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Download Avoiding the Trainwreck of SHOCK
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Avoiding the Train Wreck of SHOCK Kay Kamish, RN, BSN, EMT-P Tulsa Life Flight OBJECTIVES Train Wreck of SHOCK ‡ ‡ ‡ ‡ Define the four types of SHOCK Understand the difference in etiologies Recognize the progression of symptoms Understand the difference in approach to treatments SHOCK • Think of the Engine as the Heart…. The Tracks as the blood vessels The cars as the RBC’s…. The Freight as the Oxygen and nutrients…. SHOCK Train Wreck of SHOCK Inadequate tissue perfusion Inability of the body to keep up with the tissue demand for oxygen and nutrients. SHOCK Train Wreck of Shock * FOCUS of INTERVENTION: * Identify the type of Shock * Initiate the proper care TYPES of SHOCK Train Wreck of SHOCK › Hypovolemic › Cardiogenic › Distributive › Obstructive HYPOVOLIEMIC SHOCK Train Wreck of SHOCK * Hemorrhage * Vomiting * Diarrhea * Third Spacing * Diuresis SHOCK -- Hypovolemic • Low volume -- poor carrying capacity of the cells -- not enough ‘freight’ CARDIOGENIC SHOCK Train Wreck of SHOCK Occurs when damaged or unhealthy heart muscle is no longer able to pump effectively = Heart Failure * Myocardial Infarction * Cardiac Arrest * Dysrhythmias * Cardiomyopathies SHOCK -- Cardiogenic • Heart Failure -- an old and tired Engine SHOCK -- Cardiogenic • Cardiogenic Shock - the heart (engine) no longer functions effectively DISTRIBUTIVE SHOCK Train Wreck of SHOCK NEUROGENIC Loss of normal sympathetic vasoconstriction * spinal cord injury * severe pain * vasomotor center depression d/t drug OD DISTRIBUTIVE SHOCK Train Wreck of SHOCK 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 Stenosis * Pulmonary Embolism * Pulmonary Hypertension * Cardiac Tamponade * Tension Pneumothorax Review: Four Types of SHOCK Train Wreck of SHOCK HYPOVOLEMIC CARDIOGENIC DISTRIBUTIVE OBSTRUCTIVE Volume Loss Heart Failure Vasodilation SHOCK • You have the engine (the heart) but no cars (volume) and too many tracks to fill up (excess venous capacitance). STAGES of SHOCK Train Wreck 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 possible 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 Compensatory 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! * Can’t see it. * Never encounter it because it happens later in the course of patient’s 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 constriction 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 STAGES 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 > 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 HR = 60 to 100 bpm Normal SV = 60 to 100 cc STAGES of SHOCK - Compensatory Train Wreck of Shock Cardiac Output Increases WHY ? To perfuse Vital Organs : heart, lungs, brain, kidneys STAGES of SHOCK - Compensatory Train Wreck of Shock Pathophysiology > Renal & Chemical Compensation > Renal vasoconstriction Clinical Signs > Decreased urinary output > Skin cool, clammy, mottled decreased perfusion > Pupils dilated stimulates release of: > Decreased bowel sounds * ADH * Aldosterone * Catecholamines > 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 Dextrostix 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 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 SHOCK Train Wreck of Shock PROGRESSIVE If shock is allowed to proceed to this stage the patient’s condition will deteriorate rapidly \\ ** THIS IS A LIFE THREATENING STAGE **// SHOCK • Progressive Shock -- if condition is unchecked, patient will deteriorate rapidly! STAGES of SHOCK - Progressive Train Wreck of Shock Pathophysiology > 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 death Clinical Signs > Pulse may be too rapid to count or thready & weak > Pulmonary crackles & wheezes > Or, may develop atelectasis or absent BS > AVPU 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 >> Think about what is happening at a cellular level << * 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 discovered and steps taken to correct it, the patient will remain unresponsive to therapeutic interventions. MOF (Multiple Organ Failure) then leads to the patient’s demise. SHOCK -- Refractory • Refractory Shock -- patient will remain unresponsive to resuscitation SHOCK -- Refractory • Refractory Shock -- No hope of recovery SHOCK Train Wreck of Shock What can we, in EMS, in the pre-hospital setting, do to help avoid this disaster? SHOCK Train Wreck of Shock ABC’s Thorough and accurate assessment Determine what type of shock you are dealing with, so as to be sure your approach to treatment is appropriate. Don’t 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 Potassium Chloride 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 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 * Dextran * Plasma * Hespan * Serum albumin SHOCK - Treatment Train Wreck of Shock Hypovolemic What if the patient does not respond to fluids ? Reassess ! May need medications to: Epinephrine promote venous return enhance contractility improve myocardial perfusion Norepinephrine (Levophed) SHOCK - Treatment Train Wreck of Shock Cardiogenic Remember this is a failure in the strength of the heart - 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 already compromised state SHOCK - Treatment Train Wreck of Shock Cardiogenic Common Sense IV, O2, Monitor Transport supine Raise legs if necessary SHOCK - Treatment Train Wreck of Shock Cardiogenic Medications if Available : Dopamine -- Low range (‘renal dose’) increases urinary output Mid range stimulates b receptors High range stimulates a receptors Dobutamine -- Direct b stimulator Levophed -- 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 capillary beds. SHOCK - Treatment Distributive Train Wreck of Shock Septic Shock Most common form of Distributive Shock 40 % Mortality Rate Seen in body’s inflammatory response to overwhelming systemic infection Produces profound hypotension SHOCK - Treatment Distributive Train Wreck of Shock Septic Shock 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 Hypothermia Warm, dry skin 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 this 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 causes : massive vasodilation increased capillary permeability profound hypovolemia vascular collapse arrhythmias decreased cardiac contractility SHOCK - Treatment Distributive Train Wreck of Shock Anaphylactic Shock Assess ABC’s -- *Airway is often compromised* Counteract the anaphylactic reaction Remove the offending stimulus, if possible Fluid resuscitation Subcutaneous Epinephrine Antihistamines (Benadryl) Corticosteroids Vasopressors SHOCK - Treatment Train Wreck of Shock Obstructive Shock Figure out what is being obstructed and why SHOCK - Treatment Train Wreck of Shock Obstructive Shock What is obstructed? (As if no oxygen is loading onto the train) Airway?? 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 SHOCK - 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 Types Hypovolemic Cardiogenic Distributive Obstructive Causes * hemorrhage * vomiting and diarrhea * * * * heart failure septic neurogenic anaphylactic * tension pneumothorax * cardiac tamponade SHOCK - Summary Train Wreck of Shock Type Cause Treatment Hypovolemic * hemorrhage * vomiting/diarrhea * restore fluid volume * Improve cardiac function * Epinephrine, Levophed Cardiogenic * heart failure * Support cardiac function * Dopamine, Dobutrex Distributive * septic * neurogenic * anaphylactic * * * * Obstructive * tension pneumothorax * cardiac tamponade * Relieve obstruction fluid resuscitation Vasopressors Inotropes Antihistmines SHOCK • SHOCK -- Hopefully does not need to end in disaster
