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Chapter 3 Define shock Recognize the shock state Determine the cause Apply treatment principles Recognize the importance of early hemorrhage identification and control Manage patient’s response What is shock? Is the patient in shock? What is the cause of the shock state? What can I do about it? What is the patient’s response? What are the pitfalls? Generalized state of hypoperfusion ◦ ◦ ◦ ◦ ◦ Inadequate substrate delivery Catecholamines and other responses Anaerobic metabolism Cellular dysfunction Cell death Tachycardia Alteration in LOC, anxiety Tachypnea, shallow respirations Cold, diaphoretic skin Lowered urinary output Hypotension Hemorrhagic Blood loss vs Non-hemorrhagic Tension pneumothorax Cardiac tamponade Cardiogenic Neurogenic Septic Physical examination Diagnostic adjuncts to primary survey ◦ Chest X-ray ◦ CT/FAST/DPL ◦ AP X-ray pelvis Direct pressure, splint fractures, reduce pelvic volume Restore volume: IV access, warmed fluids Prevent hypothermia Indentify improved organ function ◦ ◦ ◦ ◦ ◦ CNS: improved level of consciousness Renal: improved urinary output Skin: warm, capillary refill Respirations: improved rate and depth Vital signs: return to normal Rapid responder ◦ A rapid infusion of crystalloid will fill vascular space and result in a temporary improvement in vital signs Transient responder ◦ Increasing the amount of crystalloid in larger deficits will decrease hematocrit Nonresponder ◦ In large losses, crystalloid infusion will have minimal or no effect I II III IV Blood Loss (%) (mL) < 15% < 750 HR < 100 > 100 > 120 > 140 BP Normal Normal i ii RR 14-20 20-30 30-40 > 35 UOP (mL/hr) > 30 20-30 5-15 Negligible MS Slightly Anxious Mildly Anxious Anxiety & Confusion Confusion & Lethargy 15-30 30-40 750-1500 1500-2000 > 40 > 2000 Equating BP with cardiac output Hemoglobin, hematocrit levels Age extremes Hypothermia Athletes Pregnancy Medications Pacemaker What is shock? Is the patient in shock? What is the cause of the shock state? What can I do about it? What is the patient’s response? What are the pitfalls?
