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1、Avoiding the Train Wreck of SHOCK,Kay Kamish, RN, BSN, EMT-P Tulsa 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
2、 the Heart. The Tracks as the blood vessels The cars as the RBCs. 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
3、 type of Shock Initiate the proper care,SHOCK,TYPES of SHOCK,Hypovolemic,Train Wreck of SHOCK,Cardiogenic,Distributive,Obstructive,Train Wreck of SHOCK,HYPOVOLIEMIC SHOCK,* Hemorrhage,* Vomiting,* Diarrhea,* Third Spacing,* Diuresis,SHOCK - Hypovolemic,Low volume - poor carrying capacity of the cell
4、s - 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,SHO
5、CK - 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,
6、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
7、 Stenosis,* Pulmonary Embolism,* Pulmonary Hypertension,* Cardiac Tamponade,* Tension Pneumothorax,Train Wreck of SHOCK,Review: Four Types of SHOCK,HYPOVOLEMIC,Volume Loss,CARDIOGENIC,Heart Failure,DISTRIBUTIVE,Vasodilation,OBSTRUCTIVE,SHOCK,You have the engine (the heart) but no cars (volume) and t
8、oo 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 poss
9、ible,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,Train Wreck of Shock,Early Stage,Pathophysiology,Com
10、pensatory 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,Train Wreck of Shock,* Important Point *, VITAL ORGAN FUNCTION ,* Must think about this! * Cant see it. * Never encounter it be
11、cause it happens later in the course of patients 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 cons
12、triction,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,ST
13、AGES 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,
14、Heart rate increases, Respirations increase,STAGES of SHOCK - Compensatory,Train Wreck of Shock,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,Train Wreck of Shock,Cardiac Output Incre
15、ases,WHY ?,To perfuse Vital Organs : heart, lungs, brain, kidneys,STAGES of SHOCK - Compensatory,Train Wreck of Shock,Pathophysiology, Renal & Chemical Compensation, Renal vasoconstriction,decreased perfusion,stimulates release of:,* ADH,* Aldosterone,* Catecholamines,Clinical Signs, Decreased urina
16、ry 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 De
17、xtrostix 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,Train Wrec
18、k of Shock,* 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 allowe
19、d to proceed to this stage the patients 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 M
20、AP (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, AVP
21、U 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 lev
22、el ,* 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 discover
23、ed and steps taken to correct it, the patient will remain unresponsive to therapeutic interventions.,MOF (Multiple Organ Failure) then leads to the patients demise.,SHOCK - Refractory,Refractory Shock - patient will remain unresponsive to resuscitation,SHOCK - Refractory,Refractory Shock - No hope o
24、f recovery,Train Wreck of Shock,What can we, in EMS, in the pre-hospital setting, do to help avoid this disaster?,SHOCK,SHOCK,ABCs,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,Dont
25、 jump to a conclusion and then be unwilling to alter your approach as needed!,SHOCK - Approaches to Treatment,Train Wreck of Shock,Hypovolemic Shock,GOAL :,Restore Fluid Volume,SHOCK - Treatment,Train Wreck of Shock,Hypovolemic,Fluid Choices:,Crystaloids,Normal Saline,Lactated Ringers,Sodium Chlorid
26、e,Potassium Calcium,Lactate,SHOCK - Treatment,Train Wreck of Shock,Hypovolemic,Fluid Choices: Crystaloids,Avoid 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
27、 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,Hypovolemi
28、c,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 h
29、eart - 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 alre
30、ady compromised state,SHOCK - Treatment,Train Wreck of Shock,Common Sense,IV, O2, Monitor,Transport supine,Raise legs if necessary,Cardiogenic,SHOCK - Treatment,Train Wreck of Shock,Cardiogenic,Medications if Available :,Dopamine -,Dobutamine -,Levophed -,Low range (renal dose) increases urinary out
31、put,Mid range stimulates b receptors,High range stimulates a receptors,Direct b stimulator,Potent inotropic agent; predominantly a - 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 capill
32、ary beds.,SHOCK - Treatment,Train Wreck of Shock,Distributive,Septic Shock,Most common form of Distributive Shock,40 % Mortality Rate,Seen in bodys inflammatory response to overwhelming systemic infection,Produces profound hypotension,SHOCK - Treatment,Distributive,Train Wreck of Shock,Septic Shock,
33、Provide aggressive fluid resuscitation,What will you do if blood pressure continues to drop ?,Vasopressors,Inotropic drugs,SHOCK - Treatment,Distributive,Train Wreck of Shock,Neurogenic Shock,Typically the result of head injury or spinal cord injury,Initial Symptoms:,Hypotension,Bradycardia,Hypother
34、mia,Warm, dry skin,What symptoms are present here that are opposite to other forms of shock ?,SHOCK - Treatment,Distributive,Train Wreck of Shock,Neurogenic Shock,Treatment is aimed at the cause of cardiovascular instability,Eg:,Bradycardia,Atropine,Hypotension,Vasopressors,Not a volume problem in t
35、his case,SHOCK - Treatment,Distributive,Train Wreck of Shock,Anaphylactic Shock,Hypersensitivity to an environmental exposure,Food,Venom,Medications,SHOCK - Treatment,Distributive,Train Wreck of Shock,Anaphylactic Shock,Causes large release of histamine and other vasoactive substances,This in turn c
36、auses :,massive vasodilation,increased capillary permeability,profound hypovolemia,vascular collapse,arrhythmias,decreased cardiac contractility,SHOCK - Treatment,Distributive,Train Wreck of Shock,Anaphylactic Shock,Assess ABCs - *Airway is often compromised*,Counteract the anaphylactic reaction,Rem
37、ove 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,Wh
38、at 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,SHOC
39、K - Summary,Train Wreck of Shock,TYPES of SHOCK,HYPOVOLEMIC,CARDIOGENIC,DISTRIBUTIVE,OBSTRUCTIVE,SHOCK - Summary,Train Wreck of Shock,STAGES OF SHOCK,EARLY,COMPENSATORY,PROGRESSIVE,REFRACTORY,SHOCK - Summary,Train Wreck of Shock,SHOCK - Summary,Train Wreck of Shock,SHOCK,SHOCK - Hopefully does not need to end in disaster,