23: Shock

5-1.9 List signs and symptoms of shock (hypoperfusion).

5-1.10 State the steps in the emergency medical care of a patient with signs and symptoms of shock (hypoperfusion).

5-1.11 Explain the sense of urgency to transport patients who are bleeding and show signs of shock (hypoperfusion).

Cognitive and Affective Objectives

Psychomotor Objectives

5-1.16 Demonstrate the care of the patient exhibiting signs and symptoms or shock (hypoperfusion).

5-1.17 Demonstrate completing a prehospital care report for the patient with bleeding and/or shock (hypoperfusion).

Shock

• State of collapse and failure of the cardiovascular system

• Leads to inadequate circulation• Without adequate blood flow, cells cannot

get rid of metabolic wastes • The result of hypoperfusion to cells that

causes the organ, then organ systems, to fail

Perfusion

• The cardiovascular system’s circulation of blood and oxygen to all the cells in different tissues and organs of the body

Heart (Pump Function)

Damage to the heart by disease or injury.

It cannot move blood adequately to support

perfusion.

Blood Vessels (Container Function)

If all the vessels dilate at once, the normal amount of blood

volume is not enough to fill the system and provide adequate

perfusion to the body.

Blood (Content Function)

If blood or plasma is lost, the volume in the container is not

enough to support the perfusion needs of the body.

Perfusion Triangle

Capillary Sphincters

• Regulate the blood flow through the capillary beds.

• Sphincters are under the control of the automatic nervous system.

• Regulation of blood flow is determined by cellular need.

Perfusion and Neurogenic Shock

Cardiovascular Causes of Shock (1 of 4)

• Pump failure (cardiogenic shock)– Inadequate function of the heart or pump failure– Causes a backup of blood into the lungs– Results in pulmonary edema– Pulmonary edema leads to impaired ventilation

Cardiovascular Causes of Shock (2 of 4)

• Poor vessel function (neurogenic shock)– Damage to the cervical spine may affect control

of the size and muscular tone of blood vessels.– The vascular system increases.

• Blood in the body cannot fill the enlarged system.

• Neurogenic shock occurs.

Cardiovascular Causes of Shock (3 of 4)

• Content failure (hypovolemic shock)

– Results from fluid or blood loss

– Blood is lost through external and internal bleeding.

– Severe thermal burns cause plasma loss.

– Dehydration aggravates shock.

Cardiovascular Causes of Shock (4 of 4)

• Combined vessel and content failure– Some patients with severe bacterial infections,

toxins, or infected tissues contract septic shock.

– Toxins damage vessel walls, causing leaking and impairing ability to contract.

– Leads to dilation of vessels and loss of plasma, causing shock

Noncardiovascular Causes of Shock (1 of 3)

• Respiratory insufficiency

– Patient with a severe chest injury or airway obstruction may be unable to breathe adequate amounts of oxygen.

– Insufficient oxygen in the blood will produce shock.

Noncardiovascular Causes of Shock (2 of 3)

• Anaphylactic shock– Occurs when a person reacts violently to a

substance. – Four categories of common causes:

• Injections• Stings• Ingestion• Inhalation

Noncardiovascular Causes of Shock (3 of 3)

• Psychogenic shock– Caused by sudden reaction of the nervous

system that produces a temporary, generalized vascular dilation

– Commonly referred to as fainting or syncope– Can be brought on by serious causes: irregular

heartbeat, brain aneurysm– Can be brought on by fear, bad news,

unpleasant sights

Progression of Shock

• Compensated shock

– When the body compensates for blood loss

• Decompensated shock

– The late stage of shock when blood pressure is falling

• Irreversible shock

– The terminal stage

Compensated Shock

• Agitation• Anxiety• Restlessness• Feeling of impending

doom• Altered mental status• Weak pulse

• Clammy skin• Pallor• Shallow, rapid breathing• Shortness of breath• Nausea or vomiting• Delayed capillary refill• Marked thirst

Decompensated Shock

• Falling blood pressure (<90 mm Hg in an adult)

• Labored, irregular breathing

• Ashen, mottled, cyanotic skin

• Thready or absent pulse• Dull eyes, dilated pupils• Poor urinary output

Irreversible Shock

• This is the terminal stage of shock.

• A transfusion of any type will not be enough to save a patient’s life.

When to Expect Shock

• Multiple severe fractures• Abdominal or chest injuries• Spinal injuries• Severe infection• Major heart attack• Anaphylaxis

You are the Provider

• You and your partner respond to an MVC involving two cars. En route you follow BSI.

• You arrive to a 25-year-old man. • Law enforcement informs you that the other car left

the scene. Patient was restrained and is sitting outside car. He is pale.

