LO2 Shock and Haemorrhage (Chapter 4/5) Flashcards
Adequate Perfusion requires 4 components
Intact, functioning Vascular system
Adequate Air exchange
A functioning Pump
Adequate Fluid volume in vascular system
Normal perfusion
Relies on two Key Factors:
Cardiac Output
• Peripheral Vascular Resistance
The resistance blood has to flow against
How do we preserve perfusion?
Control bleeding.
-Look for other bleeding and control it
Maintain airway.
Maintain oxygenation & ventilation.
Maintain circulation
Adequate heart rate & intravascular volume.
Shock
a state of tissue hypoxia due to reduced oxygen delivery and or increased oxygen consumption or an adequate oxygen utilization
A condition during which the cardiovascular system fails to perfuse the tissues adequately.
Is a continuum.
three stages of shock
compensated decompensated and irreversible
Shock cycle:
↓ in Red Blood Cells
Anaerobic process
Hypoxia worsens
Inadequate perfusion: causes of buildup of lactic acid
Catecholamine ↑ : epi and noreepi
Cell death
repeat
Four Distinct kinds of shock
hypovolemic
distributive
obstructive
cardiogenic
Hypovolemic shock (absolute hypovolemia) causes
External hemmorage- controlled
External hemmorhage- uncontrolled
Internal hemmorahage
Other causes of intravascular volume loss such as diahrea
Distributive shock (high space) causes
Neurogenic shock
Medical causes (anaphylaxis, sepis, overdoses)
mechanical shock -Obstructive shock causes
Cardiac tamponade
Tension pneumothorax
Massive pulmonary embolism
mechanical shock -Cardiogenic shock
Cardiac contusion
MI
catecolmines
Epinephrine and Norepinephrine AKA Catecholamines are released due to a decrease in cardiac output.
• This causes:
↑ heart rate & contractility.
↑ systemic vascular resistance.
Blood is redirected from skin, gut and kidneys to the heart & brain.
Compensated Shock (first phase)
Loss of 15-25% of the blood volume
Body is compoensating
if not fixed goes to decompensated
Compensated Shock (first phase) signs and symptoms and why
Sustained tachycardia (high heart rate): catecholamines
- Pale (Pallor) & Cool skin: blood is shunted to middle of body
- Diaphoresis: catecholamines
- Tachypnea (high breathing rate): catecholamines
- Weakness/light headedness: caused by decreased blood volume
- Peripheral pulses weakened: blood is shunted to middle of body
- Thirst: hypovolemia
- Urinary output decreased: hypovolemia, hypoxia and circulating catecholamines
Decompensated Shock (second phase)
Loss of 30-45% of the blood volume: enough to cause hypotension
Body has failed to compensate
Decompensated Shock (second phase) signs and symptoms and why
- Hypotension: caused by hypovolemia, diminished cardiac output and/or vasodilation
- Altered metal status: lack of o2 to brain
- Cardiac arrest: organ failure secondary to blood loss, hypoxia
Capnography (ETCO ) 2
Normal range is 35-40 mmHg.
Falling ETCO2 indicates hyperventilation and decreased oxygenation
An ETCO less than <20mmHg means shock is worsening and may indicate circulatory collapse
Tachycardia
First sign of shock
100bpm not normal 120 red flag
Some patients in shock may not develop tacahycardia
Relative bradycardia
patients with traumatic hypotension
Consider patients meds
Beta blockers or calcium channel blocking medications might prevent them from developing tachycardia
Children in decompensated shock may develop bradycardia
Low volume shock(absolute hypovolemia)
is caused by haemorrhage or other major body fluid loss like diarrhea, vomiting and third spacing due to Burns, peritonitis and other causes
High space shock (relative hypovolemia)
is caused by spinal injury, vasovagal syncope, sepsis, anaphylaxis and certain drug overdoses that dilate the blood vessels and redistribute blood flow to a larger vascular volume
Mechanical shock (obstructive shock):
is caused by conditions preventing the filling of the heart like pericardial Tampanade, tension pneumothorax, or something obstructing blood flow through the lungs like a massive pulmonary embolism
Cardiogenic shock (pump failure):
is caused by a damaged heart like myocardial contusion or myocardial infarction
Absolute hypovolemia
• Loss of volume
Blood vessels can hold more than actually flows
Catecholamines (sympathetic nervous system) cause vasoconstriction and maintains bp high enough to perfuse vital organs
signs and symptoms of Absolute hypovolemia
LOC: possibly decreased
Airway: possibly snoring
Breathing: rapid and shallow
Pulses: rapid and “Thready” pulse: means width of artery shrinks
Skin: pale, cool, clammy
Possibly uncontrolled hemorrhage
Neck veins: flat
Trachea: midline
Chest: may be normal
Possible contusions or penetrations
Breath sounds: normal or unilaterally diminished
Abdomen: possibly tender/rigid/distended
Pelvis: may be unstable or painful
Extremities: possible fractures
TREATMENT Controllable Hemorrhage
Control bleeding w/ direct pressure.
