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SHOCK :warning: (((((Specific to Tension Pneumothorax Absent breath…

- - - - SNS activated in response to low CO
        -Will see narrowing pulse pressure
        -Tachycardia(attempt to circulate RBCs quicker)
        -Tachypnea(Attempt to Increase PaO2 and remove more CO2)
        -Peripheral shunting
        -Irritable and anxious
        -BP may be normal or slightly elevated due to vasoconstriction
        Spleen also releases more RBCs
        RAAS activated
        May even see shift of fluid from interstitial to intravascular
        Attempts to compensate for drop in perfusion
        Decreased insulin and increased released of glucagone
    - - Profound vasoconstriction from SNS leading to ischemia
        Myocardial oxygen demand increases and begins to fail with decreased CO and ejection fraction
        Extreme lactic acid production
        Metabolic acidosis
        May see skin color changes, oliguria and AMS
        Mechanisms failing
        BP begins to to fall
        Heart rate begins to fall
        
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        Mechanisms have failled
        Hypotensive
        AMS or LOC
        Bradycardia
        Cool extremities and core
        Week/absent pulses
        Cellular necrosis and Multi-organ Dysfunction Syndrome(MODS) as blood shunted to last remaining vitals such as heart and lungs
        
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  - - - Tissue under perfused, decreased CO, increased anaerobic metabolism, lactic acid builds up
- - - - -Circulating volume is insufficient
        -Preload/CO/Perfusion Decrease while SVR will initially increase before decreasing
        -Suspect in any unexplained shocks
        -Can come from burn injuries(relative), dehydration, hemorrhage, and anaphylaxis(relative)
        
        HYPOVOLEMIC
    - - -Pump failure
        -May be from single event or cumulative damage
        -In terms of ischemia, >40% of heart must be damaged
        -May be caused by infarct, arrythmias, acidosis, valve failure, cardiomyopathy, decompensated congestive heart failure, etc.
        -These all interfere with the hearts ability to pump effectively
        -Preload increases, CO decreases, SVR increases initially, and perfusion decreases
        
        CARDIOGENIC
        
        -Widespread dilation of vessels
        -May involve fluid shifts(capillary leak)
        -Low or normal preload, increased CO(tachycardia), Low SVR(hallmark), low or normal perfusion
        -Broken down into Neurogenic, Anaphylactic, Septic
        
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    - - -Heart is pumping normal but having difficulty moving blood forward due to obstruction of a vessel
        -Mechanical obstruction of either heart or vasculature impeding flow of blood
        -Blood flow to heart and great vessels is blocked
        -Can lead to cardiogenic shock
        -Preload increases, CO decreases, SVR increased, Perfusion decreased
        -Causes: Pericarditis/Pericardial Tamponade, Large PE,
        Tension Pneumothorax
        
        OBSTRUCTIVE
        
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- - - - Physical signs include:
        Poor turgor
        Shrunken tongue
        Sunken eyes
        Weak/rapid pulses with hypotension
        Cool/Pale/Clammy from peripheral shunting
        Conjunctival pallor(pale under eyelids)
        Tachypnea
        Confusion to AMS to Coma
        
        HYPOVOLEMIA
    - - CARDIOGENIC
        
        JVD,
        Pulmonary edema
        HTN early then hypotension
        Chest pain
        Arrythmia
        Decreased urine
        Organ failure
        Cool/pale/clammy/mottled
        AMS
  - - - SNS compensatory mechanisms fail
        -vasodilation
        -Bradycardia
        -Low CO
        -May see diaphragmatic breathing
        -Tachypnea
        No diaphoresis below site of injury
        **Bradycardia and lack of diaphoresis is key!
        Skin is pink/warm/dry below injury from vasodilation
        May have loss of tone and sensation
        
