EMS shock lex.ppt

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Shock: Types and PrehospitalTreatment

September 21, 2004

Todd Lang, MDVVMC EMS Medical Director


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Goals

Define Shock

Review types of shock and their essentialfeatures

Understand bodys response to shock at

basic level


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Goals (contd)

Distinguish between types of shock

Distinguish compensated vs.decompensated shock

Identify field interventions that help

and those that dont


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Definition of Shock

A condition resulting in inadequate

perfusion of tissue with impaired

tissue oxygenation

A true emergency

But, one which has many

treatments


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SHOCK

Preshockknown as warm shock orcompensated shock

homeostatic mechanisms rapidly compensate fordiminished perfusion

Despite a 10 percent reduction in total effectiveblood volume, a previously healthy adult may be

asymptomatic Tachycardia, peripheral vasoconstriction, modest

decrement in systemic blood pressure


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SHOCK

ShockDuring this stage, regulatory

mechanisms are overwhelmed - signs and

symptoms of organ dysfunction appear:

This usually occurs after a 20 to 25 percent

reduction in effective blood volume


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Shock Types Basic types

Hypovolemic - loss of volume

Cardiogenic - failure of pump

Failure of supply to pump (PE, pneumothorax, tamponade)

Vasogenic - failure of pipes-Septic

Special types

Neurogenic - spinal cord injury

Anaphylactic - allergic reaction

Psychogenic - Faintingsituational

High outputcirrhosis, AV fistula (rare)


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Hemodynamic

Classification of ShockType PAP CO SVR

hemorrhagic decr decr incr

cardiogenic incr decr incr

distributive nl nl decr

decr incr decr

obstructive incr decr incr


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Common

Pathophysiology Early Phase

Preservation of Cardiac Output

Catecholamine release: Sympathetic stimulation increased HR,

enhanced contractility

increase SVR

Maintain arterial pressure

Venoconstriction - increase preload/fillingpressure


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Shock Signs and Symptoms

(Lack of Effective Organ Circulation) Restlessness and anxiety

Nausea, occasional vomiting

Weakness and fatigue

Cyanosis

Dull or lusterless eyes Falling blood pressure

Changes in mental status


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Shock Signs and Symptoms(Bodys Attempt to Compensate)

Rapid pulse, later becomes weak and

thready

Cold, clammy, pale skin

Thirst

Abnormal respirations usually rapid at first,

then labored, and finally gasping


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Age Variation

Compensatory reflexes may be more prominently

demonstrated in young adults.

Considerable variability exists at extremes of age.

Most notably, younger individuals are able to

maintain normal blood pressure until vascular andcardiac decompensation is imminent.


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Different Shocks Have a Lot in

Common! Hypotension

Changed mental status

Difficulty breathing

Pale

Look very sick!


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Assessment of Shock

Reconstruct mechanism of injury (MOI) or nature

of illness (NOI) (!)

Assess airway and effectiveness of breathing

Take, record, and monitor vitals (!)

Assess mental status - AVPU or Glasgow Coma

Scale! - and activity levelkeep it simple

Check skin temperature and feel Check capillary refill


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Emergency Care of Shock

Urgent survey and interventions: secure airwayand control bleeding

Rapid body survey: administer high concentrationO2, treat injury or illness - splint fractures, and

keep supine and elevate lower extremities 12inches, unless contraindicated

Ongoing survey: maintain body temperature -warm not hot, nothing by mouth, and monitor and

record vitals Transport to hospital as soon as possible


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BLOOD PRESSURE GOAL

about 90 systolic/MAP of 60

But, treat the patient, not the

number! Be distrustful ofnumbers that dont fit.

Check MS, pulses, cap refilland manual BP.


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CEREBRAL PERFUSION

PRESSURE (CPP)

MAP-ICP = CPP

65-5 = 60 mmHG


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Normal Hypertensive

Relative

CBF

(Autoregulation)

50 100 150 200

MAP


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Treatment of Shock

AKA When to do a fluid bolus


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FOR MOST ACUTELY HYPOTENSIVE PTS:

if

PULMONARY EDEMA Absen t

then

FLUID CHALLENGE IS AN APPROPRIATE

FIRST RESPONSE

Basical ly , i f i t is not cardiogenic and theyare oxygenating OK, then do i t .


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BOLUS OF FLUID

HOW MUCH? 500-1000 (up to 3L OK)

HOW FAST? KVO or Wide open only.

The heart and kidneys take care ofovershooting, if they work. Young

people will not suffer from over-

resuscitation.


