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Shock and Resuscitation. Chapter 15. Objectives. Discuss etiologies of shock What the common categories of shock are Specific types of shock What the body’s responses are to shock Discuss shock assessment Discuss age considerations

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objectives
Objectives
  • Discuss etiologies of shock
  • What the common categories of shock are
  • Specific types of shock
  • What the body’s responses are to shock
  • Discuss shock assessment
  • Discuss age considerations
  • What the general goals are of pre-hospital management of shock
  • Pathophysiology of cardiac arrest
  • Discuss terms related to resuscitation
  • The points of resuscitation in cardiac arrest
  • Discuss AED and CPR
  • Discuss the recognition and treatment of cardiac arrest
  • Talk about the special considerations of the AED
etiologies of shock
Etiologies of Shock

Shock is inadequate tissue perfusion (hypoperfusion)

  • Less oxygen is delivered to the cells than is needed for normal metabolism
  • The elimination of carbon diozide and other waste products is impaired
etiologies of shock1
Etiologies of Shock

Three Etiologies provide a foundation for general emergency care;

  • Inadequate Volume
    • Will have a decrease in preload, which will cause the stroke volume and cardiac output to fall
    • May result from a loss of whole blood from bleeding
    • May result from a loss of plasma volume from diarrhea, burns, excessive urination, increased capillary leakage, and excessive vomiting
etiologies of shock2
Etiologies of Shock
  • Inadequate Pump Function
    • May result from an injury to the heart that reduces its ability to generate strong enough contractions
    • May result from weakening over time from disease, old age, or injury
    • May result from mechanical obstruction of the movement of blood into the heart
etiologies of shock3
Etiologies of Shock
  • Inadequate Vessel Tone
    • Tone is related to the size of the vessel
    • The sympathetic nervous system regulates vessel size
    • Inadequate vessel tone may result from an injury to the spinal cord or released chemical mediators that cause a systemic dilation of vessels
slide8

Perfusion Triangle

Blood Vessels

(Container Function)

If all the vessels dilate at once, the normal amount of blood volume is not enough to fill the system and provide adequate perfusion to the body.

Heart

(Pump Function)

Damage to the heart by disease or injury.

It cannot move blood adequately to support perfusion.

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.

categories of shock hypovolemic shock
Categories of Shock – Hypovolemic Shock
  • Caused by low blood volume
  • Most common type of shock
  • Generally caused by hemorrhage
  • Also be caused by burns and dehydration
categories of shock distributive shock
Categories of Shock – Distributive Shock
  • Associated with a decrease in intravascular volume
  • Massive systemic vasodilation
  • Increase in capillary permeability
  • Reduction in systemic and peripheral vascular resistance
  • Reduction in systolic blood pressure
categories of shock cardiogenic shock
Categories of Shock – Cardiogenic Shock
  • Caused by ineffective pump function of the heart
  • Patient is prone to cardiogenic shock when more than 40% of the left ventricle is lost
categories of shock obstructive shock
Categories of Shock – Obstructive Shock
  • Results from a condition that obstructs forward blood flow
  • Possible causes: Blood clot, Tension pneumothorax, or Pericardial Tamponade
categories of shock metabolic or respiratory shock
Categories of Shock – Metabolic or Respiratory Shock
  • Described as the fifth type of shock in some sources
  • Dysfunction in the ability of oxygen to diffuse into the blood, be carried by hemoglobin, off-load at the cell, or be used by the cell for metabolism
specific types of shock
Specific Types of Shock

Hemorrhagic Hypovolemic Shock

  • Results from the loss of whole blood from the intravascular space
  • Relates to whole blood loss that can occur from traumatic injury or medical illness
  • Reduction in pressure and a decrease in oxygen-carrying capability
  • Poor perfusion state from an inadequate intravascular volume
  • Bleeding must be stopped
  • Administration of whole blood or blood components
specific types of shock1
Specific Types of Shock

Non-hemorrhagic Hypovolemic shock

  • Results from the loss of fluid from the intravascular space
  • Red blood cells and hemoglobin remain within the vessels
  • Water, plasma proteins, and electrolytes are lost
  • Blood volume, pressure and perfusion of cells are reduced
  • Administration of intravenous fluids may be beneficial
specific types of shock2
Specific Types of Shock

Burn Shock

  • Non-hemorrhagic Hypovolemic shock resulting from a burn injury
  • Burns may interrupt the integrity of the capillaries and vessels
  • “Pull” effect draws fluid into the interstitial space, causing edema
  • Establish and maintain adequate airway, ventilation, and oxygenation
specific types of shock3
Specific Types of Shock

