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Paramedic Care: Principles & Practice Volume 1 Introduction to Advanced Prehospital Care Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chapter 8 General Principles of Physiology and Pathophysiology Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chapter 8, Part 2 Disease—Causes and Pathophysiology Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Part 2 Topics Genetic and Other Causes of Disease Hypoperfusion Types of Shock Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Genetic and Other Causes of Disease Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Genetic and Other Causes of Disease Many diseases result from genetic causes. Many diseases result from a combination of genetic and environmental factors as well as age and gender. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Genetics, Environment, Lifestyle, Age, and Gender Inherited traits are determined by molecules of deoxyribonucleic acid, or DNA. – Form genes that reside on chromosomes – Somatic cells (all the cells except the sex cells) contain 46 chromosomes – Sex cells contain 23 chromosomes Offspring receive 23 from mother and 23 from father Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Genetics, Environment, Lifestyle, Age, and Gender Abnormal genes or chromosomes may cause a congenital disease or a propensity toward acquiring a disease. Some diseases are thought to be purely genetic. Other diseases are caused by a combination of genetic and environmental factors. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Disease Effects on Individuals Related to Host, Agent, and Environment – Host Genetic predisposition, gender, and ethnic origin are determinants related to the host. – Agent Bacterium, toxin, gunshot, or other pathophysiological process – Environment Local climate, socioeconomic or demographic features, culture, religion, and associated factors Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Disease Effects on Populations Epidemiologists generally report disease data with three basic measures: incidence, prevalence, and mortality. Morbidity is reported as incidence and prevalence. – Incidence is occurrence of disease – Prevalence is the proportion of total population effected Mortality is the occurrence of death. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Family History and Associated Risk Factors Immunologic disorders Cancer Endocrine disorders Hematologic disorders Cardiovascular disorders Renal disorders Rheumatic disorders Gastrointestinal disorders Psychiatric disorders Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Immunologic Disorders A number of immunologic disorders are more prevalent among those with a family history of the disorder. – Rheumatic fever, allergies, and asthma Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cancer Some types of cancer tend to cluster in families and seem to have a combination of genetic and environmental causes. – Breast cancer – Colorectal cancer – Lung cancer Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Endocrine Disorders The most common endocrine disorder is diabetes mellitus. Both Type I and Type II diabetes can be family related. Causes of diabetes are complex and still not well understood. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hematological Disorders There are many causes of hereditary hematological disorders such as gene alteration and histocompatibility (tissue interaction) dysfunctions. – Hemophilia – Hemochromatosis Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiovascular Disorders The cardiovascular system can be greatly affected by genetic disorders. – – – – – Elongation of the QT interval Mitral valve prolapse Coronary artery disease Hypertension Cardiomyopathy Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Renal Disorders Caused by a variety of factors, primarily hypertension May eventually require a patient to receive dialysis treatment several times a week – Problems with vascular access devices – Localized infection and sepsis – Electrolyte imbalances Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Rheumatic Disorders Gout is a disorder both genetic and environmental characterized by the deposit of crystals in the joints, most commonly the great toe. The crystals form as a result of abnormally high levels of uric acid in the blood. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Gastrointestinal Disorders Lactose intolerance Crohn’s disease Peptic ulcers Cholecystitis Obesity Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Neuromuscular Disorders Diseases of the nervous and muscular systems include: – Huntington’s disease – Multiple sclerosis – Alzheimer’s disease Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Psychiatric Disorders Genetic and biological causes of these disorders are being studied and increasingly understood. – Schizophrenia – Manic-depressive illness (bipolar disorder) Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hypoperfusion Progressive cycle of pathophysiological events – Fatal if not corrected Although causes differ, all forms of shock have the same underlying pathophysiology at the cellular and tissue levels. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Progression of Shock Cellular Death Tissue Death Organ Death Organ System Death Organism Death Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Physiology of Perfusion Body cells require a constant supply of oxygen and other essential nutrients. – Accomplished by the passage of blood through the capillaries. The constant and necessary passage of blood through the body’s tissues is called perfusion. