Critical Systems

Question 1

Increased Intracranial Pressure

Answer 1

Anything that causes intracranial swelling or bleeding will increase pressure inside the skull. Tumor growth and excess cerebrospinal fluid (CSF) can also cause increased intracranial pressure. Increased intracranial pressure causes brain failure.

Question 2

How can a rescuer identify if the problem is ASR and not shock?

Answer 2

Time. Over time ASR will improve and shock will not.

Lack of an MOI that would cause shock.

Question 3

What are the two mechanisms for cardiogenic shock? How do you treat each?

Answer 3

Coronary Heart Disease – clogged artery resulting in not enough oxygenated blood being delivered to the heart (ischemia) or heart not pumping properly (irregular rhythm).

Trauma – bruised heart or blood or fluid fills the space around the heart squeezing it not allowing it to pump properly.

Question 4

List the three major components of the circulatory system.

Answer 4

Pump (Heart)
Pipes (Blood Vessels)
Fluid (Blood)

Question 5

What is the worry window for the development of ↑ICP after a traumatic brain injury?

Answer 5

Up to 24 hours.

Question 6

Describe the treatment principles for a patient suffering from chest wall trauma.

Answer 6

PROP

Cover the leak if there is an open wound.

Treat pain.

Evac – urgent evac if not responding to field treatment and for cases where there is more serious chest wall trauma.

Question 7

After a blow to the head, which signs/symptoms should prompt an evacuation?

Answer 7

Any change in AVPU.
Any degree of amnesia.

Question 8

Respiratory System

Answer 8

A system of organs, functioning in the process of gas exchange between the body and the environment, consisting especially of the nose, nasal passages, nasopharynx, larynx, trachea, bronchi, and lungs.

Question 9

What is volume shock?

Answer 9

Inadequate perfusion pressure caused by blood or fluid loss from blood vessels.

Question 10

Give three examples of how a rescuer can provide the best available oxygen to a patient.

Answer 10

Move from inside to outside a tent

Move stagnant air – fanning

Descend in altitude

Question 11

List the signs/symptoms of early increased intracranial pressure.

Answer 11

• Mental Status Changes
• Severe Headache
• Persistent Vomiting

Question 12

Why is it important to identify ↑ICP early?

Answer 12

This is a life-threatening condition that typically cannot be fixed in the field and requires urgent evacuation. Early recognition/quick evacuation to hospital increases chances of survival.

Question 13

Volume Shock

Answer 13

Shock due to the loss of blood volume.

Question 14

Describe the generic treatment for someone having difficulty breathing. Hint: PROP

Answer 14

Position of Comfort
Reassurance
Oxygen – best available
Positive Pressure Ventilations (PPV)

Question 15

What does “increased respiratory drive” mean and how does it impact a patient’s ability to breathe?

Answer 15

The body’s response to needing more oxygen (i.e., altitude, exercise, injury, illness). Brain tells respiratory system to breath more. We also see hyperventilation in patients having an acute stress response. However, this is not due to an increased need for oxygen.

Question 16

What does “decreased nervous drive” mean and how does it impact a patient’s ability to breathe?

Answer 16

The nervous system (brain) tells our organs what to do. “Decreased nervous drive” = brain no longer tells organs what to do or the message is delayed. This impacts breathing by slowing down or stopping respirations.

Question 17

What is cardiogenic shock and how is it different than cardiac arrest?

Answer 17

Cardiogenic Shock = not enough perfusion pressure (see definition above) caused by the heart not pumping properly.

Cardiac Arrest = heart stops pumping.

Question 18

When is a respiratory problem considered to be serious requiring evacuation?

Answer 18

• Persistent altered mental status
• No improvement
• Getting worse
• Poor skin perfusion (bluish color)
• Cannot maintain body temperature
• Cannot maintain hydration and calories
• Coexisting major problems

Question 19

What is vascular shock?

Answer 19

Not enough perfusion pressure caused by blood vessels throughout the body expanding / loss of vascular tone (systemic vasodilation).

Question 20

When is a nervous system problem considered to be serious requiring evacuation?

Answer 20

• Persistent neurological deficit
• New onset seizure
• Recurrent seizure
• Result of trauma or environmental illness
• Getting worse

Question 21

What are the eight overall mechanisms that cause brain failure?

Answer 21

Often a Goldilocks Problem – too much, too little

Sugar - Blood sugar, low or high.

Temperature - Hypothermia/Hyperthermia

Oxygen - Hypoxia/Hyperoxia

Pressure. Increased ICP or Decreased perfusion pressure|

Electricity

Altitude - Hypoxia from HAPE; Increased ICP from HACE

Toxins

Salts - Electrolyte Imbalance

Question 22

What is a Traumatic Brain Injury (TBI)?

