Ch.13 Shock Flashcards
__ is defined as inadequate cellular perfusion
Shock
The flow of blood through body tissues and vessels
Perfusion
Cells require oxygen, water, and glucose to carry out cellular processes to produce energy in the form of adenosine triphosphate. When the cells do not receive these requirements via the bloodstream, the cells cannot create energy and are categorized as_____. If cells are____, tissues and organs are also________.
hypoperfused
The nucleotide involved in energy metabolism; used to store energy
Adenosine triphosphate
In the early stages of shock, the body will attempt to compensate by maintaining____ (a balance of all systems of the body); however, as shock progresses from tissues and organs to organ systems and the whole body, blood circulation slows and eventually ceases. This state of inadequate oxygen and nutrient delivery to the cells of the body causes organs and then organ systems to fail. If not treated promptly, shock can be fatal
homeostasis
A balance of all systems of the body
Homeostasis
___is the circulation of blood to the tissues in adequate amounts to meet the cells’ needs. It includes delivery of oxygen and removal of toxic waste products.
Perfusion
The____ is a complex arrangement of connected tubes, including the arteries, arterioles, capillaries, venules, and veins, in which blood circulates throughout to the body.
circulatory system
There are two circuits in the body: the____ between the heart and the body and the_____ between the heart and the lungs.
systemic circulation
pulmonary circulation
____circulation carries oxygen-rich blood from the left ventricle through the body and back to the right atrium.
systemic
In the systemic circulation, as blood passes through the tissues and organs, it delivers oxygen and nutrients. Adequate perfusion is also important for the removal of waste products such as carbon dioxide, a by-product of energy production. The___ system carries these waste products for excretion or exhalation.
circulatory
The flow of blood from the right ventricle through the pulmonary arteries and all of their branches and capillaries in the lungs and back to the left atrium through the venues and pulmonary veins; also called the lesser circulation
Pulmonary circulation
The portion of the circulatory system outside of the heart and lungs
Systemic circulation
Organs, tissues, and cells must have adequate oxygenation to survive. Each time you take a breath, the alveoli, which are microscopic, thin-walled air sacs, receive a supply of oxygen-rich air. Oxygen diffuses through the walls of the alveoli into the bloodstream and attaches to___, a protein that makes up red blood cells. The red blood cells then circulate the oxygen to the tissues where it can be offloaded.
hemoglobin
Oxygen and carbon dioxide pass rapidly across the thin walls of the alveoli by the process of____.____ is a passive process in which molecules move from an area of higher concentration to an area of lower concentration. When the air reaches your alveoli, there is more oxygen in the air than in the bloodstream. Therefore, the oxygen molecules slip between the thin layers of the alveoli into the blood. Carbon dioxide does the same thing in the other direction. When blood is returned to the lungs from the tissues, there is more carbon dioxide in the blood than in the alveoli; thus, it diffuses into the alveoli, where it is exhaled.
diffusion
Whereas most oxygen is carried to the tissues while attached to hemoglobin, carbon dioxide can be transported in the blood back to the lungs in three ways: dissolved in the plasma, combined with water in the form of_____, or attached to hemoglobin. Carbon dioxide waste products released from cells can combine with water in the bloodstream to form___._____ concentrations become higher as more carbon dioxide is produced and blood moves back toward the lungs. Once it reaches the lungs, the____ breaks down again into carbon dioxide and water and the carbon dioxide is exhaled. In cases of poor perfusion (shock), the transportation of carbon dioxide out of the tissues becomes impaired, resulting in a dangerous buildup of waste products, which may damage cells and tissues.
bicarbonate
To protect vital organs from___, the body attempts to compensate by directing blood flow away from organs that are more tolerant of shock (such as the skin and intestines) to organs that cannot tolerate shock (such as the heart, brain, and lungs). If these tissues do not have adequate perfusion restored, they can die, resulting in permanent damage to the tissues and organ.
hypoperfusion
As described in Chapter 6, The Human Body, the cardiovascular system consists of three parts:___(FIGURE 13-1).
