Recommended
Recommended
More Related Content
What's hot
What's hot (20)
Similar to Lecture presentation amls_lesson04_shock
Similar to Lecture presentation amls_lesson04_shock (20)
Recently uploaded
Recently uploaded (20)
Lecture presentation amls_lesson04_shock
- 2. Introduction Objectives • Recognize and differentiate between the types of shock. • Recognize and differentiate between the stages of shock. • Utilize the AMLS pathway to assess a patient in shock and identify potential diagnoses and management.
- 3. Anatomy and Physiology of Perfusion
- 4. Pathophysiology of Shock • When shock occurs, the body compensates through multiple mechanisms. Increased minute ventilation Increased cardiac output Vasoconstriction
- 5. Pathophysiology of Shock • When compensatory mechanisms become ineffective Adrenal response Pituitary response Renin-angiotensin system activation
- 8. Types of Shock • Hypovolemic shock • Distributive shock • Cardiogenic shock • Obstructive shock
- 9. Case 1 • Dispatch You are dispatched to the home of a 72 year old ill male. The time is 6:00 pm. What are your concerns as you respond to this call? ©Anastasios71/Shutterstock.
- 11. Initial Observations • Scene safety considerations Is the scene safe?
- 12. Initial Observations • You arrive at a residence. Family meets you at the door and tells you the patient is upstairs. • You look into the house and see oxygen tubing in an adjoining room. • What are the scene safety and situation considerations?
- 13. Initial Observations • You find your patient upstairs in bed with his head elevated by pillows. He looks pale, and you note slight tachypnea. Family tells you he is acting differently and did not feel like getting out of bed today. ©fotoinfot/Shutterstock.
- 14. Initial Observations • Cardinal presentation Altered mental status • Chief complaint Does not feel like getting out of bed.
- 15. Initial Observations • Primary Survey LOC— Awake, lethargic Airway— Clear Breathing— shallow, slight tachypnea. Circulation/Perfusion—skin is pale, cool, dry; weak rapid radial pulse
- 16. First Impression • Do you identify any life threats? • Is the patient sick/not sick?
- 17. First Impression • What are your initial differential diagnoses? • Which do you think are most likely? More Likely Less Likely
- 18. Stroke Hypoglycemia Drug or toxic exposure Head trauma Sepsis First Impression Pulmonary emboli AMI Pneumonia
- 19. Detailed Assessment • History Taking OPQRST – Per the family and patient nods occasionally in agreement, but provides little information. • O— Gradual and getting worse for the last 2 days. • P— Nothing really seems to make a difference; he has had a headache on and off, took some acetaminophen with some relief, but the confusion has continued to get worse. • Q— Dull ache. • R— No radiation or other problems. • S— Pain is rated as 1 to 2 on a scale of 1 of 10. • T— A few days and just seems worse today and won’t get out of bed. • Ask patient/family whether this problem is new or different • He is usually up and around. He has had problems when his blood sugar gets low, but this is different.
