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

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

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

How to trouble shoot your way through it.

WHAT IS SHOCK??

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

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

Pathophysiology Review

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

About 5L per min About 70 bpm About 70 ml

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

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

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

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

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

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!!!!!!!!!!!

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

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

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

5. Dissociative CO poisoning, cyanide poisoning, severe anemia

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%

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

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

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

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

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

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

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

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

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

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

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

Symptoms depend on which side of the heart is involved

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

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

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

End Stage Liver disease

Beck s Triad

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

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

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

TREATMENT A secure airway with O2 B adequate ventilation

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

C 2 large bore IVs wide open total volume given is determined by cause of shock Obstructive Shock (PE or PTX) require 500 1000cc; Distributive, Hypovolemic and Cardiogenic Shock require much larger amounts

In general, give 500 1000cc bolus then reassess Give fluids until bp and tissue perfusion improve or pulmonary edema occurs DO NOT over resuscitate!

Don t forget ECG

SHOCK (CARDIOGENIC, HYPOVOLEMIC, DISTRIBUTIVE, SEPTIC) - CAUSES, SYMPTOMS & PATHOLOGY https://www.youtube.com/watch?v=1g w0cor2svo