ems shock lex.ppt
TRANSCRIPT
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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
Clinical Presentation
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
Clinical Presentation
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?