- 20. • History Taking, continued • SAMPLER • S— Aches, fever, just not feeling well. Tired and a headache. Confusion • A— none • M— ibuprofen, acetaminophen, metformin (Glucophage). • P— Knee replacement last year, diabetes type 2 . • L— Ate some breakfast this morning. • E— Thought he had the flu and has been getting worse. • R— Type 2 diabetes, bed rest, infection. Detailed Assessment
- 21. 120 92% 22 mm Hg 16 92/66 • Secondary survey Vital signs 96°F (35.5°C) ECGfrom:Introductionto12-LeadECG:TheArtofInterpretation, SecondEdition,courtesyofTomasB.Garcia,MD. Detailed Assessment
- 22. Clear lung sounds Abdomen soft, nontender Weak, cool to the touch Weak, healed scar to left knee, damaged and infected toenail on left foot PEARL 4 mm Confused to time and place; GCS 14; Cincinnati Stroke Scale negative
- 23. Detailed Assessment –Diagnostics BLS ALS Critical Care Blood glucose – 115 mg/dL (6.4mmol/L) Cardiac monitoring • Sinus tachycardia at 115-120 • 12-lead ECG, no ST elevation WBC – 13.9, Hemoglobin 14, Hematocrit 43, Prothrombin time, and Partial thromboplastin time within normal limits Lactate 4.2 Cardiac enzymes normal
- 24. • You ask about the oxygen you saw downstairs and find it belongs to his mother who lives with them. The patient is not on oxygen. • You ask about the medications he has taken and find them to be within the prescribed guidelines. • Family denies a previous history of cardiac problems or recent trauma/falls. • He dropped something on his foot last week, but the family thought it had been improving until now. Detailed Assessment
- 25. Refine the Differential Diagnosis Stroke Hypoglycemia Drug or toxic exposure Head trauma Sepsis Pulmonary emboli AMI Pneumonia
- 26. Stages of Shock
- 27. Treatment • Basic life support (BLS) Oxygen Vital signs • Advanced life support (ALS) IV fluids Consider pressors if indicated • Critical care Antibiotic initiation
- 28. Ongoing Management • Reassess the patient. • Further refine the diagnosis. • Modify treatment as necessary. • Transport decision.
- 29. Further Discussion • The patient met sepsis criteria • A high index of suspicion is indicated.
- 31. Case Wrap-Up • Diagnosis: Sepsis due to a foot injury that had not been managed properly • Case Closure: Patient spent 3 days in step down unit and was discharged home with follow-up management for the foot infection.
- 32. Further Discussion • Using the AMLS assessment pathway should enable you to quickly identify life threats that should be managed when found. • Obtaining a thorough history and conducting a physical exam will identify differential diagnoses that will drive your treatment based on your scope of practice. • Early recognition and intervention for sepsis has been shown to improve survival rates.
- 33. Case 2 • Dispatch You are dispatched to the home of a 44-year-old ill female. The time is 5:00 am. It is a cool fall day. What are your concerns as you respond to this call? ©HowardSandler/Shutterstock.
- 35. Initial Observations • Scene safety considerations Is the scene safe?
- 36. Initial Observations • You arrive at a residence. You see a chain for a dog on the front step. No one meets you. The house is quiet and dark with a light in the back, but the door is open. • You call into the house and someone responds from the back of the home – “We’re back here.” • What are the scene safety considerations?
- 37. Initial Observations • You find your patient lying on the floor of the hallway with a bloody towel nearby. She does not respond. She is taking shallow gasping breaths and her skin is pale. • What is the cardinal presentation or chief complaint? ©Jones&BartlettLearning. PhotographedbyLianBruno. ©Saivann/Shutterstock.
- 38. Initial Observations • Cardinal presentation Altered mental status Respiratory distress Possible head injury • Chief complaint Patient is unable to tell you
- 39. Initial Observations • Primary Survey LOC— Unresponsive to pain Airway— Noisy, with blood in the nares and mouth Breathing— Shallow, agonal Circulation/Perfusion—Extremely pale, cool, and dry; weak radial pulse
- 40. First Impression • Do you identify any life threats? • Is the patient sick/not sick?
- 41. First Impression • What are your initial differential diagnoses? Which do you think are most likely? More Likely Less Likely
- 42. First Impression Epistaxis GI bleed Esophageal bleed Shock due to bleeding Head injury Shock Seizure Hypogly- cemia Narcotic overdose
- 43. Stages of Shock
- 44. Detailed Assessment • History Taking OPQRST – Her family provides the following history as you ask. • O— She got up during the night not feeling well and complaining of pain. She vomited and then went back to bed. • P— Rest and her pain pills. • Q— Unknown. • R— None. • S— Unknown. • T— She was found on the floor about 15 minutes ago. Ask patients whether having pain is normal for her or if this pain is new or different.