• The airbag has deployed and the steering wheel has some damage.

Scene Size-up

• In addition to BSI, what are some considerations at the scene?

• What is the mechanism of injury?

You are the Provider (continued)

• You approach the patient and introduce yourself. He appears visibly upset but lets you take his vital signs.– Pulse: 115 beats/min– Respirations: 26 breaths/min– Blood pressure: 110 mm Hg

• He has a laceration on his knee where it hit the dashboard.

Initial Assessment

• Describe the steps of your initial assessment and findings:– General impression– Airway– Breathing– Circulation– Transport decision

You are the Provider (continued)

• Spinal immobilization needed.• Pallor is a sign of shock. • He is A on the AVPU scale.• Airway is open.• Breathing is rapid.• Inspect and palpate chest for DCAP-BTLS. • Observe for accessory muscle use.

You are the Provider (continued)

• Patient has rapid pulse.• Clammy skin.• Knee laceration• Priority transport

Focused History and Physical Exam

• Would you perform a rapid physical exam or focused physical exam?

• What is your reasoning?

Detailed Physical Exam

• If time permits, perform en route to the hospital.

Ongoing Assessment

• Perform reassessment.• Take vital signs every 5 minutes.

You are the Provider

(continued)

• You reassess the patient in the ambulance and he has a pulse of 122 beats/min, respirations of 30 breaths/min, and a blood pressure of 106/68 mm Hg.

• What do his vital sign changes indicate?

Emergency Medical Care (1 of 3)

• Make certain patient has open airway.

• Keep patient supine.

• Control external bleeding.

Emergency Medical Care (2 of 3)

• Splint any broken bones or joint injuries.

• Always provide oxygen.

• Place blankets under and over patient.

Emergency Medical Care (3 of 3)

• If there are no broken bones, elevate the legs 6" to 12".

• Do not give the patient anything by mouth.

Pneumatic Antishock Garment

• Some localities allow EMTs to apply a pneumatic antishock garment (PASG) for some patients in decompensated shock.

• Know your local protocol regarding their usage.

Treating Cardiogenic Shock

• Patient may breathe better in a sitting or semi-sitting position.

• Administer high-flow oxygen.• Assist ventilations as necessary.• Have suction nearby in case the patient

vomits.• Transport promptly.

Treating Neurogenic Shock

• Maintain airway and assist breathing as needed.

• Keep patient warm.

• Transport promptly.

Treating Hypovolemic Shock

• Control obvious bleeding.

• Splint any bone or joint injuries.

• If no fractures, raise legs 6" to 12".

• Secure and maintain airway.

• Give oxygen as soon as you suspect shock.

• Transport rapidly.

Treating Septic Shock

• Transport as promptly as possible while giving all general support available.

• Give high-flow oxygen during transport.

• Use blankets to conserve body heat.

Treating Respiratory Insufficiency

• Secure and support the airway.• Clear airway of any obstructions.• Ventilate if needed with a BVM device.• Administer oxygen.• Transport promptly.

Treating Anaphylactic Shock

• Administer epinephrine.

• Provide prompt transport.

• Provide all possible support.

– Oxygen

– Ventilatory assistance

Treating Psychogenic Shock

• It is usually self-resolving.

• Assess patient for injuries from fall.

• If patient has difficulties after regaining consciousness, suspect another problem.

Review

1. The term “shock” is MOST accurately defined as:

A. a decreased supply of oxygen to the brain.

B. cardiovascular collapse leading to inadequate perfusion.

C. decreased circulation of blood within the venous circulation.

D. decreased function of the respiratory system leading to hypoxia.

Review

Answer: B

Response: Shock, or hypoperfusion, refers to a state of collapse and failure of the cardiovascular system, or any one of its components (eg, heart, vasculature, blood volume), which leads to inadequate perfusion of the body’s cells and tissues.

Review1. The term “shock” is MOST accurately defined as:

A. a decreased supply of oxygen to the brain.Rationale: It may be a result of inadequate perfusion, but it is not the

definition of shock.B. cardiovascular collapse leading to inadequate perfusion.Rationale: Correct answerC. decreased circulation of blood within the venous circulation.Rationale: It may be a result of cardiovascular collapse, but it is not the

definition of shock.D. decreased function of the respiratory system leading to hypoxia. Rationale: Decreased function of the respiratory system will lead to

hypoxia which will cause cardiovascular collapse and eventually to shock.

Review

2. A 20-year-old man was kicked numerous times in the abdomen during an assault. His abdomen is rigid and tender, his heart rate is 120 beats/min, and his respirations are 30 breaths/min. You should treat this patient for:

A. a lacerated liver.

B. a ruptured spleen.

C. respiratory failure.

D. hypovolemic shock.

Review

Answer: D

Rationale: The patient may have a liver laceration or ruptured spleen—both of which can cause internal blood loss. However, it is far more important to recognize that the patient is in hypovolemic shock and to treat him accordingly.