Anaphylactic Shock

  • This is a type of distributive shock
  • Chemical mediators in the anaphylactic reaction cause massive and systemic vasodilation
  • Capillaries become permeable and leak
  • Fluid is forced out into the interstitial space
  • Systemic vascular resistance is reduced
  • Blood pressure and perfusion are decreased
  • Epinephrine is the medication of choice
specific types of shock4
Specific Types of Shock

Septic Shock

  • This is a type of distributive shock
  • Results from an infection that releases bacteria or toxins in the blood
  • Vessels dilate and become permeable
  • Fluid leaks into the interstitial space
  • Systemic vascular resistance, blood pressure, and perfusion are reduced
  • Intravascular volume, preload, stroke volume, cardiac output, systolic blood pressure and perfusion are decreased
  • Manage the airway, ventilation, and oxygenation
  • Administer intravenous fluids and medication to constrict the vessels
specific types of shock5
Specific Types of Shock

Neurogenic Shock

  • This is also a type of distributive shock, also known as vasogenic shock
  • May be caused by a spinal injury
  • May damage the sympathetic nerve fibers that control vessel tone
  • Vessels dilate
  • Systemic vascular resistance, blood pressure, and perfusion may drop
  • Blood will pool in the peripheral vessels
  • Preload, stroke volume, cardiac output, and systolic BP will decrease
  • Emergency care focuses on spinal immobilization and management of the airway, ventilation, and oxygenation
  • Patient may also benefit from intravenous fluids and medication to constrict the vessels
specific types of shock6
Specific Types of Shock

Cardiogenic Shock

  • Most common causes;
    • Myocardial Infarction
    • Congestive heart failure
    • Abnormal cardiac rhythm
    • Overdose on drugs that depress the pumping function of the heart
  • Emergency care focuses on management of airway, ventilation, and oxygenation
the body s responses to shock
The Body’s Responses to Shock

The body attempts to compensate for a disturbance and returns perfusion and tissue function to a normal state

Compensatory mechanisms;

  • Direct Nerve Stimulation
    • Increase in heart rate
    • Increase in force of ventricular contraction
    • Vasoconstriction
    • Stimulation of the release of epinephrine and norepinephrine
the body s responses to shock1
The Body’s Responses to Shock

Release of Hormones

  • Epinephrine stimulates alpha and beta receptors
  • Norepinephrine stimulates alpha receptors
  • Other hormones decrease urine output, cause further vasoconstriction, cause an increase in glucose in the blood
stages of shock
Stages of Shock

Compensatory Shock

  • Near normal BP and perfusion of the vital organs is maintained
  • Etiology of shock is reversed at this stage, the compensatory mechanisms will continue to maintain the BP and perfusion
  • A narrow pulse pressure should be noted in the early stages of shock
stages of shock1
Stages of Shock

Decompensatory Shock

  • Advanced stage in which the compensatory mechanisms are no longer able to maintain BP and perfusion to vital organs
  • If state continues, the compensatory mechanisms become exhausted
  • Cells, tissues, and organs become ischemic
  • Heart function depresses
  • Blood in capillaries begins to sludge and form microemboli
  • Blood leaks out of the vessels into the interstitial spaces
  • The vasomotor in the medulla becomes hypoxic, sympathetic nervous system stimulation is reduced
  • Aggressive shock management may or may not reverse the process
stages of shock2
Stages of Shock

Irreversible Shock

  • Stage where the patient outcome is death
  • Cell, tissue, and organ failure is so severe that it cannot be reversed
  • Microemboli block capillaries throughout the body
  • Fibinolysis leads to widespread uncontrolled bleeding
shock assessment
Shock Assessment

History

  • Pay attention to chief complaint
  • Identify signs/symptoms that might provide clues to the etiology of the shock
  • Gather SAMPLE history
shock assessment1
Shock Assessment

Physical Exam

  • Assess for signs of shock
  • Obtain vital signs – BP, Heart rate, pulse character, respiratory rate and tidal volume, skin color, temperature, and condition, SpO2
  • Note signs of poor perfusion;
    • Altered mental status
    • Pale, cool, clammy skin
    • Delayed capillary refill
    • Decreased urine output
    • Weak or absent peripheral pulses
age consideration in shock
Age Consideration in Shock
  • Elderly and infants deteriorate rapidly
  • Children/young adults exhibit minor signs over a long period of time and then decompensate suddenly
  • Medications in the elderly may prevent some signs/symptoms from appearing
  • Altered mental status and tachypnea may be most profound signs of shock in the elderly
general goals of prehospital management of shock
General Goals of Prehospital Management of Shock

