bystanders or
relatives, but do not interrupt chest compressions
or delay defibrillation.

Arrest (7 of 16)
– Emergency medical care
▪ Continue CPR and defibrillation, as indicated.
– Reassessment
▪ Once perfusion is restored, continue
reassessment.
▪ Patients may revert into cardiac arrest.

Arrest (8 of 16)
• Performing Defibrillation
– Using an AED
▪ Ideally, at least two EMTs are present.
▪ Take standard precautions.
▪ Perform a brief primary assessment.
▪ Perform CPR minimizing breaks.
▪ Prepare and apply the AED.
▪ Analyze the rhythm and defibrillate as
recommended by the AED.

EMT Skills 15-1
Using a Semiautomated AED

In the Unresponsive Patient Suspected of Being in
Cardiac Arrest, Quickly Assess for Apnea or Agonal
Ventilations and a Pulse

One EMT Should Immediately Initiate CPR
Beginning with Chest Compressions While the Other
EMT Prepares the AED

Turn on the AED and Follow the Prompts

Apply the Defibrillation Pads While Chest
Compressions are Being Performed - Minimize Any
Interruption in Chest Compressions

Clear the Patient for Rhythm Analysis

Deliver a Defibrillation If Advised

Immediately Resume CPR Beginning with Chest
Compressions Following the Defibrillation

After Two Minutes of CPR, Follow the AED Prompts
to Check Breathing and Pulse in a Non-Shockable
Rhythm

Arrest (9 of 16)
• Performing Defibrillation
– Use of the AED by a Single EMT
▪ Simultaneously verify that the patient is
unresponsive, with no breathing and no pulse.
▪ Call for additional EMS and the AED.
▪ Immediately begin chest compressions and apply
the AED as soon as it is available.
▪ Minimize interruption of compressions.

Arrest (10 of 16)
• Cardiac Arrest in a Pregnant Patient
– A pregnant patient in cardiac arrest who is at 20
weeks of gestation or greater, it is necessary to place
the patient in a supine position and to manually
displace the uterus off the vena cava when doing
chest compressions.

Arrest (11 of 16)
• Transporting the Cardiac Arrest Patient
– After emergency care procedures and operating the
AED, if ALS is not responding to the scene, transport
if:
▪ The patient regains a pulse.
▪ Your protocol indicates transport after a
prescribed number of shocks or no shock
indicated messages.

Arrest (12 of 16)
– Transporting a Patient with a Pulse
▪ Provide oxygen/ventilation as needed.
▪ Have suction ready.
▪ Transfer the patient to the ambulance.
▪ Consider getting ACLS to the patient.
▪ Keep AED attached.
▪ Perform secondary assessment.
▪ Reassess every five minutes.

Arrest (13 of 16)
– Transporting a patient without a pulse
▪ Continue to CPR and defibrillation.
▪ Follow protocol.
▪ Use extreme caution when defibrillating in the
ambulance.
▪ Rendezvous with ALS as early as possible.

Arrest (14 of 16)
• Post-Resuscitation Care
– Indications that ROSC has occurred
▪ A pulse is felt after the AED indicates a no shock
advisory.
▪ Patient regains spontaneous breathing.
▪ The patient begins to move.
– Upon ROSC
▪ Assess the patient’s ventilation.
▪ Avoid potential oxygen toxicity issues.

Arrest (15 of 16)
• Providing for Advanced Cardiac Life Support
– The AHA’s 2015 Chain of Survival advocates for
advanced cardiac life support.
– Minimize the time from the delivery of CPR and
defibrillation to the arrival of ACLS.

Recognizing and Treating Cardiac Arrest (16
of 16)
• Summary: Assessment and Care
– Review assessment findings that may be associated
with cardiac arrest and emergency care for cardiac
arrest.
Assessment Summary
Cardiac Arrest
The following are findings that indicate cardiac arest. These
findings are obtained during the primary assessment:
• Unresponsive
• Apneic (not breathing)
• Pulseless

Emergency Care Protocol: Cardiac Arrest (1 of 3)
1. Take Standard Precautions.
2. Perform a brief primary assesment of the patient. It the patient is
unresponsive, is apneic or has agonal ventilation, has no pulse (checked
simulataneously with ventilation and for no less than 5 seconds but more
than 10 seconds), and no other signs of life, immediately initiate CPR
beginning with chest compressions.
3. Immediately intitate CPR beginning with chest compressions (CAB
intervention sequence). As soon as the AED is available, apply it while
chest compressions are being performed. When the AED is ready to start
the rhythm analysis, stop chest compressions and proceed with AED
protocol.
– If bystanders or first responders are already performing CPR when
you arrive, instruct them to continue while you prepare application of
the AED.

4. Continue with chest compressions while the AED is readled for operation.
5. Turn on power to the AED.
6. Attach the adhesive monitoring-defibrillation pads to the chest while chest
compressions are being performed. Minimize any interruption to chest
compressions.
7. Begin analysis of the patient’s cardiac rhythm.
8. If the AED’s analysis indicates a shock, it provides a “deliver shock”
message. In that case, proceed with defibrillation by depressing the shock
or defibrillation button. If the AED’s analysis determines a nonshockable
rhythm, it gives a “no shock” message. In that case, immediately resume
CPR beginning with chest compressions.
9. After a shock has been delivered, immediately resume CPR beginning
with chest compressions. Perform CPR for approximately 2 minutes.

