Chapter 40 Management and Resuscitation of the Critical Patient

Chapter 40Chapter 40

Management and Resuscitation of the Critical Patient

National EMS Education Standard CompetenciesNational EMS Education Standard Competencies

Shock and Resuscitation

Integrates a comprehensive knowledge of the causes and pathophysiology into the management of shock, respiratory failure or arrest with an emphasis on early intervention to prevent arrest.

IntroductionIntroduction

• When working with a critical patient:− Conduct a rapid assessment

− Provide life saving treatment

− Develop a differential field diagnosis.

IntroductionIntroduction

• If a patient is in critical condition, you must be well prepared to: − Make the right decision

− Use time appropriately

− Provide care

Developing Critical Thinking and Decision-Making AbilitiesDeveloping Critical Thinking

and Decision-Making Abilities

• Excellent decision making comes with experience.− Acquired through training and internships

− State and national certification/registration/ licensure follows.

Critical PatientsCritical Patients

• While caring for critical patients you will come across:− Premorbid

conditions

− Major trauma

− Patients in the periarrest period

Critical PatientsCritical Patients

• Many adult patients have preexisting conditions putting them in the critical patient category.

© Mark C. Ide

The EMS Approach to Diagnosis


• Follow a standard approach when determining a field diagnosis.



• To consider differential diagnosis for an altered mental status, use:− M-T SHIP

• For chest pain, consider:− Ischemic chest pain

− GI system causes

− Musculoskeletal problems

− Respiratory causes

− Panic attack

− Shingles

− Cancer in the chest

The Role of Intuition in Critical Decision Making


• Intuition: pattern recognition and matching based on previous experience− Can be used to “up-triage” the patient

− Don’t make decisions based on intuition that draws on incorrect experiences.



• Karl Weick’s process for communicating intuitive decisions:− Here is what I think we are dealing with.

− Here is what I think we should do.

− Here is why.

− Here is what we should keep our eyes on.

− Are there any other concerns?

Bias to Decision MakingBias to Decision Making

• Confrontation bias: tendency to gather and rely on information that confirms your views

• Anchoring bias: allowing an initial reference point to distort your estimates

A Snapshot of Critical Decision Making


• You have been dispatched to the home of a 62-year-old woman with chest pressure.− Accompanied by nausea and tingling in right

arm

− She is put on oxygen, vital signs are obtained.

− You give her four baby aspirin to chew.

− You go through the OPQRST mnemonic.



• She is tachycardic and slightly hypertensive.− A12-lead ECG is obtained and transmitted to a

hospital with a coronary catheterization lab.• The patient has ST-segment elevations in three

contiguous leads (II, III, AVF).



• When the patient is lifted from the couch, she passes out.− ECG changes to ventricular fibrillation.

− You begin chest compressions.

− An oropharyngeal airway is inserted.

− A shock at 200 joules is delivered.



• You make sure personnel perform specific tasks at the right time.− After a third shock, there is rhythm but no pulse.

• CPR continues.

• An antidysrhythmic is administered.



• You consider causes of cardiac arrest.

• After the fourth shock, the patient wakes up.

• Once en route, you update the ED.− The patient is admitted directly to the

catheterization lab.

Shock: The Critical Patient Evolving in Front of You

Shock: The Critical Patient Evolving in Front of You

• Shock: state of collapse and failure of the cardiovascular system − Leads to insufficient perfusion of organs/tissues

− Normal compensatory mechanism

− Untreated shock will lead to death.

Anatomy and Physiology of Perfusion


• Perfusion: circulation of blood in adequate amounts to meet the cells’ needs− Requires working cardiovascular system

− Requires adequate gas exchange, glucose, and waste removal



• Cardiovascular system requires three components:− Functioning pump

− Adequate fluid

− Intact system of tubing



• The heart’s contractility allows it to increase or decrease the volume of blood pumped − Cardiac output (CO): volume of blood that the

heart can pump per minutes• Heart must have adequate strength.

• Heart must receive adequate blood.



• Blood pressure is generated by: − Contractions of the heart

− Dilation and constrictions of blood vessels

• Blood pressure varies directly with cardiac output, systemic vascular resistance, and blood volume.



• Cardiac output = Heart rate × Stroke volume

• Blood pressure = Cardiac output × systemic vascular resistance

• Mean arterial pressure: blood pressure.− MAP = DBP + 1/3 (SBP – DBP)



• The body is perfused via the cardiovascular system.− Controlled by the autonomic nervous system



Respiration and OxygenationRespiration and Oxygenation

• Alveoli receive oxygen-rich air from breath.