Management of shock is geared to improving oxygenation of the blood and delivery of oxygen and glucose to the cells

General goals;

  • Secure and maintain a patent airway
  • Establish and maintain adequate ventilation and oxygenation
  • Do not hyperventilate
  • Stop the bleeding using direct pressure
  • Splint fractures
  • Do not remove impaled objects
  • Maintain the body temperature
  • Keep the patient in a supine position
general goals of prehospital management of shock1
General Goals of Prehospital Management of Shock
  • Apply PASG
    • Refer to Whatcom County Protocol’s page 17
    • A pelvic fracture is suspected
    • Systolic BP less than 90 mmHg
    • Profound hypertension is present
    • Intra-abdominal hemorrhage is suspected with severe hypotension
    • Retroperitoneal hemorrhage is suspected with hypotension
    • Rapidly transport patient
    • Consider ALS
pathophysiology of cardiac arrest
Pathophysiology of Cardiac Arrest

Resuscitation is bringing a patient back from a potential or apparent death

Cardiac arrest occurs when the ventricles are not contracting or when the cardiac output is completely ineffective

Sudden death occurs when the patient dies within one hour of the onset of signs/symptoms

pathophysiology of cardiac arrest1
Pathophysiology of Cardiac Arrest

Three phases the patient goes through following cardiac arrest that lead to biological death;

  • Electrical phase
  • Begins immediately upon cardiac arrest and ends four minutes afterwards
  • Heart is in good condition for resuscitation
  • Restore an effective electrical rhythm
pathophysiology of cardiac arrest2
Pathophysiology of Cardiac Arrest

2. Circulatory Phase

  • Begins at 4 minutes and last through ten minutes following a cardiac arrest
  • Myocardial cells shift from aerobic to anaerobic metabolism
  • Myocardial cells become ischemic
  • Heart is not prepared for defibrillation and is not prone to restarting
  • CPR will provide oxygen and glucose to the heart, improving chances for defibrillation
pathophysiology of cardiac arrest3
Pathophysiology of Cardiac Arrest
  • Metabolic Phase
  • Begins at 10 minutes after cardiac arrest
  • Heart is starved of oxygen and glucose
  • Acid has built up in the heart
  • Tissues are very ischemic and may begin to die
  • Sodium/Potassium pump fails
  • Sodium that stays in the cells attracts water
  • Cells swell, rupture, and die
  • Resuscitation during this phase is typically unsuccessful
terms related to resuscitation
Terms Related to Resuscitation
  • Downtime – time the patient goes into cardiac arrest until CPR is being performed
  • Total downtime – Total time from when the patient goes into cardiac arrest until patient is delivered into the emergency department
  • Return of Spontaneous Circulation (ROSC) – Patient regains a spontaneous pulse during resuscitation
  • Survival – Patient who survives to be discharged from the hospital
withholding a resuscitation attempt
Withholding a Resuscitation Attempt
  • DNR – Do Not Resuscitate
  • POLST – Physicians Orders for Life-Sustaining Treatment
  • MOLST – Medical Orders for Life-Sustaining Treatment
  • A patient with injuries that are not compatible to life
  • Obvious death in patients who are beyond the point of resuscitation
chain of survival
Chain of Survival
  • Early Access
    • Early recognition of cardiac event
    • Easy access to EMS system
  • Early CPR
    • Immediate CPR can double or triple chance of survival form VF SCA
    • Important to begin CPR within 2 minutes of cardiac arrest
chain of survival1
Chain of Survival
  • Early defibrillation
    • Survival of VF SCA decreases approximately 7 – 10% for every minute that defibrillation is delayed
    • Defibrillation is the procedure of sending an electrical current through the chest
  • Early ALS
    • Paramedics who can provide advanced cardiac life support (ACLS)
    • Advanced EMT’s may be able to provide either all or certain components of ALS
automated external defibrillation cardiopulmonary resuscitation
Automated External Defibrillation & Cardiopulmonary Resuscitation

