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Avoiding the Train Wreckof SHOCKKay Kamish,RN,BSN,EMT-PTulsa Life FlightOBJECTIVES Define the four types of SHOCK Understand the difference in etiologies Recognize the progression of symptoms Understand the difference in approach to treatmentsTrain Wreck of SHOCKSHOCKThink of the Engine as the Heart.The Tracks as the blood vessels The cars as the RBCs.The Freight as the Oxygen and nutrients.SHOCKg Inadequate tissue perfusiong Inability of the body to keep up g with the tissue demand for oxygen g and nutrients.Train Wreck of SHOCKTrain Wreck of Shock*FOCUS of INTERVENTION:*Identify the type of Shock*Initiate the proper care SHOCKTYPES of SHOCK HypovolemicTrain Wreck of SHOCK Cardiogenic Distributive ObstructiveTrain Wreck of SHOCKHYPOVOLIEMIC SHOCK*Hemorrhage*Vomiting*Diarrhea*Third Spacing*DiuresisSHOCK-HypovolemicLow 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 InfarctionTrain Wreck of SHOCK*Cardiac Arrest*Dysrhythmias*CardiomyopathiesSHOCK-CardiogenicHeart Failure-an old and tired EngineSHOCK-Cardiogenic Cardiogenic Shock-the heart(engine)no longer functions effectivelyDISTRIBUTIVE SHOCKNEUROGENICLoss of normal sympathetic vasoconstriction*spinal cord injury*severe pain*vasomotor center depression d/t drug ODTrain Wreck of SHOCKDISTRIBUTIVE SHOCKTrain Wreck of SHOCKVASOGENICDiminished arterial resistance and increased venous capacitance*Due to a release of vasodilating substance from the body itself*Anaphylactic Shock*Septic ShockSHOCK-DistributiveVasodilation-too many tracks/blood vessels to fillOBSTRUCTIVE SHOCKTrain Wreck of SHOCK*Arterial Stenosis*Pulmonary Embolism*Pulmonary Hypertension*Cardiac Tamponade*Tension PneumothoraxTrain Wreck of SHOCKReview:Four Types of SHOCKHYPOVOLEMICVolume LossCARDIOGENICHeart FailureDISTRIBUTIVEVasodilationOBSTRUCTIVESHOCKYou have the engine(the heart)but no cars(volume)and too many tracks to fill up(excess venous capacitance).Train Wreck of ShockSTAGES 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 possibleSTAGES of SHOCKTrain Wreck of Shock Early StagePathophysiology Decrease in MAP Results in reduced or uneven microcirculatory blood flow and decreased O2 delivery to cellsClinical Signs Usually there are few at this point STAGES of SHOCKTrain Wreck of ShockEarly StagePathophysiologyCompensatory mechanisms can restore MAP to reasonable levels.Clinical SignsTherefore:There are few clinical signsAND:No disruption of vital organ functionSTAGES of SHOCKTrain Wreck of Shock*Important Point*VITAL ORGAN FUNCTION Now drops 10-15 mmHg*Compensatory Mechanisms are put in motion Heart rate increases Respirations increaseSTAGES of SHOCK-CompensatoryTrain Wreck of ShockCardiac OutputCO=Heart rateXStroke volumeNormal CO =4 to 6 Liters/minuteNormal SV =60 to 100 ccNormal HR =60 to 100 bpmSTAGES of SHOCK-CompensatoryTrain Wreck of ShockCardiac Output Increases WHY?To perfuse Vital Organs:heart,lungs,brain,kidneysSTAGES of SHOCK-CompensatoryTrain Wreck of ShockPathophysiology Renal&Chemical Compensation Renal vasoconstriction decreased perfusion stimulates release of:*ADH*Aldosterone*CatecholaminesClinical Signs Decreased urinary output Skin cool,clammy,mottled Pupils dilated Decreased bowel sounds Hyperglycemia WHY?STAGES of SHOCK-CompensatoryTrain Wreck of ShockHyperglycemia*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 elevatedSTAGES of SHOCK-CompensatoryTrain Wreck of Shock Pathophysiology*Decrease of blood to the pulmonary system*Leads to poorer oxygenation of all organ systemsClinical Signs*Restlessness*Mental confusion*Agitation*LethargySTAGES of SHOCK-CompensatoryTrain Wreck 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 SHOCKTrain Wreck of Shock If shock is allowed to proceed to this stage the patients condition will deteriorate rapidly *THIS IS A LIFE THREATENING STAGE */PROGRESSIVESHOCKProgressive Shock-if condition is unchecked,patient will deteriorate rapidly!STAGES of SHOCK-ProgressiveTrain Wreck of ShockPathophysiology 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 deathClinical Signs Pulse may be too rapid to count or thready&weak Pulmonary crackles&wheezes Or,may develop atelectasis or absent BS AVPU declinesSTAGES of SHOCK-ProgressiveTrain 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 initiatedwithin an hour after onset of this stage IF NOT.STAGES of SHOCK-RefractoryTrain Wreck of Shockv By this stage the body has sustained too much cell damage and death to survive.v Even if the underlying cause of shock has been discovered and steps taken to correct it,the patient will remain unresponsive to therapeutic interventions.v MOF(Multiple Organ Failure)then leads to the patients