hi everybody it's john from florida again uh chapter 13 shock uh is our next topic so again the national education standard competencies we're going to be talking about the pathophysiology the management of shock respiratory failure or rest cardiac arrest and post resuscitation management stuff so the pathophysiology we're going to be talking about it with shock relates to perfusion and especially to our patient assessment and patient management skills shock another name for shock is hypoperfusion uh the definition that we've always heard about is it's an inadequate cellular perfusion basically any compromising perfusion that can lead to cellular death or injury and in early stages the body tries to maintain homeostasis by different ways and it's really amazing how our body tries to to combat shock diffusion is a passive process in which molecules molecules move from an area to uh with an area with higher concentration to molecules uh of a lower concentration what we're really talking about here is oxygen and carbon dioxide going across the walls of the alveoli so that's where we get the oxygen dropped off into the blood and the waste products picked up and removed so in the case of shock the transportation of carbon dioxide out of the tissues is impaired so this results in this waste product being built up in our body we we can't get rid of that so it's a state of collapse in failure of our cardiovascular systems that lead to inadequate circulation here's the here's the key part early recognition of shock saves lives not the late interventions but the early recognition saves lives and that requires immediate recognition and rapid treatment this is where you as an emt come into play because the faster we can recognize that this person is in shock the better it is for them so i've always said this that there's three parts to the cardiovascular system there's the pump the pipes in the in the fluid the heart the vessels and the blood now if you have a problem with any one of these three parts it's going to lead to shock it's called the perfusion triangle and again the heart the pump which is the pump the blood which is the the fluid or the the vessels or containers which is the pipes again one or more of those parts not working is going to lead to shock blood pressure is the pressure of blood within the vessels at any moment in time so the systolic is your peak arterial pressure in your diastolic that's the pressure still in the arteries when the heart's at rest in between beets blood pressure is the difference between the systolic and diastolic pressures so it signifies the amount of force the heart generates with each contraction and a pulse pressure less than 20 may be seen in sorry pulse pressure less than 25 millimeters of mercury may be seen in patients with shock blood flow through the capillary beds is regulated by capillary sphincters under the control of the autonomic nervous system and the regulation of blood flow is determined by cellular needs hang on we're going to get to all this in a second perfusion also requires adequate oxygen exchange in the lungs adequate nutrients in the form of glucose or sugar in the blood and we have to be able to remove the waste product through our lungs when we exhale so these mechanisms are in place to help support the respiratory cardiovascular system in need for profusion of our vital organs so this increases our autonomic nervous system and our hormones and the hormones are triggered when the body senses pressure falling so these hormones then increase your heart rate increase your cardiac contractions and increase your peripheral vasoconstriction making the pipes smaller so this response causes all those signs and symptoms of shock so there's three different types of shock again the pump the pipes or the or the fluid the heart the vessels or the uh blood if you have a pump failure that can be caused by heart attack uh trauma to the heart uh maybe some obstructive causes we're gonna talk about fluid could be a problem where the person is bleeding out or you have a an elderly or young person especially who gets affected by this but an elderly or a young person who's had a few days of vomiting and diarrhea and they haven't had any intake of fluids or you might have a vessel problem such as infection an overdose spinal cord injury anaphylaxis leads to those pipe problems so again it's either a pump a pipe or a fluid problem here's the different causes of shock with a pump the obstructive shock might be a tension pneumothorax a cardiac tamponade a pulmonary embolism we'll get into these in a second poor vessel function like septic shock neurogenic shock anaphylactic shock even something like psychogenic shock and then low blood volume or low fluid volume and that might be hemorrhagic shock so you're bleeding out or it's going to be non-hemorrhagic shock so with cardiogenic shock it's an inadequate function of the heart the major effect is the back up of blood into the pulmonary vessels and it results uh the the buildup of pulmonary fluid is called pulmonary edema cardiogenic shocks it starts when the heart can't pump efficiently and there's not as much output so cardiac output depends on the contractility of the heart muscle the amount of blood to pump which is the preload and the resistance in the flow which is the after flo after load sorry so again cardiogenic shock is not good the heart is not working properly so that it it kind of has this backup obstructive shock the most common causes of obstructed shock are cardiac tamponade tension pneumothorax and a pulmonary embolism this is putting pressure on the heart so that it keeps the heart from filling properly cardiac tamponade that's fluid between the pericardial sac that's the sac that surrounds the heart and the myocardium and that becomes large enough to prevent the ventricles from filling with blood a lot of causes are typically going