hello and welcome to chapter 13 shock of the emergency care and transportation of the sick and injured 12th edition you complete this chapter and the related coursework you will have an understanding of the different types of shock the process of perfusion the signs and symptoms associated with shock application of the assessment process with the shock patient and the general and specific emergency care provided to patients experiencing shock okay so let's get started shock when you think of shock also think of hypoperfusion you're going to hear those terms interchangeably often okay so it's defined as an inadequate cellular perfusion and any compromise in perfusion can lead to cellular injury or death okay and so in the early stages the body is going to attempt to maintain homeostasis diffusion is the passive process in which molecules move from an area with a higher traction of molecules to a lower area concentration so this is how oxygen and carbon dioxide move across the alveoli the majority of oxygen is carried to the tissues attached to hemoglobin now carbon dioxide can be transported in the blood from tissues back to the lungs in three ways so carbon dioxide could be dissolved in plasma it could be combined with water in the form of bicarbonate and also attached to the hemoglobin okay so carbon dioxide is that waste product that's released from the cells and can combined with water in the bloodstream to form bicarbonate right so just a little bit more on that and once it reaches the lungs the bicarbonate breaks back down into carbon dioxide and water and the carbon dioxide is then exhaled in cases of poor perfusion remember this is called shock the transportation of the carbon dioxide out of the tissues will become impaired and this results in dangerous buildup of waste products and it can cause cellular damage so shock refers to a state of collapse and failure of the cardiovascular system that leads to inadequate circulation okay to protect vital organs the body directs blood flow from organs that are more tolerant of low flow such as let's say the skin and the intestines to organs that cannot tolerate low blood flow and these are organs such as the heart brains and lungs okay so early recognition of the signs and symptoms of shock can save lives and shock is a life-threatening and requires immediate recognition and treatment the cardiovascular system consists of three parts so it consists of the pump the container and the contents and so this is the heart the blood vessels or all the tubes in the body that blood goes through and the blood okay so this is a great slide you've seen it probably already in the um body systems chapter but this is a great slide like i said that illustrates the cardiovascular system and it shows those three parts so it's showing you the heart on the vessels and the blood so the perfusion triangle so these three parts can be refused referred to as the perfusion triangle the heart blood vessels in the blood and when a patient is in shock one or more of these three parts is not working properly okay so blood pressure is the pressure of blood within the vessels at any moment we know that and the systolic pressure is the peak arterial pressure and that means it's the pressure generated every time the heart contracts and then the diastolic pressure is the pressure maintained within the arteries while the heart rests between heartbeats pulse pressure is the difference between the systolic and the diastolic so the systolic minus the diastolic is the pulse pressure so let's say that somebody has a a 140 heart or 140 systolic over 80 so the pulse pressure is going to be 140 minus 80 is going to be 60. and it signifies the amount of force the heart can generate with each contraction so a pulse pressure less than 85 millimeters of mercury may be seen in patients with shock so for example this might be somebody who has a blood pressure of a hundred and ten over ninety now that pressure difference is only twenty so that can signify patients um who may be in shock all right so blood flow through the capillary buds is regulated by the capillary sphincters and this is uh circular muscle walls that constrict and dilate these sphincters are under a control of the autonomic nervous system which regulates involuntary functions such as swelling and digestion and these sphincters are also in other areas such as and they respond to stimuli such as heat cold or the need for oxygen or the need for waste removals and the regulation of blood flow is determined by cellular needs so perfusion also requires adequate oxygen from the lungs nutrient in the form of glucose and waste removal which is primarily through the lungs okay so mechanisms are in place to help support the respiratory and cardiovascular system when the need for perfusion of vital organs is increased and this includes the autonomic nervous system and hormones okay so the sympathetic side of the autonomic nervous system which is responsible for the fight or flight will assume more control of the body's function during a state of shock okay so remember we have the sympathetic and the parasympathetic and the sympathetic takes over um when the body is in the state of shock okay so this response by the autonomic nervous system causes release of hormones such as epi and norepi these hormones increase the heart rate and the strength of the cardiac contractions as well as vasoconstricting non-essential areas okay so primarily in the skin and gastrointestinal tract and this response causes all of the signs and symptoms of shock in a patient so let's talk about causes of shock now there's three of them and remember that perfusion triangle we could go all the way back to that because if there is a problem it's one of those basic three things that are failing so either you have a pump failure you have a poor blood vessel function or you have low fluid volume okay so we when we look at it we look at this illustration on the slide