• Oxygen and carbon dioxide pass across tissue layers through diffusion.− Molecules move from area of higher

concentration to area of lower concentration

Respiration and OxygenationRespiration and Oxygenation

• Carbon dioxide is dissolved in plasma and attaches to the blood’s hemoglobin.− Combines with water to create carbonic acid.

• Breaks down at the lungs and carbon dioxide is exhaled.

Regulation of Blood FlowRegulation of Blood Flow

• Blood flow through capillary beds is regulated by the capillary sphincters.− Under control of the autonomic nervous system

− Regulation is determined by cellular need.

Pathophysiology of ShockPathophysiology of Shock

• Shock results from: − Inadequate CO

− Decreased SVR

− Inability of RBCs to deliver oxygen

• The body shunts blood flow to vital organs.


• The cardiovascular system consists of the “perfusion triangle.”− Shock means one

part is not working properly.


• Blood carries oxygen and nutrients through vessels to the capillary beds to tissue cells.

• Blood clots control blood loss.− Form depending on:

• Retention of blood because of blockage

• Changes in a vessel wall

• Blood’s ability to clot


• When pressure is failing, neural and hormonal mechanisms are triggered.− Epinephrine and norepinephrine causes

changes in pulse rate, cardiac contractions, and vasoconstriction.

− Body fluids shift to maintain pressure.

Compensation for Decreased Perfusion


• The body responds to any event that leads to decreased profusion.− Baroreceptors activate vasomotor center to

begin constriction of the vessels.

− Chemoreceptors measure shifts in carbon dioxide in the arterial blood



• Stimulation normally occurs when the systolic pressure is between 60–80 mm Hg.− Drop in pressure causes baroreceptor

stimulation to decrease.

− Sympathetic nervous system is stimulated.

− The renin-angiotensin-aldosterone system is activated and antidiuretic hormone is released.



• The overall response is to increase preload, stroke volume, and pulse rate.

• Myocardial oxygen demand increases if hypoperfusion persists.− Cells switch to anaerobic metabolism.



• The release of epinephrine and norepinephrine improves cardiac output.



• Failure to preserve perfusion leads to decreases in preload and cardiac output.− Myocardial blood supply decreases.

− Coronary artery perfusion decreases.

− Liver and pancreas functions are impacted.

− Gastrointestinal motility is decreased.

− Urine production decreases.

Shock-Related Events at the Capillary and Microcirculatory Levels


• Decreased perfusion leads to cellular ischemia.− The body can tolerate anaerobic metabolism for

only a short time.• Leads to systemic acidosis

• Ischemia stimulates increased carbon dioxide.



• Sodium-potassium pump normally sends sodium back out against the concentration gradient.− Reduced ATP results in dysfunctional pump

• Excessive sodium diffuses into the cells.



• Intracellular enzymes are usually bound in an impermeable membrane.− Cellular flooding explodes the membrane.

• Leads to last phase of shock

• Decreases venous return and diminishes blood flow.



• Reduced blood supply results in slowing of sympathetic nervous system activity.

• The buildup of lactic acid and carbon dioxide acts as a potent vasodilators.− Accumulation washes into the venous

circulation



• White blood cells and blood clotting systems are impaired.− May lead to:

• Decreased resistance to infection

• Disseminated intravascular coagulation (DIC)

Multiple-Organ Dysfunction Syndrome


• Progressive condition characterized by failure of two or more organs that were initially unharmed − Each tissue has its own warm ischemic time.

− Patients have a mortality rate of 60-90%

− Classified as primary or secondary



• Occurs when injury or infection triggers a massive systemic response.− Results in the release of inflammatory

mediators and activation of the:• Complement system

• Coagulation system

• Kallikren-kinnin system



• Overactivity results in a maldistribution of systemic and organ blood flow.− Body accelerates tissue metabolism.

− Progression causes organs to malfunction.



• Typically develops within hours or days after resuscitation.

• Affects specific organs and organ systems:− Heart

− Lungs

− Central nervous system

− Kidneys

− Liver

− GI tract

Causes of ShockCauses of Shock

• Normal tissue perfusion requires an intact heart, fluid volume, and tubing.− Damage to any one disrupts tissue perfusion.

− Shock results from many conditions.

− Have a high index of suspicion in emergency medical situations.

Causes of ShockCauses of Shock

• Three basic causes of shock:− Pump failure

− Low fluid volume

− Poor vessel function

• Certain patients are more at risk.

The Progression of ShockThe Progression of Shock

• Shock occurs in three phases: compensated, decompensated, and irreversible.− Also called four grades of hemorrhage or four

classes of shock• Class I and II = compensated shock

• Class III = decompensated shock

• Class IV = irreversible shock

The Progression of ShockThe Progression of Shock

• Recognize signs and symptoms early on.