to be blunt or penetrating trauma and the signs and symptoms are what we call bex triad attention pneumothorax is caused by damage to lung tissue air within the lung escapes into the chest cavity the lung collapses the air puts pressure on the organs which includes your heart and great vessels remember the great vessels located within the center of your chest pulmonary embolism that's a blood clot that blocks the flow of blood through the pulmonary vessels so if massive it can result in complete backup of blood into the right ventricle again the right ventricle is the one that pumps the blood to the lungs and it can lead to catastrophic obstructive shock and complete pump failure and ultimately death so a pulmonary embolism or a pe uh we it's really hard to recover from that so distributive shock now we're talking distributed shock now we're talking about a pipe problem uh again widespread dilation of our arterials and venules or both and and basically what is happening is the pipes are opening up very big so the circulating blood pools in the expanded vascular beds and there's tissue perfusion decreases some of the reasons like septic shock that's an infection in which toxins are generated by bacteria these toxins damage the vessel walls walls causing increased cellular permeability basically these vessel walls leak and they're not able to contract well septic shock widespread dilation of vessels in combination with plasma loss through the vessel walls and results in shock so again plasma is that that transportation system within your vessels that moves the red and white blood cells and and that kind of stuff neurogenic shock this is typically because of a spinal cord injury and the nerve impulses to the blood vessels below that level of injury are blocked and all vessels cut off from nerve impulses will dilate causing the blood to pool so really with this distributive shock you're going to see above and below the injury site your body responding differently anaphylactic shock we've heard about this basically when they react violently to a substance and then sensation sensation becomes sensitive to the substance that did not initially cause a reaction and the subsequent exposure tends to produce a more severe reaction with all that being said uh sometimes we develop allergies and sometimes we kind of grow out of these allergies so you might be the first person to recognize that this person is having an allergic reaction to peanuts or a bee sting so the signs and symptoms of anaphylactic shock itchy burning redness on the chest uticaria which is hives edema or swelling of the face tongue and lips they're going to be pale they might have cyanosis around their lips and again it's because of this reaction to this this toxic substance for their body is really what it is the circulatory system we have a drop in blood pressure a weak barely palpable pulse some things with the respiratory system you might have sneezing or itchy um in the nasal passages stridor that's the upper airway problem that you hear the the strider when they inhale they might have a tightness in their chest you might hear wheezing too so you might have stridor and wheezing secretions in the fluid and the bronchial passages which causes this coughing uh difficult breathing obviously cessation of breathing they stop breathing some other things might be abdominal cramping nausea vomiting they've altered mental status dizziness fainting coma there's all kinds of reactions to distributive shock there's even something called psychogenic shock psychogenic shock is caused by a sudden reaction of the nervous system which results uh in fainting basically or syncope psychogenic shock could be a life-threatening causes by irregular heartbeat or maybe even a brain aneurysm oh my gosh non-life-threatening events might be somebody getting bad news or experiencing fear or unpleasant sights such as blood you see it on tic tac toe tick tock sorry where people are launched into the air in those bungee cages and they are screaming and they're having fun the next thing you know they're they're out conscious and then they come to and they're screaming having fun and then they go out again that's what we're really talking about is this psychogenic shock hypovolemic shock now this is the one that we really really are are probably concerned with as emts because we talk a lot about trauma so hypovolemic shock is the inadequate amount of fluid or volume in your circulatory system and then hemorrhagic causes and non-hemorrhagic causes are the ones that we have to look out for and then sometimes it occurs with severe thermal burns even because we are losing fluids when we lose we have bad burns there are stages in the progression of shock compensated shock is an early stage when the body can still compensate for blood loss that's when those hormones are working to increase the contractility of the heart increase the heart speed decrease the the size of the pipes so the hormones are working to help maintain homeostasis in compensated shock when you get to decompensated shock that is a late stage and that's when you're going to see the blood pressure fall so many students are are are caught up with this blood pressure and and i'm not just saying students so many emts in general are caught up with a blood pressure being that that determining factor whether they're in shock or not truly if that blood pressure drops they've been in shock for a while they've just progressed now to decompensated shock so as emts sometimes by the time we get there with our ambulance the person has transitioned into decompensated shock but if we can recognize those early signs like the increased heart rate increased respiratory rate those things are clues that can lead us to determine if the person's in shock or not there's no way to assess when the effects are irreversible and it must we must recognize and treat shock