Download Hypoperfusion and Shock

Hypoperfusion and Shock
Hypoperfusion
 Common problem
 Extent makes resuscitation
difficult
 Shock due to hypoperfusion
 Start fluid resuscitation as soon
as possible
© 2009 NAEMT
Overview
 Describe differences between
compensated and uncompensated
shock
 Review differences of distributive,
non-distributive and obstructive shock
 Explore pathophysiology for different
etiologies of shock
 Discuss interventions for early and late
shock
© 2009 NAEMT
Physiology
BP = Cardiac Output x Systemic Resistance
Cardiac Output = Stroke Volume x Heart Rate
After-load = Resistance to blood being ejected
Pre-load = Blood returned to heart
Starling’s Law = Amount of cardiac
muscle stretch
LifeART
NHTSA
© 2009 NAEMT
Shock Compensation
Children vs. Adults
Children
 Increased heart
rate
 Vasoconstriction
 Prolonged
compensation
 Rapid
decompensation
Adults
 Increased stroke
volume
 Vasoconstriction
 Tachycardia
 Slow, but
sustained
compensation
EPS411.com
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Categories of Shock
Non-Distributive
Hypovolemic
 Hemorrhagic
 Metabolic
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Categories of Shock
Distributive
 Anaphylaxis
 Septic
 Neurogenic
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Categories of Shock
Obstructive
 Pulmonary embolus
 Tension pneumothorax
 Cardiac
tamponade
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Etiologies of Hypoperfusion
(Common)
 Emesis and diarrhea
 Osmotic diuresis from diabetes
 Internal or external blood loss
 Plasma loss from sepsis or
anaphylaxis
© 2009 NAEMT
Etiologies of Hypoperfusion
(Uncommon)
 Spinal cord injury
 Cardiac failure
Medications required to
restore perfusion
© 2009 NAEMT
Severity of Hypoperfusion
Compensated
Volume
Compensated
Decompensated
Signs are due
to inadequate
tissue perfusion
Compensated
shock is
reversible with
fluids
Time
© 2009 NAEMT
Severity of Hypoperfusion
Compensated Shock Signs
Compensated
Decompensated
Volume
Pulse
Breathing
Blood
Pressure
AVPU
Altered Mental Status
Time
© 2009 NAEMT
Severity of Hypoperfusion
Compensated Shock Signs
Compensated
Decompensated
Weak or absent
peripheral
pulses, weak
central pulses
Volume
Weak
peripheral
pulses, strong
central pulses
EPS411.com
Time
© 2009 NAEMT
Severity of Hypoperfusion
Dehydration Testing
Hypovolemic patient’s
skin will “tent”
© 2009 NAEMT
Severity of Hypoperfusion
Decompensated Shock
Compensated
Decompensated
Volume
Inadequate
tissue perfusion
to all organs
Body is unable
to continue
compensation
Time
© 2009 NAEMT
Severity of Hypoperfusion
Decompensated Shock Signs
Compensated
Decompensated
Volume
Pulse
Breathing
Blood
Pressure
AVPU
V
Altered Mental Status
P
U
Weak or absent peripheral pulses, weak central pulses
Time
© 2009 NAEMT
Severity of Hypoperfusion
Decompensated Shock Signs
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Assessment
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Scene Survey
Hazards to you, your partner,
the patient and bystanders
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First Impression
Pediatric Assessment Triangle
Compensated or
decompensated
EPS411.com
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First Impression
General Appearance
 Observe interactions
 Not sick - attentive to environment,
focus on familiar people and
objects, alert for threats
 Good brain function requires
adequate oxygenation, ventilation,
cerebral perfusion
 Sick - does not care you are
present or recognize parents
© 2009 NAEMT
First Impression
General Appearance




Muscle tone
Spontaneous movements
Skin color
Other signs of distress
KyleDavidBates.com
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First Impression
Work of Breathing
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First Impression
Circulation to the Skin
Skin color, capillary refill,
distal vs. central pulses
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First Impression
Sick
Rapid Initial Assessment
Not Sick
Yes
Significant MOI?
No
Appropriate Interventions
Relationship
Transport Priority
Involve Family
Transport Method
Detailed History
Transport Destination
Focused Physical Exam
© 2009 NAEMT
Initial Assessment
Airway
Loss of airway
may occur in
decompensated
shock
Identify and treat life
threats
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Initial Assessment
Breathing
Assess for chest trauma
Abnormal sounds
Rate effort and volume
Administer O2 and
treat cause
© 2009 NAEMT
Initial Assessment
Circulation
Compensated
Weak peripheral pulses,
strong central pulses
Decompensated
Weak or absent peripheral
pulses, weak central pulses
EPS411.com
EPS411.com
© 2009 NAEMT
Initial Assessment
Circulation Management – Intravenous
 Fluid bolus if any signs of shock
 Early recognition of hypoperfusion
and fluid resuscitation are key
 Select a large bore catheter
 Location close to central circulation
 Two IVs may be needed
© 2009 NAEMT
Initial Assessment
Circulation Management – Intraosseous
Can be used on any age
child
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Intraosseous Space
Blood Flow
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Anatomy
Neonate Leg Cross Section
Skin
Intraosseous
Catheter
Tibia
Lateral
Compartment
Fibula
Subcutaneous
Fat
Anterior
Compartment
Posterior
Compartment
© 2009 NAEMT
Other Issues
IO Insertion





Depth based on patient size and weight
Gently insert catheter
Advance catheter slowly
Feel needle drop into medullary space
Frequently monitor insertion site and
extremity
 Need hands-on training
© 2009 NAEMT
IO Insertion
Anatomical Landmarks
Patella
Tibial
Tuberosity
Medial
Tibia
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IO Insertion
Unable to Palpate Tibial Tuberosity
Finger Width
Finger Width
Often difficult or impossible
to palpate
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IO Insertion
Able to Palpate Tibial Tuberoisty
Finger Width
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Anatomy
Neonate Leg Cross Section
Traditional IO
Catheter
Tibia
Fibula
Left Leg
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Anatomy
11 y.o. Tibia Cross Section
Tibia
Fibula
Left Leg
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Pain
Somatic and Visceral
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Initial Assessment
Circulation Management – Crystalloids
20 mL/kg, < 20 minutes
Reassess patient after
each fluid bolus
© 2009 NAEMT
Initial Assessment
Never Administer D5W
D5W can lead to
hyperglycemia
© 2009 NAEMT
Initial Assessment
Circulation Management – Medications
Sepsis
Pressers and
antibiotics
Cardiogenic
Shock
Pressers, furosemide,
morphine and
antiarrhythmics
Anaphylaxis
Epinephrine,
diphenhydramine,
Solu-Medrol
EPS411.com
© 2009 NAEMT
Initial Assessment
Circulation Management – Medications
Use medications after fluid
boluses
EPS411.com
© 2009 NAEMT
Transport Decision
Rapid transport for
pediatric shock patients
© 2009 NAEMT
Focused History
Questions to Determine Type of Shock
Bleeding
Vomiting
Diarrhea
Fluid intake /
urine output
Fever
Anaphylaxis
signs
FEMA Photo Library / Andrea Boomer
© 2009 NAEMT
Head to Toe Physical Exam
Done En Route
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Ongoing Assessment
Done Frequently
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Summary
 Recognition and rapid intervention
are keys to treatment
 Pulse quality and level of
consciousness are key indicators
 Obtain IV or IO access if shock
treatment is needed
 Deliver crystalloid fluids at 20
mL/kg
© 2009 NAEMT