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					23: Shock
Cognitive and Affective Objectives
 5-1.9 List signs and symptoms of shock
   (hypoperfusion).

 5-1.10 State the steps in the emergency medical
   care of a patient with signs and symptoms of
   shock (hypoperfusion).

 5-1.11 Explain the sense of urgency to transport
   patients who are bleeding and show signs of
   shock (hypoperfusion).
        Psychomotor Objectives
5-1.16 Demonstrate the care of the patient exhibiting
  signs and symptoms or shock (hypoperfusion).
5-1.17 Demonstrate completing a prehospital care
  report for the patient with bleeding and/or shock
  (hypoperfusion).
                  Shock
• State of collapse and failure of the
  cardiovascular system
• Leads to inadequate circulation
• Without adequate blood flow, cells cannot
  get rid of metabolic wastes
• The result of hypoperfusion to cells that
  causes the organ, then organ systems, to
  fail
                      Perfusion
• The cardiovascular system’s
  circulation of blood and oxygen
  to all the cells in different tissues
  and organs of the body
                  Perfusion Triangle
         Heart                                            Blood Vessels
   (Pump Function)                                    (Container Function)
Damage to the heart by                          If all the vessels dilate at once,
    disease or injury.                             the normal amount of blood
 It cannot move blood                           volume is not enough to fill the
 adequately to support                           system and provide adequate
       perfusion.                                      perfusion to the body.




                                 Blood
                           (Content Function)
                     If blood or plasma is lost, the
                     volume in the container is not
                    enough to support the perfusion
                            needs of the body.
         Capillary Sphincters
• Regulate the blood flow through the capillary
  beds.
• Sphincters are under the control of the
  automatic nervous system.
• Regulation of blood flow is determined by
  cellular need.
Perfusion and Neurogenic Shock
         Cardiovascular Causes
              of Shock (1 of 4)
• Pump failure (cardiogenic shock)
   – Inadequate function of the heart or pump failure
   – Causes a backup of blood into the lungs
   – Results in pulmonary edema
   – Pulmonary edema leads to impaired ventilation
          Cardiovascular Causes
               of Shock (2 of 4)
• Poor vessel function (neurogenic shock)
   – Damage to the cervical spine may affect control
     of the size and muscular tone of blood vessels.
   – The vascular system increases.
      • Blood in the body cannot fill the enlarged
        system.
      • Neurogenic shock occurs.
         Cardiovascular Causes
              of Shock (3 of 4)
• Content failure (hypovolemic shock)
  – Results from fluid or blood loss
   – Blood is lost through external and internal
     bleeding.
   – Severe thermal burns cause plasma loss.
   – Dehydration aggravates shock.
        Cardiovascular Causes
             of Shock (4 of 4)
• Combined vessel and content failure
  – Some patients with severe bacterial infections,
    toxins, or infected tissues contract septic
    shock.
  – Toxins damage vessel walls, causing leaking
    and impairing ability to contract.
  – Leads to dilation of vessels and loss of plasma,
    causing shock
      Noncardiovascular Causes
            of Shock (1 of 3)
• Respiratory insufficiency
  – Patient with a severe chest
    injury or airway obstruction
    may be unable to breathe
    adequate amounts of
    oxygen.
   – Insufficient oxygen in the
     blood will produce shock.
     Noncardiovascular Causes
           of Shock (2 of 3)
• Anaphylactic shock
   – Occurs when a person reacts violently to a
     substance.
   – Four categories of common causes:
      • Injections
      • Stings
      • Ingestion
      • Inhalation
     Noncardiovascular Causes
           of Shock (3 of 3)
• Psychogenic shock
   – Caused by sudden reaction of the nervous
     system that produces a temporary, generalized
     vascular dilation
   – Commonly referred to as fainting or syncope
   – Can be brought on by serious causes: irregular
     heartbeat, brain aneurysm
   – Can be brought on by fear, bad news,
     unpleasant sights
       Progression of Shock
• Compensated shock
   – When the body compensates for blood loss
• Decompensated shock
   – The late stage of shock when blood pressure is
     falling
• Irreversible shock
   – The terminal stage
            Compensated Shock
• Agitation               •   Clammy skin
• Anxiety                 •   Pallor
• Restlessness            •   Shallow, rapid breathing
• Feeling of impending    •   Shortness of breath
  doom                    •   Nausea or vomiting
• Altered mental status   •   Delayed capillary refill
• Weak pulse              •   Marked thirst
Decompensated Shock
 • Falling blood pressure
   (<90 mm Hg in an adult)
 • Labored, irregular
   breathing
 • Ashen, mottled, cyanotic
   skin
 • Thready or absent pulse
 • Dull eyes, dilated pupils
 • Poor urinary output
     Irreversible Shock
• This is the terminal stage of shock.
• A transfusion of any type will not be
  enough to save a patient’s life.
When to Expect Shock
•   Multiple severe fractures
•   Abdominal or chest injuries
•   Spinal injuries
•   Severe infection
•   Major heart attack
•   Anaphylaxis
• You and your partner respond to an MVC involving
  two cars. En route you follow BSI.
                       You are the Provider



