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Shock (The Fabulous Four (Cardiogenic Shock, Obstructive Shock,…
Shock
The Fabulous Four
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Telltale symptoms of shock:
- Reduced cardiac output
- Circulatory insufficiency
- Tachycardia
- Pallor
- Altered mental status
- Low blood pressure
Treatments
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Tx of Hypovolemic Shock
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The goal is to maintain perfusion without increasing internal or uncontrolled external bleeds/fluid loss
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Tx of Cardiogenic Shock
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Place pt in supine, secure airway, monitor SP02 and administer oxygen
Tx of Distrubutive Shock
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Thorough history, especially for septic shock
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Stages of Shock
When the body's defence army is successful in maintaining perfusion, it's called Compensated Shock
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Increased respiration rate to control acid-base balance
ex. creating respiratory alkalosis to counterbalance respiratory acidosis
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Normal compensation looks like:
- Progressive vasodilation
- Increased Blood flow
- Increased cardiac output
- Increased respiration rate and volume
- Decreased urine output
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Types of Shock
Cardiogenic Shock
Failure of the heart's ability to pump effectively due to muscle dysfunction.
It may also occur post myocardial infarction, cardiac arrthymias, pulmonary embolism, severe acidosis, etc.
Symptoms of Cardiogenic shock are (but not limited to):
- Chest pain
- Variable heart rates
- Decreased blood pressure
- Shortness of breath with pulmonary edema
- Varied ECG changes
- Altered mental status
- JVD
Obstructive Shock
Obstruction of either the heart or vessels. Impedes the flow of blood and products. It is possible that obstructive can change to cardiogenic, if left untreated.
In a trauma setting this type of shock is commonly a result of a cardiac tamponade, pulmonary embolus, tension pneumothorax and pericarditis.
Symptoms of Obstructive shock are (but not limited to):
- JVD
- Any findings that might suggest a tension pneumothorax: unilateral decreased breath sounds, tracheal deviation, hypoxia
Hypovolemic Shock
Caused by internal or external blood loss.
In other terms the circulating blood volume is not sufficient enough to maintain adequate perfusion.
Our priorities in managing hypovolemia are: early recognition, management and rapid transport to a trauma centre.
Symptoms of Hypovolemic Shock include (but are not limited to):
- The MOI
- Signs of internal or external bleeding
- Increased HR
- Decreased blood pressure
- Increased levels of shortness of breath
- Altered mental status
- ECG changes
- Lack of JVD
There is 2 types of Hypovolemic Shock
- Exogenous - external bleeding organs with high exsanguination from penetrating injuries are: heart, liver, spleen, thoracic vascular system and abdominal.
- Endogenous - fluid loss is contained inside the body. ex. Dehydration, burns or crush injuries
Distributed Shock
Distributed shock has 5 different types that can occur within the body:
- Neurogenic Shock
- Anaphylactic Shock
- Septic Shock
- Toxicological Shock
- Endocrine Shock
It is a widespread dilation of the resistance vessels like arterioles and venules.
The circulation blood volume tends to pool in the vascular beds which decreases tissue perfusion.
It is important to distinguish what was the MOI.
NASTE
Neurogenic Shock
Results from a spinal cord injury by which there is a loss of normal sympathetic nervous system tone end vasodilation.Symptoms include (but are not limited to):
- Relative bradycardia
- Profound hypotension
- Shortness of breath
- Altered mental status
- Lack of JVD
- Unresponsive to food challenges
- Parasthesia below injury site
- Sweating below the level of injury
Anaphylactic Shock
Results from a patient that reacts severely to a substance that they have a hypersensitivity too. In this type of shock, there is no loss of blood, no vascular damage and only a slight possibility of direct cardiac muscular injury.Symptoms include (but are not limited to):
- Uticaria
- Angioedema
- Tachycardia
- Hypertension
- Nausea/vomiting
- Shortness of breath
Side note: Spinal Shock is not to be confused with Neurogenic Shock. Spinal shock occurs after an injury and likely will result in motor and sensory loss
Septic Shock
Results from a widespread infection. You will also find a presence of sepsis syndrome. In most cases infection is usually due to a gram-negative organism. It can also be due to a gram-positive bacteria, fungi or viruses.Symptoms include (but are not limited to):
- Increased temperature
- Increased heart rate
- Increased respiratory rate
- Warm to touch
- Patients will likely have a history of being involved with something that is likely to cause infection ex. surgery
Toxicological Shock
Results from either intentional or unintentional exposures to toxic levels of substances. Toxic shock can fall under cardiogenic and/or distributive categories in shock. Alcohol, medications, illegal drugs or the environment can all play a role in toxic shock.Symptoms include (but are not limited to):
- Constricted or dilated pupils
- Dry mouth or burns in the mouth
- Dry, hot skin
- Sweating
- Decreased or increased respirations
- Tachycardia or bradycardia
- Hypotension or hypertension
- Seizures
- Nausea/vomiting
Endocrine Shock
Results from a disruption of the patients endocrine system which in turn affects the adrenal and thyroid functions.
Commonly prehospitally we will see patients be in a state of shock because of recent corticosteroid therapy.
It can present as a blend of cardiogenic, hypovolemic and distributive shock.
Hypoperfusion
Occurs in the body when the level of tissue perfusion decreases to a point where it is affecting cell metabolism
Signs and Symptoms include (but not limited to):
- Dusky skin
- Oliguria
- Impaired mentation
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During this time, the body will release catecholamines and antiduretics, RAAS is activated
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3 main components: Pump, Container and Fluid
The pump or heart has one defined role to play in the body, which is to keep the blood circulating to promote perfusion and to circulate blood systemically and pulmonary.
The container or vessels are a system of tubing capable of vasoconstriction and vasodilation in response to changes in the pump and fluid volume.
The fluid or blood or body fluids consists of plasma and formed elements, like your red blood cells!
Blood carries oxygen and nutrients to tissue cells and takes out the trash at the same time.
To maintain adequate perfusion, your blood moves at a pace that is fast enough to provide enough perfusion to cells yet keep flowing at a normal, constant rate.
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Remember to treat by using only the tools in the PCP toolbox aka stay in your scope!
Recognize and treat early signs!
In order to maintain life within organisms, your body processes a bunch of chemical reactions as whole called metabolism
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"So...what is sepsis?"
"When they say 2% milk but you have no idea what the other 98% is"
"When the immune system sends the body into anaphylaxis over a peanut antigen"
"We did it basophil! We saved the body."