These three parts can be referred to as the perfusion triangle (FIGURE 13-2). When a patient is in shock, one or more of the three parts is not working properly.
a pump (the heart), a set of pipes (the blood vessels or arteries that act as the container), and the contents of the container (the blood)
Heart (pump function) meaning
Damage to the heart by disease or injury decreases the ability of the heart to properly function as a pump. Therefore, it cannot move enough blood through the body to support perfusion
Blood vessels (container function) meaning
If all the blood vessels dilate rapidly, the normal amount of blood volume is not enough to fill the system and provide adequate perfusion to the body
Blood (content function) meaning
If there is enough blood or plasma loss, the volume of fluid in the container is not enough to support the perfusion needs of the body
___is the vehicle for carrying oxygen and nutrients through the vessels to the capillary beds and tissue, where they are exchanged for waste products. For this process to happen, the vessels (container) must be intact. Blood is composed of red blood cells, white blood cells, platelets, and a liquid called plasma. As discussed in Chapter 6, The Human Body, red blood cells are responsible for transporting oxygen to the cells and transporting carbon dioxide away from the cells to the lungs, where it is exhaled and removed from the body. Each component of blood has an important role in overall health: white blood cells help the body fight infection, platelets assist in forming blood clots, and plasma contains electrolytes and fluid, which are important for cells to function.
These components are all vital to maintain homeostasis. If, at any time, tissue is hypoperfused, the body will attempt to compensate by regulating the blood pressure, or the amount of blood delivered to any given part of the body, thereby preventing shock.
Blood
_____(pressure within the capillary bed) tends to force fluids through capillary walls, whereas interstitial fluid hydrostatic pressure (pressure around the capillary bed and between the cells) pushes fluid back into the cells.
Capillary hydrostatic pressure
Remember, blood pressure is the pressure of blood within the vessels at any moment in time. The systolic pressure is the peak arterial pressure, or pressure generated when the heart contracts; the diastolic pressure is the pressure maintained within the arteries while the heart is at rest, or between beats.___ is the difference between the systolic and
diastolic pressures (Systolic - Diastolic =_____). It signifies the amount of force the heart generates with each
contraction.
Pulse pressure
Blood flow through the capillary beds is regulated by the capillary__, circular muscular walls that constrict and dilate. These____ are under the control of the autonomic nervous system, which regulates involuntary functions such as sweating and digestion. Capillary____ also respond to other stimuli such as heat, cold, the need for oxygen, and the need for waste removal. This regulation is important because not all organs require the same amount of blood. Whereas your brain requires a constant amount of blood, your digestive tract requires more blood while digesting food and less when you are not eating
Thus, regulation of blood flow is determined by cellular need and is accomplished by vessel constriction or dilation and capillary____ constriction or dilation. This team effort of the heart, blood, and vessels helps ensure blood gets to the tissues when it is needed
sphincters
Muscles that encircle and, by contracting, constrict a duct, tube, or opening. Examples are found within the rectum, bladder, and blood vessels
Sphincters
The body has neural and endocrine or hormonal mechanisms in place to help support the respiratory and cardiovascular systems when the need for perfusion of vital organs is increased. These mechanisms include the autonomic nervous system and hormones, which are triggered when the body senses that the pressure in the system is falling. The sympathetic side of the autonomic nervous system, which is responsible for the fight-or-flight response, assumes more control of the body’s functions during a state of shock. This response by the autonomic nervous system causes the release of the hormones epinephrine and norepinephrine. These hormones cause changes in certain body functions, including an increase in the heart rate and the strength of cardiac contractions. The fight-or-flight response also causes____ in nonessential areas, primarily in the skin and gastrointestinal tract. Reducing blood flow to the skin is called peripheral____ and helps to shunt blood to the vital organs. Together, these actions help maintain pressure in the system and, as a result, sustain perfusion to the vital organs.
Eventually, a shifting of body fluids to help maintain pressure within the system also occurs by reabsorption of fluid into the bloodstream when it passes through the kidneys. However, the response of the autonomic nervous system and hormones comes within seconds. It is this response that causes the signs and symptoms of shock in a patient.
vasoconstriction
The sympathetic side of the autonomic nervous system, which is responsible for the fight-or-flight response,____ during a state of shock.
