Shock

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

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Shock

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

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