הלם- Shock Dan Drory, MDA Paramedic and Instructor, 2011
What is shock? A decrease in supply of oxygen to body tissue. Blood distribution depends on all of the following: Pump ( heart ) Plumbing ( vessels ) Fluid ( blood )
Kinds of shock Hypovolemic Fluids loss Septic Dilation of the vessels Anaphylactic Dilation of the vessels Neurogenic Dilation of the vessels Cardiogenic Failure of the heart
How does it work? Once the brain and the kidneys sense lowering of oxygen supply, they act ( in two different ways ) to increase it. The first to show its effects is the Sympathetic system ( of the autonomic nervous system ) that causes the heart to contract faster.
So what happens in shock? Phase 1: blood pressure starts going down for what ever reason. Phase 2: heart rhythm accelerates in order to bring the blood pressure to normal and manages to do so ( Compensated ). Phase 3: no matter how fast the heart goes, the blood pressure keeps going down. Peripheral vessels close, but even that is not enough, level of consciousness will start to decrease ( Uncompensated ). Phase 4: Heart rhythm is even higher. The blood pressure is so low, that the brain suffers from hypoxia. The body fails to correct this low BP by itself ( Irreversible )
Let s review compensated uncompensated irreversible HR + ++ +++ BP normal - --- RR normal + ++ LOC normal normal ( - ) --- Skin normal Pale \ Wet white Digestion normal Nausea \ vomiting none Let s see if you follow What changes first? What? I can t hear you!
Hypovolemic Shock Loss of fluids will be compensated by the rise in pulse and constriction of vessels. First the vessels that supply blood to the digestion system and than to the skin.
Hypovolemic Shock - Signs Remember the table two slides earlier?
Septic Shock Infection that have spread to the blood will cause vasodilatation and relative decrease of blood volume will take place. Those patients might show redness of skin and fever.
Septic Shock - Signs Similar to Hypovolemic shock but: Redness of skin ( possible ) Fever ( possible ) Red and Hot for touch but no hyperthermia ( probable )
Anaphylactic Shock Autoimmune system will hyper react to minor\vast stimulation. It will do so by vasodilatation which will cause fluids to escape from the vessels to the tissue around them. Both relative decrease in blood volume and a very real one.
Anaphylactic shock This might be caused even by a touch with an animal sting\byte\food\material. A distention must be made between Allergic reaction and Anaphylactic shock. The first does not involve several systems. The main system that presents danger to the patient is the obstruction of the airway because of swelling.
Anaphylactic Shock Anaphylactic Shock could come along with anaphylaxis but they are two separate reactions to an allergen. Anaphylaxis is a severe, whole-body allergic reaction to a chemical that has become an allergen. After being exposed to the allergen, the person's immune system becomes sensitized to it. This reaction happens quickly after the exposure and is severe.
Anaphylactic Shock - Signs Signs of hypovolemic shock Itching Redness of skin, Rush Wheezing Cough, Sneezing Nausea, Vomiting Hoarseness Swelling ( Neck and Face )
Spinal \ Neurologic Shock The vessels receive commands from autonomic nervous system ( Sympathetic and Parasympathetic ). Other ways also exist but lets focus. The spine supplies the sympathetic transmittion. Once the conduction fails the parasympathetic system is the main one to determine the diameter of the vessels, and it dilates.
Spinal \ Neurologic Shock Signs If a spinal injury happens, a vasodilatory effect is to be expected below the injury line. Lower back red and swallen legs ( and penis ) In a neurologic shock a bradycardia might present first to acceleration in heart beat, but only in first ( very early ) stage. That, if the vagous nerve was stimulated. Otherwise, a usual hypovolemic presentation.
Cardiogenic Shock Or When the pump Fails Acute Congestive Heart failure ( Pulmonary Edema ) Acute MI Tamponade Tension Pneumothorax
Cardiogenic Shock - Signs Same as Hypovolemic Shock and Signs of Pulmonary Edema ( possible ) Signs of AMI ( possible ) Signs of tamponade ( possible ) Signs of Tension Pneumothorax ( possible )
Treatment Same treatment for all kinds of shock! By the ABC, by PHTLS if needed IV Fluids ( medic authority only ), to sustain BP at 90 Not higher or lower! ( Pop the cloth ) Consider MICU
Emphasis The most reliable measurement of state of shock is pulse Normal BP does not rule out shock, but low BP with elevated pulse points to it. Hence, constant monitoring of the patient is very important
Questions?