assumes more control of the body’s functions
Narrowing of a blood vessel
Vasoconstriction
Understanding the basic physiologic causes of shock will better prepare you to treat it (FIGURE 13-3). Shock results from
three basic causes
Pump failure
Causes: Heart attack, trauma to heart, obstructive causes (large pulmonary embolus)
Low fluid volume
Causes: Trauma to vessels or tissues, fluid loss from Gl tract (vomiting/diarrhea can also lower the fluid component of blood)
Poor vessel function
Causes: Infection, drug overdose (narcotic), spinal cord injury, anaphylaxis
Types of shock from pump failure
Cardiogenic shock
Obstructive shock
• Tension pneumothorax
• Cardiac tamponade
• Pulmonary embolism
Types of shock from poor vessel function
Distributive shock
• Septic shock
• Neurogenic shock
• Anaphylactic shock
• Psychogenic shock
Types of shock from low fluid volume
Hypovolemic shock
• Hemorrhagic shock
• Nonhemorrhagic shock
A state in which not enough oxygen is delivered to the tissues of the body, caused by low output of blood from the heart. It can be a severe complication of a large acute myocardial infarction, as well as other conditions
Cardiogenic shock
Shock that occurs when there is a block to blood flow in the heart or great vessels, causing an insufficient blood supply to the body’s tissues
Obstructive shock
Compression of the heart as the result of buildup of blood or other fluid in the pericardial sac, leading to decreased cardiac output
Cardiac tamponade
A condition that occurs when there is widespread dilation of the small arterioles, small venules, or both
Distributive shock
Circulatory failure causes by paralysis of the nerves that control the size of the blood vessels, leading to widespread dilation; seen in patients with spinal cord injuries
Neurogenic shock
Shock caused by a sudden, temporary reduction in blood supply to the brain that causes fainting (syncope)
Psychogenic shock
The muscular contraction of the heart moves blood through the vessels at distinct pressures. For blood to circulate efficiently throughout the entire system, the amount of pressure must be right and there must be an adequate number of heartbeats.
________develops when the heart cannot maintain sufficient output (cardiac output) to meet the demands of the body. Cardiac output is the volume of blood that the heart can pump per minute and depends on several factors. First, the heart must have adequate strength, which is largely determined by the ability of the heart muscle to contract. This ability to contract is referred to as myocardial contractility. Second, the heart must receive adequate blood to pump. As the volume of blood coming to the heart increases, the pressure in the heart builds up. This pressure is known as preload. As preload increases, the volume of blood within the ventricles increases, which causes the heart muscle to stretch. When the muscle is stretched, myocardial contractility increases, leading to greater force of contraction and increased cardiac output. Last, the resistance to flow in the peripheral circulation must be appropriate. The force, or resistance against which the heart pumps, is known as afterload. In general, as afterload increases, cardiac output decreases. Increased afterload may also cause the heart to overwork while trying to maintain adequate cardiac output. Chronically high afterload is often the reason heart failure develops in patients with hypertension. Cardiogenic shock may result from low cardiac output due to high afterload, low preload, poor contractility, or any combination of the three.
Cardiogenic shock
The ability of the heart muscle to contract
Myocardial contractility
The precontraction pressure in the heart as the volume of blood builds up
Preload
The force or resistance against which the heart pumps
Afterload
A measure of the volume of blood circulated by the heart in 1 minute, calculated by multiplying the stroke volume by the heart rate
Cardiac output
_____is caused by an obstruction that prevents an adequate volume of blood from being distributed to the body.
Three of the most common examples of____ are cardiac tamponade, tension pneumothorax, and pulmonary. embolism
obstructive shock
A collection of fluid between the pericardial sac and the myocardium is called a___. If the effusion becomes large enough, it can prevent the ventricles from filling with blood a condition called cardiac tamponade or pericardial tamponade.
pericardial effusion
Large pericardial effusions leading to____ can also be seen in patients with cancer and autoimmune diseases.____ occurs when blood leaks into the space between the tough fibrous membrane known as the pericardium and the outer walls of the heart, an area called the pericardial sac. As more blood or fluid accumulates in this confined space, the outer walls of the heart become compressed. Because the pericardium has a limited ability to stretch, the accumulated blood or fluid in the pericardial space eventually exerts back pressure on the outer walls of the heart, compressing the walls of the heart and preventing the heart from completely refilling with blood. Continued pressure within the pericardial sac obstructs the flow of blood into the heart, resulting in decreased outflow from the heart
cardiac tamponade
Signs and symptoms of___ are referred to as the Beck triad: the presence of jugular vein distention, muffled heart sounds, and a narrowing pulse pressure, where the systolic and diastolic blood pressures start to merge (systolic pressure decreases and the diastolic pressure increases).
cardiac tamponade
____is another obstructive condition (FIGURE 13-6). A____ is caused by damage to the lung tissue. This damage allows air normally held within the lung to escape into the chest cavity. The lung eventually collapses, causing a pneumothorax. If a pneumothorax is allowed to progress, air will accumulate within the chest cavity and begin applying pressure to the heart and greater vessels. When the trapped air begins to shift the chest organs toward the uninjured side, a pneumothorax becomes known as a____, which is a serious, life-threatening condition.
