66 Shock & Fluid Resuscitation

Shock & Fluid Resuscitation

LessonLesson

Prehospital Trauma Life Support Prehospital Trauma Life Support

Developed by the

National Association ofEmergency Medical Technicians

Developed by the

National Association ofEmergency Medical Technicians

In cooperation withThe Committee on Trauma,American College of Surgeons

In cooperation withThe Committee on Trauma,American College of Surgeons

This slide presentation is intended for use onlyin approved PHTLS courses.

This slide presentation is intended for use onlyin approved PHTLS courses. 6-1B6-1B

Lesson 6 ObjectivesLesson 6 Objectives

Correlate perfusion, hypoperfusion, hypoxia, hypovolemia and hypotension to the signs and symptoms of shock.

Differentiate between early and late signs of shock.

Describe the pathophysiological changes of shock.

Identify the management of shock, including conservation of heat, fluid replacement and the pneumatic anti-shock garment.

Correlate perfusion, hypoperfusion, hypoxia, hypovolemia and hypotension to the signs and symptoms of shock.

Differentiate between early and late signs of shock.

Describe the pathophysiological changes of shock.

Identify the management of shock, including conservation of heat, fluid replacement and the pneumatic anti-shock garment.

6-26-2

Shock:Shock:

6-36-3

A rude unhinging of A rude unhinging of

the machinery of the machinery of

life.life.Samuel Gross, Samuel Gross, 18521852

Shock Redefined:Shock Redefined:

6-46-4

Pitfall: Defining shock as decreased blood pressure.

Lack of end-tissue perfusion.Lack of end-tissue perfusion.

ScenarioScenario

You are caring for the sole victim of a

motorcycle crash. He is lying on the

ground next to his motorcycle. The

scene appears safe.

6-56-5

Findings Findings

A - Open, clear.

B - RR fast. BS clear. Bruising noted over sternum; no other chest deformity.

C - Radial pulse weak & rapid.

D - PEARL. Anxious & confused. Normal movement & sensation.

E - No deformity noted. Skin cool & diaphoretic.

A - Open, clear.

B - RR fast. BS clear. Bruising noted over sternum; no other chest deformity.

C - Radial pulse weak & rapid.

D - PEARL. Anxious & confused. Normal movement & sensation.

E - No deformity noted. Skin cool & diaphoretic.

6-66-6

Is this patient in shock?

Why?

What is the patient’s real problem?

Is this patient in shock?

Why?

What is the patient’s real problem?

DiscussionDiscussion

6-76-7

Cell Perfusion Cell Perfusion

6-86-8

Aerobic metabolism requires adequate oxygenation.

Cells require oxygen and sugar to produce energy and carbon dioxide.

Aerobic metabolism requires adequate oxygenation.

Cells require oxygen and sugar to produce energy and carbon dioxide.

Is the patient in this Is the patient in this scenario adequately scenario adequately perfusing his cells?perfusing his cells?

Anaerobic Metabolism Anaerobic Metabolism

6-96-9

Inadequate oxygenation Inadequate oxygenation for metabolism.for metabolism.

By-products: Less energy.

More acid.

Potassium.

By-products: Less energy.

More acid.

Potassium.

Leads to Acidosis• Inadequate oxygen delivery, cellular

extraction, and consumption result in cellular conversion to anaerobic metabolism for energy substrate production (ATP production)

• Increased production and release of lactate

Shock

Tissue injury

Organ dysfunction syndrome

Multiple organ failure

Death

Definition – Decreased utilization of oxygen by the tissues

If prolonged - downward spiral

Cellular DeathCellular Death

6-106-10

SHOCKCellular Hypoxia - Anaerobic

Metabolism

Hypotension

Hypoperfusion

Cellular Hypoxia

Anaerobic Metabolism

Cell DeathIf cellular death is not If cellular death is not prevented, organism prevented, organism death will follow.death will follow.

Staged DeathStaged Death

Organism death: May be quick - prior to EMS.

May be prolonged - 2 to 3 weeks later.

Occurs in stages: Stages occur as the body tries to

compensate.

We see the stages through signs & symptoms.

Organism death: May be quick - prior to EMS.

May be prolonged - 2 to 3 weeks later.

Occurs in stages: Stages occur as the body tries to

compensate.

We see the stages through signs & symptoms.

6-116-11

What Organs Fail?Combination of respiratory failure

(ARDS) with renal failure, metabolic failure, or cardiac failure– Poor prognosis

Mortality rate– One organ/systems 40%– Two organ/systems 60%– Four or more 100%

Recognize shock early.

Restore cellular perfusion.

Restore aerobic metabolism.

Recognize shock early.

Restore cellular perfusion.

Restore aerobic metabolism.

Prevent Cellular DeathPrevent Cellular Death

6-126-12

Pitfall: Waiting until it is too late to restore perfusion to cells.

3 Phases of Shock

Compensatory

Progressive

Irreversible

Early RecognitionEarly Recognition

6-136-13

Signs & Symptoms of Uncompensated Shock

Description Compensated Decompensated

Pulse

Skin

BP

LOC

Tachycardia

White, cool, and moist

Normal range

Unaltered

Marked tachycardia; can progress to bradycardia

White, “waxy,” cold, marked diaphoresis

Lowered

Altered, ranging from disoriented coma

What are the earliest signs of shock?