• You arrive to a 25-year-old man.
• Law enforcement informs you that the other car left
  the scene. Patient was restrained and is sitting
  outside car. He is pale.
• The airbag has deployed and the steering wheel
  has some damage.
       Scene Size-up




• In addition to BSI, what are some
  considerations at the scene?
• What is the mechanism of injury?
• You approach the patient and introduce yourself.
  He appears visibly upset but lets you take his vital
  signs.                You are the Provider
                            (continued)


   – Pulse: 115 beats/min
   – Respirations: 26 breaths/min
   – Blood pressure: 110 mm Hg
• He has a laceration on his knee where it hit the
  dashboard.
                    Initial
                 Assessment




• Describe the steps of your initial assessment and
  findings:
   – General impression
   – Airway
   – Breathing
   – Circulation
   – Transport decision
•   Spinal immobilization needed.
•   Pallor is a sign of shock.You are the Provider
                                  (continued)



•   He is A on the AVPU scale.
•   Airway is open.
•   Breathing is rapid.
•   Inspect and palpate chest for DCAP-BTLS.
•   Observe for accessory muscle use.
•   Patient has rapid pulse.
•   Clammy skin.           You are the Provider
                               (continued)

•   Knee laceration
•   Priority transport
              Focused History and
                Physical Exam




• Would you perform a rapid physical exam or
  focused physical exam?
• What is your reasoning?
                 Detailed Physical Exam




• If time permits, perform en route to the hospital.
                 Ongoing
                Assessment




• Perform reassessment.
• Take vital signs every 5 minutes.
• You reassess the patient in the ambulance and
  he has a pulse of 122 beats/min, respirations
  of 30 breaths/min, and a blood pressure of
                              You are the

  106/68 mm Hg.                 Provider
                              (continued)



• What do his vital sign changes indicate?
     Emergency Medical Care (1 of 3)
• Make certain patient
  has open airway.
• Keep patient supine.
• Control external
  bleeding.
     Emergency Medical Care (2 of 3)
• Splint any broken
  bones or joint injuries.
• Always provide oxygen.
• Place blankets under
  and over patient.
      Emergency Medical Care (3 of 3)
• If there are no broken
  bones, elevate the legs
  6" to 12".
• Do not give the patient
  anything by mouth.
   Pneumatic Antishock Garment
• Some localities allow EMTs to apply a pneumatic
  antishock garment (PASG) for some patients in
  decompensated shock.
• Know your local protocol regarding their usage.
Treating Cardiogenic Shock
• Patient may breathe better in a sitting or
  semi-sitting position.
• Administer high-flow oxygen.
• Assist ventilations as necessary.
• Have suction nearby in case the patient
  vomits.
• Transport promptly.
Treating Neurogenic Shock
 • Maintain airway and assist
   breathing as needed.
 • Keep patient warm.
 • Transport promptly.
Treating Hypovolemic Shock
 • Control obvious bleeding.
 • Splint any bone or joint injuries.
 • If no fractures, raise legs 6" to 12".
 • Secure and maintain airway.
 • Give oxygen as soon as you suspect
   shock.
 • Transport rapidly.
  Treating Septic Shock
• Transport as promptly as possible
  while giving all general support
  available.
• Give high-flow oxygen during
  transport.
• Use blankets to conserve body
  heat.
Treating Respiratory Insufficiency
    •   Secure and support the airway.
    •   Clear airway of any obstructions.
    •   Ventilate if needed with a BVM device.
    •   Administer oxygen.
    •   Transport promptly.
Treating Anaphylactic Shock
  • Administer epinephrine.
  • Provide prompt transport.
  • Provide all possible support.
     – Oxygen
    – Ventilatory assistance
  Treating Psychogenic Shock
• It is usually self-resolving.
• Assess patient for injuries from fall.
• If patient has difficulties after regaining
  consciousness, suspect another problem.
                     Review
1. The term “shock” is MOST accurately defined as:

