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Shock (Stages of Shock (Decompensated (Indicators (AMS, Hypotension,…

- - - - Compensatory mechanisms fail
      - Increased Heart Rate
      - Increased Respiratory Rate
        
        Results in
        
        Decreased LOC
        
        Decreased BP
        
        Blood shunted to brain, heart, kidneys from extremities
      - Decreased Temperature
    - - AMS
      - Hypotension
      - Difficulty Breathing
      - Thready or absent peripheral pulses
      - Impending cardiac arrest
      - Ashen, mottled, or cyanotic skin
      - Diminished urine output
      - Dilated pupils
  - - - Decreased HR
      - Decreased RR
      - End Organ Failure
      - All blood being shunted to brain, heart
  - - - RAAS activated
        
        Maintained(or increased) Blood Pressure
        
        Increased PVR( Sympathetic stimulation and RAAS)
        
        Decreased urine output
      - Increase in Respiratory Rate
        
        Helps maintain acid-bas balance by respiratory alkalosis
      - Increase in Respiratory depth
      - Increased Heart rate by simulation of sympathetic nervous system
    - - Agitation, anxiety, restlessness
      - Sense of impending doom
      - Weak, rapid pulse
      - Cool, moist skin
      - Palor with cyanotic lips
      - SOB
      - Nausea, vomiting
      - Delayed cap -refil in infants and children
      - Thirst
- - - - Increased Heart Rate
      - Decreased Blood Pressure
      - Increased Respiration Rate
      - Chest Pain
      - Shortness of Breath
      - Jugular Vein Distention
      - Altered Mental Status
      - ECG changes
    - - Cardiac Tamponade (Muffled lung sounds)
      - Constrictive Pericarditis
      - Aortic Stenosis
      - Tension Pneumothorax (Absent lung sounds)
      - Pulmonary Embolism
    - - Treat the cause
        
        Needle Decompression
      - Dual Large Bore IV
      - Non- Rebreather at 15Lpm
  - - - Ischemic Heart Disease
        
        40% myocardial death(approx.)
        
        Most often left ventricle
      - Decompensated CHF
    - - Decreased Blood Pressure
      - Variable Heart Rate
      - Pale, cool, moist skin
      - Crackles in lungs
      - SOB(Pulmonary Edema)
      - Jugular Vein Distention
      - Altered Mental Status
      - ECG Changes
    - - Sympathomimetic
        
        Low Dose Dopamine
        
        Indicated for Cardiogenic Shock
        
        Low dose produces dopaminergic efficts(0.5-5ug/kg/min)
      - Dual Large Bore IV
      - Non Rebreather at 15Lpm
- - - - Distributive Shock causes widespread dilation of resistance vessels(small artioles), the capacitance vessels (small venules), or both. This causes blood to pool, blood pressure to drop, and tissue perfusion to decrease. Three problems occur with septic shock 1) Insufficient volume in container. 2) Fluid that leaks out often collects in the respiratory system. 3) Larger than normal capillary beds have to contain smaller than normal intravascular fluid. Sepsis + systolic BP less than 90mm Hg = Septic shock
      - Result of widespread infection
        
        Activation of Inflammatory-Immune Response
        
        Increased microvascular permeability
        
        Vasodilation
        
        Third space fluid shift
        
        Microthrombi
      - Presentation
        
        Crackles in lungs if pulmonary edema
        
        Flushed or pale, hot or cold, moist skin
        
        Increased Heart Rate
        
        Decreased Blood Pressure
      - Treatment
        
        Sympathomimetic
        
        High Dose Dopamine
        
        Indicated for Septic shock after fluid bolus of at least 2L of NS
        
        5-10ug/kg/min produces B1 effects
        
        10ug/kg/min produces alpha effects
        
        Dual Large Bore IV
        
        Non Rebreather at 15Lpm
        
        Vassopressor/inotrope
        
        Increase heart force of contraction
        
        Norepinephrine
        
        Increase Stroke Volume Resistance
    - - Neurogenic Shock usually results from a spinal cord injury above the T6 Vertebrae. This causes loss of normal sympathetic tone and vasodilation. The Tunica Media is effectively cut off from the sympathetic nervous system which results in hypo-perfusion. Neurogenic shock also inhibits the the release of catecholamines to the heart which causes bradycardia.
      - Causes
        
        Spinal cord injury about vertebrae T6
        
        Brain injury
      - Presentation
        
        Decreased blood pressure(maybe be immediate)
        
        Bradycardia
        
        Pink, dry, warm skin
        
        Respiratory arrest(if high spinal injury)
        
        Priaprism
        
        Absence of sweating below injury
      - Treatment
        
        Sympathomimetic
        
        High Dose Dopamine
        
        Indicated for Septic shock after fluid bolus of at least 2L of NS
        
        5-10ug/kg/min produces B1 effects
        
        10ug/kg/min produces alpha effects
        
        Dual Large Bore IV
        
        Non Rebreather at 15Lpm
        
        Vasopressor/inotropic
        
        Inotropic Agent
        
        Increase Contraction force of heart
        
        Norepinephrine
        
        Increase Stroke Volume resistance
    - - Presentation
        
        Decreased Blood Pressure
        
        Increased heart rate
        
        Shortness of Breath
        
        Angioedema
        
        Wheezes or stridor( no sounds)
        
        Flushed, warm, moist skin
      - Causes
        
        Allergic reaction
      - Anaphylaxis is caused by sensitization to a foreign substance. It results in widespread vascular dilation resulting in relative hypovolemia. Histamine and other vasodilator proteins are released which causes severe bronchoconstriction, urticaria, and swelling caused by interstitial fluid.
      - Treatment
        
        Epinephrine
        
        Indicated for Severe allergic reaction
        
        0.3-0.5mg of 1:1000 for Anaphylaxis
        
        Produces A1, B1, B2, effects
        
        Inhibits Histamine release
        
        Chronotropic, dromotropic, inotropic effects
        
        Diphenhydramine
        
        Indicated for allergic reaction
        
        25-50mg
        
        Antihistamine with anticholinergic and sedative side effects
        
        Salbutamol
        
        Indicated for bronchospasm
        
        B2 Stimulation, slight B1 stimulation
        
        100ug/ per puff via MDI (4-6 puffs)
        
        Ipratropium Bromide
        
        Inhibits stimulation for parasympathetic nervous system
        
        Indicated for bronchospasm
        
        Inhibits Vagal stimulation(allows sympathetic nervous system to dominate
        
        Dual Large Bore IV
        
        Non Rebreather at 15Lpm
  - - - External and Internal Haemorrhage
        
        Long bone or Pelvic Fracture
        
        Blunt or Penetrating Injury
        
        Amputation
        
        Multisystem Injury
    - - Fluid loss contained inside the body
        
        Crush Injury
        
        Dehydration
        
        GI Losses
        
        Fever, hyperventilation
        
        Increased Sweating
        
        Internal Losses
        
        Pancreatitis
        
        Peritonitis
        
        Ileus
        
        Plasma Loss
        
        Anaphylaxis
        
        Severe Burns
    - - Apparent MOI
      - High blood or fluid loss
      - Increased Heart Rate
      - Decreased Blood Pressure
      - Altered Mental Status
      - ECG Change
      - Lack of JVD
    - - IV Fluids
        
        Cystolloid Solution
        
        250ml Bolus