Answer 22

Brain damage from trauma.

Question 23

Circulatory System

Answer 23

An organ system that circulates blood and lymph through the body, consisting of the heart, blood vessels, blood, lymph, and the lymphatic vessels and glands.

Question 24

Why is it important to recognize early signs/symptoms of shock?

Answer 24

We can treat early s/sx and keep shock from progressing and can possibly even reverse it. It is much more difficult to treat or reverse shock after the initial stages of development.

Question 25

List four mechanisms of vascular shock. Which two are the most common?

Answer 25

• Toxins
• Spinal Cord Injury
• Anaphylaxis – common
• Systemic Infection – common

Question 26

Acute Stress Response (ASR)

Answer 26

Autonomic nervous system-controlled response to physical or emotional stress that can cause severe, but temporary and reversible, changes in vital signs. ASR can mimic respiratory distress, shock, and brain failure.

Question 27

What are the two mechanisms that cause volume shock? Which one is more common in the field?

Answer 27

Bleeding

Dehydration from sweating, vomiting/diarrhea, excessive urination, prolonged fluid restriction. This is more common in a wilderness setting.

Question 28

Vascular Shock

Answer 28

Shock due to the dilation of blood vessels / loss of vascular tone.

Question 29

Compensated Volume Shock

Answer 29

Condition in which the body is successfully maintaining enough pressure to adequately perfuse vital organs.

Question 30

Describe how fluid in the lower airway affects oxygenation of cells in the blood.

Answer 30

Fluid in the lower airway makes it difficult for oxygen to move from the alveoli into the blood vessels and slows the rate of oxygen exchange.

Question 31

Is ASR a form of shock? Why or why not?

Answer 31

No. ASR is not a result of something wrong with the circulatory system. While it can look like a critical system problem it resolves over time and treatment (PROP).

Question 32

What is shock?

Answer 32

Not enough pressure in the system to keep the blood flowing and deliver oxygen to all tissues.

Question 33

Describe how chest wall trauma impacts a patient’s ability to breathe.

Answer 33

Most often pain from a rib fracture is what makes it difficult to inhale. Other problems include collapsing of the lung due to collection of blood and/or air in the space between the chest wall and the lungs preventing the affected lung(s) from expanding and filling up with air.

Question 34

Nervous System

Answer 34

A complex network of nerves and cells that carry messages to and from the brain and spinal cord to various parts of the body.

Question 35

What is the difference between compensated volume shock and decompensated volume shock? How do you know when a patient is starting to decompensate?

Answer 35

Compensated volume shock - the brain signals the body to makes adjustments to maintain enough pressure in the system to deliver oxygen to the brain and maintain its function.

Decompensated volume shock occurs when the body can no longer keep up, perfusion pressure drops, and the brain no longer receives enough oxygenated blood. A patient’s mental status/level of conscious will decline at this point. A patient who reaches the decompensated stage has a poor prognosis for survival.

Question 36

Respiratory Distress

Answer 36

Difficulty breathing, but the respiratory system is still able to adequately oxygenate the blood to maintain brain function. The patient remains awake and responsive. Any mental status changes are mild or primarily due to ASR.

Question 37

Describe the interventions rescuers can do to treat volume shock caused by internal bleeding or dehydration.

Answer 37

Well aimed direct pressure. Place fingers or palm (rescuer or patient) directly on wound and press firmly.

Apply a pressure dressing and wrap using the following principles:

• Should be rigid and bulky
• Wrap wide in the back and pinpoint at source (i.e., twist of wrap)

Apply a tourniquet if pressure dressing not working, if limb is amputated, or wound is in an area that can’t be accessed using the following principles:

• Apply 2-3” above the wound not over a joint or “high and tight”
• Material should be a couple inches wide.
• Make sure there is no pulse downstream.
• Note time of application.
• Continue to monitor for no pulse. If pulse present, tighten.
• Consider removing after ~ 1 hour to see if bleeding has stopped. When doing so, loosen slowly. If bleeding continues reapply and leave on.

Question 38

List four ways an airway can be obstructed.

Answer 38

Cork – blocks airway preventing oxygen from getting into lungs

Kink – pinches off airway preventing oxygen from getting into lungs

Fluid – can block airway preventing oxygen from getting into lungs (i.e., vomit in mouth) or make it difficult for oxygen to pass from alveoli to capillaries (i.e., fluid in lungs)

Swelling – squeezes airway preventing oxygen from getting into lungs

Question 39

Describe the main function of the circulatory system.

Answer 39

To maintain enough pressure in the system to keep oxygenated blood flowing throughout the body (referred to as perfusion pressure).

Question 40

What is the main sign of a patient transitioning from early to late ↑ICP?