- 45. • History Taking, continued • SAMPLER • S— Found her on the floor, vomiting last night. • A— None. • M— Interferon injections, pain pills, but family member does not know what it is and offers to try to find it for you. Acetaminophen and aspirin for aches and pain. • P— Multiple sclerosis – she had a flare up a few months ago with some increased weakness, but has not had problems since. • L— Had some small bites of dinner last night. • E— Found her in the hall and called 911 when she would not wake up. • R— Multiple sclerosis, interferon, motor vehicle crash, medications. Detailed Assessment
- 46. 80 46% 34 mm Hg 6 to 8 76/52 • Secondary survey Vital signs 96°F (35.5°C) ECGfrom:Introductionto12-LeadECG:TheArtofInterpretation, SecondEdition,courtesyofTomasB.Garcia,MD. Detailed Assessment
- 47. PEARL 2-3 mm, small laceration to head, dried blood Slow, shallow respirations. Lungs have rhonchi when auscultated No abnormalities Older bruising to hip. Skin cool and dry to touch. Moves extremities slightly to painful stimuli Older bruising to right shoulder. Skin cool and dry to touch. Detailed Assessment
- 48. Detailed Assessment— Diagnostics BLS ALS Critical Care Blood glucose level, 136 mg/dL (7.5 mmol/L) Cardiac monitoring • Sinus Tachycardia at 120 - 130 • 12-lead ECG, no ST elevation FAST – No internal bleeding noted. Liver slightly enlarged. Lab Work - Hemoglobin -10, Hematocrit – 28%, WBC – 7,000, Platelet- 110,000, Liver enzymes slightly elevated
- 49. Detailed Assessment –12-Lead ECG ECG from: 12-Lead ECG: The Art of Interpretation, Second Edition, courtesy of Tomas B. Garcia, MD.
- 50. • You look in the bathroom and find bloody vomit on the stool and floor. • You also find a bottle of ibuprofen and oxycodone (Combunox). The bottle was filled 2 days ago with 32 pills for 7 days. There are 8 pills left in the bottle. • You have made 2 IV attempts and the veins have blown each time. • Your patient vomits large amounts of coffee- colored liquid as you are managing her airway. Detailed Assessment
- 51. Epistaxis GI bleed Esophageal bleed Shock due to bleeding Head injury Shock Seizure Hypoglycemia Narcotic overdose Refine the Differential Diagnosis
- 52. Treatment • Basic Life Support (BLS): Suction oral airway as tolerated, assist ventilations, administer naloxone • Advanced Life Support (ALS): Intubate and ventilate, IV fluids, naloxone • Critical Care: Blood administration
- 53. Ongoing Management • Reassess the patient. Further refine the diagnosis. Modify treatment as necessary. Transport decision.
- 54. Case Wrap-Up • Diagnosis: The patient had a gastrointestinal bleed brought on by pain medications. The condition was complicated by low RBC and platelet counts resulting from interferon therapy and a recent motor vehicle accident. Drug overdose of the pain medications was reversed by the naloxone.
- 55. Case Wrap-Up • Case Closure: The patient was admitted to the ICU and received blood, was treated for aspiration pneumonia, was taken off pain medication, and discharged 5 days later with no negative outcome. She received follow up on the stomach ulcer that had developed and close monitoring of her blood work. She reported taking the additional medications because she was vomiting and thought she had vomited them up, then she couldn’t remember how many she had taken so she took more, which resulted in the overdose.
- 56. Further Discussion • Using the AMLS assessment pathway should enable you to quickly identify life threats that should be managed when found. • Obtaining a thorough history and conducting a physical exam will identify differential diagnoses that will drive your treatment based on your scope of practice. • Failure to recognize the potential for bleeding caused by a narcotic overdose in this case would be detrimental.
Editor's Notes
- Discuss each learning objective and the importance of thoroughly understanding each one.
- The cardiovascular system requires continuous operation of the 3 components in this photo: the heart (or pump), the blood vessels (or container), and the blood and body fluids (or contents). Note to instructor: Ask students the definition of shock or what a shock response indicates. Shock is a progressive state of cellular hypoperfusion in which insufficient oxygen is available to meet tissue demands, which results in inadequate energy production to perform cellular activities. Shock is a mechanism used by the body when the body is stressed and no longer able to compensate or meet the metabolic demands.