As pressure from one side of the chest begins to push the mediastinum toward the other side, the vena cava loses its ability to stay fully expanded. This compression of the vena cava leads to reduced blood return to the right side of the heart and blood pressure drops. As the patient has more difficulty breathing, the heart also has more difficulty pumping. You may notice 537 difficulty when attempting to ventilate the patient with a bag-mask device. The affected side will have absent lung sounds, and the patient may become cyanotic. Tracheal deviation is a late sign of____
Tension pneumothorax
A_____ can also lead to obstructive shock. A pulmonary embolism is a blood clot that occurs in the pulmonary arteries and blocks the flow of blood through the lungs. When a massive___ occurs, it can prevent blood from being pumped from the right side of the heart to the left, resulting in complete backup of blood in the right ventricle and catastrophic obstructive shock.
pulmonary embolism
Understanding the main differences among the types of shock is as simple as considering the terms themselves.
• Cardiogenic shock. Consider the parts of the word cardiogenic. Cardio suggests the heart, and genic means produced by.
• Obstructive shock. Think of obstructive shock as an obstruction blocking blood flow to an area of the body.
• Distributive shock. Think of distributive shock as a problem distributed throughout the body.
• Hypovolemic shock. Consider the parts of the word hypovolemic. Hypo means less than normal, and volemic suggests volume specifically, the volume of fluid in the circulatory system.
Words of wisdom :)
____results when there is widespread dilation of the small arterioles, small venules, or both. As a result, the circulating blood volume pools in the expanded vascular beds and tissue perfusion decreases. The four most common types of____ are septic shock, neurogenic shock, anaphylactic shock, and psychogenic shock.
Distributive shock
____occurs as a result of severe infections, usually bacterial, in which toxins (poisons) are generated by the bacteria. In this condition, the toxins damage the vessel walls, causing increased cellular permeability. The vessel walls leak and are unable to constrict well. Widespread dilation of vessels, in combination with plasma loss through the injured vessel walls, results in shock
___is a complex problem. First, there is an insufficient volume of fluid in the container, because much of the plasma has leaked out of the vessels (hypovolemia). Second, the fluid that has leaked out often collects in the alveoli, interfering with respiration. Third, the vasodilation leads to a larger-than-normal vascular volume. This increase in space combined with smaller-than-normal volume of intravascular fluid leads to shock.
Septic shock
Damage to the spinal cord, particularly at the upper cervical levels, may cause loss of control to the musculature and vessels below the injury site.____ is usually the result of high spinal cord injury. Although not as common, there are medical causes as well. These include brain conditions, tumors, pressure on the spinal cord, and spina bifida. In____, the muscles in the walls of the blood vessels are cut off from the sympathetic nervous system and nerve impulses that cause them to contract. Therefore, all vessels below the level of the spinal injury dilate widely, increasing the size and capacity of the vascular system (FIGURE 13-7) and causing blood to pool. The available 6 L of blood in the body can no longer fill the enlarged vascular system. Even if there is no blood or fluid loss, perfusion of organs and tissues becomes inadequate, and shock occurs. In this condition, a change in the size of the vascular system has caused shock.
Characteristic signs of this type of shock are the absence of sweating below the level of injury, normal and low heart rate in the presence of hypotension, and normal, warm skin. This is the only type of shock that presents without the characteristic pale, cool skin, because the peripheral vasoconstriction cannot be triggered through the autonomic nervous system.
Neurogenic shock
A development defect in which a portion of the spinal cord or meninges may protrude outside of the vertebrae and possibly even outside of the body, usually at the lower third of the spine in the lumbar area
Spina bifida
With_____, many other functions that are under the control of the same part of the nervous system are also lost. The most important of them, in an acute injury setting, is the ability to control body temperature. Body temperature in a patient in ____can rapidly fall to match that of the environment. In many situations, significant hypothermia occurs, severely complicating the situation. Hypothermia is a condition in which the internal body temperature falls below 95°F (35°C), usually after prolonged exposure to cool or freezing temperatures. Maintenance of body temperature is always an important element of treatment for a patient in shock.
neurogenic shock
____, occurs when a person reacts quickly to a substance to which he or she has been sensitized. Sensitization means becoming sensitive to a substance that did not initially cause a reaction. Do not be misled by a patient who reports no history of allergic reaction to a substance on first or second exposure. Each subsequent exposure after sensitization tends to produce a more severe reaction.
