LO2 Shock and Haemorrhage (Chapter 4/5)

Question 1

Adequate Perfusion requires 4 components

Answer 1

Intact, functioning Vascular system

Adequate Air exchange

A functioning Pump

Adequate Fluid volume in vascular system

Question 2

Normal perfusion

Relies on two Key Factors:

Answer 2

Cardiac Output

• Peripheral Vascular Resistance
The resistance blood has to flow against

Question 3

How do we preserve perfusion?

Answer 3

Control bleeding.
-Look for other bleeding and control it

Maintain airway.

Maintain oxygenation & ventilation.

Maintain circulation

Adequate heart rate & intravascular volume.

Question 4

Shock

Answer 4

a state of tissue hypoxia due to reduced oxygen delivery and or increased oxygen consumption or an adequate oxygen utilization

A condition during which the cardiovascular system fails to perfuse the tissues adequately.

Is a continuum.

Question 5

three stages of shock

Answer 5

compensated decompensated and irreversible

Question 6

Shock cycle:

Answer 6

↓ in Red Blood Cells

Anaerobic process

Hypoxia worsens

Inadequate perfusion: causes of buildup of lactic acid

Catecholamine ↑ : epi and noreepi

Cell death
repeat

Question 7

Four Distinct kinds of shock

Answer 7

hypovolemic

distributive

obstructive

cardiogenic

Question 8

Hypovolemic shock (absolute hypovolemia) causes

Answer 8

External hemmorage- controlled

External hemmorhage- uncontrolled

Internal hemmorahage

Other causes of intravascular volume loss such as diahrea

Question 9

Distributive shock (high space) causes

Answer 9

Neurogenic shock

Medical causes (anaphylaxis, sepis, overdoses)

Question 10

mechanical shock -Obstructive shock causes

Answer 10

Cardiac tamponade

Tension pneumothorax

Massive pulmonary embolism

Question 11

mechanical shock -Cardiogenic shock

Answer 11

Cardiac contusion

MI

Question 12

catecolmines

Answer 12

Epinephrine and Norepinephrine AKA Catecholamines are released due to a decrease in cardiac output.

• This causes:
↑ heart rate & contractility.

↑ systemic vascular resistance.

Blood is redirected from skin, gut and kidneys to the heart & brain.

Question 13

Compensated Shock (first phase)

Answer 13

Loss of 15-25% of the blood volume

Body is compoensating

if not fixed goes to decompensated

Question 14

Compensated Shock (first phase) signs and symptoms and why

Answer 14

Sustained tachycardia (high heart rate): catecholamines

• Pale (Pallor) & Cool skin: blood is shunted to middle of body
• Diaphoresis: catecholamines
• Tachypnea (high breathing rate): catecholamines
• Weakness/light headedness: caused by decreased blood volume
• Peripheral pulses weakened: blood is shunted to middle of body
• Thirst: hypovolemia
• Urinary output decreased: hypovolemia, hypoxia and circulating catecholamines

Question 15

Decompensated Shock (second phase)

Answer 15

Loss of 30-45% of the blood volume: enough to cause hypotension
Body has failed to compensate

Question 16

Decompensated Shock (second phase) signs and symptoms and why

Answer 16

• Hypotension: caused by hypovolemia, diminished cardiac output and/or vasodilation
• Altered metal status: lack of o2 to brain
• Cardiac arrest: organ failure secondary to blood loss, hypoxia

Question 17

Capnography (ETCO ) 2

Answer 17

Normal range is 35-40 mmHg.

Falling ETCO2 indicates hyperventilation and decreased oxygenation

An ETCO less than <20mmHg means shock is worsening and may indicate circulatory collapse

Question 18

Tachycardia

Answer 18

First sign of shock

100bpm not normal 120 red flag

Some patients in shock may not develop tacahycardia

Question 19

Relative bradycardia

Answer 19

patients with traumatic hypotension

Consider patients meds

Beta blockers or calcium channel blocking medications might prevent them from developing tachycardia

Children in decompensated shock may develop bradycardia

Question 20

Low volume shock(absolute hypovolemia)

Answer 20

is caused by haemorrhage or other major body fluid loss like diarrhea, vomiting and third spacing due to Burns, peritonitis and other causes

Question 21

High space shock (relative hypovolemia)

Answer 21

is caused by spinal injury, vasovagal syncope, sepsis, anaphylaxis and certain drug overdoses that dilate the blood vessels and redistribute blood flow to a larger vascular volume

Question 22

Mechanical shock (obstructive shock):

Answer 22

is caused by conditions preventing the filling of the heart like pericardial Tampanade, tension pneumothorax, or something obstructing blood flow through the lungs like a massive pulmonary embolism

Question 23

Cardiogenic shock (pump failure):

Answer 23

is caused by a damaged heart like myocardial contusion or myocardial infarction

Question 24

Absolute hypovolemia

• Loss of volume

Answer 24

Blood vessels can hold more than actually flows

Catecholamines (sympathetic nervous system) cause vasoconstriction and maintains bp high enough to perfuse vital organs