- Increased minute ventilation raises arterial oxygen content. The body boosts cardiac output by elevating the pulse rate, increasing cardiac contractility, or both. Construction of vessels improves perfusion pressure in the tissues.
- Compensatory mechanisms are effective only up to a point. Once that critical threshold has been reached, hypoxia develops, and shock takes over the body.
- Shock can be categorized into four types: hypovolemic, distributive, cardiogenic, and obstructive, depending on which portion of the cardiovascular system fails. It is important for you to try to determine the causes and cardinal signs quickly because the patient may need a life-threatening intervention immediately. Instructor note: Refer students to Table 4-9, page 156, to review the types of shock and their causes.
- Case 1 involves an older man who is ill. Instructor note: For students other than prehospital practitioners, dispatch information can be modified for setting other than prehospital care.
- Review the steps of the AMLS assessment pathway. Assessment is a dynamic process that occurs simultaneously. The key is to slow the provider down and move through each of these steps so as not to miss an important piece of information needed to develop a differential diagnosis.
- Initial impression begins when the dispatch information is received. When you arrive on scene, assess for safety threats and situational clues. You’ll be able to determine how well your initial impression agrees with your initial observations. Follow standard precautions. Use personal protective equipment to shield yourself from exposure to body fluids. At the scene, providers must ask themselves the following: Are the scene and crew safe? How many patients are involved? Do you have enough resources? Do you have the right resources? Is there any need for special personal protective equipment (PPE)? What is your general impression?
- Providers should address that the scene is safe, but additional assistance and special equipment such as a stair chair may be needed. The presence of oxygen indicates the possibility of a chronic pulmonary or cardiac condition may be present. Students may verbalize other comments as well.
- Ask the students what they would consider as the cardinal presentation or chief complaint. An altered mental status should be a concern and a change in behavior.
- Instructor note: Differentiating cardinal presentation from chief complaint is important. The cardinal presentation is the patient’s medical problem − altered mental status. The chief complaint is what the patient complains of − does not feel like getting out of bed. For some patients, the cardinal presentation and chief complaint might be the same.
- The patient is awake and oriented. Airway—His airway is patent. Breathing—Note his breathing is shallow. Circulation/Perfusion—His radial pulses are weak and rapid.
- The patient has no life threats. His airway and circulation are intact. He is sick and needs immediate evaluation due to an altered mental status.
- Instructor note: Ask the students to generate a list of possible problems. Discuss from the list of differentials for shortness of breath how you would categorize the different causes from more likely to less likely. Students may have lists that do match and/or lists that are shorter. Here are diagnoses to consider. Ask students to provide a rationale for each diagnosis that is shared. Stroke – due to age and change in behavior. Hypoglycemia – due to change in mental status. Drug or toxic exposure – due to change in mental status. Head trauma – due to change in mental status. Pneumonia – due to change in respiratory rate. Pulmonary emboli – due bedrest – and increase in respiratory rate and tachycardia. Acute myocardial infarction (AMI) – due to age – possible silent MI. Sepsis – tachycardia and change in mental status.
- Instructor note: Students may debate how the conditions are categorized. Categories are not absolute and depend on the severity of the patient, which is not presented here. Keep an open mind with a broad differential at this initial stage. Take this opportunity to list all of the potential causes of the chief complaint/cardinal presentation. Later in the case you can narrow it down to a smaller number of causes that should still be of concern either due to their seriousness or their likelihood. Possible diagnoses include: Pulmonary emboli – potentially life threatening. AMI – potentially life threatening. Stroke – critical. Hypoglycemia – critical. Drug or toxic exposure – critical. Head trauma – critical. Sepsis – critical. Pneumonia – noncritical.
- Review history taking using the OPQRST mnemonic. Consider discussing additional diagnoses such as diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic nonketonic coma (HHNC), and electrolyte imbalances.
- Review history taking using SAMPLER. Once again ask for additional diagnoses—hyperglycemia or hypoglycemia, meningitis.