What is a late sign of shock?

What are the earliest signs of shock?

What is a late sign of shock?

Early vs. LateEarly vs. Late

6-146-14

Maintain chemical balance.

Maintain fluid balance.

Maintain chemical balance.

Maintain fluid balance.

Restore Cellular PerfusionRestore Cellular Perfusion

6-156-15

Chemical BalanceChemical Balance

Decrease in oxygen. Detected by chemical receptors in the carotid

arteries and in the arch of the aorta. Respirations increase in rate & depth.

Rise in acidity. Buffer system converts acid to CO2 & water.

Medulla senses increased CO2.

Respirations increase; lungs “blow off” CO2.

Decrease in oxygen. Detected by chemical receptors in the carotid

arteries and in the arch of the aorta. Respirations increase in rate & depth.

Rise in acidity. Buffer system converts acid to CO2 & water.

Medulla senses increased CO2.

Respirations increase; lungs “blow off” CO2.

6-166-16

continued...continued...

Common Shock Pathways

MechanismsMechanisms Oxygen deficiency Cellular hypoxia Ischemia Anoxia

Compensation ↑ Catecholamines

↑ HR, contractility Vasoconstriction of

both arterial and venous beds–↑ oxygen delivery

↑ Cellular extraction of oxygen

Chemical BalanceChemical Balance

Key: increase in respiratory rate is an early sign of shock.

What signs or symptoms indicate that the patient’s body is trying to restore its chemical balance?

What steps could you take to help the body restore balance and aerobic metabolism?

Key: increase in respiratory rate is an early sign of shock.

What signs or symptoms indicate that the patient’s body is trying to restore its chemical balance?

What steps could you take to help the body restore balance and aerobic metabolism?

6-176-17

cont’d.

Fluid DecreaseFluid Decrease

6-186-18

Fluid volume decreases

Baroreceptors note change

Epinephrine and norepinephrine released

Vasoconstriction Increased rate & strength of cardiac

contractions

Fluid DecreaseFluid Decrease

Hormonal response: Various hormones are released,

causing vasoconstriction and fluid retention.

Compensation: Blood vessels constrict. Heart increases strength & rate. Fluid is retained.

Hormonal response: Various hormones are released,

causing vasoconstriction and fluid retention.

Compensation: Blood vessels constrict. Heart increases strength & rate. Fluid is retained.

6-196-19

continued...continued...

In the scenario, which signs suggest that the patient’s body is trying to restore its fluid balance?

Is the patient compensating well? Why?

What steps could you take to help the body restore balance?

In the scenario, which signs suggest that the patient’s body is trying to restore its fluid balance?

Is the patient compensating well? Why?

What steps could you take to help the body restore balance?

6-206-20

cont’d.Fluid DecreaseFluid Decrease

Defines what is necessary to achieve end-tissue perfusion: On-loading oxygen to the RBCs. Delivering the RBCs to the tissue. Off-loading oxygen to the tissue.

As part of the process, patient must have an adequate number of RBCs to transport oxygen.

Defines what is necessary to achieve end-tissue perfusion: On-loading oxygen to the RBCs. Delivering the RBCs to the tissue. Off-loading oxygen to the tissue.

As part of the process, patient must have an adequate number of RBCs to transport oxygen.

The Fick PrincipleThe Fick Principle

6-216-21

ScenarioScenario

You are responding to a patient that has

fallen from a 40-foot cliff while rock climbing.

He is awake. He tells you that he can’t move

his legs, and has no feeling below his waist.

Pulse 119, RR 20, and BP 104/72.

6-226-22

How does the Fick Principle apply here?How does the Fick Principle apply here?

How well is this patient compensating?How well is this patient compensating?

ScenarioScenario

You are called to the scene of a house fire,

where firefighters have just removed one

patient. He is unresponsive. Pulse 102, RR

6, and BP 104/76.

6-236-23

How does the Fick Principle apply here?How does the Fick Principle apply here?

How well is this patient compensating?How well is this patient compensating?

ScenarioScenario

You respond to a scene where a skier has

struck a tree at high speed. Exam reveals pain

on palpation of the right lateral chest, absent

breath sounds on the right and labored

breathing. Pulse 142, RR 40, and BP 88/70.

6-246-24

How does the Fick Principle apply here?How does the Fick Principle apply here?

How well is this patient compensating?How well is this patient compensating?

ScenarioScenario

You are dispatched to an MVC. On arrival, you

find a 47-year-old male driver still in the vehicle.

There are 10-15 inches of intrusion to the front

of the vehicle. The patient is unresponsive as

you approach.

6-256-25

Findings Findings

A - Blood & vomitus in airway.

B - Slow & labored. BS absent on left.

C - No palpable radial pulse. Cool, wet skin. No external bleeding.

D - Pupils equal but reacting slowly.

E - Obvious fracture of left femur.

A - Blood & vomitus in airway.

B - Slow & labored. BS absent on left.

C - No palpable radial pulse. Cool, wet skin. No external bleeding.

D - Pupils equal but reacting slowly.

E - Obvious fracture of left femur.

6-266-26

How does the Fick Principle apply here?How does the Fick Principle apply here?

Shock SummaryShock Summary

Shock is staged death...Shock is staged death...

6-276-27

…catch it in the first act!…catch it in the first act!