• Begin immediate treatment before damage occurs.

Compensated ShockCompensated Shock

• Earliest stage of shock − The body can still compensate for blood loss.

• Level of responsiveness is the best indication of tissue perfusion.

• Blood pressure is maintained.

Decompensated ShockDecompensated Shock

• Blood volume drops more than 30%

• Compensatory mechanisms begin to fail− Signs and symptoms become obvious.

• Sometimes treatment will result in recovery.

Decompensated ShockDecompensated Shock

• Once blood pressure drop is detected, shock is well developed.− Consider an emergency and start transport in

less than 10 minutes.

Irreversible (Terminal) ShockIrreversible (Terminal) Shock

• Last phase of shock

• Life-threatening reductions in cardiac output, blood pressure, tissue perfusion− Cells begin to die and vital organ damage

cannot be repaired.

Scene Size-UpScene Size-Up

• Size up the scene for hazards.

• Follow standard precautions.

• Determine the number of patients and the need for additional resources.

• Quickly assess the MOI or nature of illness.

Primary AssessmentPrimary Assessment

• Form a general impression− How does the patient look?

− Assess mental status using AVPU

− Introduce yourself and ask their name, location and day of the week.


• Airway and breathing− If you suspect cardiac arrest, use CAB

approach.• Otherwise, asses the ABCs.

− Manage immediate threats.

− If difficulty breathing, examine the chest.

− Assess the adequacy of the patient’s ventilation.


• Circulation− Take CAB approach if you suspect the patient

does not have a pulse.• In patients with a pulse, determine if it is adequate.

− In conscious patients, assess the radial pulse.• In unconscious patients, check the carotid pulse.


• Circulation (cont’d)− If you know the patient is hypotensive, provide

immediate transport to the ED.

− Also note the patient’s skin color, temperature, and condition.


• Transport decision− All patients need to be prioritized

• If shock is from a medical problem, fast-track to an assessment based on body systems.

• If shock is from trauma, let the MOI guide your assessment.

History TakingHistory Taking

• Can be done en route to the ED in a high-priority patient− Unless patient is pinned, and you suspect a

delay in extrication, delay establishing IV/IO access.

Secondary AssessmentSecondary Assessment

• Drop in systolic blood pressure or altered mental status indicates the body can no longer compensate.− Other indicators include

end-tidal carbon dioxide and lactic acid buildup.• Portable lactate

monitors can be used.

Courtesy of EKF Diagnostics www.ekfdiagnostics.com

ReassessmentReassessment

• Re-visit the primary assessment, vital signs, chief complaint, and treatment performed.

• Determine what interventions are needed.− Patients in decompensated shock will need

rapid intervention.

Special Considerations for Assessing Shock

Special Considerations for Assessing Shock

• Healthy, fit, young adults are equipped to combat life-threatening blood loss.− Resilient cardiovascular system

− Not smoking increases oxygenation

Pediatric ConsiderationsPediatric Considerations

• Pediatric patients can compensate until a 30–35% blood loss.

• Treat aggressively and early with significant MOI or indication of shock.− Never wait to see a drop in blood pressure.

Geriatric ConsiderationsGeriatric Considerations

• Ability to manage blood loss is diminished

• Manage fluid therapy carefully.

• Cardiovascular disorders or diabetes affect ability to compensate.

• Medications may prevent clot formations.

Emergency Medical Care of a Patient With Suspected ShockEmergency Medical Care of a Patient With Suspected Shock

• Airway and ventilatory support take priority when treating a patient with shock.− Maintain an open airway and suction as

needed.

− Administer high-flow supplemental oxygen.


• IV therapy can be helpful in supplementing initial therapies.− Administer IV volume expanders.

− Maintain perfusion without increasing internal or uncontrollable external hemorrhage.


• If signs of tension pneumothorax, perform the needle chest decompression.

• With suspected cardiac tamponade, recognize the need for pericardiocentesis.


• Nonpharmacologic interventions include:− Proper positioning of the patient

− Prevention of hypothermia

− Rapid transport

IV TherapyIV Therapy

• IV lines are inserted to provide:− Immediate replacement of fluids

− Potential replacement

− Administration of medication

• All patients in (or who are likely to develop) hypovolemic shock need fluid replacement.

IV TherapyIV Therapy

• IV lines should be inserted to keep a vein open for emergency administration of drugs.− Patients who need a vein kept open include:

• Those at risk of cardiac arrest

• Those needing parenteral medication

• IV flow rate is determined by local protocol.

