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Prehospital Trauma Life Support. Lesson. Shock & Fluid Resuscitation. 6. Developed by the National Association of Emergency Medical Technicians. In cooperation with The Committee on Trauma, American College of Surgeons. - PowerPoint PPT Presentation
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66 Shock & Fluid Resuscitation
Shock & Fluid Resuscitation
LessonLesson
Prehospital Trauma Life Support Prehospital Trauma Life Support
Developed by the
National Association ofEmergency Medical Technicians
Developed by the
National Association ofEmergency Medical Technicians
In cooperation withThe Committee on Trauma,American College of Surgeons
In cooperation withThe Committee on Trauma,American College of Surgeons
This slide presentation is intended for use onlyin approved PHTLS courses.
This slide presentation is intended for use onlyin approved PHTLS courses. 6-1B6-1B
Lesson 6 ObjectivesLesson 6 Objectives
Correlate perfusion, hypoperfusion, hypoxia, hypovolemia and hypotension to the signs and symptoms of shock.
Differentiate between early and late signs of shock.
Describe the pathophysiological changes of shock.
Identify the management of shock, including conservation of heat, fluid replacement and the pneumatic anti-shock garment.
Correlate perfusion, hypoperfusion, hypoxia, hypovolemia and hypotension to the signs and symptoms of shock.
Differentiate between early and late signs of shock.
Describe the pathophysiological changes of shock.
Identify the management of shock, including conservation of heat, fluid replacement and the pneumatic anti-shock garment.
6-26-2
Shock:Shock:
6-36-3
A rude unhinging of A rude unhinging of
the machinery of the machinery of
life.life.Samuel Gross, Samuel Gross, 18521852
Shock Redefined:Shock Redefined:
6-46-4
Pitfall: Defining shock as decreased blood pressure.
Lack of end-tissue perfusion.Lack of end-tissue perfusion.
ScenarioScenario
You are caring for the sole victim of a
motorcycle crash. He is lying on the
ground next to his motorcycle. The
scene appears safe.
6-56-5
Findings Findings
A - Open, clear.
B - RR fast. BS clear. Bruising noted over sternum; no other chest deformity.
C - Radial pulse weak & rapid.
D - PEARL. Anxious & confused. Normal movement & sensation.
E - No deformity noted. Skin cool & diaphoretic.
A - Open, clear.
B - RR fast. BS clear. Bruising noted over sternum; no other chest deformity.
C - Radial pulse weak & rapid.
D - PEARL. Anxious & confused. Normal movement & sensation.
E - No deformity noted. Skin cool & diaphoretic.
6-66-6
Is this patient in shock?
Why?
What is the patient’s real problem?
Is this patient in shock?
Why?
What is the patient’s real problem?
DiscussionDiscussion
6-76-7
Cell Perfusion Cell Perfusion
6-86-8
Aerobic metabolism requires adequate oxygenation.
Cells require oxygen and sugar to produce energy and carbon dioxide.
Aerobic metabolism requires adequate oxygenation.
Cells require oxygen and sugar to produce energy and carbon dioxide.
Is the patient in this Is the patient in this scenario adequately scenario adequately perfusing his cells?perfusing his cells?
Anaerobic Metabolism Anaerobic Metabolism
6-96-9
Inadequate oxygenation Inadequate oxygenation for metabolism.for metabolism.
By-products: Less energy.
More acid.
Potassium.
By-products: Less energy.
More acid.
Potassium.
Leads to Acidosis• Inadequate oxygen delivery, cellular
extraction, and consumption result in cellular conversion to anaerobic metabolism for energy substrate production (ATP production)
• Increased production and release of lactate
Shock
Tissue injury
Organ dysfunction syndrome
Multiple organ failure
Death
Definition – Decreased utilization of oxygen by the tissues
If prolonged - downward spiral
Cellular DeathCellular Death
6-106-10
SHOCKCellular Hypoxia - Anaerobic
Metabolism
Hypotension
Hypoperfusion
Cellular Hypoxia
Anaerobic Metabolism
Cell DeathIf cellular death is not If cellular death is not prevented, organism prevented, organism death will follow.death will follow.
Staged DeathStaged Death
Organism death: May be quick - prior to EMS.
May be prolonged - 2 to 3 weeks later.
Occurs in stages: Stages occur as the body tries to
compensate.
We see the stages through signs & symptoms.
Organism death: May be quick - prior to EMS.
May be prolonged - 2 to 3 weeks later.
Occurs in stages: Stages occur as the body tries to
compensate.
We see the stages through signs & symptoms.
6-116-11
What Organs Fail?Combination of respiratory failure
(ARDS) with renal failure, metabolic failure, or cardiac failure– Poor prognosis
Mortality rate– One organ/systems 40%– Two organ/systems 60%– Four or more 100%
Recognize shock early.
Restore cellular perfusion.
Restore aerobic metabolism.
Recognize shock early.
Restore cellular perfusion.
Restore aerobic metabolism.
Prevent Cellular DeathPrevent Cellular Death
6-126-12
Pitfall: Waiting until it is too late to restore perfusion to cells.
3 Phases of Shock
Compensatory
Progressive
Irreversible
Early RecognitionEarly Recognition
6-136-13
Signs & Symptoms of Uncompensated Shock
Description Compensated Decompensated
Pulse
Skin
BP
LOC
Tachycardia
White, cool, and moist
Normal range
Unaltered
Marked tachycardia; can progress to bradycardia
White, “waxy,” cold, marked diaphoresis
Lowered
Altered, ranging from disoriented coma
What are the earliest signs of shock?