Shock position
High‐flow oxygen
Rapid safe transport
Large‐bore IV access
Fluid bolus 500‐1000 ml for adult or 20 ml/kg for pediatrics
—Only restore perfusion
Monitor patient’s ECG, SPO2 and ETCO2.
treatment Uncontrollable Hemorrhage (external)
Control bleeding quickly and aggressively
Shock position
High‐flow oxygen
Rapid safe transport
Large‐bore IV access
Fluid administration
TXA Administration
Monitor patient’s ECG, SPO2 and ETC
treatment Uncontrollable Hemorrhage (internal)
Rapid safe transport
- Shock position
- High-flow oxygen
- Large-bore IV access
- Fluid administration
- TXA Administration
- Monitor patient’s ECG, SPO2 and ETCO2.
Low-volume Shock – Burns
Cutaneous injury as a result of thermal (heat, flame or scald) or non thermal (chemical or electrical).
May be associated with smoke inhalation injury or other traumatic injuries.
Severity of a burn is determined by:
- -Age, medical history of the patient.
- -Body area involved
- -Size and depth of burn.
Major burns
Burns greater than 20% total body surface area (TBSA) are considered
Major Burns.
result in the loss of or the evaporation of:
Plasma or water.
Large amounts of electrolytes.
They can cause generalized edema and hypovolemia.
TREATMENT Burn treatment (<20 TBSA)
- Cool the burn
- Analgesia
- Apply moist sterile dressing
- Fluid administration
- Safe transport
TREATMENT Burn treatment (>20 TBSA)
Cool the burn • Airway support • High-flow oxygen • Apply sterile dry dressings • Large-bore IV access • Analgesia • Fluid administration • Rapid safe transport • Monitor patient’s ECG, SPO2 and ETCO2 • Monitor patient for hypothermia
Distributive Shock
Relative hypovolemia
“Vasodilatory shock”
Large intact vascular space
Interruption of sympathetic nervous system
Loss of normal vasoconstriction; vascular space becomes much “too large”
Clinical presentation
Varies dependent on type of high-space shock
Distributive shock – Neurogenic Shock
Neurogenic shock typically occurs after an injury to the spinal cord (C6 and above).
Injury prevents additional catecholamine release.
Neurogenic Shock signs and symptoms
oHypotension
oHeart rate normal or slow
oSkin warm, dry, pink à not pale because catecholmines are not released
oParalysis or deficit
oNo chest movement, simple diaphragmatic
Neurogenic Shock treatment
Treat symptomatically • Spinal motion restriction • Rapid safe transport • High-flow oxygen • Large-bore IV access • Fluid administration • Monitor patient’s ECG, SPO2 and ETCO2.
Distributive shock – Sepsis shock
Septic shock has a high mortality rate.
An infectious processes initiates it.
Bacteria, endotoxins and exotoxins initiate the inflammatory process which initiates widespread vasodilation.
Common sites of infection are:
i. Lungs
ii. Bloodstream
iii. Intravascular catheter
iv. Urinary tract
v. Surgical wound
signs and symptoms of septic shock
Tachycardia • Tachypnea • Temperature instability • Altered mental status • ↓ renal function • Clotting abnormalities
• There are phases of Sepsis not every patient is in shock.
Sepsis
SIRS with signs of infection
Severe sepsis
Involvement of 1 or more organ system dysfunctions
Septic shock
Development of hypotension
Systemic inflammatory response syndrome (SIRS)
Temp: >38°C or <36°C; Pulse: >90; R/R: >20/min
Sepsis Treatment
- Identify the source of infection
- Large-bore IV access
• Fluid replacement - 20 mL/kg with the intent to repeat following a reassessment
–Start pts with crackles at 250ml if not 500ml and reassess
- Oxygen administration
- Rapid safe transport
- Temperature management
- Monitor patient’s ECG, SPO2 and ETCO2
- Inotropic support (ALS ONLY)
- IV antibiotic administration (ALS ONLY)
Distributive shock – Anaphylaxis
This response typically involves 2 body systems and causes massive vasodilation.