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Components of the Circulatory System The pump (heart) The fluid (blood) The container (blood vessels) Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Pump The heart is the pump of the cardiovascular system. – Receives blood from the venous system, pumps it to the lungs for oxygenation, and then pumps it to the peripheral tissues. The amount of blood ejected by the heart in one contraction is referred to as the stroke volume. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Stroke Volume Factors affecting stroke volume: – Preload Amount of blood delivered to the heart during diastole – Cardiac contractile force The strength of contraction of the heart – Afterload The resistance against which the ventricle must contract Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiac Output Cardiac output is the amount of blood pumped by the heart in one minute. An increase in stroke volume or an increase in heart rate can increase cardiac output. SV x HR = CO Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Blood Pressure Peripheral vascular resistance is the pressure against which the heart must pump. Increasing cardiac output or peripheral vascular resistance will increase blood pressure. CO x PVR = BP Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Blood Pressure Peripheral Vascular Resistance – Blood pressure maintained by compensatory mechanisms and negative feedback loops – Baroreceptors Increased pressure causes a decreased heart rate, preload, and peripheral vascular resistance Decreased pressure stimulates vasoconstriction and adrenal hormone release Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Fluid Blood is thicker and more adhesive than water. Blood consists of plasma and the formed elements. – Red cells, white cells, platelets Nutritional function An adequate amount of blood is needed for perfusion, and volume must be adequate to fill the container. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Fluid Natriuretic Hormone – Endocrine function of the heart – Involved in the long-term regulation of sodium and water balance, blood volume, and arterial pressure – Natriuretic peptides Atrial natriuretic peptide (ANP) Released by atrial muscle cells in response to such things as atrial distension and sympathetic stimulation Brain natriuretic peptide (BNP) Released by ventricular muscle cells in response to ventricular dilation and sympathetic stimulation Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Fluid Natriuretic Hormone (cont.) – Counterregulatory system to the reninangiotensin system Decreases aldosterone release Produces natriuresis (sodium loss) and diuresis (water loss) Decreases renin release – BNP levels are elevated in congestive heart failure Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Container Blood vessels – A continuous, closed, and pressurized pipeline by which blood moves throughout the body Autonomic regulation Microcirculation – Comprised of the small vessels: arterioles, capillaries, and venules – Responsive to local tissue needs Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Container Capillaries – The precapillary sphincter opens in response to local tissue demands such as acidosis and hypoxia. – The postcapillary sphincter opens when blood is to be emptied into the venous system. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Blood Flow Regulation Blood flow through the vessels is regulated by two factors: – Peripheral vascular resistance – Pressure within the system Vessels with larger inside diameters offer less resistance. Vessels with smaller diameters offer more resistance. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Blood Flow Regulation Click here to view an animation on capillary pressure. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Blood Flow Regulation A significant change in peripheral resistance occurs at the arterioles and precapillary sphincters. – Local tissue needs and sympathetic stimulation Contraction of the venous side of the vascular system – Decreased capacitance and increased cardiac preload Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Oxygen Transport Surrounding the alveoli are capillaries that are perfused by the pulmonary circulation. – Alveolar air is far richer in oxygen than blood that enters the pulmonary capillaries. – Oxygen from the alveoli diffuses across the alveolar-capillary membrane. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Oxygen Transport Oxygen binds to the hemoglobin molecules of the red blood cells. – 97% of oxygen is transported reversibly bound to hemoglobin. – 3% of oxygen is transported as a gas dissolved in the plasma. Oxygen-enriched blood is pumped throughout the body via systemic circulation. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Oxygen Transport The oxygen-rich blood interfaces with the tissues in capillary beds. – Cells in tissue are oxygen-deficient. – Partial pressure of oxygen is greater in the bloodstream than in the cells. – Oxygen will diffuse from the red blood cells across the capillary wall. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Oxygen Transport The movement and utilization of oxygen in the body is dependent upon the following conditions: – Adequate concentration of oxygen – Appropriate movement of oxygen across the alveolar/capillary membrane – Adequate number of red blood cells – Proper tissue perfusion – Efficient off-loading of oxygen at the tissue level Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Waste Removal The waste products of cellular metabolism are expelled from the cells and carried away by the blood. The majority of carbon dioxide (approximately 70%) is transported in the form of bicarbonate ion (HCO3¯). Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Waste Removal Some cellular waste products are picked up by the lymphatic system. Waste is cleansed from the blood by the kidneys and excreted as urine. Some cellular waste products are expelled in the feces. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Waste Removal There is some local control of both tissue perfusion and waste removal. Local acidosis causes nearby pre-capillary sphincters to relax. Increases perfusion of the affected tissues – Provides increased capacity for waste elimination Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hypoperfusion Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Causes of Hypoperfusion Inadequate pump – Decreased preload, inadequate contractile strength, inadequate rate, or excessive afterload Inadequate fluid – Hypovolemia Inadequate container – Dilated container without change in fluid volume (inadequate systemic vascular resistance) – Leak in the container Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Shock at the Cellular Level Shock is inadequate tissue perfusion. Ultimate outcome is impairment of cellular metabolism. Two characteristics of impaired cellular metabolism: – Impaired oxygen use – Impaired glucose use Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Impaired Use of Oxygen When cells don’t receive enough oxygen or cannot use it effectively, they change from aerobic to anaerobic metabolism. – A far less efficient means of producing energy. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Impaired Use of Oxygen Glycolysis – Stage 1 Anaerobic Inefficient – Stage 2 Aerobic Efficient Hypoperfusion does not allow stage 2 glycolosis Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Impaired Use of Oxygen Accumulation of lactic acid – The acidic condition of the blood reduces the ability of hemoglobin in red blood cells to bind with and carry oxygen. – Cellular stores of ATP are used up much faster than they can be replaced. – Cellular death then occurs. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Impaired Use of Glucose Factors that reduce delivery of oxygen to the cells also reduce delivery of glucose to the cells. – Also by: Fever Cell damage The presence of bacteria or toxins Histamine or other substances produced by the body’s immune and inflammatory responses Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Impaired Use of Glucose Glucose that is prevented from entering the cells remains in the blood. – Certain body cells can create fuel for energy production by converting other substances to glucose. Glycogenolysis Lipolysis Waste products of metabolism build up in the cells, further impairing cell function and damaging cell membranes. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Compensation and Decompensation Usually the body is able to compensate for metabolic processes in order to maintain homeostasis through perfusion. When the various compensatory mechanisms fail, shock develops. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Compensation Mechanisms The fall in arterial blood pressure is a negative feedback mechanism. – Catecholamines, epinephrine, and norepinephrine may be secreted – The renin-angiotensin system aids in maintaining blood pressure – Secretion of anti-diuretic hormone (ADH) – Splenic discharge – Shunting Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Shock Variations Compensated shock – The early stage of shock when the body’s compensatory mechanisms are able to maintain perfusion Decompensated shock – Compensatory mechanisms may not be able to restore normal function – Intervention may still be able to correct the condition Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Shock Variations Irreversible shock – Correction is no longer possible – Cardiac depression Myocardium has a greatly increased demand for oxygen Coronary blood flow is reduced; cardiac output falls more – Cellular deterioration progresses to tissue deterioration, which progresses to organ failure. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Types of Shock Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Types of Shock Cardiogenic Hypovolemic Neurogenic Anaphylactic Septic Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiogenic Shock The heart loses its ability to supply all body parts with blood Usually the result of left ventricular failure secondary to acute myocardial infarction or CHF Many patients will have normal blood volume Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiogenic Shock Evaluation – Difference between cardiogenic shock and other types of shock is the presence of pulmonary edema Wheezes or crackles (rales) may be heard There may be a productive cough with white or pinktinged foamy sputum – Cyanosis, altered mentation, and oliguria Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiogenic Shock Treatment – Treat for shock Assure an open airway, administer oxygen, assist ventilations as necessary, keep the patient warm – Elevate the patient’s head and shoulders – Establish IV access with minimal fluid administration – Monitor the heart rate – Dopamine or dobutamine may be administered Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hypovolemic Shock Shock due to loss of intravascular fluid Causes of hypovolemia – – – – – – – Internal or external