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Shock: Types and Prehospital

Treatment

September 21, 2004

Todd Lang, MD
VVMC EMS Medical Director
Goals
Define Shock
Review types of shock and their essential
features
Understand bodys response to shock at
basic level
Goals (contd)
Distinguish between types of shock
Distinguish compensated vs.
decompensated shock
Identify field interventions that help
and those that dont
Definition of Shock
A condition resulting in inadequate
perfusion of tissue with impaired
tissue oxygenation
A true emergency
But, one which has many
treatments
SHOCK
Preshock known as warm shock or
compensated shock
homeostatic mechanisms rapidly compensate for
diminished perfusion
Despite a 10 percent reduction in total effective
blood volume, a previously healthy adult may be
asymptomatic
Tachycardia, peripheral vasoconstriction, modest
decrement in systemic blood pressure
SHOCK
Shock During 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
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 - Fainting situational
High outputcirrhosis, AV fistula (rare)
Hemodynamic
Classification of Shock
Type PAP CO SVR
hemorrhagic decr decr incr
cardiogenic incr decr incr
distributive nl nl decr
decr incr decr
obstructive incr decr incr
Common
Pathophysiology
Early Phase
Preservation of Cardiac Output
Catecholamine release: Sympathetic stimulation
increased HR,
enhanced contractility
increase SVR
Maintain arterial pressure
Venoconstriction - increase preload/filling
pressure
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
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
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 and
cardiac decompensation is imminent.

Different Shocks Have a Lot in
Common!
Hypotension
Changed mental status
Difficulty breathing
Pale
Look very sick!
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
Emergency Care of Shock
Urgent survey and interventions: secure airway
and control bleeding
Rapid body survey: administer high concentration
O
2
, treat injury or illness - splint fractures, and
keep supine and elevate lower extremities 12
inches, 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
BLOOD PRESSURE GOAL
about 90 systolic/MAP of 60
But, treat the patient, not the
number! Be distrustful of
numbers that dont fit.
Check MS, pulses, cap refill
and manual BP.
CEREBRAL PERFUSION
PRESSURE (CPP)
MAP-ICP = CPP
65-5 = 60 mmHG

<60 risk of brain ischemia
and neuronal damage
Normal Hypertensive
Relative
CBF
(Autoregulation)
50 100 150 200
MAP
Treatment of Shock


AKA When to do a fluid bolus
FOR MOST ACUTELY HYPOTENSIVE PTS:
if
PULMONARY EDEMA Absent
then
FLUID CHALLENGE IS AN APPROPRIATE
FIRST RESPONSE

Basically, if it is not cardiogenic and they
are oxygenating OK, then do it.
BOLUS OF FLUID
HOW MUCH? 500-1000 (up to 3L OK)
HOW FAST? KVO or Wide open only.
The heart and kidneys take care of
overshooting, if they work. Young
people will not suffer from over-
resuscitation.
Key Concept:
Intravascular Volume
5% Actual Body Weight
8% Total Body Water

We must change intravascular volume to raise
blood pressure. It wont change unless we put
fluid 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!
DURING RESUSCITATION
REMEMBER TO MONITOR:
MENTAL STATUS
VITAL SIGNS (MAP - O2 SATS)
URINE OUTPUT
SKIN PERFUSION
(LACTATE)
Pulmonary Edema is a Cardinal
Sign of Cardiogenic Shock!
So, look for it specifically in every
patient who is in the ambulance, prior
to giving fluid bolus.
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