Instances that cause severe allergic reactions commonly fall into the following four categories of exposure:
• Injections (tetanus antitoxin, penicillin)
• Stings (wasps, bees, hornets, ants)
• Ingestion (fish, shellfish, nuts, eggs, medication)
• Inhalation (dust, pollen, mold)
____reactions can develop within minutes after contact with the substance to which the patient is allergic. The signs of such allergic reactions are distinct and not seen with other forms of shock. TABLE 13-2 lists the signs of___ shock in the order in which they typically occur. Note that cyanosis (blue discoloration of the skin) is a late sign of anaphylactic shock. Although paleness, or a decrease in blood flow, can be difficult to detect in dark-skinned people, it may be observed by examining mucous membranes inside the inner lower eyelid and capillary refill. On general observation, the patient may appear ashen or gray.
Anaphylaxis, or anaphylactic shock
What anaphylactic shock does to the circulatory system
Dilated peripheral blood vessels
• Increased vessel permeability
• Drop in blood pressure
• Weak, barely palpable pulse
What anaphylactic shock does to the respiratory system
Sneezing or itching in the nasal passages
• Stridor
• Upper airway obstruction
• Tightness in the chest, with a persistent dry cough
• Wheezing and dyspnea (difficulty breathing)
• Secretions of fluid and mucus into the bronchial passages, alveoli, and lung tissue, causing coughing
• Constriction of the bronchi; difficulty drawing air into the lungs
• Forced expiration, requiring exertion and accompanied by wheezing
• Cessation of breathing
In____, there is no loss of blood or vascular damage. Instead, there is widespread vascular dilation, increased permeability, and bronchoconstriction. The combination of poor oxygenation and poor perfusion in___ may easily prove fatal.
anaphylactic shock
A patient in ____has had a sudden reaction of the nervous system that produces a temporary, generalized vasodilation, resulting in fainting, or syncope. The fainting episode is temporary, and the patient rouses soon after. Syncope occurs when blood pools in the dilated vessels, reducing the blood supply to the brain; as a result, the brain temporarily ceases to function normally, and the patient faints.
psychogenic shock
There are many causes of__, and it is important to realize that some are serious.____ that is potentially life threatening may be caused by events such as an irregular heartbeat or a brain aneurysm. Non-life-threatening events that cause syncope include receiving bad news, experiencing fear, or encountering an unpleasant sight, such as blood. Those experiencing___ should receive a full assessment.
syncope
____is the result of an inadequate amount of fluid in the circulatory system. There are hemorrhagic and nonhemorrhagic causes of___. For example, injuries involving bleeding may result in hemorrhagic shock, whereas vomiting and diarrhea may result in nonhemorrhagic hypovolemic shock.
_____also occurs with severe thermal burns. In this case, intravascular plasma (the colorless part of the blood) loss is caused when fluid leaks from the capillaries into the surrounding tissue. Likewise, crushing injuries may result in the loss of blood and plasma from damaged vessels into injured tissues. These injuries can be thought of as excessive swelling.
Dehydration, the loss of water or fluid from body tissues, can cause shock. Fluid loss may be a result of severe vomiting and/or diarrhea. Patients who are very young or old are particularly susceptible to fluid loss and therefore at risk for the development of shock through dehydration. People who exercise in hot weather and are not acclimated to it may experience dehydration if they do not drink enough fluids. In these circumstances, the common factor is an insufficient volume of fluid within the vascular system to provide adequate circulation to the organs of the body.