and it shows those three basic causes of shock okay super simple it's either a pump problem a fluid problem or the vessels the tube problem and this table on the slide shows those signs of shock resulting from those three basic problems and so that's what we're going to talk about today so you have cardiogenic and obstructive and obstructive it it's further broken down into tension cardiac tamponade and pulmonary emboli and then in poor vessel function you have distributive shock inside of distributive shock you have septic neurogenic anaphylactic and the psychogenic shock and then low fluid of course you have hypovolemic shock inside of hypovolemic it's the hemorrhagic and the non-hemorrhagic is how it's going to be broken down and we're just going to go through those different types of shock next okay so cardiogenic shock remember cardiogenic shock is the first one and it is a pump failure problem cardiogenic and obstructive are a pump failure problem okay and it's caused by an adequate function of the heart or pump failure and a major effect is the backup of blood into those pulmonary vessels and the resulting buildup of pulmonary fluid is called pulmonary edema and so a lot of times cardiogenic shock is caused simply by some type of heart failure right so we have some type of heart attack perhaps the muscle of the heart is failing okay and it develops when a heart cannot maintain that output to meet the demands of the body so cardiac output of course is the volume of blood that the heart can pump per minute and it's dependent on a bunch of factors so the heart must be it must have adequate strength remember so if the heart is uh weakened from different heart attacks um then it does not uh have that ability to contract and that's called the myocardial contractibility the heart must also receive adequate blood to pump and that's the preload it has to have the blood ready to go into those chambers and then the resistance to the flow in the peripheral circulation must be appropriate okay so the afterload must be okay all right so we're still talking about different types of pump failure problems remember i'll go back to the slide one more time and the next pump failure problem we're going to have is the obstructive shock and this means that the pump is not able to work because of some type of obstruction okay so some type of obstruction is going on and this is called by a mechanical obstruction meaning the heart is not able to beat but it's still the heart problem okay so it's not a muscle it's not too weak it's actually literally obstruction obstructed and so this is um it prevents adequate flow of blood from the heart chambers okay so there's three of them and it's cardiac tamponade tension pneumo and pulmonary emboli and we're going to talk about that more okay so um cardiac tamponade so this is a collection of fluid between the pericardial sac and the myocardium and that is called a pericardial infusion so you have that sack that that surrounds the heart and there's fluid in it and so the literally the heart cannot um cannot beat cannot contract if the fusion becomes large enough it can prevent the ventricles from filling and that's a position that's a condition called cardiac tamponade it's caught it can be caused by a blunt or penetrating trauma that causes the hemorrhage around that heart inside the sac the signs and symptoms of cardiac tamponade are referred to beck's triad so when you think about cardiac tamponade you really need to think about bex triad so there's three things hence the triad the first one is the presence of the jugular vein distension and obviously the blood can't get can't return from that superior vena cava so it's backing up into those jugular veins you're also going to hear muffled heart tones because there's fluid in that sac so it's going to make a muffled and then of course the narrowing pulse pressures where the systolic and dystolic begin to um to merge okay so that's called narrowing pulse pressures so first thing of the obstructive shock is we have cardiac tampon the next one is the pneumo so this is caused by air that has damaged the lung tissue and the air normally is held within the lung escapes into the chest cavity and so the lung collapses if the pneumo is left untreated air will accumulate in that chest chest cavity and apply pressure to the organs and this is including the heart and the vessels and so when that air has um put enough pressure on the heart the heart is going to be not going to be able to be just like in the cardiac tamponade and um and so you have that obstructive shock from the tension okay then there's the third one third obstructive type shock and that is the pulmonary emboli so this is basically just a blood clot when you see the embolism you think clots and it occurs in the pulmonary circulation that blocks the flow of blood through the pulmonary vessels okay so when a massive pulmonary emboli occurs it can prevent blood from being pumped from the right side of the heart into the left resulting in a complete backup of blood in the right ventricle and leading to catastrophic obstructive shock and complete pump failure all right so that was the um cardiogenic shock and now we're going to move into distributive shock okay so here we are distributive shock this is because of the poor vessel function so now we're into the the vessels this is actually the tubes of the cardiovascular system is what we're talking about okay distributive shock this results in when there's some type of widespread dilation of those small arterioles small venules or maybe both and the circulation of blood pulls into the expanded vascular beds and the tissue perfusion decreases okay so distributive shock remember there's different types of distributive shock and we'll go back up to the slide there's septic neuro anaphylactic and psychogenic okay so we're going to talk about the four of those next septic shock and um it occurs as a result of a severe