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Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ International Trauma Life Support for Prehospital.

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Presentation on theme: "Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ International Trauma Life Support for Prehospital."— Presentation transcript:

1 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ International Trauma Life Support for Prehospital Care Providers Sixth Edition for Prehospital Care Providers Sixth Edition Patricia M. Hicks, MS, NREMTP Roy Alson, PhD, MD, FACEP Donna Hastings, EMT-P John Emory Campbell, MD, FACEP and Alabama Chapter, American College of Emergency Physicians Patricia M. Hicks, MS, NREMTP Roy Alson, PhD, MD, FACEP Donna Hastings, EMT-P John Emory Campbell, MD, FACEP and Alabama Chapter, American College of Emergency Physicians Chapter 8 Shock Evaluation and Management Chapter 8 Shock Evaluation and Management

2 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Shock Evaluation and Management

3 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Overview Four vascular system components of perfusion Progression of shock signs and symptoms Three common clinical shock syndromes Hemorrhagic and neurogenic shock pathophysiology Controllable and uncontrollable hemorrhage, nonhemorrhagic shock syndromes Hemostatic agents Current indications for fluid administration 2Shock -

4 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Shock Shock -3 Perfusion of tissues with oxygen, electrolytes, glucose, and fluid becomes inadequate.

5 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Steady state activity Normal Perfusion 4Shock - VASCULAR SYSTEM AIR EXCHANGE FLUID VOLUME PUMP Perfusion

6 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Normal Perfusion Shock -5 Heart Rate x Stroke Volume = Cardiac Output Cardiac Output x PVR = Blood Pressure Heart Rate x Stroke Volume = Cardiac Output Cardiac Output x PVR = Blood Pressure

7 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Perfusion Preservation Basic rules of shock management: Maintain airway Maintain oxygenation and ventilation Control bleeding where possible Maintain circulation Adequate heart rate and intravascular volume 6Shock -

8 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Shock Progression Shock -7 Begins with injury, spreads throughout body, multisystem insult to major organs

9 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Shock Progression 8Shock - Red blood cells decreased Inadequate perfusion Anaerobic processes Hypoxia worsens Catecholamine increases Cell death

10 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Shock Shock is a continuum. Signs and symptoms are progressive. Many symptoms due to catecholamines. Cellular process has clinical manifestations. Compensated and decompensated: Older, hypertensive, and/or head injury cannot tolerate hypotension for even short time. 9Shock -

11 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Hypovolemic Shock Compensated progression Weakness and lightheadedness Thirst Pallor Tachycardia Diaphoresis Tachypnea Urinary output decreased Peripheral pulses weakened 10Shock -

12 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Shock Progression Compensated to decompensated Initial rise in blood pressure due to shunting Initial narrowing of pulse pressure Diastolic raised more than systolic Prolonged hypoxia leads to worsening acidosis Ultimate loss of catecholamine response Compensated shock suddenly crashes 11Shock -

13 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Hypovolemic Shock Decompensated progression Hypotension Hypovolemia and/or diminished cardiac output Altered mental status Decreased cerebral perfusion, acidosis, hypoxia, catecholamine stimulation Cardiac arrest Critical organ failure –Secondary to blood or fluid loss, hypoxia, arrhythmia 12Shock -

14 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Classic Shock Pattern Early shock 15–25% blood volume Tachycardia Pallor Narrowed pulse pressure Thirst Weakness Delayed capillary refill Late shock 13Shock - 30–45% blood volume Hypotension First sign of late shock Weak or no peripheral pulse Prolonged capillary refill

15 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Capillary Refill 14Shock -

16 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Capillary Refill 15Shock -

17 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Tachycardia Early sign of illnessmost common: Transient rise with anxiety, quickly to normal Determine underlying cause Early sign of shock: Suspect hemorrhage: sustained rate >100 Red flag for shock: pulse rate >120 No tachycardia does not rule out shock. Relative bradycardia 16Shock -

18 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Capnography Level of exhaled CO 2 as waveform (EtCO 2 ) Typically ~35–40 mmHg Falling EtCO 2 Hyperventilation or decreased oxygenation EtCO 2 <20mmHg May indicate circulatory collapse Warning sign of worsening shock 17Shock -

19 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Shock Syndromes Low-volume shock Absolute hypovolemia Hemorrhagic or other fluid loss Mechanical shock 18Shock - Obstructive Cardiac tamponade Tension pneumothorax Massive pulmonary embolism Cardiogenic Myocardial contusion Myocardial infarction High-space shock Relative hypovolemia Neurogenic shock Vasovagal syncope Sepsis Drug overdose

20 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Low-Volume Shock Absolute hypovolemia Large vascular space Blood vessels hold more than actually flows. Catecholamines cause vasoconstriction. –Minor blood loss: vasoconstriction sufficient –Severe blood loss: vasoconstriction insufficient Clinical presentation Thready pulse; tachycardia; pale, flat neck veins 19Shock -

