avoiding the train wreck of shock kay kamish, rn, bsn, emt-p tulsa life flight

Avoiding the Train Wreckof SHOCK

Kay Kamish, RN, BSN, EMT-PTulsa Life Flight

OBJECTIVES

‡ Define the four types of SHOCK‡ Understand the difference in etiologies‡ Recognize the progression of symptoms‡ Understand the difference in approach to

treatments

Train Wreck of SHOCK

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

Inadequate tissue perfusion

Inability of the body to keep up

with the tissue demand for oxygen

and nutrients.


Train Wreck of Shock

* FOCUS of INTERVENTION:

* Identify the type of Shock

* Initiate the proper care

SHOCK

TYPES of SHOCK

› Hypovolemic


› Cardiogenic

› Distributive

› Obstructive


HYPOVOLIEMIC SHOCK

* Hemorrhage

* Vomiting

* Diarrhea

* Third Spacing

* Diuresis

SHOCK -- Hypovolemic

• Low volume -- poor carrying capacity of the cells -- not enough ‘freight’

CARDIOGENIC 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

NEUROGENIC Loss of normal sympathetic vasoconstriction

* spinal cord injury

* severe pain

* vasomotor center depression d/t drug OD


DISTRIBUTIVE 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


* Arterial Stenosis

* Pulmonary Embolism

* Pulmonary Hypertension

* Cardiac Tamponade

* Tension Pneumothorax


Review: Four Types of SHOCK

HYPOVOLEMIC Volume Loss

CARDIOGENIC Heart Failure

DISTRIBUTIVEVasodilation

OBSTRUCTIVE

SHOCK

• You have the engine (the heart) but no cars (volume) and too many tracks to fill up (excess venous capacitance).


STAGES 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


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


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


** 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


\\ 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


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


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



Cardiac Output

CO = Heart rate X Stroke volume

Normal CO = 4 to 6 Liters/ minute

Normal SV = 60 to 100 cc

Normal HR = 60 to 100 bpm



Cardiac Output Increases

WHY ?

To perfuse Vital Organs :

heart, lungs, brain, kidneys



Pathophysiology

> Renal & Chemical Compensation

> Renal vasoconstriction

decreased perfusion

stimulates release of:

* ADH

* Aldosterone

* Catecholamines

Clinical Signs

> Decreased urinary output

> Skin cool, clammy, mottled> Pupils dilated

> Decreased bowel sounds

> Hyperglycemia

WHY?



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


Pathophysiology

* Decrease of blood to the pulmonary

system

* Leads to poorer oxygenation of

all organ systems

Clinical Signs

* Restlessness

* Mental confusion* Agitation

* Lethargy



** 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


If shock is allowed to proceed to this stage the patient’s condition

will deteriorate rapidly

\\ ** THIS IS A LIFE THREATENING STAGE **//

PROGRESSIVE

SHOCK

• Progressive Shock -- if condition is unchecked, patient will deteriorate rapidly!

STAGES of SHOCK - Progressive


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


* 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 Why?

>> 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


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


What can we, in EMS, in the pre-hospital setting, do to help avoid this disaster?

SHOCK

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


Hypovolemic Shock

GOAL :

Restore Fluid Volume

SHOCK - Treatment


Hypovolemic

Fluid Choices:

Crystaloids

Normal Saline

Lactated RingersSodium

Chloride

Potassium

Calcium

Lactate

SHOCK - Treatment


Hypovolemic

Fluid Choices: CrystaloidsAvoid 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


Hypovolemic

Fluid Choices: Colloids Protein Containing

Tend to stay in the vascular system “Volume Expanders”

* PRBCs

* Plasma

* Serum albumin

* Dextran

* Hespan

SHOCK - Treatment


Hypovolemic

What if the patient does not respond to fluids ?

Reassess !

May need medications to:

promote venous return

enhance contractility

improve myocardial perfusion

Epinephrine Norepinephrine (Levophed)

SHOCK - Treatment


Cardiogenic

Remember this is a failure in the strength of the heart - volume is not necessarily the

problem

GOAL: Improve myocardial function

SHOCK - Treatment


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


Common Sense IV, O2, Monitor

Transport supine

Raise legs if necessary

Cardiogenic

SHOCK - Treatment


Cardiogenic

Medications if Available :

Dopamine --

Dobutamine --

Levophed --

Low range (‘renal dose’) increases urinary outputMid range stimulates receptors

High range stimulates receptors

Direct stimulator

Potent inotropic agent; predominantly - adrenergic

SHOCK - Treatment


Distributive

Remember ~

this is due to the loss of sympathetic

tone, resulting in pooling of blood in

venous and capillary beds.

SHOCK - Treatment


Distributive

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

DistributiveTrain Wreck of Shock

Septic Shock

Provide aggressive fluid resuscitation

What will you do if blood pressure continues to drop ?

Vasopressors

Inotropic drugs

SHOCK - Treatment


Neurogenic Shock

Typically the result of head injury or spinal cord injury

Initial Symptoms:

Hypotension

Bradycardia

Hypothermia

Warm, dry skin

What symptoms are

present here that are

opposite to other forms of

shock ?

SHOCK - Treatment


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


Anaphylactic Shock

Hypersensitivity to an environmental exposure

Food

Venom

Medications

SHOCK - TreatmentDistributive


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 - TreatmentDistributive


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

Obstructive Shock


Figure out what is being obstructed

and why

SHOCK - Treatment


Obstructive Shock

What is obstructed?

Airway?? (As if no oxygen is loading onto the train) Tension Pneumothorax

Circulation?? (Something is hampering the engine.)

Cardiac Tamponade

SHOCK - Treatment


Obstructive Shock

** Treatment is emergent in both cases **

Needle decompression

Pericardiocentesis

SHOCK - Summary


TYPES of SHOCK

HYPOVOLEMICCARDIOGENIC

DISTRIBUTIVE

OBSTRUCTIVE

SHOCK - Summary


STAGES OF SHOCK

EARLY

COMPENSATORY

PROGRESSIVE

REFRACTORY

SHOCK - Summary


Types Causes

Hypovolemic* hemorrhage* vomiting and diarrhea

Cardiogenic * heart failure

Distributive* septic* neurogenic* anaphylactic

Obstructive * tension pneumothorax* cardiac tamponade

SHOCK - Summary

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

* fluid resuscitation* Vasopressors* Inotropes* Antihistmines

Obstructive * tension pneumothorax* cardiac tamponade

* Relieve obstruction


SHOCK

• SHOCK -- Hopefully does not need to end in disaster

avoiding the train wreck of shock kay kamish, rn, bsn, emt-p tulsa life flight

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