Types of Defibrillators

  • Applied to the outside of the chest
  • Manual
  • Automated (AED)
  • Advantages of AED’s
    • Initial training and education
    • Speed to operation
    • Safer, more effective delivery
    • More efficient monitoring
analysis of cardiac rhythms
Analysis of Cardiac Rhythms
  • Ventricular Fibrillation (VF or VFib)
    • Disorganized cardiac rhythm
    • No pulse or cardiac output
    • Commonly associated with advanced coronary disease
analysis of cardiac rhythms1
Analysis of Cardiac Rhythms
  • Ventricular tachycardia (V-Tach)
    • Described as a very fast heart rate
    • Generated in the ventricle instead of the sinoatrial node in the atrium
    • Cardiac output is sharply reduced
    • Be aware that some V-Tach patients are not appropriate candidates for defibrillation
    • AED should only be used on patients who are pulseless, not breathing and unresponsive
analysis of cardiac rhythms2
Analysis of Cardiac Rhythms

AED will detect rhythms for which no shock is indicated

  • Asystole – Electrical activity and pumping action in the heart is absent
  • Pulseless Electrical Activity (PEA) – Heart has an organized rhythm, but does not pump
  • The AED is very sensitive
    • No one should be touching the patient
    • Ambulance should be stopped with the motor off
when when not to use the aed
When & When Not to Use the AED
  • Infants – Do not use AED on infants. This statement is in disagreement with Whatcom Co. Protocol page 4.
  • Patients between 1 – 8 – use AED with a does attenuating system to reduce defibrillation energy
  • Patients over 8 years of age
  • Within 5 minutes, apply AED
  • If over 5 minutes, immediate perform 2 minutes of CPR 30:2 and then apply AED
  • AED in not for trauma patients
  • Consult Med control and protocols if unsure about using AED
recognizing and treating cardiac arrest
Recognizing and Treating Cardiac Arrest

Scene size-up and Primary Assessment

  • Take appropriate Standard Precautions
  • Ensure scene is secure
  • Form a general impression
  • If a suspected cardiac patient is unresponsive, assess and care for cardiac-related emergencies
recognizing and treating cardiac arrest1
Recognizing and Treating Cardiac Arrest

Unresponsive patients

  • Open airway
  • Assess breathing and pulse
  • No breathing/pulse, patient in cardiac arrest
  • One member of team start CPR
  • Deliver emergency care appropriate for age
recognizing and treating cardiac arrest2
Recognizing and Treating Cardiac Arrest

Secondary Assessment

  • Gather the history from bystanders/relatives
  • Identify signs/symptoms of cardiac arrest
    • No breathing, pulse, unresponsive to stimuli

Emergency Care

  • Follow steps to provide emergency care with AED
  • Use CPR/defibrillation as appropriate according to age and downtime

Reassessment

  • Pulse is restored, continue to perform reassessment
  • Monitor patients pulse, breathing and mental status
performing defibrillation use of semiautomated aed
Performing Defibrillation – Use of Semiautomated AED
  • BSI
  • Primary Assessment
  • Begin/resume CPR
  • Attach adhesive monitoring-defibrillation pads to cables
  • Turn on AED
  • Apply 2 pad to patients bared chest
performing defibrillation use of semiautomated aed1
Performing Defibrillation – Use of Semiautomated AED
  • Stop ongoing CPR and clear anyone from touching the patient
  • Begin analysis of patients heart rhythm
using a semiautomatic aed
Using a semiautomatic AED
  • Deliver shock if indicated by AED and resume CPR
  • Check for pulse for no longer than 10 seconds
  • If pulse present, check for breathing to apply ventilation as soon as possible
using a semiautomatic aed1
Using a semiautomatic AED
  • If no pulse present, deliver second shock, resume CPR
  • If ALS is not responding, transport after 3 shocks
use of the aed by a single emt
Use of the AED by a Single EMT
  • Only one EMT may be available for a cardiac arrest patient
  • Adjust the procedure to the situation until help arrives
using a fully automated aed
Using a Fully Automated AED
  • The fully automated AED will deliver the shock to the patient
  • The device gives directions to the EMT throughout the defibrillation process
transporting the cardiac arrest patient
Transporting the Cardiac Arrest Patient
  • Patient with pulse
    • Check airway, provide oxygen
    • Provide PPV if breathing inadequate
    • Have suction ready
    • Secure patient onto gurney and transfer to ambulance
    • Consult with dispatch to connect with ALS
    • Continue to keep AED attached to patient
    • Perform secondary assessment enroute every 5 minutes
transporting a patient with a pulse
Transporting a Patient with a Pulse

Patients brought out of ventricular fibrillation through use of AED have a high likelihood to slipping back into that state