hemorrhage Trauma Long-bone or open fractures Dehydration Plasma loss from burns Excessive sweating Diabetic ketoacidosis with resultant osmotic diuresis Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hypovolemic Shock Hypovolemic shock can also be due to internal third-space loss. – Bowel obstruction, peritonitis, pancreatitis, or liver failure resulting in ascites Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hypovolemic Shock Evaluation – – – – Altered level of consciousness Pale, cool, clammy skin Blood pressure may be normal, then fall Pulse may be normal then become rapid, finally slowing and disappearing – Urination decreases – Cardiac dysrhythmias may occur Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hypovolemic Shock Treatment – Airway management, supplemental oxygenation, assisted ventilations (if necessary), hemorrhage control, and rapid transport – Administer a bolus of crystalloid solution for fluid replacement Non-trauma or no blood loss: Bolus crystalloid or colloid solutions Trauma or blood loss: “Permissive hypotension.” – SBP of 70-85 mmHg PASG if part of local protocol Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Neurogenic Shock Injury to brain or spinal cord causes an interruption of nerve impulses to the arteries – The arteries dilate causing relative hypovolemia – Sympathetic impulses to the adrenal glands are lost Prevents the release of catecholamines with their compensatory effects Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Neurogenic Shock The arteries lose tone and dilate, causing a relative hypovolemia A disproportionate amount of blood collects in the capillary bed – Reduces venous return, cardiac output, and arterial blood pressure Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Neurogenic Shock Evaluation – Warm, dry, red skin – Low blood pressure – Slow pulse The lack of compensatory stimulation from catecholamine release Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Neurogenic Shock Treatment – – – – – Airway control Maintain body temperature Immobilization of patient Consider other possible causes of shock IV access and medications that increase peripheral vascular resistance Norepinephrine (Levophed) and dopamine (Intropin) Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anaphylactic Shock A severe immune response to a foreign substance Signs and symptoms most often occur within a minute The most rapid reactions are in response to injected substances: – Penicillin injections – Stings from bees, wasps, hornets Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anaphylactic Shock Evaluation – Because immune responses can affect different body systems, signs and symptoms vary widely. Skin: Flushing, itching, hives, swelling, cyanosis Respiratory system: Breathing difficulty, sneezing, coughing, wheezing, stridor, laryngeal edema, laryngospasm Cardiovascular system Vasodilation, increased heart rate, decreased blood pressure Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anaphylactic Shock Evaluation – Gastrointestinal system: Nausea, vomiting, abdominal cramping, diarrhea – Nervous system: Altered mental status, dizziness, headache, seizures, tearing Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anaphylactic Shock Treatment – Airway protection May include endotracheal intubation – Establish an IV of crystalloid solution – Pharmacological intervention: Epinephrine, antihistamines, corticosteroids, vasopressors, inhaled beta agonists Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Septic Shock An infection that enters the bloodstream and is carried throughout the body Toxins released overcome the compensatory mechanisms Can cause the dysfunction of an organ system or result in multiple organ dysfunction syndrome Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Septic Shock Evaluation – The signs and symptoms are progressive Increased to low blood pressure High fever, no fever, or hypothermic Skin flushed, pale, or cyanotic Difficulty breathing and altered lung sounds Altered mental status Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Septic Shock Treatment – – – – Airway control IV of crystalloid solution Dopamine to support blood pressure Monitor heart rhythm Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Multiple Organ Dysfunction Syndrome Progressive impairment of two or more organ systems – An uncontrolled inflammatory response to a severe illness or injury Sepsis and septic shock are the most common causes of MODS Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Multiple Organ Dysfunction Syndrome Stages of MODS – Primary Stage Results directly from a specific cause Neutrophils and macrophages as well as mast cells are thought to be “primed” by cytokines Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Multiple Organ Dysfunction Syndrome Stages of MODS – Secondary Stage Primed cells are activated, producing an exaggerated inflammatory response Inflammatory response enters a self-perpetuating cycle Triggers an exaggerated neuroendocrine response A massive immune/inflammatory and coagulation response develops Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Clinical Presentation of MODS Usually will develop over a period of 2, 3, or more weeks There is no specific therapy for MODS MODS will usually be detected in the hospital – EMS may encounter patient following discharge or during transfer Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Part 2 Summary Genetic and Other Causes of Disease Hypoperfusion Types of Shock Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