This vasodilation causes fluid to shift from the intravascular space to the extravascular space
Distributive shock – Anaphylaxis signs and symptoms
- Anxiety/altered mental status
- Dyspnea
- Edema
- Hypotension
- Gastrointestinal (GI) cramps
- Hives (urticaria)
- Sensations of burning or itching of the skin
- Fever
Anaphylaxis treatment
Epinephrine administration • Bronchodilator administration • Oxygen administration • Rapid safe transport • Large-bore IV access • Fluid administration • Monitor patient’s ECG, SPO2 and ETCO2.
Mechanical Shock – Cardiogenic
Impairment of the pump.
This is typically caused by a myocardial
infarction (MI).
Leads to decreased cardiac output.
Cardiac contusions: right ventricle most common place
Arrythmias
Stiffness/decrease contraction
Mechanical Shock – Cardiogenic signs and symptoms
Tachycardia, tachypnea, hypotension, JVD, dysrhythmia Chest pain Dyspnea Faintness Feelings of impending doom
Cardiogenic shock treatment
ASA administration
• STEMI/NSTEMI, dysrhythmia identification & treatment.
• IV access
• Monitor patient’s ECG, SPO2 and ETCO2.
• Nitroglycerin administration
• Rapid safe transport
Mechanical Shock – Obstructive (outside of the heart somewhere)
Is inadequate cardiac output caused by an impediment to blood flow to or from the heart into the pulmonary or systemic circulation.
Obstructive shock treatment
- Identify & treat cause.
- Chest decompression (ALS)
- Rapid safe transport
- High-flow oxygen
- Large-bore IV access
- Fluid administration
- Monitor patient’s ECG, SPO2 and ETCO2.
Mechanical Shock – Obstructive (outside of the heart somewhere) causes
Tension pneumothorax
Cardiac tamponade
pulmonary embolism
Tension pneumothorax
High Air tension that may develop in plural space due to lung or chest wall injury
Blood returns to the chest largely because of negative pressure that results when individuals inhales in the absence of this negative pressure blood return will be decreased oh preventing the return of venous blood to the heart resulting in a back up of blood
Increased venous return results in lower cardiac output in the development of shock
Tension pneumothorax s/s
decreased or absent breath sounds on the affected side, JVD, deviated trachea, cyanosis and a decreased LOC
Cardiac tamponade
Occurs when blood feels the potential space between the heart and the pericardium squeezing the heart and preventing the heart from filling
This decreased feeling the heart causes cardiac output to fall resulting in development of shock
May occur in more than 75% of cases of penetrating cardiac injury
Cardiac tamponade s/s
Signs and symptoms have been labelled Becks triad
JVD, muffled heart tones and pulses paradoxus (hypotension)
shock in children
Most common type and causes
• Hypovolemic
- Dehydration
- Trauma
shock in children
Second most common type and causes
Relative hypovolemia
- Burns
- Sepsis
- “Third spacing” – fluid leaks from inside veins to outside
Manifestations of Shock in children
Vitals are not always indicative
Manifestations of Shock in children
consciousness and responsiveness
Extremely irritable
Lethargy: Severe deterioration of consciousness
Decreased response to painful stimulation (usually indicates severe cardiorespiratory or neurologic compromise)
Manifestations of Shock in children
breathing
Extremely rapid respiratory rate: Tachypnea
Increased depth of respirations: Hyperpnea
Evidence of increased respiratory effort: Retractions (breath in really deep and everything retracts), grunting, nasal flaring
Apnea or inadequate respiratory rate or effort
Manifestations of Shock in children
skin color
Mottling – marbleized or blotchy appearance to the skin (may come from a cold environment)
Pallor – poor perfusion
Flushed, bright red skin – sepsis
Manifestations of Shock in children
cap refill
Capillary refill:
• Compromise in systemic perfusion
• Prolonged capillary refill time (>2 seconds)
• Subjective interpretation – reliable?
Manifestations of Shock in children
bradycardia
Possible cause or a symptom of deterioration
Most common cause: Hypoxia
Often indicates impending cardiovascular collapse
Most common terminal cardiac rhythm observed in children
Pt is detreating
Manifestations of Shock in children
blood pressure
Shock may be present despite a systolic blood pressure within the normal range for the age of the child
If systolic hypotension develops or the mean arterial pressure fallsàindicates hypotensive shock
10mL/kg of fluid