10. After 2 minutes, the AED reanalyzes the rhythm. If a shock is indicated,
proceed with the defibrillation, then immediately resume CPR beginning
with chest compressions. If the AED gives a prompt to check breathing and
pulse, quickly asses the patient’s breathing and pulse. The AED may
indicate the patient now has a pulse or no longer has a shockable rhythm. If
the patient is unresponsive, apenic or has agonal ventilations, and has no
pulse, immediately resume CPR beginning with chest compressions.
Continue to repeat this sequence. If the patient has a pulse, continue with
ventilation. Continuously reassess the patient.
11. Follow your local protocol regarding when to transport the patient in cardiac
arrest.

Click on the Compression-to-Ventilation Ratio Used
When Two EMTs Are Performing CPR on a Five-
Year-Old Child
A. 30:2
B. 15:2
C. 30:1
D. 15:1

Case Study (5 of 6)
Tess is assisting the patient’s ventilations with a bag-valve-
mask and supplemental oxygen as they begin transport to
the emergency department. Two minutes into the transport,
the patient becomes unresponsive and has agonal
respirations. Steph quickly checks for a carotid pulse, but
cannot detect one.

Case Study (6 of 6)
• What is the sequence of steps that Tess and Steph must
take to maximize the chances of successful
resuscitation?
• What safety concerns are there in carrying out those
steps?

Special Considerations for the AED (1 of 7)
• Safety Considerations
– Clear everyone from patient before delivering a
shock.
– Do not defibrillate a patient who is wet.
– Use caution defibrillating on metal surfaces.
– Remove transdermal medication patches on the
chest.
– Remove excessive chest hair.

• AED maintenance
– Scheduled maintenance is critical.
– Replace batteries on schedule.
– Allow machine to perform self-check at the beginning
of the shift.
– Have extra batteries available.

• Training and Skills Maintenance
– Refresh and maintain skills through continuing
education.
– Incident review.
– Maintain knowledge of protocols.

• Medical Direction and the AED
– AEDs are used under the authority of medical
direction.
– Medical directors play several roles in an AED
program, including ensuring EMTs’ skills and quality
improvement.

• Cardiac pacemakers
– Do not place AED pads directly over the pacemaker.

• Automatic Implanted Cardioverter Defibrillators
– Detect rhythm disturbances and deliver shocks.
– Do not place AED pads over the ICD.
– If the ICD is operating, allow 30 to 60 seconds for it to
complete its cycle before attaching the AED.

• Automated Chest Compression Devices
– Mechanical piston device
– Load-distributing band or vest
– Impedance threshold device

The Autopulse, a Load-Distributing-Band CPR
Device, Compresses the Thorax

Case Study Conclusion (1 of 2)
Signaling the EMT who is driving to pull to the side of the
road, Steph immediately begins chest compressions, as
Tess continues airway management. They perform CPR
with ratio of 30 compressions to two ventilations, as an EMT
from the engine crew attaches the AED.

Case Study Conclusion (2 of 2)
The AED detects a shockable rhythm and, after clearing
the patient, the EMT delivers a shock. Tess immediately
resumes chest compressions as they resume transport.
Two minutes after defibrillation, Steph stops CPR to check
a pulse. The patient has a weak radial pulse. Tess
continues ventilations, as Steph gives an update to the
receiving hospital.

Summary (1 of 2)
• Shock is a critical condition related to a decrease in
vascular volume, poor cardiac function, or vessel
disturbances.
• Shock results in a shift to anaerobic cell metabolism.
• Shock management focuses on airway, ventilation,
oxygenation, circulation, and rapid transport.

Summary (2 of 2)
• The Chain of Survival from cardiac arrest includes:
– Immediate recognition and activation
– Early CPR
– Rapid defibrillation
– Effective ACLS
– Integrated post-cardiac arrest care

Correct! (1 of 2)
When the blood vessels dilate, resulting in inadequate
systemic vascular resistance to maintain perfusion, the
type of shock is classified as distributive. Anaphylactic,
neurogenic, and septic shock are all forms of distributive
shock.
Click here to return to the program.

Incorrect (1 of 5)
Obstructive shock results when forward flow of blood
through the circulatory system is prevented by an
obstruction. Causes include pulmonary embolism, tension
pneumothorax, and pericardial tamponade.
Click here to return to the quiz.

Incorrect (2 of 5)
Metabolic shock occurs when something interferes with on-
loading of oxygen to hemoglobin, off-loading of oxygen
from hemoglobin, or use of oxygen by the cell. Causes
include cyanide poisoning and carbon monoxide poisoning.

Incorrect (3 of 5)
Cardiogenic shock results when the heart fails as a pump
and cannot maintain adequate cardiac output and blood
pressure. Causes include myocardial infarction and heart
failure.

Correct! (2 of 2)
The compression-to-ventilation ratio for a 1- to 8-year-old
child, with two rescuers performing CPR, is 15:2.
Click here to return to the program.

Incorrect (4 of 5)
30:2 is the compression-to-ventilation ratio used when one
rescuer is performing CPR on a one- to eight-year-old
child.

Incorrect (5 of 5)
Neither 15:1 nor 30:1 are compression-to-ventilation ratios
used in CPR.

Copyright

Prehospital Emergency Care Chapter on Shock and Resuscitation

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Prehospital Emergency Care Chapter on Shock and Resuscitation