Volume Expanders and Plasma Substitutes


• Hypovolemic shock should be treated with volume expanders.

• A variety of solutions have properties similar to those of plasma.− Used to maintain circulatory volume



• Plasma substitutes and volume expanders include:− Dextran

− Plasma protein fraction (Plasmanate)

− Polygeline, hetastarch, and other starch solutions

CrystalloidsCrystalloids

• Solutions that do not contain proteins or other large molecules

• Rapidly equilibrates into tissues

• Fluids of choice when only salt and water have been lost

CrystalloidsCrystalloids

• Commonly used crystalloids are: − Normal saline

− Lactated Ringer’s solution

• Most ALS protocols limit the number of liters administered to the patient.

Pathophysiology, Assessment, and Management of Specific Types of Shock


• Three classifications of shock: cardiogenic, distributive, hypovolemic− Cardiogenic shock results from a weakening

pumping action of the heart.

− Distributive shock is broken down into:• Septic shock

• Neurogenic shock



• Other conditions decrease tissue perfusion:− Conditions that obstruct the flow of oxygen into

the bloodstream and tissue• Leads to obstructive shock

• Nonhemorrhagic causes of hypovolemic shock are grouped by how they reduce perfusion.



• Initial management of shock:− Manage the airway.

− Administer supplemental oxygen.

− Put the patient in a position of comfort.

− Obtain vital signs and IV access.

− Maintain body heat.

Cardiogenic ShockCardiogenic Shock

• Occurs when the heart cannot circulate sufficient blood to maintain adequate peripheral oxygen delivery

• Most commonly caused by an AMI accompanied by dysfunction of left ventricle


• Manifests with poor contractility, decreased cardiac output, impaired ventricular filling

• Populations at the greatest risk include: − Elderly

− Patients with a history of diabetes mellitus

− Patients with a history of AMI with an ejection fraction of less than 35%


• Prolonged efforts to stabilize the patient is not recommended.− Expedite transport as quickly as possible.

− Secure the airway and administer oxygen.

− Obtain a 12-lead ECG.

− Administer crystalloid solution.

− Auscultate the lungs.


• Some EMS systems use dopamine at low doses if the patient has a MAP of less than 60 mm Hg.

• Combination drug therapy is often needed at the hospital.

Obstructive ShockObstructive Shock

• Causes are not directly associated with loss of fluid, pump failure, or vessel dilation.

• Occurs when blood flow in the heart or great vessels becomes blocked


• Tension pneumothorax− Caused by damage to the lung tissue

− Air accumulates within the chest cavity and applies pressure to the mediastinum.• Life-threatening condition


• Cardiac tamponade− Caused by blunt or penetrating trauma, tumors,

or pericarditis

− Occurs when blood leaks into the pericardium• Leads to compression of the heart


• Cardiac tamponade (cont’d)− The ultimate treatment is pericardiocentesis.

− Signs include:• Muffled heart sounds

• Systolic and diastolic blood pressure merging

Distributive ShockDistributive Shock

• Occurs when there is widespread dilation of the resistance vessels, the capacitance vessels, or both− Circulating blood volume pools in vascular

beds.


• Septic shock− Occurs from a widespread infection

• Usually caused by gram-negative bacterial organisms

• Activates inflammatory-immune response

• An uncontrolled response results in hypoperfusion.


• Septic shock (cont’d)− Septic shock is complex.

• Insufficient volume of fluid in the container

• Fluid leaks out and collects in respiratory system.

• Larger-than-normal vascular bed must contain the smaller-than-normal volume of fluid.


• Septic shock (cont’d)− Presents similarly to hemorrhagic shock

• But patients usually have warm or hot skin.

− Treatment requires complex hospital management.• Transport as quickly as possible.


• Septic shock (cont’d)− Give normotensive patients dopamine.

− Give norepinephrine for “warm” shock.

− Give epinephrine for “cold” shock.


• Neurogenic shock− Usually results from spinal cord injury

− Results in loss of normal sympathetic nervous system tone and vasodilation

− Muscles in blood vessels are cut off from nerve impulses that cause them to contract.


• Neurogenic shock (cont’d)− Spinal shock: occurs after a spinal injury

produces motor and sensory losses• Characterized by flaccid paralysis, flaccid

sphincters, and absent reflexes

• Level of injury is related to severity of shock.


• Neurogenic shock (cont’d)− Care is similar to general management.

• The patient should also be immobilized.

− Determine the necessity for IV fluids.

− With pure neurogenic shock, vagal blockers and vasopressor agents may be used.


