Contact Information Tim Hillier, EMT-P Director of Professional Development M.D. Ambulance Saskatoon, SK (306) 975-8825 (Office) t.hillier@mdambulance.com Tim Hillier, EMT-P Shock Kills! By the time you see it, it is probably too late! Overview Anatomy of the circulatory system. Causes of shock. Types of shock. Treatment of shock. 1
Anatomy Heart hollow muscular organ the right heart receives blood from the body and pumps it to the lungs to get oxygen the left heart receives oxygenated blood from the lungs and pumps it all around the body Anatomy Arteries carry oxygenated blood to the body high pressure constrict or dilate to maintain blood pressure spurting blood when cut Anatomy Anatomy Capillaries tiny blood vessels where exchange of oxygen and waste products take place oozing blood when cut Veins return blood to the heart lower pressure steady flow when cut 2
Pulses Importance Of Blood Radial at the wrist Usually? indicates a blood pressure above 80mmhg systolic Carotid at the neck Usually? indicates a blood pressure above 60mmhg systolic Mosquito Food Respiratory Functions Carrier Of O 2 and CO 2 Nutrition Functions Carrier Of Sugars and Nutrients Excretion Functions Carrier Of Waste Products Importance Of Blood Regulatory Functions Carrier Of Hormones To Organs Regulates Temperature Defensive Functions Carrier Of Defensive Cells Shock Definition Inadequate Tissue Perfusion Flow of oxygenated blood to the tissues Removal of waste from the tissues Every cell needs perfusion 3
Low Blood Pressure Does Not Equal Shock! Shock Can Be Injury or Illness Related. Causes of Shock Failure of the heart or obstruction of vessels (inadequate pump) Fluid loss (loss of volume) Blood vessels dilate with same amount of fluid (inadequate vessel control) Types Of Shock Hemorrhagic Shock Cardiogenic Shock Neurogenic Shock Anaphylactic Shock 4
Types Of Shock Rick Mercer Report Psychogenic Shock Metabolic Shock Septic Shock Respiratory Shock C Stages of Shock Shock is a progressive syndrome that passes through three stages; compensated decompensated irreversible Compensated Shock The body uses its normal mechanisms in an attempt to maintain normal function Clinical symptoms minimal minimal increase in pulse rate cool skin decreased capillary refill barring further loss/complications, the body will recover in 24 hours 5
Decompensated Shock A point when the body s compensatory mechanisms fail and normal function cannot be maintained Patient is in rapid decline Irreversible Shock Cells in the vital organs begin to die from inadequate tissue perfusion Hemorrhagic/Hypovolemic Blood Loss Plasma Loss (Burns) Classification of Hemorrhage The average adult has» 5-6 liters of circulating blood. 6
Class I Hemorrhage (Mild) Represents a loss of 15% or less of circulating volume 750 ml or 1.5 units of blood No clinical signs other than perhaps a slight increase in the pulse rate Little or no change in the BP Respiratory rate remains normal Class II Hemorrhage (Moderate) Represents a loss of 20-25% of circulating volume 1000-1250 ml or 2-2.5 units of blood Clinical signs: tachycardia-p>100 bpm tachypnea-r³24/min systolic/ diastolic (narrowing pulse pressures) pallor, thirst, weakness Class III Hemorrhage (Severe) represents a loss of 30-35% of circulating blood volume 1500-1800 ml or 3-3.5 units of blood clinical signs similar to Class II with the following urinary output LOC agitation Class IV Hemorrhage (Catastrophic) represents a loss of 40-50% of circulating volume 2000-2500 ml or 4-5 units of blood clinical signs unresponsive weak/faint rapid pulse unobtainable BP 7
How the body reacts: Signs and symptoms Blood loss (hypoperfusion) Catecholamine release (Adrenaline) Epinephrine, norepinephrine BP maintained, increased heart rate, vasoconstriction, sweating Altered consciousness : mild (early sign) - to severe (late) Weakness Thirst (caused by hypovolemia) Pallor (from vasoconstriction) Tachycardia (from catecholamine release) More S/S Vital Signs Tachypnea (from hypoxia) Delayed capillary refill Diaphoresis (from catecholamines) Nausea and vomiting Decreased urinary output Hypotension (late sign) Pupils dilated (late sign) Pulse Blood Pressure Respirations Skin - Rapid and Weak - Normal to Low - Shallow and Rapid - Pale - Sweaty - Cool 8