A. a decreased supply of oxygen to the brain.
B. cardiovascular collapse leading to inadequate
    perfusion.
C. decreased circulation of blood within the venous
    circulation.
D. decreased function of the respiratory system
    leading to hypoxia.
                     Review
Answer: B

Response: Shock, or hypoperfusion, refers to a state
  of collapse and failure of the cardiovascular
  system, or any one of its components (eg, heart,
  vasculature, blood volume), which leads to
  inadequate perfusion of the body’s cells and
  tissues.
                              Review
1. The term “shock” is MOST accurately defined as:

A. a decreased supply of oxygen to the brain.
Rationale: It may be a result of inadequate perfusion, but it is not the
    definition of shock.
B. cardiovascular collapse leading to inadequate perfusion.
Rationale: Correct answer
C. decreased circulation of blood within the venous circulation.
Rationale: It may be a result of cardiovascular collapse, but it is not the
    definition of shock.
D. decreased function of the respiratory system leading to hypoxia.
Rationale: Decreased function of the respiratory system will lead to
    hypoxia which will cause cardiovascular collapse and eventually to
    shock.
                      Review
2. A 20-year-old man was kicked numerous times in
   the abdomen during an assault. His abdomen is
   rigid and tender, his heart rate is 120 beats/min,
   and his respirations are 30 breaths/min. You
   should treat this patient for:

A. a lacerated liver.
B. a ruptured spleen.
C. respiratory failure.
D. hypovolemic shock.
                     Review
Answer: D

Rationale: The patient may have a liver laceration or
  ruptured spleen—both of which can cause internal
  blood loss. However, it is far more important to
  recognize that the patient is in hypovolemic shock
  and to treat him accordingly.
                             Review
2. A 20-year-old man was kicked numerous times in the abdomen
    during an assault. His abdomen is rigid and tender, his heart rate is
    120 beats/min, and his respirations are 30 breaths/min. You should
    treat this patient for:

A. a lacerated liver.
Rationale: You cannot treat a lacerated liver in the field. You can treat
    the symptoms of hypovolemic shock associated with the injury.
B. a ruptured spleen.
Rationale: You cannot treat a ruptured spleen in the field. You can treat
    the symptoms of hypovolemic shock associated with the injury.
C. respiratory failure.
Rationale: If you treat the hypovolemic shock, then you will treat the
    respiratory compromise as well.
D. hypovolemic shock.
Rationale: Correct answer
                     Review
3. Signs of compensated shock include all of the
   following, EXCEPT:

A. restlessness or anxiety.
B. pale, cool, clammy skin.
C. a feeling of impending doom.
D. weak or absent peripheral pulses.
                     Review
Answer: D

Rationale: In compensated shock, the body is able to
  maintain perfusion to the vital organs of the body
  via the autonomic nervous system. Signs include
  pale, cool, clammy skin; restlessness or anxiety; a
  feeling of impending doom; and tachycardia. When
  the body’s compensatory mechanism fails, the
  patient's blood pressure falls; weak or absent
  peripheral pulses indicates this.
                         Review
3. Signs of compensated shock include all of the following,
    EXCEPT:

