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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