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Division 1 Introduction to Advanced Prehospital Care Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Chapter 4 General Principles of Pathophysiology Part I How Normal Body Processes Are Altered by Disease and Injury Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Topics Disease Risk Hypoperfusion Shock Multiple Organ Dysfunction Syndrome Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Pathophysiology The study of how diseases alter the normal physiological processes of the human body From the root “patho” meaning disease Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ How Cells Respond to Change and Injury Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Cellular Adaptation Cells, tissues, organs, and organ systems can adapt to both normal and injurious conditions. Adaptation to external stressors results in alteration of structure and function. Examples: Growth of the uterus during pregnancy, dilation of the left ventricle after an MI. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Types of Cellular Adaptations (1 of 2) Atrophy – Decreased size resulting from a decreased workload Hypertrophy – An increase in cell size resulting from an increased workload Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Types of Cellular Adaptations (2 of 2) Hyperplasia – An increase in the number of cells resulting from an increased workload Metaplasia – Replacement of one type of cell by another type of cell that is not normal for that tissue Dysplasia – A change in cell size, shape, or appearance caused by an external stressor Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Cellular Injury Hypoxic Chemical Infectious Immunologic/Inflammatory Physical agents Nutritional balances Genetic factors Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Manifestation of Cellular Injury When cells are injured metabolism is changed, causing substances to infiltrate or accumulate to an abnormal degree in cells. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Cellular Swelling Results from a permeable or damaged cellular membrane Caused by an inability to maintain stable intra- and extracellular fluid and electrolyte levels Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Fatty Change Lipids invade the area of injury. Occurs most commonly in vascular organs, most frequently the liver. Causes a disruption of the cellular membrane and metabolism and interferes with the vital functions of the organ. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Signs and Symptoms of Cellular Change Fatigue and malaise Altered appetite Fever Increased heart rate associated with fever Pain Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Cell Death (1 of 3) Apoptosis – Injured cell releases enzymes that engulf and destroy the cell. – Cells shrink. – Eliminating damaged and dead cells allows tissues to repair and possibly regenerate. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Cell Death (2 of 3) Necrosis – A pathological process – Cells swell and rupture – Coagulative – Liquefactive – Caseous – Fatty Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Cell Death (3 of 3) Gangrenous necrosis – Cell death over a wide area – Dry – Wet – Gas Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Fluids and Fluid Imbalances Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Water is the most abundant substance in the human body. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Where the Water Is Found Intracellular fluid—fluid inside the cells Extracellular fluid—all the fluid outside the body cells – Intravascular fluid—fluid within the circulatory system – Interstitial fluid—fluid outside of the cell membranes but not within the circulatory system Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Edema Accumulation of water in the interstitial space due to disruption in the forces and mechanisms that normally keep net filtration at zero Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Mechanisms That Cause Edema A decrease in plasma oncotic force An increase in hydrostatic pressure Increased capillary permeability Lymphatic channel obstruction Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Edema (1 of 2) Can be local or within a certain organ system – Sprained ankle vs. pulmonary edema Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Edema (2 of 2) Water in interstitial spaces is not available for metabolic processes. Edema, therefore, can cause a relative condition of dehydration. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Intravenous Therapy Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Blood Components Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ The percentage of the blood occupied by the red blood cells is termed the hematocrit. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Fluid Replacement Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Transfusion Reactions Transfusion reactions occur when there is a discrepancy between the blood type of the patient and the type of the blood being transfused. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Signs and Symptoms of Transfusion Reactions Fever Chills Hives Hypotension Palpitations Tachycardia Flushing of the skin Headache Loss of consciousness Nausea Vomiting Shortness of breath Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Treatment of Transfusion Reactions (1 of 2) IMMEDIATELY stop the transfusion. Save the substance being transfused. Rapid IV infusion. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Treatment of Transfusion Reactions (2 of 2) Assess the patient’s mental status. Administer oxygen. Contact medical direction. Be prepared to administer mannitol, diphenhydramine, or furosemide. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Intravenous Fluids Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Hemoglobin-Based OxygenCarrying Solutions (HBOCs) Commonly referred to as “blood substitutes” – Compatible with all blood types – Do not require blood typing, testing, or cross-matching – PolyHeme – Hemopure Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Colloids Colloids remain in intravascular spaces for an extended period of time and have oncotic force. – – – – Plasma protein fraction (Plasmanate) Salt-poor albumin Dextran Hetastarch (Hespan) Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Crystalloids Crystalloid solutions are the primary compounds used in prehospital care. – Isotonic solutions – Hypertonic solutions – Hypotonic solutions Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ The effects of hypertonic, isotonic, and hypotonic solutions on red blood cells Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Most Commonly Used Solutions in Prehospital Care Solution Tonicity Lactated Ringer’s Isotonic Normal Saline Isotonic D5W Hypotonic Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Acid-Base Derangements Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Respiratory Acidosis Caused by abnormal retention of CO2 from impaired ventilation due to problems occurring in the lungs or respiratory center of the brain. Respiration = CO2 + H2O H2CO3 H+ + HCO3- Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Respiratory Alkalosis Caused by increased respiration and excessive elimination of CO2. The CO2 level is decreased and the pH is increased. Respiration = CO2 + H2O H2CO3 H+ + HCO3- Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Metabolic Acidosis Results from the production of metabolic acids such as lactic acid. These acids consume bicarbonate ions. Can be the result of dehydration, diabetes, or medication usage. H+ + HCO3- H2CO3 H2O + CO2 Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Compensation for metabolic acidosis begins with an increase in respirations. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Metabolic Alkalosis The pH is increased and the CO2 level is normal. It is usually caused by administration of diuretics, loss of chloride ions associated with prolonged vomiting, and overzealous administration of sodium bicarbonate. H+ + HCO3- H2CO3 H2O + CO2 Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Genetics and Other Causes of Disease Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Many Factors Combine to Cause Disease (1 of 3) Genetics Environment Lifestyle Age Gender Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Many Factors Combine to Cause Disease (2 of 3) Inherited traits are determined by molecules of deoxyribonucleic acid (DNA). Each somatic cell contains 46 chromosomes. Sex cells contain 23 chromosomes. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Many Factors Combine to Cause Disease (3 of 3) An offspring receives 23 chromosomes from the mother and 23 chromosomes from the father. One or more chromosomes may be abnormal and may cause a congenital disease or a propensity toward acquiring a disease later in life. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Most disease processes are multifactorial in origin. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Disease Effects on Individuals Host Agent Environment Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Disease Effects on Populations Incidence Prevalence Mortality Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Family History and Associated Risk Factors Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 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. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 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 Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Endocrine Disorders The most common endocrine disorder is diabetes mellitus. Leading cause of: – Blindness – Heart disease – Kidney failure – Premature death Both Type I and Type II diabetes can be family related. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 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., Essentials of Paramedic Care: Division 1 © 2007 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., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Renal Disorders Caused by a variety of factors, primarily hypertension. EMS is increasingly being called upon to deal with complications of dialysis including: – Problems with vascular access devices – Localized infection and sepsis – Electrolyte imbalances Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 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., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Gastrointestinal Disorders Lactose intolerance Crohn’s disease Peptic ulcers Cholecystitis Obesity Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 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., Essentials of Paramedic Care: Division 1 © 2007 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., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Hypoperfusion Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Hypoperfusion (shock) is inadequate perfusion of body tissues. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Cellular Death Tissue Death Progression of Shock Organ Death Organ System Death Organism Death Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ The Pathophysiology of Hypoperfusion Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Causes of Hypoperfusion (1 of 3) Inadequate pump – Inadequate preload – Inadequate cardiac contractile strength – Excessive afterload Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Causes of Hypoperfusion (2 of 3) Inadequate fluid – Hypovolemia Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Causes of Hypoperfusion (3 of 3) Inadequate container – Dilated container without change in fluid volume (inadequate systemic vascular resistance) – Leak in the container Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Shock at the Cellular Level Shock causes vary; however, the ultimate outcome is impairment of cellular metabolism. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 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. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Glucose Breakdown (1 of 2) Stage one, glycolysis, is anaerobic (does not require oxygen). It yields pyruvic acid, with toxic byproducts such as lactic acid, and very little energy. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Glucose Breakdown (2 of 2) Stage two is aerobic (requires oxygen). In a process called the Krebs or citric acid cycle, pyruvic acid is degraded into carbon dioxide and water, which produces a much higher yield of energy. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Compensation and Decompensation Usually the body is able to compensate for any changes. However, when the various compensatory mechanisms fail, shock develops and may progress. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Compensation Mechanisms The catecholamines epinephrine and norepinephrine may be secreted. The renin-angiotensin system aids in maintaining blood pressure. Another endocrine response by the pituitary gland results in the secretion of anti-diuretic hormone (ADH). Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Shock Variations (1 of 3) Compensated shock is the early stage of shock during which the body’s compensatory mechanisms are able to maintain normal perfusion. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Shock Variations (2 of 3) Decompensated shock is an advanced stage of shock that occurs when the body’s compensatory mechanisms no longer maintain normal perfusion. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Shock Variations (3 of 3) Irreversible shock is shock that has progressed so far that the body and medical intervention cannot correct it. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Types of Shock Cardiogenic Hypovolemic Neurogenic Anaphylactic Septic Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 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 pressures. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Cardiogenic Shock Evaluation The major difference between cardiogenic shock and other types of shock is the presence of pulmonary edema causing: – Difficulty breathing. – As fluid levels rise, wheezes or crackles (rales) may be heard. – There may be a productive cough with white or pink-tinged foamy sputum. – Cyanosis, altered mentation, and oliguria. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Cardiogenic Shock Treatment (1 of 2) Assure an open airway. Administer oxygen. Assist ventilations as necessary. Keep the patient warm. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Cardiogenic Shock Treatment (2 of 2) 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., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Hypovolemic Shock Shock due to loss of intravascular fluid – Internal or external hemorrhage – Trauma – Long bones or open fractures – Dehydration – Plasma loss from burns – Excessive sweating – Diabetic ketoacidosis with resultant osmotic diuresis Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Hypovolemic Shock Evaluation (1 of 2) Altered level of consciousness. Pale, cool, clammy skin. Blood pressure may be normal, then fall. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Hypovolemic Shock Evaluation (2 of 2) Pulse may be normal then become rapid, finally slowing and disappearing. Urination decreases. Cardiac dysrhythmias may occur. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Hypovolemic Shock Treatment Airway control. Control severe bleeding. Keep the patient warm. 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., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Neurogenic Shock Results from injury to brain or spinal cord causing an interruption of nerve impulses to the arteries. The arteries dilate causing relative hypovolemia. Sympathetic impulses to the adrenal glands are lost, preventing the release of catecholamines with their compensatory effects. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Neurogenic Shock Evaluation Warm, dry, red skin Low blood pressure Slow pulse Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 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. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 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, but can take up to an hour. The most rapid reactions are in response to injected substances: – Penicillin injections – Bees, wasps, hornets Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Anaphylactic Shock Evaluation Cardiovascular system: – Vasodilation, increased heart rate, decreased blood pressure Gastrointestinal system: – Nausea, vomiting, abdominal cramping, diarrhea Nervous system: – Altered mental status, dizziness, headache, seizures, tearing Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 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., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Septic Shock An infection that enters the bloodstream and is carried throughout the body. The toxins released overcome the compensatory mechanisms. Can cause the dysfunction of an organ system or result in multiple organ dysfunction syndrome. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 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., Essentials of Paramedic Care: Division 1 © 2007 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., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Multiple Organ Dysfunction Syndrome MODS is the progressive impairment of two or more organ systems from an uncontrolled inflammatory response to a severe illness or injury. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ MODS Stages Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Primary MODS Organ damage results directly from a specific cause such as ischemia or inadequate tissue perfusion from shock, trauma, or major surgery. Stress and inflammatory responses may be mild and undetectable. During this response, neutrophils, macrophages, and mast cells are thought to be “primed” by cytokines. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Secondary MODS The next time there is an injury, ischemia, or infection, the “primed” cells are activated, producing an exaggerated inflammatory response. The inflammatory response enters a selfperpetuating cycle causing damage and vasodilation. An exaggerated neuroendocrine response is triggered causing further damage. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ MODS 24 Hours after Resuscitation Low grade fever Tachycardia Dyspnea Altered mental status General hypermetabolic, hyperdynamic state Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ MODS within 24 to 72 Hours Pulmonary failure begins. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ MODS within 7 to 10 Days Hepatic failure begins. Intestinal failure begins. Renal failure begins. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ MODS within 14 to 21 Days Renal and hepatic failure intensify. Gastrointestinal collapse. Immune system collapse. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ MODS after 21 Days Hematological failure begins. Myocardial failure begins. Altered mental status resulting from encephalopathy. Death. Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Summary Disease Risk Hypoperfusion Shock Multiple Organ Dysfunction Syndrome Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