Question 25

signs and symptoms of Absolute hypovolemia

Answer 25

LOC: possibly decreased Airway: possibly snoring Breathing: rapid and shallow Pulses: rapid and “Thready” pulse: means width of artery shrinks Skin: pale, cool, clammy Possibly uncontrolled hemorrhage Neck veins: flat Trachea: midline Chest: may be normal Possible contusions or penetrations Breath sounds: normal or unilaterally diminished Abdomen: possibly tender/rigid/distended Pelvis: may be unstable or painful Extremities: possible fractures

Question 26

TREATMENT Controllable Hemorrhage  

Answer 26

Control bleeding w/ direct pressure.   Shock position   High‐flow oxygen   Rapid safe transport   Large‐bore IV access   Fluid bolus 500‐1000 ml for adult or 20 ml/kg for pediatrics ---Only restore perfusion  Monitor patient’s ECG, SPO2 and ETCO2.  

Question 27

treatment Uncontrollable Hemorrhage (external)

Answer 27

Control bleeding quickly and aggressively   Shock position  High‐flow oxygen  Rapid safe transport   Large‐bore IV access  Fluid administration  TXA Administration  Monitor patient’s ECG, SPO2 and ETC  

Question 28

treatment Uncontrollable Hemorrhage (internal)

Answer 28

Rapid safe transport * Shock position  * High-flow oxygen  * Large-bore IV access * Fluid administration   * TXA Administration  * Monitor patient’s ECG, SPO2 and ETCO2.  

Question 29

Low-volume Shock – Burns

Answer 29

Cutaneous injury as a result of thermal (heat, flame or scald) or non thermal (chemical or electrical). May be associated with smoke inhalation injury or other traumatic injuries. Severity of a burn is determined by: - -Age, medical history of the patient. - -Body area involved - -Size and depth of burn.

Question 30

Major burns

Answer 30

Burns greater than 20% total body surface area (TBSA) are considered Major Burns. result in the loss of or the evaporation of: Plasma or water. Large amounts of electrolytes. They can cause generalized edema and hypovolemia.

Question 31

``` TREATMENT Burn treatment (<20 TBSA)   ```

Answer 31

* Cool the burn  * Analgesia  * Apply moist sterile dressing * Fluid administration  * Safe transport  

Question 32

``` TREATMENT Burn treatment (>20 TBSA)   ```

Answer 32

``` Cool the burn  • Airway support  • High-flow oxygen  • Apply sterile dry dressings  • Large-bore IV access  • Analgesia  • Fluid administration  • Rapid safe transport  • Monitor patient’s ECG, SPO2 and ETCO2 • Monitor patient for hypothermia   ```

Question 33

Distributive Shock | Relative hypovolemia

Answer 33

“Vasodilatory shock” Large intact vascular space Interruption of sympathetic nervous system Loss of normal vasoconstriction; vascular space becomes much “too large” Clinical presentation Varies dependent on type of high-space shock

Question 34

Distributive shock – Neurogenic Shock

Answer 34

Neurogenic shock typically occurs after an injury to the spinal cord (C6 and above). Injury prevents additional catecholamine release.

Question 35

Neurogenic Shock signs and symptoms

Answer 35

oHypotension oHeart rate normal or slow oSkin warm, dry, pink à not pale because catecholmines are not released oParalysis or deficit oNo chest movement, simple diaphragmatic

Question 36

Neurogenic Shock treatment  

Answer 36

``` Treat symptomatically  • Spinal motion restriction   • Rapid safe transport  • High-flow oxygen  • Large-bore IV access   • Fluid administration  • Monitor patient’s ECG, SPO2 and ETCO2.   ```

Question 37

Distributive shock – Sepsis shock

Answer 37

Septic shock has a high mortality rate. An infectious processes initiates it. Bacteria, endotoxins and exotoxins initiate the inflammatory process which initiates widespread vasodilation.

Question 38

Common sites of infection are:

Answer 38

i. Lungs ii. Bloodstream iii. Intravascular catheter iv. Urinary tract v. Surgical wound

Question 39

signs and symptoms of septic shock

Answer 39

``` Tachycardia • Tachypnea • Temperature instability • Altered mental status • ↓ renal function • Clotting abnormalities ```

Question 40

• There are phases of Sepsis not every patient is in shock.

Answer 40

Sepsis SIRS with signs of infection Severe sepsis Involvement of 1 or more organ system dysfunctions Septic shock Development of hypotension

Question 41

Systemic inflammatory response syndrome (SIRS)

Answer 41

Temp: >38°C or <36°C; Pulse: >90; R/R: >20/min

Question 42

Sepsis Treatment  

Answer 42

* Identify the source of infection   * Large-bore IV access   • Fluid replacement - 20 mL/kg with the intent to repeat following a reassessment   --Start pts with crackles at 250ml if not 500ml and reassess   * Oxygen administration  * Rapid safe transport  * Temperature management  * Monitor patient’s ECG, SPO2 and ETCO2 * Inotropic support (ALS ONLY)  * IV antibiotic administration (ALS ONLY)  

Question 43

Distributive shock – Anaphylaxis

Answer 43

This response typically involves 2 body systems and causes massive vasodilation. This vasodilation causes fluid to shift from the intravascular space to the extravascular space

Question 44

Distributive shock – Anaphylaxis signs and symptoms

Answer 44

* Anxiety/altered mental status * Dyspnea * Edema * Hypotension * Gastrointestinal (GI) cramps * Hives (urticaria) * Sensations of burning or itching of the skin * Fever

Question 45

Anaphylaxis treatment  

Answer 45