Hypovolemic shock
The signs and symptoms of shock can become apparent as a patient progresses through them (TABLE 13-3). The early stage of shock, while the body can still compensate for blood loss, is called___.
compensated shock
The late stage, when blood pressure is falling and the mental status is declining, is called__.
decompensated shock
When shock progresses too far, it becomes irreversible; however, there is no way to know when a patient has reached that point. It is therefore important to recognize and treat shock early, before the patient has developed___, a condition defined by the inability to successfully achieve resuscitation regardless of the methods employed.
irreversible shock
Signs and symptoms of compensated shock
• Agitation
• Anxiety
• Restlessness
• Feeling of impending doom
• Weak, rapid (thready) pulse
• Clammy (pale, cool, moist) skin
• Pallor, with cyanosis about the lips
• Shallow, rapid breathing
• Nausea or vomiting
• Capillary refill of longer than 2 seconds in infants and children
• Marked thirst
• Narrowing pulse pressure
Signs and symptoms of decompensated shock
• Falling blood pressure (systolic blood pressure of 90 mm Hg or lower in an
• Declining mental status, altered level of consciousness
• Labored or irregular breathing
• Ashen, mottled, or cyanotic skin
• Thready or absent peripheral pulses
• Dull eyes, dilated pupils
• Poor urinary output
Remember that____ may be the last measurable factor to change in shock. As we have seen, the body has several automatic mechanisms to compensate for initial blood loss and to help maintain___. Thus, by the time you detect a decrease in blood pressure, shock is well developed. This is particularly true in infants and children, who can maintain their blood pressure until they have sustained blood loss equivalent to more than one-half their blood volume. By the time blood pressure drops in infants and children who are in shock, they are close to death.
You should expect shock in many emergency medical situations. For example, you would expect shock to accompany massive external or internal bleeding. You should also expect shock if a patient has any one of the following conditions:
• Multiple severe fractures
• Abdominal or chest injury
• Spinal injury
• Severe infection
• Major heart attack
• Anaphylaxis
blood pressure
The primary assessment for a patient with suspected shock should include a rapid exam to look for evidence of severe or exsanguinating hemorrhage, determine level of consciousness, identify and manage life-threatening concerns as they are found, and determine priority of the patient and transport. A patient with massive hemorrhage may require a tourniquet or wound packing____ the airway is opened. If the patient has obvious life-threatening external bleeding, it should be addressed first (even before airway and breathing) by controlling it quickly, then the ABCs can be assessed and treated.
When treating a patient in shock, provide high-flow oxygen to assist in perfusion of damaged tissues. If the patient has bled out, saturating the red blood cells they have left will help prevent hypoxia. If the patient has signs of hypoperfusion, treat aggressively and provide rapid transport to the hospital. Request advanced life support (ALS) as necessary to assist with more aggressive shock management. Do not delay transport of the seriously injured trauma patient to complete non-lifesaving treatments in the field, such as splinting extremity fractures; instead, complete these types of treatments en route to the hospital
Before
Anticoagulants can increase bleeding and worsen shock. Blood pressure medicines such as beta blockers can prevent the heart rate from rising to compensate for__.
shock
The secondary assessment begins by repeating the____ followed by a focused assessment. In some instances, such as a critically injured patient or short transport time, you may not have time to conduct a secondary assessment.
If your patient is a trauma patient with a significant mechanism of injury or multiple injuries, if the patient gives you a poor initial general impression, or if you found problems in the primary assessment, perform a secondary assessment of the entire body. If your patient has a medical problem but is not responsive or if problems were noted in the primary assessment, perform a secondary assessment of the entire body. These assessments should be performed quickly but thoroughly to ensure that you do not miss any significant or life-threatening problems or delay needed care.
If your patient has a simple mechanism of injury, such as a twisted ankle, focus your examination on the specific area affected. Whether your examination is of the entire body or of a specific area, if a life-threatening problem is found, treat it immediately.
primary. assessment
You must begin immediate treatment for___ as soon as you realize that the condition may exist. As with any type of patient care, you should begin by following standard precautions. Control all obvious external bleeding. Place dry, sterile dressings over the bleeding sites, and secure with bandages. If direct pressure is not rapidly successful in the control of bleeding from an extremity, apply a tourniquet proximal to the bleeding site (FIGURE 13-8). The use of tourniquets is further described in Chapter 26, Bleeding. Make sure the patient has an open airway. Maintain manual in-line stabilization if necessary, and check breathing and pulse.
shock
Comfort, calm, and reassure the patient, while maintaining the patient in the___ position. Never allow patients to eat or drink prior to being evaluated by a physician.
supine
Apply spinal motion restriction if there is a concern about neck or back injuries. Do not delay transport to apply individual___ in the field when shock is present. If time allows, splint individual extremity fractures during transport. Splinting minimizes pain, bleeding, and discomfort, all of which can aggravate shock. It also prevents the broken bone ends from further damaging adjacent soft tissue.