  • Be alert if patient becomes unresponsive
  • Check breathing/pulse
  • If patient shows no breathing/pulse
    • Stop vehicle
    • Start CPR
    • Initiate rhythm analysis
    • Deliver shock if warranted
    • Resume CPR for 2 minutes
    • Deliver 2nd shock
    • CPR for 2 minutes
    • Reanalyze until 2 or 3 “no shock” messages
    • Continue sequence
    • Continue transport
transporting a patient without a pulse
Transporting a Patient without a pulse
  • Provide CPR
  • Contact Med Control
  • Follow protocols, page 4 Whatcom County
providing for advanced cardiac life support
Providing for Advanced Cardiac Life Support
  • Keep AHA’s chain of survival in mind
  • Inform Med Control and request ACLS backup
  • Minimize the time from delivery of CPR and defibrillation shocks to the arrival of ACLS
special considerations for the aed
Special Considerations for the AED

Safety Considerations

  • The shock from AED can travel through different substances
  • No one should be touching patient during rhythm analysis or delivery of shocks
  • AED should not be operated if machine or patient in contact with water
  • Ensure no one is directly in contact with metal that is touching the patient during shocks
  • Use gloves to remove any transversal medication patches and dry the area before shocking
  • Do not put AED adhesive pad on top of surgically implanted pacemaker
  • Make certain electrodes are adhering properly to a very hairy chest
aed maintenance
AED Maintenance
  • Scheduled maintenance is crucial to ensuring proper functioning
  • Follow local protocols and manufacturer’s directions
  • Batteries should be replaced on a set schedule
  • Extra, fully charged batteries should always be available
training skills maintenance
Training & Skills Maintenance
  • EMT’s should be properly educated in operating the AED
  • Operators should review incidents of AED use, study new protocols, and practice working with the device
  • EMT’s should check updated research on AED procedures at sources such as EMS journals, state EMS offices, and the AHA
medical direction and the aed
Medical Direction and the AED
  • Medical direction plays a significant role in providing AED services
  • Medical direction involvement
    • Make sure EMS system has necessary links in the AHA Chain of Survival
    • Oversee all levels of EMT’s
    • Review the continual competency skill review program (OTEP)
    • Engage in audit and/or quality improvement
energy levels of defibrillation
Energy Levels of Defibrillation
  • Electrical current for defibrillators is measured in joules
  • It is important that EMT’s know how to deliver the appropriate amount of energy for their type of AED
cardiac pacemakers
Cardiac Pacemakers
  • Is placed under the skin with electrodes connecting to the heart
  • Cardiac pacemakers are usually positioned beneath one of the clavicles
  • An AED can still be used in a patient with one
  • The adhesive pad should not be placed directly over the pacemaker
automatic implantable cardioverter defibrillators aicd
Automatic Implantable Cardioverter Defibrillators (AICD)
  • Is used for ventricular heart rhythm disturbances that cannot be controlled by medication
  • For responsive patients with AICD, allow the device to operate, stabilize the patient, and prepare for transport
  • Unresponsive patients, look for surgical scars or medical ID tags
    • Treat as other unresponsive cardiac patients
    • Do not apply AED adhesive pads directly over the implanted AICD
automated chest compression devices
Automated Chest Compression Devices

Mechanical piston device

  • Apparatus that depresses the sternum with a compressed-gas-powered plunger that has been affixed to a backboard
  • Can be configured to deliver a specific rate and depth of compressions
  • Delivers uniform compressions with no diminishment
  • Frees up an EMS provider
  • Can become useless if compressed gas runs out
load distributing band cpr or vest cpr
Load-Distributing-Band CPR or Vest CPR
  • Composed of a wide band applied to the chest circumferentially
  • Is either pneumatically or electrically driven to provide an inward constrictive pressure on the thorax
  • Frees up an EMS provider
  • Has been shown to improve coronary and cerebral blood flow over traditional CPR
impedance threshold device
Impedance Threshold Device
  • The “Pod”
  • Piece of equipment with a valve that limits air that enters the chest and lungs during chest recoil phase of active compressions
  • Has been shown to improve blood flow through the heart during CPR
  • May be considered for use in nonintubated patients
  • A tight mask seal must be maintained
other circulation enhancing devices
Other Circulation Enhancing Devices
  • Have been developed to actively compress and decompress the thorax during resuscitation
  • Compression phase generates the positive pressure to move blood out of the heart
  • The decompression is designed to increase the negative pressure inside the thorax to improve blood return to the heart