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Key Concept:

Intravascular Volume 5% Actual Body Weight

8% Total Body Water

We must change intravascular volume to raiseblood pressure. It wont change unless we putfluid into veins fast because they leak fluid to the

rest of the body. Like trying to fill up a tire with a leak in ityou

gotta pump the air in fast or it stays flat!


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DURING RESUSCITATION

REMEMBER TO MONITOR:

MENTAL STATUS

VITAL SIGNS (MAP - O2 SATS)

URINE OUTPUT

SKIN PERFUSION

(LACTATE)


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Pulmonary Edema is a Cardinal

Sign of Cardiogenic Shock!

So, look for it specifically in every

patient who is in the ambulance, priorto giving fluid bolus.


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You CAN detect Pulmonary

Edema in the Ambo!! Are you SOB?

Prior CHF or MIs

Meds list Sx of MI lately?

Orthopnea (can you breath when you lie

flat)? Absence of hemorrhage, sepsis, volume loss

from other cause


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Examine for Pulmonary Edema

SaO2

Uncontrolled Afib or SVT?

(Can be hypovolemia) Resp rate

Jugular Venous distention

Crackles and occasionally wheezes Decreased breaths at lung bases (effusions)

Edema of legs or sacral area


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Pulmonary Edema Bat wings


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Cardiogenic Shock

Clinical Presentation

Hypotension - < 80 syst., decr. of

90 mm Hg in patient with HTN Cool diaphoretic skin, dyspnea,

disorientation, oliguria

May or may not be tachycardic


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Cardiogenic Shock

Management Principles

Primary Goal: Improve myocardial

functionDecrease O2consumption (VO2)

Intubation, sedation, analgesia

Increase O2delivery (DO2)

Optimize CI, Hgb., Hgb. sat. (SaO2)


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Cardiogenic Shock

Management Methods

Pharmacologic Manipulation

Preload (RAP,PAP) - morphine,nitro, lasix, volume

Cardiac contractility - inotropes,chronotropes, vasopressors

Afterload (PVR,SVR) - nitro, beta-blockers


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Hemorrhagic Shock


Early Phase

Tachycardia, narrow pulsepressure, may exhibit orthostatic

changes in HR/AP

Healthy patient with 25-30% loss

may exhibit only these signs


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Hemorrhagic Shock

Less healthy patients will exhibit

rapid decompensation with this

magnitude of volume lossLater Phase

Cool moist skin, hypotensive, pale,

anxious, disoriented, oliguric

KEY: EARLY RECOGNITION


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Hemorrhagic Shock

Restoration of intravascular volume

Initial Management:

OxygenStop the hemorrhage

Fluids

Transfusions


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Distributive Shock

Peripheral vascular dilatation disproportionate to

existing intravascular volume.

Septic/Systemic inflammatory

Shock (SIRS)

anaphylaxis,spinal shock


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Definitions:

Sepsisa syndrome of shock caused byinfection

Bacteremia - defined as an organism ororganisms that are circulating in the blood\

Systemic Inflammatory ResponseSyndrome (SIRS) - the systemic response toa variety of insults which activate commoninflammatory mechanisms.


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Septic Shock: High Mortality

1909 Jacob 41%

1924 Felty & Keefer 32%

1950 Minn. General 33%1974 Boston Hosp. 32%

15 other studies 40%

Due to bacteremia 20%


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Risk Factors for the Development of

SIRS*: Neutropenia (ANC < 500/mm3)

Severe underlying disease

Corticosteroid therapy

Burn injury

Advanced age

Deficient immunity

Recent prior surgery Instrumentation - ET tube, IV catheter, Foley, arterial lines* Adapted from Piper J.Probl Crit Care 1990;4:90-124.


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SIRS: Inflammatory Shock

Defined as presence of 2 or more of the following:

Hyperthermia (> 38C) or hypothermia (< 36C)

Tachycardia (HR > 90 bpm) without b-blockers or Cablockers

RR > 24 bpm or arterial PCO2< 32 mm Hg

leukocytosis (WBC > 12,000/mm3) or leukopenia ( 15% band forms


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Septic Shock and Inflammation

Results in microvascular clotting and activation of the

clotting cascade.

Activates immune cells throughout body

Activated stress hormone response

Some responses seem to be helpful in survival, others seem

to be harmful to survival


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Significant Differences Between

Early Septic Shock and

Cardiogenic/Hypovolemia Shock

Warm skin rather than cold, clammy skin

An increase in cardiac output rather than a

decrease in cardiac output


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Septic Shock


Early Phase

Vasodilatation, CO nl. or high, fever,agitation/confusion, hyperventilation

Often, fever and hyperventilation are

the earliest signs.

