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Hypoperfusion and Shock
© 2009 NAEMT Hypoperfusion Common problem Extent makes resuscitation difficult Shock due to hypoperfusion Start fluid resuscitation as soon as possible
© 2009 NAEMT Overview Describe differences between compensated and uncompensated shock Review differences of distributive, non-distributive and obstructive shock Explore pathophysiology for different etiologies of shock Discuss interventions for early and late shock
© 2009 NAEMT Physiology BP = Cardiac Output x Systemic Resistance Cardiac Output = Stroke Volume x Heart Rate Pre-load = Blood returned to heart Starlings Law = Amount of cardiac muscle stretch After-load = Resistance to blood being ejected NHTSA LifeART
© 2009 NAEMT Shock Compensation Children vs. Adults Children Increased heart rate Vasoconstriction Prolonged compensation Rapid decompensation Adults Increased stroke volume Vasoconstriction Tachycardia Slow, but sustained compensation EPS411.com
© 2009 NAEMT Hypovolemic Hemorrhagic Metabolic Categories of Shock Non-Distributive
© 2009 NAEMT Anaphylaxis Septic Neurogenic Categories of Shock Distributive
© 2009 NAEMT Pulmonary embolus Tension pneumothorax Cardiac tamponade Categories of Shock Obstructive
© 2009 NAEMT Emesis and diarrhea Osmotic diuresis from diabetes Internal or external blood loss Plasma loss from sepsis or anaphylaxis Etiologies of Hypoperfusion (Common)
© 2009 NAEMT Etiologies of Hypoperfusion (Uncommon) Medications required to restore perfusion Spinal cord injury Cardiac failure
© 2009 NAEMT Severity of Hypoperfusion Compensated CompensatedDecompensated Time Signs are due to inadequate tissue perfusion Compensated shock is reversible with fluids Volume
© 2009 NAEMT Volume Altered Mental Status Severity of Hypoperfusion Compensated Shock Signs Decompensated AVPU Time Breathing Pulse Blood Pressure Compensated
© 2009 NAEMT Volume Severity of Hypoperfusion Compensated Shock Signs Decompensated Time Compensated Weak peripheral pulses, strong central pulses Weak or absent peripheral pulses, weak central pulses DecompensatedCompensated EPS411.com
© 2009 NAEMT Severity of Hypoperfusion Dehydration Testing Hypovolemic patients skin will tent
© 2009 NAEMT Severity of Hypoperfusion Decompensated Shock CompensatedDecompensated Time Body is unable to continue compensation Inadequate tissue perfusion to all organs Volume
© 2009 NAEMT Severity of Hypoperfusion Decompensated Shock Signs Volume Altered Mental Status Decompensated AVPU Time Breathing Pulse Blood Pressure V P U Weak or absent peripheral pulses, weak central pulses Compensated
© 2009 NAEMT Severity of Hypoperfusion Decompensated Shock Signs
© 2009 NAEMT Assessment
© 2009 NAEMT Scene Survey Hazards to you, your partner, the patient and bystanders
© 2009 NAEMT First Impression Pediatric Assessment Triangle Compensated or decompensated EPS411.com
© 2009 NAEMT First Impression General Appearance Observe interactions Not sick - attentive to environment, focus on familiar people and objects, alert for threats Good brain function requires adequate oxygenation, ventilation, cerebral perfusion Sick - does not care you are present or recognize parents
© 2009 NAEMT First Impression General Appearance KyleDavidBates.com Muscle tone Spontaneous movements Skin color Other signs of distress
© 2009 NAEMT First Impression Work of Breathing
© 2009 NAEMT First Impression Circulation to the Skin Skin color, capillary refill, distal vs. central pulses
© 2009 NAEMT First Impression Significant MOI? Sick Rapid Initial Assessment Appropriate Interventions Transport Priority Transport Method Transport Destination Relationship Involve Family Detailed History Focused Physical Exam Yes No Not Sick
© 2009 NAEMT Loss of airway may occur in decompensated shock Initial Assessment Airway Identify and treat life threats
© 2009 NAEMT Administer O 2 and treat cause Initial Assessment Breathing Rate effort and volume Abnormal sounds Assess for chest trauma
© 2009 NAEMT Initial Assessment Circulation EPS411.com Compensated Weak peripheral pulses, strong central pulses Decompensated Weak or absent peripheral pulses, weak central pulses
© 2009 NAEMT Initial Assessment Circulation Management – Intravenous Fluid bolus if any signs of shock Early recognition of hypoperfusion and fluid resuscitation are key Select a large bore catheter Location close to central circulation Two IVs may be needed
© 2009 NAEMT Initial Assessment Circulation Management – Intraosseous Can be used on any age child
© 2009 NAEMT Intraosseous Space Blood Flow
© 2009 NAEMT Anatomy Neonate Leg Cross Section Skin Subcutaneous Fat Intraosseous Catheter Tibia Fibula Posterior Compartment Anterior Compartment Lateral Compartment
© 2009 NAEMT Other Issues IO Insertion Depth based on patient size and weight Gently insert catheter Advance catheter slowly Feel needle drop into medullary space Frequently monitor insertion site and extremity Need hands-on training
© 2009 NAEMT IO Insertion Anatomical Landmarks Patella Tibial Tuberosity Medial Tibia
© 2009 NAEMT IO Insertion Unable to Palpate Tibial Tuberosity Finger Width Often difficult or impossible to palpate
© 2009 NAEMT IO Insertion Able to Palpate Tibial Tuberoisty Finger Width
© 2009 NAEMT Anatomy Neonate Leg Cross Section Fibula Traditional IO Catheter Tibia Left Leg
© 2009 NAEMT Anatomy 11 y.o. Tibia Cross Section Left Leg Fibula Tibia Insertion Site
© 2009 NAEMT Pain Somatic and Visceral
© 2009 NAEMT Initial Assessment Circulation Management – Crystalloids Reassess patient after each fluid bolus 20 mL/kg, < 20 minutes
© 2009 NAEMT Initial Assessment Never Administer D5W D5W can lead to hyperglycemia
© 2009 NAEMT Initial Assessment Circulation Management – Medications Sepsis Pressers and antibiotics Cardiogenic Shock Pressers, furosemide, morphine and antiarrhythmics EPS411.com Anaphylaxis Epinephrine, diphenhydramine, Solu-Medrol
© 2009 NAEMT Initial Assessment Circulation Management – Medications Use medications after fluid boluses EPS411.com
© 2009 NAEMT Transport Decision Rapid transport for pediatric shock patients
© 2009 NAEMT Bleeding Vomiting Diarrhea Fluid intake / urine output Fever Anaphylaxis signs Focused History Questions to Determine Type of Shock FEMA Photo Library / Andrea Boomer
© 2009 NAEMT Head to Toe Physical Exam Done En Route
© 2009 NAEMT Ongoing Assessment Done Frequently
© 2009 NAEMT Summary Recognition and rapid intervention are keys to treatment Pulse quality and level of consciousness are key indicators Obtain IV or IO access if shock treatment is needed Deliver crystalloid fluids at 20 mL/kg
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