Review2. A 20-year-old man was kicked numerous times in the abdomen

during an assault. His abdomen is rigid and tender, his heart rate is 120 beats/min, and his respirations are 30 breaths/min. You should treat this patient for:

A. a lacerated liver. Rationale: You cannot treat a lacerated liver in the field. You can treat

the symptoms of hypovolemic shock associated with the injury.B. a ruptured spleen.Rationale: You cannot treat a ruptured spleen in the field. You can treat

the symptoms of hypovolemic shock associated with the injury.C. respiratory failure. Rationale: If you treat the hypovolemic shock, then you will treat the

respiratory compromise as well.D. hypovolemic shock.Rationale: Correct answer

Review

3. Signs of compensated shock include all of the following, EXCEPT:

A. restlessness or anxiety.

B. pale, cool, clammy skin.

C. a feeling of impending doom.

D. weak or absent peripheral pulses.

Review

Answer: D

Rationale: In compensated shock, the body is able to maintain perfusion to the vital organs of the body via the autonomic nervous system. Signs include pale, cool, clammy skin; restlessness or anxiety; a feeling of impending doom; and tachycardia. When the body’s compensatory mechanism fails, the patient's blood pressure falls; weak or absent peripheral pulses indicates this.

Review3. Signs of compensated shock include all of the following,

EXCEPT:

A. restlessness or anxiety.Rationale: This indicates compensated shock.B. pale, cool, clammy skin.Rationale: This indicates compensated shock.C. a feeling of impending doom.Rationale: This indicates compensated shock and the anxiety

associated with it.D. weak or absent peripheral pulses.Rationale: Correct answer

Review

4. A 60-year-old woman presents a BP of 80/60 mm Hg, a pulse rate of 110 beats/min, mottled skin, and a temperature of 103.9°F. She is MOST likely experiencing:

A. septic shock.

B. neurogenic shock.

C. profound heart failure.

D. a severe viral infection.

Review

Answer: A

Rationale: In septic shock, bacterial toxins damage the blood vessel walls, causing them to leak and rendering them unable to constrict. Widespread dilation of the vessels, in combination with plasma loss through the injured vessel walls, results in shock. A high fever commonly accompanies a bacterial infection.

Review4. A 60-year-old woman presents a BP of 80/60 mm Hg, a pulse

rate of 110 beats/min, mottled skin, and a temperature of 103.9°F. She is MOST likely experiencing:

A. septic shock. Rationale: Correct answerB. neurogenic shock. Rationale: Neurogenic shock is an injury to the nervous system

and shows bradycardia and hypotension — not fever.C. profound heart failure. Rationale: This is part of cardiogenic shock, associated with low

blood pressure, weak pulse, and cyanotic skin.D. a severe viral infection. Rationale: Septic shock is caused by a bacterial infection.

Review

5. A patient with neurogenic shock would be LEAST likely to present with:

A. tachypnea.

B. hypotension.

C. tachycardia.

D. altered mentation.

Review

Answer: C

Rationale: In neurogenic shock, the nerves that control the sympathetic nervous system are compromised. The nervous system is responsible for secreting the hormones epinephrine and norepinephrine, which increases the patient’s heart rate, constricts the peripheral vasculature, and shunts blood to the body’s vital organs. Without the release of these hormones, the compensatory effects of tachycardia and peripheral vasoconstriction are absent.

Review

5. A patient with neurogenic shock would be LEAST likely to present with:

A. tachypnea.

Rationale: Respirations increase to compensate for the hypoxia associated with shock.

B. hypotension.

Rationale: Hypotension results from massive vasodilation.

C. tachycardia.

Rationale: Correct answer

D. altered mentation.

Rationale: The patient will present with mental status changes secondary to hypoxia.

Review

6. A 33-year-old woman presents with a generalized rash, facial swelling, and hypotension approximately 10 minutes after being stung by a hornet. Her BP is 70/50 mm Hg and her heart rate is 120 beats/min. In addition to high-flow oxygen, this patient is in MOST immediate need of:

A. epinephrine. B. rapid transport.C. an antihistamine. D. IV fluids.

Review

Answer: A

Rationale: This patient is in anaphylactic shock—a life-threatening overexaggeration of the immune system that results in bronchoconstriction and hypotension. After ensuring adequate oxygenation and ventilation, the MOST important treatment for the patient is epinephrine, which dilates the bronchioles and constricts the vasculature, thus improving breathing and blood pressure respectively.