``` Epinephrine administration  • Bronchodilator administration  • Oxygen administration  • Rapid safe transport  • Large-bore IV access  • Fluid administration  • Monitor patient’s ECG, SPO2 and ETCO2.  ```

Question 46

Mechanical Shock – Cardiogenic

Answer 46

Impairment of the pump. This is typically caused by a myocardial infarction (MI). Leads to decreased cardiac output. Cardiac contusions: right ventricle most common place Arrythmias Stiffness/decrease contraction

Question 47

Mechanical Shock – Cardiogenic signs and symptoms

Answer 47

``` Tachycardia, tachypnea, hypotension, JVD, dysrhythmia Chest pain Dyspnea Faintness Feelings of impending doom ```

Question 48

Cardiogenic shock treatment  

Answer 48

ASA administration  • STEMI/NSTEMI, dysrhythmia identification & treatment.   • IV access  • Monitor patient’s ECG, SPO2 and ETCO2.  • Nitroglycerin administration  • Rapid safe transport  

Question 49

Mechanical Shock – Obstructive (outside of the heart somewhere)

Answer 49

Is inadequate cardiac output caused by an impediment to blood flow to or from the heart into the pulmonary or systemic circulation.

Question 50

Obstructive shock treatment  

Answer 50

* Identify & treat cause.  * Chest decompression (ALS)   * Rapid safe transport   * High-flow oxygen  * Large-bore IV access   * Fluid administration   * Monitor patient’s ECG, SPO2 and ETCO2.  

Question 51

Mechanical Shock – Obstructive (outside of the heart somewhere) causes

Answer 51

Tension pneumothorax Cardiac tamponade pulmonary embolism

Question 52

Tension pneumothorax

Answer 52

High Air tension that may develop in plural space due to lung or chest wall injury Blood returns to the chest largely because of negative pressure that results when individuals inhales in the absence of this negative pressure blood return will be decreased oh preventing the return of venous blood to the heart resulting in a back up of blood Increased venous return results in lower cardiac output in the development of shock

Question 53

Tension pneumothorax s/s

Answer 53

decreased or absent breath sounds on the affected side, JVD, deviated trachea, cyanosis and a decreased LOC

Question 54

Cardiac tamponade

Answer 54

Occurs when blood feels the potential space between the heart and the pericardium squeezing the heart and preventing the heart from filling This decreased feeling the heart causes cardiac output to fall resulting in development of shock May occur in more than 75% of cases of penetrating cardiac injury

Question 55

Cardiac tamponade s/s

Answer 55

Signs and symptoms have been labelled Becks triad JVD, muffled heart tones and pulses paradoxus (hypotension)

Question 56

shock in children | Most common type and causes

Answer 56

• Hypovolemic * Dehydration * Trauma

Question 57

shock in children | Second most common type and causes

Answer 57

Relative hypovolemia * Burns * Sepsis * “Third spacing” – fluid leaks from inside veins to outside

Question 58

Manifestations of Shock in children

Answer 58

Vitals are not always indicative

Question 59

Manifestations of Shock in children consciousness and responsiveness

Answer 59

Extremely irritable Lethargy: Severe deterioration of consciousness Decreased response to painful stimulation (usually indicates severe cardiorespiratory or neurologic compromise)

Question 60

Manifestations of Shock in children | breathing

Answer 60

Extremely rapid respiratory rate: Tachypnea Increased depth of respirations: Hyperpnea Evidence of increased respiratory effort: Retractions (breath in really deep and everything retracts), grunting, nasal flaring Apnea or inadequate respiratory rate or effort

Question 61

Manifestations of Shock in children | skin color

Answer 61

Mottling – marbleized or blotchy appearance to the skin (may come from a cold environment) Pallor – poor perfusion Flushed, bright red skin – sepsis

Question 62

Manifestations of Shock in children cap refill

Answer 62

Capillary refill: • Compromise in systemic perfusion • Prolonged capillary refill time (>2 seconds) • Subjective interpretation – reliable?

Question 63

Manifestations of Shock in children bradycardia

Answer 63

Possible cause or a symptom of deterioration Most common cause: Hypoxia Often indicates impending cardiovascular collapse Most common terminal cardiac rhythm observed in children Pt is detreating

Question 64

Manifestations of Shock in children blood pressure

Answer 64

Shock may be present despite a systolic blood pressure within the normal range for the age of the child If systolic hypotension develops or the mean arterial pressure fallsàindicates hypotensive shock 10mL/kg of fluid