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
Pulmonary Edema Bat wings
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
Cardiogenic Shock
Management Principles
Primary Goal: Improve myocardial
function
Decrease O
2
consumption (VO
2
)
Intubation, sedation, analgesia
Increase O
2
delivery (DO
2
)
Optimize CI, Hgb., Hgb. sat. (SaO
2
)
Cardiogenic Shock
Management Methods
Pharmacologic Manipulation
Preload (RAP,PAP) - morphine,
nitro, lasix, volume
Cardiac contractility - inotropes,
chronotropes, vasopressors
Afterload (PVR,SVR) - nitro, beta-
blockers
Cardiogenic Shock
Interventional Therapy
Intraaortic Balloon Pump (IABP)
or Counterpulsation
IABP + Early CABG (12-16 hr.
post AMI)
Left Ventricular Assist Device
(LVAD)
Hemorrhagic Shock
Clinical Presentation
Early Phase
Tachycardia, narrow pulse
pressure, may exhibit orthostatic
changes in HR/AP
Healthy patient with 25-30% loss
may exhibit only these signs
Hemorrhagic Shock
Less healthy patients will exhibit
rapid decompensation with this
magnitude of volume loss
Later Phase
Cool moist skin, hypotensive, pale,
anxious, disoriented, oliguric
KEY: EARLY RECOGNITION
Hemorrhagic Shock
Restoration of intravascular volume
Initial Management:
Oxygen
Stop the hemorrhage
Fluids
Transfusions
Distributive Shock
Peripheral vascular dilatation disproportionate to
existing intravascular volume.

Septic/Systemic inflammatory
Shock (SIRS)
anaphylaxis,
spinal shock
Definitions:
Sepsis a syndrome of shock caused by
infection
Bacteremia - defined as an organism or
organisms that are circulating in the blood\
Systemic Inflammatory Response
Syndrome (SIRS) - the systemic response to
a variety of insults which activate common
inflammatory mechanisms.

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%
Risk Factors for the Development of
SIRS*:
Neutropenia (ANC < 500/mm
3
)
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.
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 Ca
blockers
RR > 24 bpm or arterial PCO
2
< 32 mm Hg
leukocytosis (WBC > 12,000/mm
3
) or leukopenia (<
4,000/mm
3
) or > 15% band forms

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
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
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.
Septic Shock
Late Phase
CO decreased, hypotension,
vasoconstriction, impaired perfusion,
decreased level of consciousness,
oliguria, DIC
Atypical Presentation
Elderly/debilitated Fever, respiratory
alkalosis, confusion, hypotension
Complications of SIRS with Shock
Acute Renal Failure
Disseminated Intravascular Coagulopathy
Adult Respiratory Distress Syndrome
Unresponsive Hypotension
GI bleed
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


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
Inpatient Treatment of Septic Shock Patient
Fluids
Vasopressors-dopamine/norepinephrine
Antibiotics
Steroids?
Other avenues?
Anaphylactic shock
Dont fail to diagnose
Low threshold for Epi use in people with
healthy hearts and blood vessels
Certainly use it if airway symptoms or
hypotension
Beware of GI symptoms
Aggressive IV fluids as above
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
Case 1
Healthy 38 yo man in farm accident avulsed his R
arm at elbow and bled profusely at the scene. His
brother tourniqueted the stump and controlled
bleeding after significant blood loss. Blood
everywhere.
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?
Case 1- Basic trauma patient
He needs 2 large bore
IVs
Give 2L wide open
NS/LR
His history is enough
to know he can handle
a lot of fluid
His HCT/Hb will be
normal acutely
Use VS changes to
assess response and
volume status
He will need blood, so
prepare for this.
Case 2
4 yo boy with hx asthma has 5 days vomiting and
diarrhea. 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?
Case 2-pediatric dehydration
Take a good history. How many times and
how often has 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

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
Case 3
77 yo woman who has hx of CHF and CRI
with 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 SM
and irreg irreg. No peripheral edema.
What is appropriate from here?
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

Case 3-unclear volume status
Either try fluids or try diuretics
Not a good patient to give an ambulance
fluid bolus to unless discussed with
physician.
Case Presentation:
A 77 yo man calls you for feels sick. He has a
history of CHF, COPD (from smoking), and
IDDM. Over the past several days he has
complained of fever to 101, chills, and a
productive cough. This has been increasing in
frequency and his symptoms are getting
progressively worse. He started getting dizzy
today and is feeling very weak. Vital signs are
T=101.7, HR=132, RR=30, BP=80/42, RA
SaO2=84%.
Probably Septic from Lung
Oxygen
IV
Fast H&P
Assess for pulmonary edema
Bolus 500cc open and recheck vitals to
assess response
Thanks!

Any Questions?

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