A. restlessness or anxiety.
Rationale: This indicates compensated shock.
B. pale, cool, clammy skin.
Rationale: This indicates compensated shock.
C. a feeling of impending doom.
Rationale: This indicates compensated shock and the anxiety
    associated with it.
D. weak or absent peripheral pulses.
Rationale: Correct answer
                       Review
4. A 60-year-old woman presents a BP of 80/60 mm
   Hg, a pulse rate of 110 beats/min, mottled skin,
   and a temperature of 103.9°F. She is MOST likely
   experiencing:

A. septic shock.
B. neurogenic shock.
C. profound heart failure.
D. a severe viral infection.
                     Review
Answer: A

Rationale: In septic shock, bacterial toxins damage
  the blood vessel walls, causing them to leak and
  rendering them unable to constrict. Widespread
  dilation of the vessels, in combination with plasma
  loss through the injured vessel walls, results in
  shock. A high fever commonly accompanies a
  bacterial infection.
                          Review
4. A 60-year-old woman presents a BP of 80/60 mm Hg, a pulse
    rate of 110 beats/min, mottled skin, and a temperature of
    103.9°F. She is MOST likely experiencing:

A. septic shock.
Rationale: Correct answer
B. neurogenic shock.
Rationale: Neurogenic shock is an injury to the nervous system
    and shows bradycardia and hypotension — not fever.
C. profound heart failure.
Rationale: This is part of cardiogenic shock, associated with low
    blood pressure, weak pulse, and cyanotic skin.
D. a severe viral infection.
Rationale: Septic shock is caused by a bacterial infection.
                        Review
5. A patient with neurogenic shock would be LEAST
   likely to present with:

A. tachypnea.
B. hypotension.
C. tachycardia.
D. altered mentation.
                     Review
Answer: C

Rationale: In neurogenic shock, the nerves that
  control the sympathetic nervous system are
  compromised. The nervous system is responsible
  for secreting the hormones epinephrine and
  norepinephrine, which increases the patient’s heart
  rate, constricts the peripheral vasculature, and
  shunts blood to the body’s vital organs. Without the
  release of these hormones, the compensatory
  effects of tachycardia and peripheral
  vasoconstriction are absent.
                           Review
5. A patient with neurogenic shock would be LEAST likely to present
    with:

A. tachypnea.
Rationale: Respirations increase to compensate for the hypoxia
    associated with shock.
B. hypotension.
Rationale: Hypotension results from massive vasodilation.
C. tachycardia.
Rationale: Correct answer
D. altered mentation.
Rationale: The patient will present with mental status changes
    secondary to hypoxia.
                       Review
6. A 33-year-old woman presents with a generalized
   rash, facial swelling, and hypotension
   approximately 10 minutes after being stung by a
   hornet. Her BP is 70/50 mm Hg and her heart rate
   is 120 beats/min. In addition to high-flow oxygen,
   this patient is in MOST immediate need of:

A. epinephrine.
B. rapid transport.
C. an antihistamine.
D. IV fluids.
                    Review
Answer: A

Rationale: This patient is in anaphylactic shock—a
  life-threatening overexaggeration of the immune
  system that results in bronchoconstriction and
  hypotension. After ensuring adequate oxygenation
  and ventilation, the MOST important treatment for
  the patient is epinephrine, which dilates the
  bronchioles and constricts the vasculature, thus
  improving breathing and blood pressure
  respectively.
                           Review
6. A 33-year-old woman presents with a generalized rash, facial
    swelling, and hypotension approximately 10 minutes after being
    stung by a hornet. Her BP is 70/50 mm Hg and her heart rate is
    120 beats/min. In addition to high-flow oxygen, this patient is in
    MOST immediate need of:

A. epinephrine.
Rationale: Correct answer
B. rapid transport.
Rationale: Rapid transport follows high flow oxygen and epinephrine
    administration.
C. an antihistamine.
Rationale: This is an ALS treatment.
D. IV fluids.
Rationale: This is an ALS treatment.
                      Review
7. Elevating the legs of a patient who is in shock:

A. causes the blood vessels to constrict, thereby
  raising the blood pressure.
B. allows blood in the lower extremities to more
  rapidly return to the heart.
C. makes the patient more comfortable, which will
  decrease oxygen demand.
D. returns warmed blood from the legs to the body,
  preventing hypothermia.
                      Review
Answer: B