- Instructor note: Ask the students what their concerns are regarding these vital signs and the actions they would continue to take or take if not initiated. Students should indicate that the HR and BP are representative of shock. The elevated HR, low BP, and capnography are suggestive of sepsis since he has a history of a flu. The sats are low, suggesting the need for oxygen administration. Having seen the oxygen tubing downstairs, students should question whether the patient uses oxygen regularly… you will find the answer is no – the oxygen is for his mother who lives with them. Students should indicate continued treatment and packaging for transport is essential. You may elect to address interventions such as these now or later under treatment. Students should assist ventilations with oxygen. Initiate IV fluids and consider rapid transport. Respirations—16 breaths/min Pulse—118 beats/min Blood pressure—92/66 mm Hg Pulse oximetry—92% CO2—22 mm Hg Temperature—96°F (35.5°C)
- HEENT: Head: Unremarkable Eyes: PEARL 4 mm Ears: Unremarkable Nose: Unremarkable Throat: Unremarkable Heart and Lungs: Clear lung sounds Neuro: Confused to time and place; GCS 14; Cincinnati Stroke Scale negative Abdomen and Pelvis: Soft, nontender Upper and Lower Extremities: Weak, cool to touch, healed scar to left knee, damaged and infected toenail on left foot. Ask the students if any of the findings help rule out or confirm the diagnoses listed and any others that may have been identified. COPD – less likely no history of lung problems CHF – less likely, no cardiac history and lung problems isolated to right side. Asthma – less likely due to no history Pneumonia – Likely due to lung sounds on right side, fever and cough Pulmonary Emboli – less likely, but possible due to bedrest and low sats, lung involvement on one side. AMI – possible due to Type II diabetes risk factors, 12 lead indicated Sepsis – possible due to fever, BP, infection history and low ETCO2 Flu – possible due to history of respiratory infection and fever Pleurisy – possible due to cough and pneumonia
- Instructor note: Discuss how these diagnostics support the differentials. Blood glucose level is slightly elevated – possibly due to stress response. Normal ECG and cardiac enzymes tend to rule against a silent myocardial infarction. Elevated WBC and lactate tend to suggest sepsis.
- Ask if this changes or confirms their diagnoses? It would eliminate the head trauma, and drug overdose. The diabetic history and injury to the foot are suggestive of sepsis as well. Does it alter their plan of care? – They should focus on fluid administration and contacting the ED with possible sepsis. A pulmonary emboli may still be considered, but sepsis is more likely.
- Instructor note: Discuss where students would place him now. Use the “pen” in PowerPoint to make comments or circle the potential differential. Discuss each differential and either rule it in or out. Stroke – less likely due to Cincinnati stroke scale negative Hypoglycemia – not a problem – normal to slightly elevated blood sugar. Drug or toxic exposure – not likely due to lack of history Head trauma – not likely as family denies a fall, but patient a poor historian at this time. Pulmonary Emboli – possible due bedrest – and increase in respiratory rate and tachycardia AMI – due to age – possible silent MI – not likely due to negative ECG and labs. Sepsis – most likely due to infection history, elevated lactate and WBC and tachycardia and change in mental status Others may be presented by students – ask for rationale for each diagnosis that is shared.
- Discuss the signs and symptoms and which stage of shock he is in. Instructor note: Refer students to page 146 in the textbook.
- The patient should be treated for sepsis due to the injury to his foot. Improve oxygenation – administer oxygen to improve the sats. IV fluids to address hypotension and possible sepsis. Notify ED of possible sepsis patient and initiate sepsis protocol and bundles.
- Instructor note: Discuss with students the treatment options based on scope of practice and local protocols. Treatment should be directed at improving oxygenation, ventilation, and initiating antibiotic treatment and possible sepsis protocol.
- Instructor note: Discuss sepsis criteria with students and show the table in the next slide.
- This table is important in helping students determine whether sepsis should be considered in patients.
- Sepsis Sepsis is a precursor to septic shock. Several changes in health care have contributed to a recent rise in the incidence of sepsis. More patients are remaining at home and have medical devices inserted, making the patients prone to infection. Many of these patients also have compromised immune systems, putting them at even greater risk for sepsis.
