Shock by Ruth

8/6/2019 Shock by Ruth

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Defined, shock is a widespread state of inadequate cellular

profusion. Shock occurs frequently and is potentially lethal. It is TIME

CRITICAL. It is for this reason all ambulance officers should be able to

recognise and treat a patient in shock early, quickly and efficiently.

Clinical shock is

NOT the same as emotional shock/distress, althoughdistress is associated with the condition.

Cell function requires a constant supply of oxygen and glucose

(glucose is the only source of food for the brain). These two

essential chemicals are supplied from the blood stream.

For this mechanism to work, there has to be adequate Blood pressure

to allow Oxygen and Glucose to cross the capillary wall and to move

to the cells. This process in referred to as perfusion.


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Fluid loss Fluid can be lost from the circulatory systemdue to injury that causes bleeding, burns that cause plasmaloss, and dehydration.

Pump Failure If the heart is damaged, e.g. M.I or

Trauma, and cannot pump enough blood to the body.

Vasodilatation In some cases the blood vessels willdilate, e.g. Spinal injuries, and the heart is unable to keepperfusion and blood pressure at normal levels.

Hypoxemia A severe chest injury, airwayobstruction, or other cause of respiratory/cardiac difficultymay prevent an inadequate amount of oxygen getting tothe blood stream. Without oxygen the bodys cells willbegin to die


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The degree of shock depends on several factors:

Amount of blood/fluid loss

Rate of blood/fluid loss

Age of patient (most elderly people are alreadydehydrated and, children do not need to lose asmuch blood as children before going into shock)

Patients overall physical condition

Patients ability to mobilise compensatorymechanisms.


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Each TYPE/CLASIFICATION of shock has its own

distinguishing signs and symptoms.

CLASSES of shock in the main refer to Hypovolemic

shock, based on blood loss.

STAGES of shock in the main refer to all other types

of shock.


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Cardiogenic

Relating to the heart and its inefficiency to act as a pump, it is unable to

pump the blood around the body.

This type of shock is seen in patients who may have had a MI, myocardialcontusions,cardiomyopathies,myocarditis,dysrhythmias,pericardial

tamponade.

Signs and symptoms; signs of MI, chest pain, nausea, syncope, ECG changes,

cardiac dysrhythmias, decreased cardiac output.

Distributive

A form of shock characterized by loss of blood vessel tone, enlargement of

the vascular compartment, and displacement of the vascular volume

away from the heart and central circulation.Seen in septic (infection), anaphylactic (allergic), and neurogenic ( general

anaesthetics, spinal injury, brain injury) shock.

Signs and symptoms; decreased cardiac output, hypocapnia, pyrexia, chills,

tremors, rigors, pink, warm dry skin, diahrrea, nausea/vomiting, rash.


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Restlessness, anxious, fearful:

Reduced oxygen levels to the brain.

Cool, clammy, pale skin, cyanotic(blue) lips:

Peripheral vasoconstriction. Vessels are constricted to maintain peripheral

resistance and blood pressure

Weak, rapid pulse (tachycardia):

Less fluid (volume) in the blood vessels, The heart speeds up to

compensate. This helps maintain cardiac output and blood pressure.

Rapid breathing (tachypnoea):

Breathing rate is increased to pack the red blood cells with oxygen.

Confusion, Altered mental status, Reduced Level of Consciousness

(L.O.C.):

Not enough oxygen to the brain. Hypoxia.

Muscle weakness:

Not enough oxygen reaching the muscles, causing loss of response


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Thirst:

A response to raise blood volume

Nausea:

Stomach and intestines are considered non-vital organs, and are shut down, causing

vomiting

Slow capillary refill (longer than two seconds):

Reduced perfusion of the skin and extremities as blood is redirected to vital organs

Dilated pupils, delayed reaction: Low perfusion and hypoxic states

Normal to slightly high blood pressure, then rapidly falling. (Going from

Compensatory shock to decompensatory shock)

As the body detects a fall in B.P with fluid volume loss ( baroreceptors in the carotid and

aortic bodies), blood vessels constrict to maintain blood pressure, then the smooth muscles

in artery walls themselves begin to suffer from oxygen depletion, and release their hold,

causing the BP to fall, This patient is in serious trouble.


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As you can see, the Human body does have defence mechanisms that it uses

when it is under attack from illness and injury. However, these mechanisms can

only be sustained for a limited time before the patient, if untreated, will die. An

understanding of the progressive stages of shock will help you determinetreatment and management of your patient.


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Classes of shock in the main refer to Hypovolemic shock

Stages of shock in the main refer to all other types of shock

Each type of shock has its own distinguishing signs andsymptom.


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Shock is progressive if untreated, and can be broken down into several stages

Pre-shock/Initial phase:

Baroreceptors detect a slight fall in BP, so the body mobilises thecompensatory mechanisms.

Compensatory: (Blood loss up to 15%, approx 500ml in a healthy adult)

In the first stage, the body is able to use its normal defences to maintainnormal perfusion and function, it can compensate. In most cases the

patient does not exhibit any signs or symptoms. As the body detects a

drop in BP, it signals the heart to increase its rate and blood vessels to

constrict in an attempt to maintain the BP. If the blood loss is stopped,the body may replenish the lost volume within 24 hours.


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Progressive or Decompensatory: (Blood loss up to 40%)

If bleeding goes on uncontrolled, then the body works tomaintain adequate perfusion to the vital organs. Blood will beshunted away from less vital organs and sent to the blood,

brain and lungs. The body cannot correct itself from this stagewithout outside assistance. The cardiovascular system is not

receiving enough oxygenated blood to maintain the

compensatory stage. The heart no longer contracts efficiently,so the blood pressure and circulatory flow drops.

Irreversible: (Blood loss over 40%)

This is a state where cell death has begun and the cardiovascular

system is no longer capable of sustaining life. Multi-system

organ damage and death of the organs has begun. If Shockreaches this magnitude, even if treated, death will result.


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Classes of shock are related to volume ofblood lost. Hence, it is important to have some

knowledge of the normal blood volumes.

Adult 5-6 Litres 65-70mls Per kg

10-11yr old child 2.5 Litres 80-85mls Per kg

3-5 yr old infant 1.5 Litres 70-76mls per kg

Infant 0.6 Litres 70-76mls per kg


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Stages of Shock compensated decompensated irreversible

Classes of Shock I II III IV

Amount of blood loss. %

TBV

40%Pulse rate Normal -slightly

increased>100 >120 >140

Pulse quality Normal Thready Thready/veryweak

No radial/ threadycarotid

Pulse pressure Normal/increased Decreased Decreased decreased

Capillary refill Normal Delayed. 3-5 sec Delayed >5 sec Delayed >5 sec

Resp rate 14 20 20 30 30 40 >35

SBP Normal Normal Decreased < 80mmHg

Greatly decreasedapprox 60mmHg

Skin colour Pink Pale Whiteextremities/ashengrey

Whiteextremities/ashengrey/ cyanotic

Skin temp Cool Cool/clammy/moist

Cool extremities Cold extremities

Mental status Normal/ slightlyanxious

Anxiety/fright/mildly anxious

Severeanxiety/confused

Lethargic/confused/ unconscious


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Task

In groups, choose a lead crew member.

Working as a team and your given scenario, what isyour management and treatment of your patient?

What type, stage of shock is your patient in?

What is the expectation and tasks asked of the secondcrew person.

You have 20 mins to complete the task, if notcompleted, your patient will be pronounced dead.

Presentation of your task with rationale to be presentedto all those present.

Shock by Ruth

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