Prehospital Trauma Life Support

Lesson

Shock & Fluid Resuscitation

Developed by the

National Association of Emergency Medical Technicians

In cooperation with

The Committee on Trauma, American College of Surgeons

This slide presentation is intended for use only in approved PHTLS courses.

6-1B

Lesson 6 Objectives

Correlate perfusion, hypoperfusion, hypoxia, hypovolemia and hypotension to the signs and symptoms of shock. Differentiate between early and late signs of shock.
Describe the pathophysiological changes of shock.

Identify the management of shock, including conservation of heat, fluid replacement and the pneumatic anti-shock garment.
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Shock: A rude unhinging of

the machinery of life.

Samuel Gross, 1852
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Shock Redefined:
Lack of end-tissue perfusion.
Pitfall: Defining shock as decreased blood pressure.
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Scenario
You are caring for the sole victim of a

motorcycle crash. He is lying on the

ground next to his motorcycle. The scene appears safe.

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Findings
A - Open, clear.
BRR fast. BS clear. Bruising noted over sternum; no other chest deformity.

C - Radial pulse weak & rapid.

D - PEARL. Anxious & confused. Normal movement & sensation. ENo deformity noted. Skin cool & diaphoretic.
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Discussion
Is this patient in shock? Why?

What is the patients real problem?

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Cell Perfusion
Aerobic metabolism requires adequate oxygenation.
Cells require oxygen and sugar to produce energy and carbon dioxide.
Is the patient in this scenario adequately perfusing his cells?
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Anaerobic Metabolism

Inadequate oxygenation for metabolism.

By-products:

Less energy.
More acid.

Potassium.
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Cellular Death
Cellular Hypoxia - Anaerobic Metabolism

SHOCK

Hypotension
Hypoperfusion

Cellular Hypoxia
Anaerobic Metabolism Cell Death
If cellular death is not prevented, organism death will follow.
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Staged Death
Organism death:

May be quick - prior to EMS. May be prolonged - 2 to 3 weeks later.

Occurs in stages:

Stages occur as the body tries to compensate. We see the stages through signs & symptoms.
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Prevent Cellular Death

Recognize shock early. Restore cellular perfusion. Restore aerobic metabolism.
Pitfall: Waiting until it is too late to restore perfusion to cells.

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Early Recognition
Signs & Symptoms of Uncompensated Shock
Description Compensated Decompensated

Pulse

Tachycardia

Marked tachycardia; can progress to bradycardia

White, waxy, cold, marked diaphoresis Lowered Altered, ranging from disoriented coma
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Skin BP LOC

White, cool, and moist Normal range Unaltered

Early vs. Late

What are the earliest signs of shock? What is a late sign of shock?

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Restore Cellular Perfusion

Maintain chemical balance. Maintain fluid balance.

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Chemical Balance
Decrease in oxygen.

continued...

Detected by chemical receptors in the carotid arteries and in the arch of the aorta. Respirations increase in rate & depth.

Rise in acidity.

Buffer system converts acid to CO2 & water.

Medulla senses increased CO2.

Respirations increase; lungs blow off CO2.
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Chemical Balance
Key: increase in respiratory rate is an early sign of shock.

contd.

What signs or symptoms indicate that the patients body is trying to restore its chemical balance? What steps could you take to help the body restore balance and aerobic metabolism?
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Fluid Decrease
Fluid volume decreases

Baroreceptors note change

Epinephrine and norepinephrine released

Vasoconstriction

Increased rate & strength of cardiac contractions

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Fluid Decrease
Hormonal response:

continued...

Various hormones are released, causing vasoconstriction and fluid retention.

Compensation:

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

contd.

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

Is the patient compensating well? Why?

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

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The Fick Principle

Defines what is necessary to achieve end-tissue perfusion:

On-loading oxygen to the RBCs. Delivering the RBCs to the tissue. Off-loading oxygen to the tissue.

As part of the process, patient must have an adequate number of RBCs to transport oxygen.
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Scenario
You are responding to a patient that has

fallen from a 40-foot cliff while rock climbing.

He is awake. He tells you that he cant move his legs, and has no feeling below his waist. Pulse 119, RR 20, and BP 104/72.

How does the Fick Principle apply here? How well is this patient compensating?
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Scenario
You are called to the scene of a house

fire, where firefighters have just removed

one patient. He is unresponsive. Pulse 102, RR 6, and BP 104/76.

How does the Fick Principle apply here?

How well is this patient compensating?

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Scenario
You respond to a scene where a skier has struck a tree at high speed. Exam reveals pain on palpation of the right lateral chest, absent breath sounds on the right and labored

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

How does the Fick Principle apply here? How well is this patient compensating?
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Scenario
You are dispatched to an MVC. On arrival, you
find a 47-year-old male driver still in the vehicle. There are 10-15 inches of intrusion to

the front of the vehicle. The patient is

unresponsive as you approach.

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Findings
A - Blood & vomitus in airway.
BSlow & labored. BS absent on left.

C - No palpable radial pulse. Cool, wet skin. No external bleeding. D - Pupils equal but reacting slowly.

E - Obvious fracture of left femur.

How does the Fick Principle apply here?
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Shock Summary Shock is staged death... catch it in the first act!

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