Review6. A 33-year-old woman presents with a generalized rash, facial

swelling, and hypotension approximately 10 minutes after being stung by a hornet. Her BP is 70/50 mm Hg and her heart rate is 120 beats/min. In addition to high-flow oxygen, this patient is in MOST immediate need of:

A. epinephrine. Rationale: Correct answerB. rapid transport.Rationale: Rapid transport follows high flow oxygen and epinephrine

administration.C. an antihistamine. Rationale: This is an ALS treatment.D. IV fluids. Rationale: This is an ALS treatment.

Review

7. Elevating the legs of a patient who is in shock:

A. causes the blood vessels to constrict, thereby raising the blood pressure.

B. allows blood in the lower extremities to more rapidly return to the heart.

C. makes the patient more comfortable, which will decrease oxygen demand.

D. returns warmed blood from the legs to the body, preventing hypothermia.

Review

Answer: B

Rationale: Elevating the shock patient’s lower extremities 6” to 12” allows blood in the legs to return to the heart, thus helping maintain perfusion to the vital organs. It also helps control venous bleeding in the lower extremities.

Review (1 of 2)

7. Elevating the legs of a patient who is in shock:

A. causes the blood vessels to constrict, thereby raising the blood pressure.

Rationale: Vasoconstriction is accomplished by the administration of medication and not by elevating the patient’s legs.

B. allows blood in the lower extremities to more rapidly return to the heart.

Rationale: Correct answer

Review (2 of 2)

7. Elevating the legs of a patient who is in shock:

C. makes the patient more comfortable, which will decrease oxygen demand.

Rationale: Oxygen demand will not be effected by elevating the patient’s legs.

D. returns warmed blood from the legs to the body, preventing hypothermia.

Rationale: Heat loss secondary to shock is a concern, but body heat is maintained by placing a blanket over the patient.

Review

8. The PASG would MOST likely cause further harm to a patient with:

A. an unstable pelvis and severe pain.

B. external bleeding from bilateral femur fractures.

C. severe, ongoing bleeding in the pelvic cavity.

D. blunt thoracic trauma with internal hemorrhage.

Review

Answer: D

Rationale: The pneumatic antishock garment (PASG) is mainly used as a splint for patients with pelvic or bilateral femur fractures. They should not be used in any patient with trauma above the last rib. The PASG causes vasoconstriction, which, in the patient with intrathoracic hemorrhage, may worsen the bleeding by dislodging internal clots that may have formed.

Review

8. The PASG would MOST likely cause further harm to a patient with:

A. an unstable pelvis and severe pain.

Rationale: PASG is an appropriate device used to splint unstable pelvic fractures.

B. external bleeding from bilateral femur fractures.

Rationale: PASG can be utilized to apply pressure to external bleeding if the PASG is inflated to splinting pressures only.

C. severe, ongoing bleeding in the pelvic cavity.

Rationale: PASG will stabilize the pelvis and blood loss.

D. blunt thoracic trauma with internal hemorrhage.

Rationale: Correct answer

Review

9. Anaphylactic shock is typically associated with:

A. urticaria.

B. bradycardia.

C. localized welts.

D. a severe headache.

Review

Answer: A

Rationale: Urticaria (hives) is typically associated with allergic reactions—mild, moderate, and severe. They are caused by the release of histamines from the immune system. In anaphylactic shock, urticaria is also accompanied by cool, clammy skin; tachycardia; severe respiratory distress; and hypotension.

Review

9. Anaphylactic shock is typically associated with:

A. urticaria.

Rationale: Correct answer

B. bradycardia.

Rationale: Tachycardia is a symptom of anaphylactic shock.

C. localized welts.

Rationale: Welts are a raised ridge or bump on the skin caused by a lash from a whip, a scratch, or a similar blow.

D. a severe headache.

Rationale: Altered mental status secondary to hypoxia may be a symptom, but not a headache.

Review

10. When treating a trauma patient who in shock, LOWEST priority should be given to:

A. spinal protection.

B. thermal management.

C. splinting fractures.

D. notifying the hospital.

Review

Answer: C

Rationale: Critical interventions for a trauma patient in shock include spinal precautions, high-flow oxygen (or assisted ventilation), thermal management, rapid transport, and early notification of a trauma center. Splinting fractures should not be performed at the scene if the patient is critically-injured; it takes too long and only delays transport.

Review

10. When treating a trauma patient who in shock, LOWEST priority should be given to:

A. spinal protection.

Rationale: Stabilization of the spine must take place during the first interaction with a trauma patient.

B. thermal management.

Rationale: Preventing hypothermia is standard treatment.

C. splinting fractures.

Rationale: Correct answer

D. notifying the hospital.

Rationale: Trauma centers need to be notified early during patient interaction and transport.