splints
Remember that inadequate ventilation may be a major factor in the development of shock. Always provide oxygen, assist with ventilations, and use airway control adjuncts as needed, and continue to monitor the patient’s breathing. To prevent the loss of body heat, place blankets under and over the patient. Do not use external heat sources, such as hot water bottles or heating pads. They may harm a patient in__ by causing vasodilation and decreasing blood pressure even more.
shock
Accurately record the patient’s vital signs approximately every 5 minutes throughout treatment and transport. It is essential to transport trauma patients to the ED as rapidly as possible for definitive treatment. The critically important period for the early resuscitation and treatment of severely injured trauma patients is often referred to as the__. This concept underscores the importance of rapid evaluation, stabilization, and transport. The goal of EMS is to limit on-scene time (time on scene until transport to hospital is started) to 10 minutes or less. Remember to speak calmly and reassuringly to a conscious patient throughout assessment, care, and transport.
Golden Period
Keep in mind that chronic lung disease will aggravate___ shock. If the patient has chronic obstructive pulmonary disease and heart disease, oxygenation of the blood passing through the lungs is impaired. Because fluid is collecting in the lungs, this patient is often able to breathe better in a sitting or semi-sitting position and may tell you so.
cardiogenic
Usually, patients with____ shock do not have an injury, but they may be having chest pain. Such a patient may have taken nitroglycerin before your arrival and may want to take more. Patients in cardiogenic shock should not receive nitroglycerin; by definition, they are hypotensive. In addition to low blood pressure, other signs include a weak, irregular pulse; cyanosis about the lips and underneath the fingernails; anxiety; and nausea.
Treatment of cardiogenic shock should begin by placing the patient in the position in which breathing is easiest as you administer high-flow oxygen. Be ready to assist ventilations as necessary, and have suction nearby in case the patient vomits. Provide prompt transport to the ED. If ALS is not already on the scene, consider a rendezvous en route to the hospital if available. Frequently check for a pulse in an unresponsive patient to identify early whether CPR and an AED are needed.
cardiogenic
As discussed previously, two of the most common examples of___ are cardiac tamponade and tension pneumothorax.
Increasing cardiac output should be the priority in treating cardiac tamponade. The preload must be increased because increasing pressure in the pericardium is squeezing the heart. Apply high-flow oxygen. The only definitive treatment for cardiac tamponade is surgery. Pericardiocentesis involves penetrating the pericardium with a needle to withdraw the accumulated blood from the pericardial sac. This procedure is an advanced skill, and it is rarely performed in the field
To treat a tension pneumothorax, administer high-flow oxygen via nonrebreathing mask early to prevent hypoxia. Usually the only action that can prevent eventual death from a tension pneumothorax is decompression of the injured side of the chest, relieving the pressure in the chest and allowing the heart to expand fully again. Chest decompression is an ALS skill.
Ask for ALS assistance early in the call if available; however, do not delay transport waiting for the arrival of ALS.
obstructive shock
The proper treatment of___ requires complex hospital management, including expeditious administration of antibiotics. If you suspect that a patient has septic shock, use appropriate standard precautions and transport as promptly as possible, administering high-flow oxygen during transport. Ventilatory support may be necessary to maintain adequate tidal volume. Use blankets to conserve body heat. Sepsis has become an increasingly common illness. Some hospitals have instituted specialized sepsis teams, which, when notified, will meet the patient in the ED. Sepsis teams have protocols that decrease the amount of time spent in identification of the infectious agent and initiation of the appropriate treatment, thereby decreasing the mortality from septic shock. EMS agencies may have sepsis protocols in which EMTs alert the hospital to the potential for sepsis when giving their radio report. Be familiar with your local protocols for sepsis alerts and notifications.
septic shock
Shock that accompanies spinal cord injury is best treated by a combination of all known supportive measures. Emergency treatment must be directed toward obtaining and maintaining a proper airway, providing spinal stabilization, assisting inadequate breathing as needed, conserving body heat, and ensuring the most effective circulation possible.
A patient in neurogenic shock is usually not losing blood; however, the capacity of the blood vessels has become significantly larger than the available volume of the blood inside the vessels. Supplemental oxygen will boost the concentration of oxygen in the blood. If respirations are weak or inadequate, assist ventilations. Because the injury may have disabled the body’s normal temperature controls, keep the patient as warm as possible with blankets. Transport the patient promptly to a facility capable of managing spinal injuries.
