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Avoiding the Train Wreckof SHOCK
Kay Kamish, RN, BSN, EMT-PTulsa Life Flight
OBJECTIVES
‡ Define the four types of SHOCK‡ Understand the difference in etiologies‡ Recognize the progression of symptoms‡ Understand the difference in approach to
treatments
Train Wreck of SHOCK
SHOCK
• Think of the Engine as the Heart…. The Tracks as the blood vessels The cars as the RBC’s…. The Freight as the Oxygen and nutrients….
SHOCK
Inadequate tissue perfusion
Inability of the body to keep up
with the tissue demand for oxygen
and nutrients.
Train Wreck of SHOCK
Train Wreck of Shock
* FOCUS of INTERVENTION:
* Identify the type of Shock
* Initiate the proper care
SHOCK
TYPES of SHOCK
› Hypovolemic
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› Cardiogenic
› Distributive
› Obstructive
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HYPOVOLIEMIC SHOCK
* Hemorrhage
* Vomiting
* Diarrhea
* Third Spacing
* Diuresis
SHOCK -- Hypovolemic
• Low volume -- poor carrying capacity of the cells -- not enough ‘freight’
CARDIOGENIC SHOCK
Occurs when damaged or unhealthy heart
muscle is no longer able to pump effectively
= Heart Failure* Myocardial Infarction
Train Wreck of SHOCK
* Cardiac Arrest
* Dysrhythmias
* Cardiomyopathies
SHOCK -- Cardiogenic
• Heart Failure -- an old and tired Engine
SHOCK -- Cardiogenic
• Cardiogenic Shock - the heart (engine) no longer functions effectively
DISTRIBUTIVE SHOCK
NEUROGENIC Loss of normal sympathetic vasoconstriction
* spinal cord injury
* severe pain
* vasomotor center depression d/t drug OD
Train Wreck of SHOCK
DISTRIBUTIVE SHOCK
Train Wreck of SHOCK
VASOGENIC Diminished arterial resistance and increased venous capacitance
* Due to a release of vasodilating substance from
the body itself
* Anaphylactic Shock
* Septic Shock
SHOCK -- Distributive
• Vasodilation -- too many tracks/ blood vessels to fill
OBSTRUCTIVE SHOCK
Train Wreck of SHOCK
* Arterial Stenosis
* Pulmonary Embolism
* Pulmonary Hypertension
* Cardiac Tamponade
* Tension Pneumothorax
Train Wreck of SHOCK
Review: Four Types of SHOCK
HYPOVOLEMIC Volume Loss
CARDIOGENIC Heart Failure
DISTRIBUTIVEVasodilation
OBSTRUCTIVE
SHOCK
• You have the engine (the heart) but no cars (volume) and too many tracks to fill up (excess venous capacitance).
Train Wreck of Shock
STAGES of SHOCK
* Whatever the type of shock, the signs and
symptoms are the result of diminished blood flow* Symptoms follow a predictable path
YOUR GOAL: Identify the type of shock and intervene at the earliest
stage possible
STAGES of SHOCK
Train Wreck of Shock
Early Stage
Pathophysiology
> Decrease in MAP
> Results in reduced or uneven
microcirculatory blood flow
and decreased O2 delivery
to cells
Clinical Signs
> Usually there are
few at this point
STAGES of SHOCK
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Early Stage
Pathophysiology
Compensatory mechanisms can restore MAP to reasonable levels.
Clinical Signs
Therefore: There are few clinical signs
AND: No disruption of
vital organ function
STAGES of SHOCK
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** Important Point **
>> VITAL ORGAN FUNCTION <<
* Must think about this!
* Can’t see it.
* Never encounter it because it happens later in the
course of patient’s care and recovery.
STAGES of SHOCK - EARLY
Train Wreck of Shock
\\ Significant to Note: //
* Few obvious clinical signs are seen in Early Stage* The body has compensated to restore and maintain
MAP, so blood pressure appears normal How ?
Peripheral constriction
Usually supine on a backboard
STAGES of SHOCK - EARLY
Train Wreck of Shock
Clinical Signs
* Increased heart rate
* Restlessness, anxiety
sense of impending doom
Cellular Level * Decrease in Oxygen availability
* Shift from aerobic to anaerobic
metabolism
* Lactic acid is waste by-product
STAGES of SHOCK - Compensatory
Train Wreck of Shock
Compensatory Stage
Pathophysiology
* Anaerobic metabolism has now progressed long enough to trigger the Sympathetic NS
* Acidosis becomes worse
Clinical Signs
* MAP continues to drop
> Now drops 10 -15 mmHg
*Compensatory Mechanisms are put in motion> Heart rate increases
> Respirations increase
STAGES of SHOCK - Compensatory
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Cardiac Output
CO = Heart rate X Stroke volume
Normal CO = 4 to 6 Liters/ minute
Normal SV = 60 to 100 cc
Normal HR = 60 to 100 bpm
STAGES of SHOCK - Compensatory
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Cardiac Output Increases
WHY ?