• Anaphylactic shock− Occurs when a person reacts violently to a

substance to which he or she has been sensitized

− Patient experiences widespread vascular dilation. • While the container is larger, the blood volume is

less.


• Anaphylactic shock (cont’d)− Fluid leaks out of

the blood vessels and into interstitial space, resulting in:• Hypovolemia

• Significant swelling© SPL/Photo Researchers, Inc.


• Anaphylactic shock (cont’d)− Management needs to occur quickly.

• Remove the inciting cause and resolve life threats.

• Evaluate the patient’s ventilatory status.

• Provide cardiovascular support.

• Administer epinephrine or vasopressor.


• Psychogenic shock− Sudden reaction of the nervous system that

produces a temporary vascular dilation, resulting in syncope

− Life-threatening causes include:• Irregular heartbeat

• Brain aneurysm


• Psychogenic shock (cont’d)− If the patient has fallen, check for injuries.

− Assess the patient for any other abnormality.

− Record your initial observations.

− Obtain an ECG.

Hypovolemic ShockHypovolemic Shock

• Occurs because of inadequate blood volume

• Hemorrhagic and nonhemorrhagic causes− Nonhemorrhagic hypovolemic shock occurs

when the fluid loss is contained within the body.

− Early signs are restlessness and anxiety.


• Physical exam reveals: − Poor skin turgor

− Shrunken tongue

− Sunken eyes

− Weak, rapid pulse

• Symptoms of dehydration:− Loss of appetite

− Nausea

− Vomiting

− Fainting when standing up


• Give a dehydrated patient an IV infusion of normal saline or lactated Ringer’s solution.

• Establish and maintain an open airway.

• Do not administer anything orally.

• If patient vomits, administer an antiemetic.


• Monitor patient’s:− ECG rhythm

− Mental status

− Pulse rate

− Blood pressure

− SpO2

− ETCO2

• The goal is to save the brain, lungs, and kidneys.− Rely on state of

consciousness to tell you how well the vital organs are being perfused.

Respiratory InsufficiencyRespiratory Insufficiency

• The inability to breathe in adequate amounts of oxygen affects the ventilation process.

• Insufficient amounts of oxygen in the blood can produce shock.− Some poisoning may affect the ability of cells to

metabolize or carry oxygen.


• An abnormally low amount of RBCs causes anemia.− Tissues may become hypoxic.

− Pulse oximeter may still indicate adequate saturation.• Hypoxemic hypoxia


• When treating a patient in shock from poor respiration, you must:− Seal the hole and stabilize impaled objects.

− Secure and maintain the airway.

− Assess SpO2, ETCO2, and vital signs.

− Determine need for assisted ventilations.

− Determine most appropriate destination.

Transportation of Shock Patients


• Ask yourself when, where, and how.

• Limit scene time to 10 minutes or less.

• Know how to access aeromedical transportation.



• Consider the priority of the patient and availability of a regional trauma center.− Transport to a facility with appropriate

capabilities.• If not available, medical control will help make the

transport decision.

Prevention StrategiesPrevention Strategies

• Prevention begins with your assessment of the MOI, findings, and the clinical picture.− Be alert and search for early signs of shock.

− Don’t rationalize irregularities.

SummarySummary

• Develop expertise in quickly developing a differential field diagnosis of patients found in periarrest condition or period.

• Work with an experienced paramedic to develop skills in intuition and become comfortable in making critical decisions.

SummarySummary

• Hypoperfusion occurs when the level of tissue perfusion decreases below normal. Shock refers to a state of failure of the cardiovascular system.

• The body is perfused via the cardiovascular system.

• Tissue perfusion requires a pump (heart), fluid volume (blood and body fluids), and tubing capable of reflex adjustments (constriction and dilation).

SummarySummary

• Shock occurs in three successive phases (compensated, decompensated, and irreversible). This is also referred to as the four grades of hemorrhage or four classes of shock.

• Airway and ventilatory support are top priority when treating a patient with shock.

• If a patient is in shock, transport is inevitable.

SummarySummary

• Don’t wait for blood pressure to drop.

• Nonhemorrhagic causes of hypovolemic shock are grouped by how they reduce perfusion.

• Prevention of shock and its effects begins with your assessment of the MOI, primary assessment findings, and the patient’s clinical picture.

CreditsCredits

• Chapter opener: © Mark C. Ide

• Backgrounds: Blue—Jones & Bartlett Learning. Courtesy of MIEMSS; Red—© Margo Harrison/ShutterStock, Inc.; Purple—Courtesy of Rhonda Beck; Lime—© Photodisc

• Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.

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Chapter 40 Management and Resuscitation of the Critical Patient