demise.SHOCK-RefractoryRefractory Shock-patient will remain unresponsive to resuscitationSHOCK-RefractoryRefractory Shock-No hope of recoveryTrain Wreck of ShockWhat can we,in EMS,in the pre-hospital setting,do to help avoid this disaster?SHOCKSHOCK 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 jump to a conclusion and then be unwilling to alter your approach as needed!SHOCK-Approaches to TreatmentTrain Wreck of ShockHypovolemic ShockGOAL:Restore Fluid VolumeSHOCK-TreatmentTrain Wreck of ShockHypovolemicFluid Choices:Crystaloids Normal Saline Lactated RingersSodiumChloride Potassium CalciumLactateSHOCK-TreatmentTrain Wreck of ShockHypovolemicFluid 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-TreatmentTrain Wreck of ShockHypovolemicFluid Choices:Colloids Protein Containing Tend to stay in the vascular system“Volume Expanders*PRBCs*Plasma*Serum albumin*Dextran*HespanSHOCK-TreatmentTrain Wreck of ShockHypovolemicWhat if the patient does not respond to fluids?Reassess!May need medications to:D promote venous returnD enhance contractilityD improve myocardial perfusion Epinephrine Norepinephrine(Levophed)SHOCK-TreatmentTrain Wreck of ShockCardiogenic Remember this is a failure in the strength of theheart-volume is not necessarily the problemGOAL:Improve myocardial functionSHOCK-TreatmentTrain Wreck of ShockCardiogenic 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 stateSHOCK-TreatmentTrain Wreck of ShockCommon Sense IV,O2,Monitor Transport supine Raise legs if necessaryCardiogenicSHOCK-TreatmentTrain Wreck of ShockCardiogenicMedications if Available:F Dopamine-F Dobutamine-F Levophed-Low range(renal dose)increases urinary outputMid range stimulates b receptors High range stimulates a receptorsDirect b stimulatorPotent inotropic agent;predominantly a-adrenergic SHOCK-TreatmentTrain Wreck of ShockDistributiveRemember this is due to the loss of sympathetic tone,resulting in pooling of blood in venous and capillary beds.SHOCK-TreatmentTrain Wreck of ShockDistributiveSeptic Shock Most common form of Distributive Shock 40%Mortality Rate Seen in bodys inflammatory response to overwhelming systemic infection Produces profound hypotensionSHOCK-TreatmentDistributiveTrain Wreck of ShockSeptic Shock Provide aggressive fluid resuscitation What will you do if blood pressure continues to drop?Vasopressors Inotropic drugsSHOCK-TreatmentDistributiveTrain Wreck of ShockNeurogenic Shockh Typically the result of head injury or spinal cord injury Initial Symptoms:T HypotensionT BradycardiaT HypothermiaT Warm,dry skin What symptoms are present here that are opposite to other forms of shock?SHOCK-TreatmentDistributiveTrain Wreck of ShockNeurogenic Shock Treatment is aimed at the cause of cardiovascular instabilityEg:T Bradycardia AtropineT Hypotension Vasopressors Not a volume problem in this caseSHOCK-TreatmentDistributiveTrain Wreck of ShockAnaphylactic Shock Hypersensitivity to an environmental exposureg Foodg Venomg MedicationsSHOCK-TreatmentDistributiveTrain Wreck of ShockAnaphylactic 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 contractilitySHOCK-TreatmentDistributiveTrain Wreck of ShockAnaphylactic Shock Assess ABCs -*Airway is often compromised*Counteract the anaphylactic reactionT Remove the offending stimulus,if possibleT Fluid resuscitationT Subcutaneous EpinephrineT Antihistamines (Benadryl)T CorticosteroidsT VasopressorsSHOCK-TreatmentObstructive ShockTrain Wreck of Shock Figure out what is being obstructed and whySHOCK-TreatmentTrain Wreck of ShockObstructive Shock What is obstructed?Airway?(As if no oxygen is loading onto the train)Tension PneumothoraxCirculation?(Something is hampering the engine.)Cardiac TamponadeSHOCK-TreatmentTrain Wreck of ShockObstructive Shock*Treatment is emergent in both cases*Needle decompression PericardiocentesisSHOCK-SummaryTrain Wreck of ShockTYPES of SHOCKHYPOVOLEMICCARDIOGENICDISTRIBUTIVEOBSTRUCTIVESHOCK-SummaryTrain Wreck of ShockSTAGES OF SHOCKEARLYCOMPENSATORYPROGRESSIVEREFRACTORYSHOCK-SummaryTrain Wreck of Shock Types CausesHypovolemic*hemorrhage*vomiting and diarrheaCardiogenic*heart failureDistributive*septic*neurogenic*anaphylacticObstructive*tension pneumothorax*cardiac tamponadeSHOCK-SummaryTypeCauseTreatmentHypovolemic*hemorrhage*vomiting/diarrhea*restore fluid volume*Improve cardiac function*Epinephrine,LevophedCardiogenic*heart failure*Support cardiac function*Dopamine,DobutrexDistributive*septic*neurogenic*anaphylactic*fluid resuscitation*Vasopressors*Inotropes*AntihistminesObstructive*tension pneumothorax*cardiac tamponade*Relieve obstructionTrain Wreck of ShockSHOCK SHOCK-Hopefully does not need to end in disaster
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