early compensated shock here's some signs and symptoms that you have to be aware of agitation anxiety restlessness sometimes they have this feeling of impending doom sometimes i'll tell you i feel like i'm going to die pale cool clammy skin um shallow respirations nausea and vomiting this capillary refill remember we talked about capillaries a little bit earlier well when you push on the fingernail and let go we're counting the number of seconds it goes from pink to white do it on your finger right now if you push on your fingernail let go it goes from white to pink in less than two seconds that means you're good you have good capillary refill if you do that and the person you might have four seconds you have bad capillary refill and you might be in compensated shock three or four seconds is not good they might be really thirsty you might have a narrowing pulse pressure remember we talked about pulse pressures so decompensated shock now we have that falling blood pressure the systolic of 90 or lower so now we know that we're in decompensated shot but we don't know that for sure unless we know what their blood pressure was before the problem with just getting a single blood pressure is it doesn't really tell us anything but if we have a second blood pressure now it tells us if they're getting better getting worse or staying the same you probably have people that you know in life that have a low blood pressure already well that doesn't mean that they live in a constant state of decompensated shock it just means that they have a low blood pressure but when you take that blood pressure and you see that it's less than 90 is it because that's normal for them or is that because they're in decompensated shock so again one blood pressure by itself doesn't mean anything that's why when we assess our patient assessment skills if you look at your patient assessment skill sheets blood pressure and vitals are near the bottom they're not at the top at the top we're checking abc's and within those abc's we can determine if that person is in the early stages of shock and we can treat it before we even get a blood pressure if you're decompensated you have a declining mental status you have labored or maybe even irregular breathing uh action modeled modeled is kind of like a pale skin and you can kind of see all the blood vessels on the top and it looks kind of purplish reddish it looks really bad cyanotic skin thready or absent peripheral pulses in other words you check for a radial pulse and thready means rapid and weak or maybe you don't even feel one at all holy smokes if you don't feel a radial pulse go up to check the carotid or a central pulse they talk about this dull eyes or dilated pupils and and that it's hard to describe to you what a dull eye looks like but you you will see it if you see it uh you'll notice it uh and poor urinary output which is a big hospital finding but not for ems blood pressure may be the last factor to change in shock when that blood pressure drops shock is well developed again in ems we need to be able to recognize the signs and symptoms of early shock so we can treat it before it goes into the decompensated shock in infants and children it is so true we always talk about infants and children compensating until they don't compensate anymore i know that sounds kind of weird compensate till they don't compensate it's kind of like they're they're going along walking along this cliff and all of a sudden they fall off the cliff that's what happens when they get into decompensated shock they fall off that cliff and they they really drop it rapidly as adults we kind of trail off slowly kids and infants they drop off the quick off the cliff quickly and they're really quickly into that decompensated shock and really into trouble so when that blood pressure drops they are really close to death we really really have to make sure that we recognize those early signs and symptoms of shock also expect shocked if the patient has one of the following conditions multiple fractures abdominal or chest trauma a spinal injury severe infections you know it's not always trauma it could be a medical condition causing shock major heart attack anaphylaxis so if you're seeing size up be alert to the potential hazards yep we know that use gloves and eye protection we know that and then we talk about this mechanism of injury or nature of illness and i think a lot of people are confused with that part and and that's really that what you're dispatched for or what why you're called to this residence in your primary assessment you do a rapid exam you determine the level of consciousness that's going to be an indication or could be an indication to show early shock are they restless and are they unconscious are they altered not sure their surroundings identify and manage life-threatening concerns this is where we put oxygen on our patient we don't wait until we finish our assessment to give them oxygen if we recognize that they have pale cool clammy skin they don't look good they're having difficulty breathing put oxygen on now if you recognize signs of shock treat them for shock now load them in the ambulance and get going did you notice that in no point in your primary assessment have we talked about a blood pressure because again the blood pressure is not that important when we're doing our primary assessment provide oxygen for hypoperfusion treat aggressively and provide rapid transport and then we request als as necessary there's only so much we can do as emts there's a and they're really truly as a paramedic there's only so much i can do but between the two of us we can really work to help reverse that that shock or at least stabilize until they get to definitive care at the hospital your primary assessment we form a general impression you walk in you look at them what do you see that that general impression is what you physically see on that