        NEUROGENIC
  - - - ANAPHYLACTIC
        
        Facial/neck edema
        SOB/wheezes
        Horseness
        Confusion/Agitated/AMS/Syncope
        Diaphoretic
        Flushed/Warm
        Hypotension
        Rash/itchiness
        Tachycardia
        Weak pulse
        N&V
  - - - Two Phases:
        1)Warm Shock(Hyperdynamic/Vasodilation)
        -Tachycardia
        -Bounding pulse
        -Skin pink/warm/flush
        -Lethargy
        2)Cold Shock(Hypodynamic/Decompensation)
        -AMS
        -Tachypnea
        -Significant Tachycardia
        -Hypotension
        -Vasoconstriction
        Skin pale/cool
        
        SEPTIC SHOCK
  - - - Specific to Tension Pneumothorax
        Absent breath sounds
        Tachycardia(due to reduced preload)
        JVD(late; considered engorged when 2cm above clavicle)
        Tracheal deviation(late)
        Pain
        Dyspnea
        Hyperresonance.
        
        Specific To Pulmonary Embolism
        Common dyspnea
        Pleuritic chest pain
        Tachypnea
        Possible fever or diaphoresis
        Cough with hemoptysis/Rales
        Syncope
        Possible cyanosis or lower extremity edema
        May be refractory to O2
        May see non-specific ECG
      - Specific to Peicarditis
        Chest pain
        -Positional. Worse laying down. Better leaning forward
        -Sudden onset
        -Sharp
        -Pleuritic
        -Worse when cough
        -May Radiate to traps
        Fever/Cough/Hoarseness
        Dyspnea/Tachypnea
        Nausea
        May hear friction rub
        
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      - Specific to Pericardial Tamponade:
        Beck's Triad(Hypotension, Muffled Heart Sounds, JVD)
        Possible fever, chest pain, and pericardial friction rub if related to pericarditis
        May be longer in onset with dyspnea, and weakness
        May cause initial drop in CO which equals a drop in SBP causing a narrowing pulse pressure
        May also see tachycardia in response to this
        Pulsus Paradoxus is common sign!
        In trauma, hard to distinguish from penumothorax. Remember that Cardiac Tamponade will have equal lung sounds
- - - - CARDIOGENIC
        Manage airway & breathing
        -(consider BVM)
        Vitals and ECG!
        Obtains IV access large bore
        Give fluids VERY cautiously
        -ascultate for edema
        Consider an Inotrope(Dobutamine) or Inodilator(Milrinone)
        -Helps increase inotropy and CO and will also reduce SVR
        -Dobutamine(2-20mcg/kg/min)
        -Milrinone(50mcg/kg)
        Consider pain management(Fentanyl or morphine)
        May need to be paced
        Definitive treatment is correcting underlying cause
      - HYPOVOLEMIC
        Goals are control bleeds, replacing volume,
        and restoring O2 delivery to tissue
        -Control any obvious bleeds!
        -Vitals!
        -Support Airway and breathing as necessary
        -Obtain IV access but do not delay on scene
        -Keep patient warm(AVOID HYPOTHERMIA)
        -Give fluids(LR or NS)
        --Maintain core perfusion
        -Consider TXA in uncontrolled bleed(1g in 250ml D5W)
  - - - ANAPHYLACTIC
        Manage airway and breathing best as possible
        Give Epi
        -0.3 – 0.5mg IM 1:1000
        -0.1mg IV 1:10,000
        IV access
        Bronchodilators
        -Salbutomol(100mcg/puff x 6)
        Antihistamines
        -Diphenhydramine(50mg IV)
        Consider corticosteroids
        Consider glucagone if beta blocker use
        
        SEPTIC
        Manage airway and breathing!
        Vitals and ECG with temperature
        Obtain IV and bolus NS
        -1-2L
        Norepi is pressor of choice
        -0.1-0.5mcg/kg/min
        Consider Dobutamine for cardiovascular support
        -2-20mcg/kg/min
        Auscultate lungs and reevaluate continuously
        Needs Antibiotics!