infection usually bacteria in which toxins are generated by bacteria or by infected body tissues okay so what you have is widespread dilation of those vessels combined with plasma loss through the injured vessel walls and because of the the decrease in that fluid you're gonna it result in shock okay and that's the same same thing that the last slide just shows all right so neurogenic shock is the next type of distributive shock remember there's four of them and this is usually a result of some type of spinal cord injury basically the muscles of the in the walls of the blood vessels are cut off from that nervous system and nerve impulses that cause them to contract and so what's going to happen is all the vessels below that level of the spinal cord injury are going to dilate widely increasing the size and capacity of the vascular system and of course then blood is going to pull you're going to lose lose the the good container right so you're going to lose that next we have anaphylactic shock this is that third type of shock it occurs when a person reacts violently to a substance to which he or she has been sensitized so sensitization means becoming sensitive to that substance that they did not initially cause a reaction and then each each time they are exposed to that sensitization it tends to produce produce a more severe reaction okay so this table on the slide lists the signs and symptoms of the anaphylactic shock okay and then the fourth and final type of distributive shock of the vessel problem is going to be the psychogenic shock and this is when a patient is in um when they're in psychogenic shock they've had some type of sudden reaction of the nervous system that produces a temporarily and a generalized vascular dilation and usually they'll have a sinkable episode okay usually life-threatening causes include some type of irregular heartbeat or some type of brain injurism but you also have non-lethal left life-threatening events which include maybe hearing some bad noise or bad new news or experiencing fear or unpleasant sights such as some type of blood okay now we move into the fluid issue right so now we have the fluid problems and um so that the the one that we're going to talk about is hypovolemic shock and of course there's two there's hemorrhagic and non-hemorrhagic and we'll get into those next but um the result is obviously an inadequate amount of fluid or volume in that circulatory system so this is the blood part um the third third thing right so you have the the pump problem vessel problem and now the blood problem okay so this occurs with usually some thermal burns you could have thermal burns and we'll talk about the different types okay all right so you have stages of shock so the different stages of shock okay so you have the compensated where the body is able to compensate then you have the decompensate and then once shock has progressed too far it becomes irreversible so no way to assess when the patient has reached this point just you that's why we need to recognize and treat shock very early um well before the patient transforms into this decompensated state okay the table on the slide lists the signs and symptoms of compensated versus decompensated shock so very good to get to know those different signs okay all right so blood pressure will be the last measurable factor to change with shock and so when the blood pressure is evident um shock has well developed okay when a drop in blood pressure when you see that so this is particularly true in infants and children who can maintain their pressure until they have blood loss that is more than half their blood volume okay so by the time pressure drops in infants and children who are in shock they're pretty close to death okay so expect shock in many emergency medical situations also expect shock if a patient has one of the following conditions so say that they have multiple fractures or some type of abdominal or chest injury spinal injury severe infection a heart attack or anaphylaxis okay all right so now we're just gonna go through um how you treat the patient so we're gonna start off with the scene size up of course and make sure that the scene's safe and then try and determine that mechanism of injury or nature of illness then do that primary assessment and when you suspect some type of shock you should probably do a rapid exam all right so we're going to do a real rapid exam and we want to determine the loc level of consciousness and identify and treat any of those life-threatening concerns first okay so determine the priority of the patient transport it's if there's a massive hemorrhage you may be required to put on that tourniquet remember direct pressure dressings when tourniquets are not feasible or available so before the airway is opened you should stop that bleeding so if the patient has life-threatening external hemorrhage it should be addressed first like i said even before the airway then the abcs must be assessed and treated and and treatments for shock provided okay so provide high flow to to assist with profusion of damaged tissues if the patient has signs of hypoperfusion you need to treat aggressively and provide rapid transport so request an advanced life support as necessary to assist with more aggressive shock management all right and then of course our general depression we're going to determine the need for spinal immobilization and we're going to do airway and breathing so we need to assess the airway to ensure that it's patent and it quickly assess the breathing and then of course there's a circulation and we're going to assess the patient's circulatory status to see if there's any clues regarding the presence of shock okay we're going to check for the distal pulse if there is none check for the central remember the carotid and determine if the pulse is fast slow weak strong or altogether absent a rapid pulse suggests compensated shock so in shock or compensate shock the skin may be cool clammy