To perfuse Vital Organs :
heart, lungs, brain, kidneys
STAGES of SHOCK - Compensatory
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Pathophysiology
> Renal & Chemical Compensation
> Renal vasoconstriction
decreased perfusion
stimulates release of:
* ADH
* Aldosterone
* Catecholamines
Clinical Signs
> Decreased urinary output
> Skin cool, clammy, mottled> Pupils dilated
> Decreased bowel sounds
> Hyperglycemia
WHY?
STAGES of SHOCK - Compensatory
Train Wreck of Shock
Hyperglycemia
* Liver is breaking down glycogen
to increase the availability of glucose
for more energy
* Therefore: if you do a finger stick, your
Dextrostix may be elevated
STAGES of SHOCK -Compensatory
Train Wreck of Shock
Pathophysiology
* Decrease of blood to the pulmonary
system
* Leads to poorer oxygenation of
all organ systems
Clinical Signs
* Restlessness
* Mental confusion* Agitation
* Lethargy
STAGES of SHOCK - Compensatory
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** IMPORTANT FACT **
At this stage, EMS interventions can at least slow, or even halt, the
progression of shock and allow the patient to escape permanent
damage !
Recognition of Signs and Symptoms of this stage of shock is imperative !
STAGES of SHOCK
Train Wreck of Shock
If shock is allowed to proceed to this stage the patient’s condition
will deteriorate rapidly
\\ ** THIS IS A LIFE THREATENING STAGE **//
PROGRESSIVE
SHOCK
• Progressive Shock -- if condition is unchecked, patient will deteriorate rapidly!
STAGES of SHOCK - Progressive
Train Wreck of Shock
Pathophysiology
> Sustained drop in MAP
(more than 20mmHg below baseline) > Vital organs develop hypoxia
> Less vital organs become anoxic & ischemic
leads to cell damage
which leads to cell death
Clinical Signs
> Pulse may be too
rapid to count or
thready & weak > Pulmonary
crackles
& wheezes> Or, may develop
atelectasis or absent BS
> AVPU declines
STAGES of SHOCK - Progressive
Train Wreck of Shock
* Patients cannot tolerate this state for long
before there is permanent damage to organs
* Patients with a cardiac history (CAD) are at
significantly increased risk for cardiac arrest Why?
>> Think about what is happening at a cellular level <<
* Life can be preserved IF interventions are initiated
within an hour after onset of this stage
IF NOT . . . .
STAGES of SHOCK - Refractory
Train Wreck of Shock
By this stage the body has sustained too much cell damage and death to survive. Even if the underlying cause of shock has
been discovered and steps taken to correct it, the patient will remain unresponsive to therapeutic interventions.
MOF (Multiple Organ Failure) then leads to the patient’s demise.
SHOCK -- Refractory
• Refractory Shock -- patient will remain unresponsive to resuscitation
SHOCK -- Refractory
• Refractory Shock -- No hope of recovery
Train Wreck of Shock
What can we, in EMS, in the pre-hospital setting, do to help avoid this disaster?
SHOCK
SHOCK
ABC’s
Thorough and accurate assessment Determine what type of shock you are dealing with, so as to be sure your approach to treatment is appropriate.
Train Wreck of Shock
Don’t jump to a conclusion and then be unwilling to alter your approach as
needed!
SHOCK - Approaches to Treatment
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Hypovolemic Shock
GOAL :
Restore Fluid Volume
SHOCK - Treatment
Train Wreck of Shock
Hypovolemic
Fluid Choices:
Crystaloids
Normal Saline
Lactated RingersSodium
Chloride
Potassium
Calcium
Lactate
SHOCK - Treatment
Train Wreck of Shock
Hypovolemic
Fluid Choices: CrystaloidsAvoid D5W, especially in head injuries ! WHY ?
D5W easily shifts out of intravascular space and
into the tissue, where it does little good.
This is especially true in the brain, where this would
cause elevation of intercranial pressure ( ICP )
SHOCK - Treatment
Train Wreck of Shock
Hypovolemic
Fluid Choices: Colloids Protein Containing
Tend to stay in the vascular system “Volume Expanders”
* PRBCs
* Plasma
* Serum albumin
* Dextran
* Hespan
SHOCK - Treatment
Train Wreck of Shock
Hypovolemic
What if the patient does not respond to fluids ?
Reassess !