Neurogenic shock
The most effective emergency treatment of a severe, acute allergic reaction is to administer__ by way of intramuscular injection. For more information on the emergency care for allergic reactions, see Chapter 21, Allergy and Anaphylaxis. A patient who is aware of having a specific sensitivity may carry a kit containing epinephrine (FIGURE 13-9). If he or she is unable to inject the medication, you may have to do so if you are allowed by local protocol. Some EMT-staffed ambulances carry pre-filled epinephrine injectors on the ambulance to administer during anaphyaxis. If the patient’s signs and symptoms recur or the patient’s condition deteriorates, consult medical control for authorization to administer a repeat injection, if available.
epinephrine
A patient with___ requires immediate transport to the ED after administration of the epinephrine auto-injector.
Additional emergency care includes high-flow oxygen. Assist ventilations with a bag-mask device if necessary. If possible, attempt to determine what agent caused the reaction (for example, drug, insect bite or sting, food item and how it was received (for example, by mouth, by inhalation, or by injection). The severity of allergic reactions can vary greatly, with symptoms ranging from mild itching to profound coma and rapid death. Keep in mind that a mild reaction may worsen suddenly or over time. Because of the potential for airway compromise, consider requesting ALS backup, if available.
anaphylaxis
In an uncomplicated case of fainting, once the patient collapses and becomes supine, circulation to the brain is usually restored and with it, a normal state of functioning. Remember that___ can significantly worsen other types of shock. If it appears the patient fell as a result of psychogenic shock, check for injuries, especially in older patients. If the patient reports not being able to walk after a fall thought to be related to psychogenic shock, you should suspect another problem, such as head injury. Transport the patient promptly. It is not safe to assume based on EMT assessment that any fainting was caused by psychogenic shock alone. All patients with loss of consciousness, even a brief one, should be transported to the ED for evaluation even if they appear normal once you arrive on scene to evaluate them.
psychogenic shock
The emergency treatment of___ or hemorrhagic shock includes the control of all obvious external bleeding. The best initial method to control external bleeding is direct pressure. To prevent continued bleeding, you must apply sufficient pressure to control obvious external bleeding. If severe extremity bleeding is not controlled with direct pressure, consider use of a tourniquet. Bleeding control, including application of a tourniquet and wound packing, is discussed in detail in Chapter 26, Bleeding. Ensure that you use great care to handle the patient gently and keep the patient warm.
Although you cannot control internal bleeding in the field, it is important to recognize its existence and provide general support and rapid transport. Secure and maintain an airway, and provide respiratory support, including supplemental oxygen and, if needed, assisted ventilations. Start oxygen as soon as you suspect shock and continue it during transport; with too little circulating blood, additional oxygen may be lifesaving. Watch to ensure that the patient does not aspirate blood or vomitus, and transport the patient as rapidly as possible to the ED.
hypovolemic shock
Use caution when caring for older patients. As a result of the aging process, older patients generally have more serious complications than younger patients. Although illness is a common complaint among older patients, you must understand that it is not just part of aging. In addition, many older patients take numerous medications that could either mask or mimic signs of shock. Keep in mind the following signs of the normal aging process when managing geriatric patients:
• The central nervous system often has a delayed response; thus, tachypnea and vasoconstriction may be slower to respond to shock.
• The cardiovascular system has a variety of changes that result in a decrease in the efficiency of the system. On assessment, be alert for higher resting heart rates and irregular pulse rates.
• The respiratory system undergoes significant changes as the elasticity of the lungs and their size and strength decrease.
On assessment, be alert for higher respiratory rates, lower tidal volume, and a decreased gag reflex. In addition, remember that cervical arthritis may be present and that dentures may cause an airway obstruction.
• The skin becomes thinner, drier, less elastic, and more fragile, thus providing less protection and thermal regulation (cold and hot).
• The renal system decreases in function and may not respond well to unusual demands such as illness or dehydration.
• The gastrointestinal system sustains changes in gastric motility that may lead to slower gastric emptying.
The principles of treatment for a pediatric or geriatric patient in shock are no different than they are for any other shock patient:
1. Provide in-line spinal stabilization if indicated. If spinal immobilization is not indicated, maintain the patient in a position of comfort.
2. Control life-threatening hemorrhage immediately with direct pressure or tourniquet application when appropriate.
3. Suction as necessary and provide high-flow oxygen via a nonrebreathing mask
4. Maintain body temperature.
5. Provide rapid transportation.
Treating shock in older patients