or ashen and if the patient has no pulse and is not breathing of course we're going to begin cpr and assess for and identify any life threats bleeding and trauma patients and we're going to treat it immediately of course so quickly assess skin color temp condition and check for cap refill okay our determination of our transport so we're going to determine whether the the patient should be treated as high priority whether advanced life support is needed and which facility to transport to all right so after that we're going to do history taking and after life threats have been managed determine the chief complaint of course and then obtain a sample history we're going to do the secondary assessments and this includes a physical exam so we're going to repeat the primary assessment followed by a focused assessment and the secondary 4 trauma is going to be a focus assessment okay and so we're going to perform it of the entire body and we're going to um to look uh very closely if if our trauma patient has any significant illness or injury okay and we're going to do this if the patient gives you a poor general impression or you find problems in the primary assessment or if your patient has a medical problem but it's not responsive or if your patient has problems that were not noted in the primary assessment these assessments should be performed quickly but thoroughly to ensure that you did not miss any significant or life-threatening problems or delay needed care so whether your examination is is of the entire body system or specific area if the life-threatening problem is found so treat it immediately okay and then you're going to do the vital signs and then we're going to reassess a patient so we're going to reassess the patient's vital signs interventions chief complaint abc's and mental status then we're going to determine what interventions are needed for the patient based on the assessment findings okay so we're going to focus on supporting the cardiovascular system we're going to treat for shock early and aggressively by providing oxygen and keeping the patient warm that's how we treat for shock remember all right so emergency care for shock we're going to begin immediate treatment for shock as soon as we recognize the condition exists we're going to follow local precautions control all external bleeding obvious external bleeding make sure the patient has an open airway and then inline maintain inline stabilization if necessary we're going to comfort calm and reassure the patient while maintaining the patient in the supine position we're never going to allow the patients to eat or drink prior to being evaluated by a physician so no food or drink and of course if c-spine is indicated we're going to put the patient on the backboard okay and we need to remember that adequate ventilation may be a major factor in the development of shock so we have to provide oxygen assistance sometimes and use airway adjuncts when needed we have to prevent body loss by placing blankets under and in over the patient and we need to transport the patient and treat additional injuries and route and then consider rendezvous advanced life support if possible and consider a helicopter aero medical if needed accurately record the patient's vital signs appropriately every five minutes throughout treatment and transport okay so specifically cardiogenic shock how are we going to treat these patients and this is a result of that it could be a result of a heart attack and because it cannot generate the necessary power to pump and so usually patients with cardiogenic shock they do not have an injury but they may have chest pain and patients with cardiogenic shock should not receive nitro um if they are hypotension tensive remember okay so signs and symptoms of that cardiogenic shock are going to be a lot of times low blood pressure or a weak irregular pulse cyanosis around the lips or under the fingernails anxiety and nausea so we want to place these guys in the position that eases the breathing and give them a high flow o2 and then initiate prompt transport and advanced life support if they're not already on scene we should consider rendezvousing with them in route then how are we going to treat obstructive shock so for cardiac tamponade we're going to increa increasing cardiac output should be the priority so we want to try and give them high flow oxygen and they're going to need surgery that's the only definitive treatment okay and then for tension pneumo of course that the next obstructive shock we're going to give them high flow 2 and a non-rebreather to try and prevent that hypoxia chest decompression is required to relieve that pressure however that's an advanced life support skill and so you should try and get als there assistance early in the call if available because um they're going to need to get that like i said the chesty compression but do not delay transport to wait for them okay okay so treating septic shock um this requires hospital management including antibiotics so we want to use standard precautions because of um any type of risk of infections and uh transport promptly so give them high flow of two and possibly support the ventilations with the bvm preserve the body heat and notify a specialized sepsis team if available to meet the patient in the emergency department room so emergency treatment we're gonna obtaining and maintaining of course proper airway c-spine may be and assisting inadequate breathing conserving body heat and ensure the most effective circulation possible okay so we're going to transport the patient promptly to the facility capable of managing oh neurogenic shock now we're on neurogenic shock okay and then now we're moving into anaphylactic shock so the most effective treatment for a severe acute allergic reaction is to administer epi um by the way of an i am intramuscular so that's for anaphylaxis so a patient with anaphylaxis requires immediate transport high flow o2 possibly assistance