21 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ High-Space 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 20Shock -

22 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ High-Space Shock Types Neurogenic shock Most typically after injury to spinal cord Injury prevents additional catecholamine release Circulating catecholamines may briefly preserve Sepsis syndrome Drug overdoses and chemical exposures Such as nitroglycerin, calcium channel blockers, antihypertensive medications, cyanide 21Shock -

23 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ High-Space Shock Neurogenic shock Hypotension Heart rate normal or slow Skin warm, dry, pink Paralysis or deficit No chest movement, simple diaphragmatic Drug overdose, sepsis 22Shock - Tachycardia Skin pale or flushed Flat neck veins

24 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Mechanical Shock Obstructs blood flow to or through heart Slows venous return Decreases cardiac output Clinical presentation Distended neck veins Cyanosis Catecholamine effects Pallor, tachycardia, diaphoresis 23Shock -

25 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Current Shock Research Prehospital management research Hemorrhagic shock due to trauma and traumatic brain injury in prehospital environment Intravenous solutions Hypertonic saline may support vascular status by pulling interstitial fluid into vascular space. Artificial blood products carry oxygen. 24Shock -

26 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ PASG Research Pneumatic antishock garment Uncontrollable internal hemorrhage due to penetrating injury May increase mortality, especially intrathoracic Probably increases bleeding, death due to exsanguination 25Shock -

27 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Fluid Administration Uncontrollable hemorrhage May increase bleeding and death Dilutes clotting factors Early blood transfusion in severe cases IV fluids carry almost no oxygen Moribund trauma patients Fluid may be indicated to maintain some circulation Local medical direction 26Shock -

28 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Fluid Administration Uncontrollable hemorrhage Maintain peripheral perfusion Peripheral pulse –Higher systolic may be required with increased ICP or with history of hypertension Maintaining consciousness –In absence of traumatic brain injury Adequate blood pressure –Controversial with ongoing research –Local medical direction 27Shock -

29 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Fluid Administration Internal hemorrhage from blunt trauma Large-bone fractures Usually self-limiting bleed, except pelvis Fluid administration for volume expansion Large internal blood vessel tear, or laceration or avulsion of internal organ Fluid may increase bleeding and death Fluid administration to maintain peripheral perfusion Local medical direction 28Shock -

30 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Controllable Hemorrhage Management Control bleeding Shock position High-flow oxygen Rapid safe transport Large-bore IV access Fluid bolus 20 ml/kg rapidly, repeat if necessary Cardiac monitor, SpO 2, EtCO 2 Ongoing Exam 29Shock -

31 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Uncontrollable Hemorrhage Management: External Control bleeding Shock position High-flow oxygen Rapid safe transport Large-bore IV access Fluid administration Cardiac monitor, SpO 2, EtCO 2 Ongoing Exam 30Shock -

32 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Uncontrollable Hemorrhage Management: Internal Rapid safe transport Shock position High-flow oxygen Large-bore IV access Fluid administration Cardiac monitor, SpO 2, EtCO 2 Ongoing Exam 31Shock -

33 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ High-Space Shock Management High-flow oxygen Shock position Rapid safe transport Large-bore IV access Fluid bolus 20 ml/kg rapidly Consider vasopressors for vasodilatory shock Calcium channel blocker overdose or sepsis Ongoing Exam 32Shock -

34 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Mechanical Shock Tension pneumothorax Vena cava collapses, prevents venous return Mediastinal shift lowers venous return Tracheal deviation away from affected side Decreased cardiac output Management Chest decompression Prompt decompression of pleural pressure 33Shock -

35 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Mechanical Shock Causes Cardiac tamponade Blood fills potential space; prevents heart filling May occur >75% with penetrating cardiac injury Becks triad Shock, muffled heart tones, distended neck veins Management Rapid safe transport to appropriate facility Cardiac arrest can occur in minutes Fluid administration by local medical direction 34Shock -

36 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Mechanical Shock Causes Myocardial contusion Heart muscle injury and/or cardiac dysrhythmias Rarely causes shock; mostly little or no signs Severe may cause acute heart failure Management Rapid safe transport Cardiac arrest may occur in 5–10 minutes Cardiac monitoring and treat arrhythmias Fluid administration may worsen condition 35Shock -

37 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Special Situations Severe head injury hypovolemic shock Glasgow Coma Score of 8 or less Fluid administration BP of 120 mmHg systolic to maintain cerebral perfusion pressure of at least 60 mmHg Nonhemorrhagic hypovolemic shock General management same as controllable Fluid administration for volume replacement 36Shock -

38 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Summary Knowledge about pathophysiology and treatment of shock is essential. Critical condition that leads to death. Assessment and intervention must be rapid. Monitor closely for early signs. Be aware of management controversies. Rely on local medical direction. 37Shock -

39 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Discussion 38Shock -

40 Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Click to take Quiz


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