- Review the points listed above.
- Case 2 involves an older female who feels ill. Instructor note: For students other than prehospital practitioners, dispatch information can be modified for settings other than prehospital care.
- Review the steps of the AMLS Assessment pathway. Assessment is a dynamic process that occurs simultaneously. The key is to slow the provider down and move through each of these steps so as not to miss an important piece of information needed to develop a differential diagnosis.
- Initial impression begins when the dispatch information is received. When you arrive on scene, assess for safety threats and situational clues. You’ll be able to determine how well your initial impression agrees with your initial observations. Follow standard precautions. Use personal protective equipment to shield yourself from exposure to body fluids. At the scene, providers must ask themselves the following: Are the scene and crew safe? How many patients are involved? Do you have enough resources? Do you have the right resources? Is there any need for special PPE? What is your general impression?
- Instructor note: Discuss with students the possibility of a dog being present and ensuring the dog is secured. Additional discussion points may include the absence of anyone to greet them. Is the patient alone? Is there any evidence of toxic exposure such as carbon monoxide poisoning because it is fall and furnace use may be starting, domestic violence, or any other hazards the class would like to include. You may want to discuss how students would address the issues. For example, asking if the dog is secure or checking the carbon monoxide detectors. Identify if others in the home are ill.
- Ask the group what they would consider as the cardinal presentation or chief complaint. An altered mental status is a concern, respiratory disorder, and a possible head injury should be on the list to start.
- Instructor note: Differentiating cardinal presentation from chief complaint is important. The cardinal presentation is the patient’s medical problem – altered mental status, respiratory disorder, possible head injury. The chief complaint is what the patient complains of – the patient is unable to give you a chief complaint. For some, the cardinal presentation and chief complaint might be the same.
- The altered level of consciousness (LOC) could be an early indicator of respiratory problems. Airway—Her airway is noisy, with blood in the nares and mouth. Breathing—Note her breathing is inadequate and needs to be managed. Circulation/Perfusion—Her skin is pale, cool, and dry; she has a weak radial pulse.
- The patient has life threats – She has airway and ventilation problems. She needs immediate suctioning and airway management. She requires placement of an oral airway or nasal airway and initiation of ventilation. Advanced airway management is a consideration as well.
- Discuss from the list of differentials for breathing problems and bleeding how you would categorize the different causes. Instructor note: Students may have lists that do match and/or lists that are shorter. The patient could have the following problems. Epistaxis (severe) GI Bleed Esophageal bleed Shock due to bleeding Stroke Seizure Hypoglycemia Head injury
- Instructor note: Students may debate how the conditions are categorized. Categories are not absolute and depend on the severity of the patient, which is not presented here. Keep an open mind with a broad differential at this initial stage. Take this opportunity to list all of the potential causes of the chief complaint/cardinal presentation. Later in the case you can narrow it down to a smaller number of causes that should still be of concern either due to their seriousness or their likelihood. Possible diagnoses include: Epistaxis (severe) – due to blood in the airway and nose – life threat. GI Bleed – due to blood in airway and nose – life threat. Esophageal bleed – due to blood in airway and nose – life threat. Shock due to bleeding – due to the presence of blood, and unresponsiveness – life threat. Stroke – unconscious – critical. Seizure – unconscious – critical. Hypoglycemia – unconscious – critical. Narcotic overdose—pain pills prescribed to patient. Head injury – due to head would and unconsciousness – life threat.
- Discuss the signs and symptoms and which stage of shock the patient is in.
- Review history taking using the OPQRST mnemonic. The patient is often uncomfortable, but the pain in her hip and shoulder is new and due to a car accident she was in a few days ago. Her car was struck from the side. The pain pills are for the hip and shoulder pain. The abdominal pain was new as of last evening. Discuss additional diagnoses such as a head injury, drug overdose, or internal bleeding from car accident.
- Review history taking using SAMPLER. Instructor note: Once again ask for additional diagnoses. Interferon can lead to stress on the liver, bleeding problems – due to low platelets and red cells, low white blood cell count, flu like symptoms. Therefore sepsis and hemorrhage are possible. Consider a pain medication overdose.