May need medications to:
promote venous return
enhance contractility
improve myocardial perfusion
Epinephrine Norepinephrine (Levophed)
SHOCK - Treatment
Train Wreck of Shock
Cardiogenic
Remember this is a failure in the strength of the heart - volume is not necessarily the
problem
GOAL: Improve myocardial function
SHOCK - Treatment
Train Wreck of Shock
Cardiogenic
More difficult to manage in the field
Support cardiac function
Patient tends to be hypotensive but administer fluids cautiously so as not to overload the heart in an already compromised state
SHOCK - Treatment
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Common Sense IV, O2, Monitor
Transport supine
Raise legs if necessary
Cardiogenic
SHOCK - Treatment
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Cardiogenic
Medications if Available :
Dopamine --
Dobutamine --
Levophed --
Low range (‘renal dose’) increases urinary outputMid range stimulates receptors
High range stimulates receptors
Direct stimulator
Potent inotropic agent; predominantly - adrenergic
SHOCK - Treatment
Train Wreck of Shock
Distributive
Remember ~
this is due to the loss of sympathetic
tone, resulting in pooling of blood in
venous and capillary beds.
SHOCK - Treatment
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Distributive
Septic Shock
Most common form of Distributive Shock 40 % Mortality Rate
Seen in body’s inflammatory response to overwhelming systemic infection
Produces profound hypotension
SHOCK - Treatment
DistributiveTrain Wreck of Shock
Septic Shock
Provide aggressive fluid resuscitation
What will you do if blood pressure continues to drop ?
Vasopressors
Inotropic drugs
SHOCK - Treatment
DistributiveTrain Wreck of Shock
Neurogenic Shock
Typically the result of head injury or spinal cord injury
Initial Symptoms:
Hypotension
Bradycardia
Hypothermia
Warm, dry skin
What symptoms are
present here that are
opposite to other forms of
shock ?
SHOCK - Treatment
DistributiveTrain Wreck of Shock
Neurogenic Shock
Treatment is aimed at the cause of cardiovascular instability
Eg: Bradycardia Atropine
Hypotension Vasopressors
Not a volume problem in this case
SHOCK - Treatment
DistributiveTrain Wreck of Shock
Anaphylactic Shock
Hypersensitivity to an environmental exposure
Food
Venom
Medications
SHOCK - TreatmentDistributive
Train Wreck of Shock
Anaphylactic Shock
Causes large release of histamine and other vasoactive substances This in turn causes :
massive vasodilation increased capillary permeability profound hypovolemia vascular collapse arrhythmias decreased cardiac contractility
SHOCK - TreatmentDistributive
Train Wreck of Shock
Anaphylactic Shock Assess ABC’s -- *Airway is often compromised*
Counteract the anaphylactic reaction
Remove the offending stimulus, if possible
Fluid resuscitation
Subcutaneous Epinephrine
Antihistamines (Benadryl)
Corticosteroids
Vasopressors
SHOCK - Treatment
Obstructive Shock
Train Wreck of Shock
Figure out what is being obstructed
and why
SHOCK - Treatment
Train Wreck of Shock
Obstructive Shock
What is obstructed?
Airway?? (As if no oxygen is loading onto the train) Tension Pneumothorax
Circulation?? (Something is hampering the engine.)
Cardiac Tamponade
SHOCK - Treatment
Train Wreck of Shock
Obstructive Shock
** Treatment is emergent in both cases **
Needle decompression
Pericardiocentesis
SHOCK - Summary
Train Wreck of Shock
TYPES of SHOCK
HYPOVOLEMICCARDIOGENIC
DISTRIBUTIVE
OBSTRUCTIVE
SHOCK - Summary
Train Wreck of Shock
STAGES OF SHOCK
EARLY
COMPENSATORY
PROGRESSIVE
REFRACTORY
SHOCK - Summary
Train Wreck of Shock
Types Causes
Hypovolemic* hemorrhage* vomiting and diarrhea
Cardiogenic * heart failure
Distributive* septic* neurogenic* anaphylactic
Obstructive * tension pneumothorax* cardiac tamponade
SHOCK - Summary
Type Cause Treatment
Hypovolemic * hemorrhage * vomiting/diarrhea
* restore fluid volume* Improve cardiac function* Epinephrine, Levophed
Cardiogenic * heart failure * Support cardiac function* Dopamine, Dobutrex
Distributive* septic* neurogenic* anaphylactic
* fluid resuscitation* Vasopressors* Inotropes* Antihistmines
Obstructive * tension pneumothorax* cardiac tamponade
* Relieve obstruction
Train Wreck of Shock
SHOCK
• SHOCK -- Hopefully does not need to end in disaster
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