Written 01/09/17 Rewritten 3/29/17 for Interior Regional EMS Symposium

Transcription

1 Written 01/09/17 Rewritten 3/29/17 for Interior Regional EMS Symposium

2 MARIA E. MANDICH MD Fairbanks Memorial Hospital Emergency Department Attending Physician Interior Region EMS Council Medical Director University Fire Department Medical Director Chena Goldstream Fire Department Medical Director Ester Volunteer Fire Department Medical Director

3 How to trouble shoot your way through it.

4 WHAT IS SHOCK??

5

6

7 DEFINITION OF SHOCK A state of cellular hypoxia due to reduced oxygen delivery and/or increased oxygen consumption or inadequate oxygen utilization

8 IN OTHER WORDS The patient s cells are: Not getting enough oxygen, Using more oxygen than they re getting, Or they can t use the oxygen they are receiving

9 Pathophysiology Review

10

11

12 The process of maintaining oxygenation and perfusion has many checks and balances..

13

14

15 About 5L per min About 70 bpm About 70 ml

16 CO = HR x SV 4,900ml = 70bpm x 70ml CO = HR x SV 4,900ml = 70bpm x 70ml at rest

17 What happens to CO if: Heart rate doubles? Stroke volume increases? Intravascular volume decreases?

18 Redistribution of blood flow is continuously occurring depending on what activity the body is engaged in or what stressor are affecting the body

19

20

21

22 Understanding blood pressure homeostasis is the key to being able to trouble shoot shock!!!!

23 DEFINITION OF SHOCK A state of cellular hypoxia due to reduced oxygen delivery and/or increased oxygen consumption or inadequate oxygen utilization

24 SHOCK Initially reversible but rapidly may become irreversible resulting in multi organ failure and death Therefore you must recognize it and intervene as soon as possible!!!!!!!!!!!

25 Shock is a sign, not a diagnosis! Since treatment of shock is based on the underlying cause you must find the cause!

26

27 When you don t know the cause it is called Undifferentiated shock Once you figure out the cause you can name it:

28 5 TYPES OF SHOCK: 1. Distributive septic, neurogenic, anaphylactic, end stage liver disease 2. Cardiogenic MI, valve or ventricle septal rupture, arrhythmias 3. Hypovolemic hemorrhagic and non hemorrhagic fluid loss 4. Obstructive PE, tension PTX, constrictive pericarditis, restrictive cardiomyopathy

29 5. Dissociative CO poisoning, cyanide poisoning, severe anemia

30 STUDY OF 1600 PTS ADMITTED TO ICU IN SHOCK: Septic shock 62% Cardiogenic shock 16% Hypovolemic shock 16% Other types of distributive shock 4% (anaphylactic, neurogenic) Obstructive shock 2%

31 SIGNS AND SYMPTOMS OF SHOCK Hypotension Tachycardia Altered Mental Status Tachypnea Cool, clammy, cyanotic skin (not always) Dry mucosa

32 THINGS YOU WONT SEE BUT ARE THERE: Decreased urine output Elevated lactate

33

34 HYPOTENSION Seen in the majority of patients with shock May be absolute (sbp <90, map <65) or relative (a drop in sbp >40mm Hg)

35 Hypotension does not have to be present for the diagnosis of shock Conversely, not every patient with hypotension has shock

36 TACHYCARDIA One of the earliest compensatory mechanisms in shock May not be present if patient is on beta blockers or has intraabdominal bleed

37 TACHYPNEA One of the most sensitive tool for detecting shock Kicks in to correct increasing metabolic acidosis

38 MENTAL STATUS CHANGES Occurs due to lack of brain perfusion causing metabolic encephalopathy Agitation confusion coma

39 COOL, CLAMMY SKIN Peripheral vasoconstriction redirects blood centrally to maintain vital organ perfusion Warm skin does not ensure the absence of shock as the patient may be in compensatory shock or vasodilatory shock

40 OLIGURIA Caused by direct shunting of blood to other vital organs and/or hypovolemia

41 5 TYPES OF SHOCK: Cardiogenic MI, valve or ventricle septal rupture, arrhythmias Hypovolemic hemorrhagic and nonhemorrhagic fluid loss Distributive septic, neurogenic, anaphylactic, end stage liver disease Obstructive PE, tension PTX, constrictive pericarditis, restrictive cardiomyopathy

42

43 CARDIOGENIC SHOCK occurs when the heart fails to pump adequately Decreased CO can be caused by extremes in heart rate, a decrease in force of pumping or damaged heart valves

44

45 Symptoms depend on which side of the heart is involved

46

47

48

49 HYPOVOLEMIC SHOCK Occurs due to loss of intravascular volume Can occurs either gradually or suddenly depending on the cause

50

51

52 DISTRIBUTIVE SHOCK A distribution problem Blood vessels dilate or leak causing blood pressure to drop

53

54

55

56 OBSTRUCTIVE SHOCK occurs when a physical obstruction alters the body's ability to maintain perfusion

57 End Stage Liver disease

58

59

60

61 Beck s Triad

62 DISSOCIATIVE SHOCK Presents with normal heart function, intact and responsive blood vessels, and plenty of blood Perfusion problems occur because the blood has a decreased ability to carry oxygen to the tissues Examples are CO poisoning, cyanide poisoning and anemia

63

64

65 REMEMBER: Treatment depends on the cause!!! 1. Distributive septic, neurogenic, anaphylactic, end stage liver disease 2. Cardiogenic MI, arrhythmias, valve or ventricle septal rupture 3. Hypovolemic hemorrhagic and non hemorrhagic fluid loss

66 4. Obstructive PE, tension PTX, constrictive pericarditis, restrictive cardiomyopathy 5. Dissociative Shock CO poisoning, cyanide poisoning, severe anemia

67 TREATMENT A secure airway with O2 B adequate ventilation

68 Positive pressure ventilation may worsen patient status! Ex: Tension Pneumothorax Hypotension

69

70

71 C 2 large bore IVs wide open total volume given is determined by cause of shock Obstructive Shock (PE or PTX) require cc; Distributive, Hypovolemic and Cardiogenic Shock require much larger amounts

72 In general, give cc bolus then reassess Give fluids until bp and tissue perfusion improve or pulmonary edema occurs DO NOT over resuscitate!

73 Don t forget ECG

74

75

76

77

78

79

80 SHOCK (CARDIOGENIC, HYPOVOLEMIC, DISTRIBUTIVE, SEPTIC) - CAUSES, SYMPTOMS & PATHOLOGY w0cor2svo