person you see that they're sitting in the recliner they're they're pale cool clammy uh they look like their their hand is on their chest and they're having trouble breathing boy we really need to like work quickly with this person we assess the airway how do you assess the airway hi sir my name is john i'm a paramedic can you tell me what's wrong today if he starts speaking to me we know he has a patent airway and he's able to speak if he's unconscious laying on the floor we do a head tilt chin lift that's how we know if he has a patent airway we always assess breathing this is where we not only assess the rate or the quality but we also can listen to lung sounds really quickly to assess what kind of breathing we have going on there again an increased respiratory rate is the body's way of compensating for shock so if they're breathing over 20 times a minute you might be catching them in the early signs of shock and then we assess their circulatory status pulse skin that kind of stuff a rapid pulse suggests compensated shock so in shock or compensated shock the skin's to be cool clammy or ashen that's kind of a grayish color so we need to address for and identify any life-threatening bleeding and treat it at once so if they don't have any bleeding okay there's going to be another reason why this person is showing signs of shock determine if there are priority yep als is needed and which facility to transport to so i come from a very rural area and i would have a choice of going to a little local hospital or a better hospital that might be in the opposite direction but a little bit further away so you really have to make the right choice to which this destination you're going to you know the little hospital that's a good place to go and die or the better hospital where they're going to be able to treat our patients trauma patients with shock or suspicious mechanism of injury generally should go to a trauma center if you live in a bigger area having the availability of a trauma center is an awesome thing we need to determine the chief complaint so when i said hi sir my name is john can you tell me what's wrong today he says my chest hurts that's his chief complaint that's what the person says if they're unconscious guess what unconscious is the chief complaint there's got to be something wrong to make this person unconscious we're going to get our sample history it's important to get a sample history why is it important when we're talking about shock well last thing they had to eat or drink that might be important secondary assessment we followed uh by a focus uh if a life-threatening problem is found treated now we get a complete set of vital signs now we use our monitoring devices like a pulse oximeter uh blood pressure that's the stuff we're talking about end tidal co2 or capnography with your reassessment we assess the the vital signs we always reassess our interventions we assess that chief complaint sir how's your chest pain now oh it feels better so we have reassessed chest pain or his chief complaint we always reassess the abcs and we reassess his mental status it's not a reassessment it's not just the vital signs no we have to reassess everything to see if our patient's getting better or getting worse or staying the same determine what interventions are needed focus on supporting the cardiovascular system the pumps the pipes and the fluid treat for shock early and aggressively by providing oxygen and keeping the patient warm this is the part where i need you to take note that at no time have we said raise their feet six to ten inches that is an old treatment for shock that we no longer do studies have proven that that really doesn't help so what does help though is oxygen and keeping that patient warm why do we keep them warm because they're going to be their bodies kind of shutting down and they're losing the ability to maintain their heat so we need to keep them warm as soon as you recognize shock treat that's the oxygen blanket and obviously we need to transport right away we control any obvious bleeding yet we know that make sure they have an open airway and if necessary we maintain inline stabilization uh and check breathing and a pulse in those unconscious patients as soon as you recognize shock yes we need to calm and comfort and reassure the patient never give them anything to eat or drink because they probably end up vomiting if spinal mobilization is indicated splint on a backboard we always provide oxygen and we monitor their breathing again if they're breathing too fast or too slow we need to treat that as well put blankets under and over why do we put them under because especially if they're on a backboard that's cold plastic and they don't have the ability to to maintain their body heat laying on cold plastic or if you're waiting for an ambulance to show up and they're laying on concrete and you want to insulate them from the concrete below because that concrete is going to suck the body heat right out of them consider the need for als absolutely for those of you who have the availability of als absolutely call als but sometimes you might live in a rural area and you are the definitive care for this person until you get them to the hospital so you can consider als but really the true definitive care is going to be getting them to the hospital i came from a very rural area in wisconsin where i would have to drive past two hospitals before i ever ran into my first paramedic service so again you might be the care and there's als is not available record the patient's vital signs every five minutes throughout treatment and transport if they're unstable it's every five minutes if they're in shock they're unstable you need to document those vital signs every five minutes so when we treat cardiogenic shock well you know they can't generate enough pressure in their pump so they might have chest pain so we don't give uh in