- Instructor note: Ask students what the vital signs tell about the patient. Students should indicate that the HR and BP are representative of shock. The slow respirations may be indicative of a head injury, stroke, or drug overdose, or late shock. The low temp indicates later shock stages and may be present in hypodynamic sepsis or cold sepsis. It may be indicative of her lying on the ground for an extended period of time and be environmental as well. Respirations—6 to 8 breaths/min Pulse—128 beats/min Blood pressure—76/52 mm Hg Pulse oximetry—46% CO2— mm Hg Temperature—96°F (35.5°C) Students should indicate continued treatment and packaging for transport is essential. You may elect to address interventions such as these now or later under treatment. Students should assist ventilations with oxygen, consider an airway and possible intubation at the advanced level. Initiate warmed IV fluids and consider rapid transport.
- HEENT: Head: Small laceration to the right side of the forehead Eyes: PEARL 2-3 mm and sluggish Ears: Unremarkable Nose: Old dried blood Throat: Old dried blood around mouth, brownish liquid in the mouth when suctioned – old blood smell on breath Heart and Lungs: Slow, shallow respirations. Lungs have rhonchi when auscultated during ventilation assistance. Respirations are too shallow to hear sounds when the patient is breathing on her own. Neuro: Moves extremities slightly to painful stimuli. Abdomen and Pelvis: No abnormalities Upper and Lower Extremities: Older bruising to right shoulder and hip. Skin cool and dry to touch.
- Instructor note: Discuss how these diagnostics support the differentials.
- 12-lead ECG showing sinus tachycardia.
- Instructor note: Ask students if this changes or confirms their diagnoses. Treatment should reconfirm bleeding and shock and the possibility of gastrointestinal bleeding. Does this information alter the plan of care? Students should consider naloxone at this time. They should consider intramuscular or subcutaneous naloxone; intranasal administration will not work because of the blood in her nose. Continue suctioning – consider IO administration at this time.
- Instructor note: Discuss where students would place him now. Use the “pen” in PowerPoint to make comments or circle the potential differential. Discuss each differential and either rule it in or out. Epistaxis (severe) – due to blood in the airway and nose – may still be a problem. GI Bleed – due to blood in airway and nose – may still be a problem. Esophageal bleed – due to blood in airway and nose – may still be a problem. Shock due to bleeding – due to the presence of blood, and unresponsiveness – may be due to previous trauma and the GI bleed. Stroke – unconscious – possible, but more emphasis on bleeding and shock at this time. Seizure – unconscious – possible – questioning for a history of seizures may help with this diagnosis, but emphasis should be on bleeding and shock. Hypoglycemia – unconscious – possible, a blood sugar should be evaluated, but not as likely without the history of diabetes – ruled out. Head injury – due to head would and unconsciousness – possible due to recent motor vehicle crash, but the focus should be on restoring oxygenation and circulatory status and then re-evaluate. Drug overdose – due to small pupils and slow irregular respiratory rate – likely due to missing medications and the narcotic component of the pain medications. Sepsis – is a possibility due to the temperature and medication use compromising the immune system, but no signs of infection identified.
- The patient needs to be treated for GI bleeding from a drug overdose. Manage the airway – suction, consider advanced airway Assist ventilations with oxygen to improve the sats IV fluids to address hypovolemia and hypotension Blood administration Naloxone – IV or subcutanously Evaluate for sepsis
- Instructor note: Discuss with participants their treatment options based on scope of practice and local protocols. Treatment should be directed at improving oxygenation and ventilation and treatment for drug overdose.
- Bleeding and Shock Late shock can trigger an overstimulation of the clotting cascade in which clotting and bleeding begin to occur simultaneously. Over time clotting factors that are normally present are rapidly exhausted and the person has a high risk of bleeding.
- It is especially important to determine the type of narcotic, the quantity ingested, the time of ingestion, and whether any other toxins were co-ingested.
- Review the points listed above.