Management of Shock Management ABC s with C-spine control Stop bleeding Secondary survey Base line vitals q5min if possible Oxygen therapy (high flow) Exposure/Environment If you are comfortable, the patient is too cold Hypothermia hampers resuscitation Immobilize and splint fractures as appropriate Give nothing by mouth Control of Bleeding TOURNIQUETS ARE ALMOST NEVER NECESSARY TO CONTROL BLEEDING Making a comeback Things to remember with hemorrhagic shock Young healthy people may lose more than 30% of circulating volume before there is a drop in their BP Easy to underestimate the severity of blood loss until it is too late All Bleeding Stops Eventually! 9
Cardiogenic Shock Heart Attack Heart Failure Cardiogenic Shock The heart loses the ability to supply all body parts with blood Usually the result of left ventricular failure secondary to acute MI or CHF S/S of Cardiogenic Shock TX for Cardiogenic Shock Major difference between other types of shock is presence of Pulmonary Edema Difficulty breathing Abnormal breath sounds are heard as fluid levels increase Productive cough with white or pink-tinged foamy sputum Cyanosis Altered mental status Assure open airway Reassurance Administer oxygen Assist ventilations as needed Keep patient warm Place patient in position of comfort Establish Iv with minimal fluid administration Monitor Vitals 10
Neurogenic Neurogenic Caused by dilation of blood vessels secondary to nervous factors such as: Spinal Cord Injury Brain damage. Results in vasomotor collapse & venous pooling. Neurogenic Anaphylactic Signs and Symptoms. Decreased LOC Normal to pink skin Respiratory rate unchanged Heart rate normal to low Decreased B/P. Treatment Assure open airway Reassurance Immobilization/PASG? Administer oxygen Assist ventilations as needed Keep patient warm Iv Monitor Vitals Extreme Allergic Reaction 11
Anaphylactic Shock Anaphylactic Shock Causes Insect bites and stings Foods and spices Inhaled substances Chemicals Drugs Signs Skin may break out or burn/itch Face and tongue may swell Breathing is difficult Pulse is weak Patient may go unconscious Anaphylactic Shock Treatment Reassurance High flow oxygen Assist with Epi-pen? Maintain body temperature ALS EPI / Diphenhydramine / Methylprednisolone Psychogenic Extreme Emotional Reaction Temporary 12
Metabolic Loss Of Fluid Severe Diarrhea, Vomiting, Excessive Urination Occurs with some disease processes such as diabetes. Septic Poisons Are Released In The Body Causes Blood Vessels To Dilate Usually develops in people with a chronic disease or a severe infection C We re All Getting Older. 13
Changes of Aging Cardiovascular Decreased cardiac output. Less able to respond to stress Fight or flight diminished Changes of Aging Pulmonary What About The Little People? Less elasticity. Less compliance and surface area. 14
Little Men, Little Women Smaller Blood Volume Greater Body Surface Area Relative To Weight More Flexible Bones Development in Progress Management Controversies MAST? High flow IV s? What s New? ResQGard What s New? Coiled IV Tubing 15
What s New? What s New? STo2 Hydrogen Sulfide? Dr Mark Roth You think I m Kidding! 1907 Nobel prize for keeping the top half of a dog alive (Alexis Carrel) 1971 Rhesus monkey heads alive for 36 hours (Case Western Reserve University, Cleveland) US patent#4666425 (Chet Fleming) 16
Pitfalls to Treating and Identifying Shock Shock Raising the BP does not mean you have taken care of the problem Age Elderly fare worse with the same injuries Medications may mask signs of shock Pacemakers Young and Healthy May maintain for long periods then rapid decline Shock must be prevented before it starts. You do this by caring for your whole patient. Summary Shock is a critical condition You must not wait for the signs to become obvious Knowledge of shock will help you to identify it quickly Treat for shock before you see it Summary Expect shock before you see it By the time you see shock, it is almost too late The Silent Killer 17
Contact Information Tim Hillier, EMT-P Director of Professional Development M.D. Ambulance Saskatoon, SK (306) 975-8825 (Office) t.hillier@mdambulance.com 18