Rationale: Elevating the shock patient’s lower
  extremities 6” to 12” allows blood in the legs to
  return to the heart, thus helping maintain perfusion
  to the vital organs. It also helps control venous
  bleeding in the lower extremities.
                         Review (1 of 2)
7. Elevating the legs of a patient who is in shock:

A. causes the blood vessels to constrict, thereby raising the blood
    pressure.
Rationale: Vasoconstriction is accomplished by the administration of
    medication and not by elevating the patient’s legs.
B. allows blood in the lower extremities to more rapidly return to the
    heart.
Rationale: Correct answer
                         Review (2 of 2)
7. Elevating the legs of a patient who is in shock:

C. makes the patient more comfortable, which will decrease oxygen
   demand.
Rationale: Oxygen demand will not be effected by elevating the
   patient’s legs.
D. returns warmed blood from the legs to the body, preventing
   hypothermia.
Rationale: Heat loss secondary to shock is a concern, but body heat
   is maintained by placing a blanket over the patient.
                      Review
8. The PASG would MOST likely cause further harm
   to a patient with:

A. an unstable pelvis and severe pain.
B. external bleeding from bilateral femur fractures.
C. severe, ongoing bleeding in the pelvic cavity.
D. blunt thoracic trauma with internal hemorrhage.
                      Review
Answer: D

Rationale: The pneumatic antishock garment (PASG)
  is mainly used as a splint for patients with pelvic or
  bilateral femur fractures. They should not be used
  in any patient with trauma above the last rib. The
  PASG causes vasoconstriction, which, in the
  patient with intrathoracic hemorrhage, may worsen
  the bleeding by dislodging internal clots that may
  have formed.
                            Review
8. The PASG would MOST likely cause further harm to a patient with:

A. an unstable pelvis and severe pain.
Rationale: PASG is an appropriate device used to splint unstable
    pelvic fractures.
B. external bleeding from bilateral femur fractures.
Rationale: PASG can be utilized to apply pressure to external
    bleeding if the PASG is inflated to splinting pressures only.
C. severe, ongoing bleeding in the pelvic cavity.
Rationale: PASG will stabilize the pelvis and blood loss.
D. blunt thoracic trauma with internal hemorrhage.
Rationale: Correct answer
                      Review
9. Anaphylactic shock is typically associated with:

A. urticaria.
B. bradycardia.
C. localized welts.
D. a severe headache.
                      Review
Answer: A

Rationale: Urticaria (hives) is typically associated with
  allergic reactions—mild, moderate, and severe.
  They are caused by the release of histamines from
  the immune system. In anaphylactic shock,
  urticaria is also accompanied by cool, clammy skin;
  tachycardia; severe respiratory distress; and
  hypotension.
                          Review
9. Anaphylactic shock is typically associated with:

A. urticaria.
Rationale: Correct answer
B. bradycardia.
Rationale: Tachycardia is a symptom of anaphylactic shock.
C. localized welts.
Rationale: Welts are a raised ridge or bump on the skin caused by
     a lash from a whip, a scratch, or a similar blow.
D. a severe headache.
Rationale: Altered mental status secondary to hypoxia may be a
     symptom, but not a headache.
                      Review
10. When treating a trauma patient who in shock,
  LOWEST priority should be given to:

A. spinal protection.
B. thermal management.
C. splinting fractures.
D. notifying the hospital.
                      Review
Answer: C

Rationale: Critical interventions for a trauma patient in
  shock include spinal precautions, high-flow oxygen
  (or assisted ventilation), thermal management,
  rapid transport, and early notification of a trauma
  center. Splinting fractures should not be performed
  at the scene if the patient is critically-injured; it
  takes too long and only delays transport.
                             Review
10. When treating a trauma patient who in shock, LOWEST priority
    should be given to:

A. spinal protection.
Rationale: Stabilization of the spine must take place during the first
     interaction with a trauma patient.
B. thermal management.
Rationale: Preventing hypothermia is standard treatment.
C. splinting fractures.
Rationale: Correct answer
D. notifying the hospital.
Rationale: Trauma centers need to be notified early during patient
     interaction and transport.

				
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