What is a late sign of shock?
What are the earliest signs of shock?
What is a late sign of shock?
Early vs. LateEarly vs. Late
6-146-14
Maintain chemical balance.
Maintain fluid balance.
Maintain chemical balance.
Maintain fluid balance.
Restore Cellular PerfusionRestore Cellular Perfusion
6-156-15
Chemical BalanceChemical Balance
Decrease in oxygen. Detected by chemical receptors in the carotid
arteries and in the arch of the aorta. Respirations increase in rate & depth.
Rise in acidity. Buffer system converts acid to CO2 & water.
Medulla senses increased CO2.
Respirations increase; lungs “blow off” CO2.
Decrease in oxygen. Detected by chemical receptors in the carotid
arteries and in the arch of the aorta. Respirations increase in rate & depth.
Rise in acidity. Buffer system converts acid to CO2 & water.
Medulla senses increased CO2.
Respirations increase; lungs “blow off” CO2.
6-166-16
continued...continued...
Common Shock Pathways
MechanismsMechanisms Oxygen deficiency Cellular hypoxia Ischemia Anoxia
Compensation ↑ Catecholamines
↑ HR, contractility Vasoconstriction of
both arterial and venous beds–↑ oxygen delivery
↑ Cellular extraction of oxygen
Chemical BalanceChemical Balance
Key: increase in respiratory rate is an early sign of shock.
What signs or symptoms indicate that the patient’s body is trying to restore its chemical balance?
What steps could you take to help the body restore balance and aerobic metabolism?
Key: increase in respiratory rate is an early sign of shock.
What signs or symptoms indicate that the patient’s body is trying to restore its chemical balance?
What steps could you take to help the body restore balance and aerobic metabolism?
6-176-17
cont’d.
Fluid DecreaseFluid Decrease
6-186-18
Fluid volume decreases
Baroreceptors note change
Epinephrine and norepinephrine released
Vasoconstriction Increased rate & strength of cardiac
contractions
Fluid DecreaseFluid Decrease
Hormonal response: Various hormones are released,
causing vasoconstriction and fluid retention.
Compensation: Blood vessels constrict. Heart increases strength & rate. Fluid is retained.
Hormonal response: Various hormones are released,
causing vasoconstriction and fluid retention.
Compensation: Blood vessels constrict. Heart increases strength & rate. Fluid is retained.
6-196-19
continued...continued...
In the scenario, which signs suggest that the patient’s body is trying to restore its fluid balance?
Is the patient compensating well? Why?
What steps could you take to help the body restore balance?
In the scenario, which signs suggest that the patient’s body is trying to restore its fluid balance?
Is the patient compensating well? Why?
What steps could you take to help the body restore balance?
6-206-20
cont’d.Fluid DecreaseFluid Decrease
Defines what is necessary to achieve end-tissue perfusion: On-loading oxygen to the RBCs. Delivering the RBCs to the tissue. Off-loading oxygen to the tissue.
As part of the process, patient must have an adequate number of RBCs to transport oxygen.
Defines what is necessary to achieve end-tissue perfusion: On-loading oxygen to the RBCs. Delivering the RBCs to the tissue. Off-loading oxygen to the tissue.
As part of the process, patient must have an adequate number of RBCs to transport oxygen.
The Fick PrincipleThe Fick Principle
6-216-21
ScenarioScenario
You are responding to a patient that has
fallen from a 40-foot cliff while rock climbing.
He is awake. He tells you that he can’t move
his legs, and has no feeling below his waist.
Pulse 119, RR 20, and BP 104/72.
6-226-22
How does the Fick Principle apply here?How does the Fick Principle apply here?
How well is this patient compensating?How well is this patient compensating?
ScenarioScenario
You are called to the scene of a house fire,
where firefighters have just removed one
patient. He is unresponsive. Pulse 102, RR
6, and BP 104/76.
6-236-23
How does the Fick Principle apply here?How does the Fick Principle apply here?
How well is this patient compensating?How well is this patient compensating?
ScenarioScenario
You respond to a scene where a skier has
struck a tree at high speed. Exam reveals pain
on palpation of the right lateral chest, absent
breath sounds on the right and labored
breathing. Pulse 142, RR 40, and BP 88/70.
6-246-24
How does the Fick Principle apply here?How does the Fick Principle apply here?
How well is this patient compensating?How well is this patient compensating?
ScenarioScenario
You are dispatched to an MVC. On arrival, you
find a 47-year-old male driver still in the vehicle.
There are 10-15 inches of intrusion to the front
of the vehicle. The patient is unresponsive as
you approach.
6-256-25
Findings Findings
A - Blood & vomitus in airway.
B - Slow & labored. BS absent on left.
C - No palpable radial pulse. Cool, wet skin. No external bleeding.
D - Pupils equal but reacting slowly.
E - Obvious fracture of left femur.
A - Blood & vomitus in airway.
B - Slow & labored. BS absent on left.
C - No palpable radial pulse. Cool, wet skin. No external bleeding.
D - Pupils equal but reacting slowly.
E - Obvious fracture of left femur.
6-266-26
How does the Fick Principle apply here?How does the Fick Principle apply here?
Shock SummaryShock Summary
Shock is staged death...Shock is staged death...
6-276-27
…catch it in the first act!…catch it in the first act!