Hypotension may not be present.


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Septic Shock

Late Phase

CO decreased, hypotension,

vasoconstriction, impaired perfusion,

decreased level of consciousness,

oliguria, DIC

Atypical Presentation

Elderly/debilitatedFever, respiratoryalkalosis, confusion, hypotension


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Complications of SIRS with Shock

Acute Renal Failure

Disseminated Intravascular Coagulopathy

Adult Respiratory Distress Syndrome

Unresponsive Hypotension

GI bleed


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Prehospital Treatment of Septic Shock Patient

History: focus on possible source of

infections, allergy to abx, recent abx use

Often wont be intubated w/o RSI

Oxygen: face mask good choice


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Prehospital Treatment of Septic Shock Patient

2

IV access 1-2 sites of good size

Fluid bolus for hypotensive or tachycardic

Possibly pressors like dopamine

Rapid transport


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Inpatient Treatment of Septic Shock Patient

Fluids

Vasopressors-dopamine/norepinephrine

Antibiotics

Steroids?

Other avenues?


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Anaphylactic shock

Dont fail to diagnose

Low threshold for Epi use in people with

healthy hearts and blood vesselsCertainly use it if airway symptoms or

hypotension

Beware of GI symptoms Aggressive IV fluids as above


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Spinal Shock

Rare

May be mixed in with hemorrhagic shock

Treatment is the same

Often a younger patient since they are the

ones that break their back and live.

Fluid tolerant


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Case 1

Healthy 38 yo man in farm accident avulsed his Rarm at elbow and bled profusely at the scene. His

brother tourniqueted the stump and controlled

bleeding after significant blood loss. Bloodeverywhere.

VS 96.0 100/60 124 22

Anxious, pale, man acutely ill. Missing R hand,tourniquet in place, cool extremities.

What should you do for his fluid status?


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Case 1- Basic trauma patient

He needs 2 large boreIVs

Give 2L wide openNS/LR

His history is enoughto know he can handlea lot of fluid

His HCT/Hb will benormal acutely

Use VS changes to

assess response and

volume status

He will need blood, so

prepare for this.


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Case 2

4 yo boy with hx asthma has 5 days vomiting anddiarrhea. Cant keep anything down per mother.Still tries to eat or drink. Less playful, poor

appetite. Mother is obviously frustrated. VS 99.5 110/56 100 16 weight 17 kg

Sleeping child, but fussy and tearful on arousal.Otherwise nl exam.

Bun 33/Cr .8, Urine sp gr 1.030, bicarb 12

What is indicated here?


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Case 2-pediatric dehydration

Take a good history. How many times and

how oftenhas he been vomiting? Ask

questions until you understand. Assess whether oral rehydration has been

adequately tried. Often, it has not.

Resuscitation fluid is lactated ringers


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Case 2-pediatric dehydration

Maintenance fluid is D5 NS

Use the formula to calculate bolus and

maintenance fluids

Give 1-2 boluses of 20cc/kg isotonic fluid

Children are very fluid tolerant


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Case 3

77 yo woman who has hx of CHF and CRIwith several days of changed mental status

and poor PO VS 99.5 155/88 92 16

Thin, elderly, pleasantly confused in NAD.Lungs: crackles both bases. CV: 3/6 SMand irreg irreg. No peripheral edema.

What is appropriate from here?


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Case 3-unclear volume status

Not obvious whether shes wet or dry from

the storyCHF + poor PO intake

Be cautiousdo further investigation

Use labs, serial exams, chest film


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Case 3-unclear volume status

Either try fluids or try diuretics

Not a good patient to give an ambulance

fluid bolus to unless discussed withphysician.


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Case Presentation:

A 77 yo man calls you for feels sick. He has ahistory of CHF, COPD (from smoking), andIDDM. Over the past several days he has

complained of fever to 101, chills, and aproductive cough. This has been increasing infrequency and his symptoms are getting

progressively worse. He started getting dizzy

today and is feeling very weak. Vital signs areT=101.7, HR=132, RR=30, BP=80/42, RASaO2=84%.


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Probably Septic from Lung

Oxygen

IV

Fast H&P

Assess for pulmonary edema

Bolus 500cc open and recheck vitals to

assess response


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Thanks!

Any Questions?

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