Answer 40

Decrease on the AVPU scale

Question 41

Shock

Answer 41

Inadequate perfusion pressure in the circulatory system, resulting in inadequate tissue oxygenation.

Question 42

Decompensated Volume Shock

Answer 42

Condition in which the body is unable to maintain adequate pressure to perfuse vital organs in the presence of low blood volume. This presents in patients as significantly altered mental status or reduced level of consciousness.

Question 43

List 8 non-traumatic brain injuries where ↑ICP is an anticipated problem.

Answer 43

• Stroke
• Hyperthermia
• Hypoxia
• Electricity
• Infection
• Exercise Induced Hyponatremia
• Altitude (HACE)
• Neuro Toxins

Question 44

Describe the treatment principles for volume shock.

Answer 44

Stop the fluid loss.
Replace fluid volume.
Maintain calories and warmth. Cold patients don’t clot!

Question 45

Irritated brain tissue _____, which is known as _________________________ and causes ___________________.

Answer 45

Irritated brain tissue swells, which causes fluid to leak into the intracranial space which is known as ↑ intracranial pressure. This causes ischemia.

Question 46

Cardiac Arrest

Answer 46

Loss of effective heart function, which results in cessation of functional circulation.

Question 47

Describe the main function of the respiratory system.

Answer 47

Oxygenates the blood and regulates pH in blood. Groceries in (oxygen), garbage out (carbon dioxide).

Question 48

What is our major concern in the upper airway?

Answer 48

The tongue – huge glob of muscle that gets in the way

Question 49

Compare/contrast respiratory distress, failure, and arrest.

Answer 49

Distress – difficulty breathing, but maintaining enough oxygenation to sustain brain function.

Failure – difficulty breathing, but no longer able to provide enough oxygen to sustain brain function. Mental status changes.

Arrest – breathing has stopped or ineffective slow breathing. Patient is unresponsive.

Question 50

If administering pain medications for someone who suffered a traumatic brain injury, which type should be avoided? Why?

Answer 50

Blood thinning drugs (i.e., Aspirin). These medications make the blood “slippery” by making the platelets less sticky. As a result, it is harder for the blood to clot. If a brain bleed is present the inability to clot could lead to further bleeding and ↑ intracranial pressure.

Question 51

Describe or draw a graph illustrating the vital sign trend for compensated and decompensated volume shock.

Answer 51

Question 52

Describe the main function of the nervous system.

Answer 52

Controls all function in the body.

Question 53

Respiratory Failure

Answer 53

Difficulty breathing where the respiratory system is not able to adequately oxygenate the blood to maintain brain function. The patient will have altered mental status or reduced level of consciousness.

Question 54

In simple terms, what causes blood vessels to dilate all throughout the body?

Answer 54

Chemical reactions create vascular tone which provide some constriction to the blood vessels. When those chemical reactions are interrupted, the nervous system is unable to send signals to keep smooth muscle cells constricted and the vessels relax (dilate) which results in a loss of vascular tone and a widening of the vessels (pipes).

Question 55

Describe the two ways that ASR presents.

Answer 55

Sympathetic Response = “Fight or Flight”. Adrenaline dump in the body resulting in ↑ pulse, ↑ respirations, ↓ skin perfusion (pale, cool), ↑ anxiety.

Parasympathetic Response = “Rest and Digest”. ↓ pulse. Causes fainting.

Question 56

What is Acute Stress Reaction (ASR)?

Answer 56

Body’s response to a stressor such as an injury, illness, pain, or emotional distress.

Question 57

Explain how each type of ASR could affect your assessment or treatment.

Answer 57

A sympathetic response looks like volume shock as well as masks pain. This can make assessing an injury accurately difficult.

A parasympathetic response can look like a TBI or other cause for ↓ mental status.

Question 58

Respiratory Arrest

Answer 58

Absence of breathing; a.k.a. apnea.

Question 59

Describe the two treatment principles for vascular shock.

Answer 59

Reverse the vasodilation – medications such as EPI for anaphylaxis

Increase fluid volume – give electrolyte drinks or water/food

Question 60

What happens to the ability of the heart to pump and maintain enough pressure to move blood around the body when the blood vessels are too big? (Hint: think fire hose vs garden hose)

Answer 60

It decreases. Normally, when the heart pumps and blood flows through the pipes it maintains forward momentum because the blood butts up against the walls, bounces back, and is pushed forward. When the pipes are too big, the blood doesn’t get pushed forward adequately and slows to trickly which results in a loss of perfusion.

Question 61

Traumatic Brain Injury

Answer 61

A blow to the head or a penetrating head injury that damages the brain tissue.

Question 62

Cardiogenic Shock

Answer 62

Shock caused by inadequate function of the heart, or pump failure.