with the bvm and try to find out what caused the reaction and how it was received okay so keep in mind that a mild reaction may worsen suddenly um so just because of the potential for airway compromise you might want to request an advanced life support backup as soon as possible and then the psychogenic shock so in any uncomplicated case of fainting once the patient collapses and becomes supine of course the circulation to the brain is restored and with that a normal state of functioning so psychogenic shock could worsen other types of shock but if it appears that the patient fell as a result of the psychogenic shock just checked for injuries especially in older patients so if the patient reserve reports not being able to walk after the fall though it is related to psychogenic shock you should suspect another problem maybe like a head injury or a hip injury so transport promptly and all patients with loss of consciousness should be transported to the emergency department for an evaluation even if they appear normal once we arrive on scene all right and then the last type of shock treating hypovolemic shock and so obvious you're going to stop that external bleeding that's the first thing you want to do and the best initial method of course is direct pressure and then if direct pressure does not work you're going to use a tourniquet okay so handle the patient gently and keep them warm and recognize internal bleeding and provide aggressive general support okay so secure and maintain an airway and provide respiratory support if needed including oxygen and of course ventilations so transport the patient as rapidly as you can to the emergency department treating shock in older patients so older patients generally have more serious complications than younger and so many older patients take numerous medications and this could either mask or mimic signs of shock so treating a patient pediatric or geriatric in shock is no difference of course no different than treating any other shock patient we need to provide inline spinal stabilization and um if it's not indicated maintain the patients in a position of comfort okay so control life-threatening hemorrhages immediately with direct pressure then suction as necessary and provide high flow oxygen as via non-rebreather mask we want to maintain body temp as with all of these patients and then rapid transport with all of the patients once again all right so that concludes the information portion of this slide or lecture and we're going to go ahead and start talking about the review questions okay see how much we've learned so the term shock is most accurately defined as what do we know what do we know it is hypoperfusion so when you hear shock think hypoperfusion and that's that state of collapse of the cardiovascular system okay anaphylactic shock is typically associated with all right i think it's probably year to carry a localized welts would be a mild severe headache they could but not usually yep you're dicarion that's hives and it's a allergic reactions all different types okay caused by those histamines signs of compensated shock include all of the following except okay i think it's the feeling of impending doom nope compensated shock is the body um basically they're able to maintain perfusion um so the only one would be weak or absent peripheral pulses and that is probably decompensated shock okay when treating a trauma patient who's in shock lowest priority should be given to so trauma patient i think it's splinting hot fractures right because we're going to do all the other thing yeah splinting fractures is a secondary uh secondary issue right potential causes of cardiogenic shock include all but the following okay so inadequate heart function yes disease of the muscle tissue yes impaired electrical system yes usually the bacteria infection is going to be a distributive right so that's a distributive issue okay 60 year old woman who presents of 80 over 60 okay so that's only a 20 point different a pulse rate of 110 and model skin and the temp of 103. okay so the temperature is the key thing here and when you see that temp you're going to think septic shock she's got some type of infection and she's in shock because we know because of the blood pressure okay so septic shock all right a patient with neurogenic shock would least likely present with to kidney so breathing fast yes hypotension yes tachycardia i'm gonna say no i'm gonna say no because usually the signal will not get to the heart perfect so it's um remember that sympathetic nervous system is compromised it's not going to be able to um to know that it needs that b or norepi right and so tachycardia is the correct answer with neurogenic shock all right 20 year old is kicked in the belly during an assault his abdomen is rigid and tender heart rate 120 and respirations of 30. how should we treat this patient okay so the what i'm going to say is let's see where in the belly doesn't say i'm thinking a liver or spleen and it's because they're bleeding so both it could be both there you go and so we could just go with the hypovolemic so the liver laceration and the ruptured spleen could both cause hypovolemic shock so that's the answer 33 year old woman who has a rash facial swelling and hypotension 10 minutes after being stung there you go she is in anaphylactic shock we've given her high to flow too she needs epi epi's going to do the exact opposite of what um of what that just did so it's epi is going to reverse all of those bad things okay although the following of potential causes of impaired tissue perfusion accept so right away increased number of red blood cells is not going to do it we know it's a pump volume or vessel problem so a is the correct answer okay so this concludes chapter 13 shock lecture so if you like this um this lecture go ahead and subscribe to the channel we're going to put out all of the chapters in this book within the next couple weeks alright have a great day