cardiogenic shock we don't give nitroglycerin if they're hypotensive remember your textbook talks about not giving nitroglycerin if their systolic blood pressure is less than i think your book says a hundred uh but in most cases we don't give nitroglycerin if their blood pressure is less than 90. patients usually have low blood pressure and cardiogenic shock they have a weak irregular pulse they have cyanosis they're anxious they might be nauseous so again those are some clues to cardiogenic shock put them in a position that eases their breathing sometimes they'll tell you that they can't breathe laying down they have to sit up to breathe okay we'll put them in the position that allows them to breathe you might have to assist with ventilations you might need to bag them you i obviously provide prop transport and again consider meeting als um i i don't want you to think that as an emt you you can't treat a patient but realize als is just another part of our team and and and the team might have uh different ways to treat different things so we're kind of limited as emts how to treat shock but the paramedics have a little bit more tools in their tool bag to help treat shock for a cardiac tamponade again increased cardiac output is the priority we have given oxygen and really truly for cardiac tamponade they need to be seen by a surgeon they need to get that fluid out of that sac that surrounds the heart for attention pneumothorax give them oxygen if they have attention pneumothorax als can get there and they can do a chest decompression or needle decompression of the chest to help with the pressures so call early don't delay on these guys when you treat septic shock um oxygen velatory support might be necessary use blankets hospitals now have what they call sepsis teams or they have like a you know how you say code blue [Music] in a hospital well they have a code sepsis uh so that they're there to be able to treat septic patients neurogenic shock when that's the ones if we have a spinal cord injury we need to backboard and maintain spinal mobilization conserve heat you notice that every single one of these is oxygen and cover with a blanket every single way that a person can go into shock that's the emt treatment anaphylactic shock epi transport the patient pro oxygen mild reaction might get worse consider als a lot of people think also with anaphylactic shock if i give you an epi auto injector you're going to be good and that's it i don't need als well the problem is with that theory is epinephrine only lasts about three to five minutes in the body and this person may go back into anaphylactic shock and if you only have the one epipen now you don't have anything to treat this patient with so again call als call als call als and if als is not needed great they can go back to their station and you can continue your transport but always always always on on any of these shocks call als if it's available and treating psychogenic shock if an uncomplicated case of fainting or once the patient collapses circulation the brain is restored so psychogenic shock can worsen other types of shock and if the patient falls we check for injuries we check for that c-spine precautions if you will if they report being able to walk or after the fall suspect another problem and again transport just because someone passes out and they come to doesn't mean everything's okay we still need to make sure we do a proper patient assessment treating hypovolemic shock obviously we're going to stop any external bleeding that we can we're going to keep them warm ah guess what there it is again recognize internal bleeding and provide aggressive support secure and maintain the airway transport as quickly as possible any trauma that results in hypovolemic shock has got to be treated at the hospital in the surgery center that's what it has to have to happen so if you see somebody who's showing signs of shock but they don't have any source of external bleeding be very suspicious that they have internal bleeding in older patients older patients have more complications in young people illness is not just a part of the aging process you know just because you're old doesn't mean you're going to be sick and then many older patients take medications that mask or mimic signs of shock so many older patients will take medications that lower their blood pressure that kind of stuff is what we're thinking about so again when you're treating the older patient you really need to know what their baseline is compared to where they are now so let's review this the term shock is most accurately defined as decreased supply of oxygen a cardiovascular collapse decrease circulation of blood or decreased function of respiratory system yep it's b it's that inadequate perfusion that we always talk about the body can't meet the needs of itself so anaphylactic shock is typically typically associated with eudicaria bradycardia localized welts or severe headache yep you're to carry it the hives the itchy uh that's the histamines being released signs of compensated shock include all the following except so this is now this person is incompensated restless anxiety pale cool clammy skin feel of impending doom weak or absent peripheral pulse so they're in the early stages of shock what should we recognize good that d that everything else is in compensated shock but when you can't feel that that peripheral pulse that or it's very very weak they're going to be a decompensated shock when treating a trauma patient who is in shock lowest priority should be given to what trauma patient in shock lowest priority spinal protection thermal management splinting fractures notifying the hospital what is the lowest priority in that trauma patient who's in shock good that that splinting fractures should not be done on scene we can do that in the back of the ambulance and if they're critical they may not get that splendid at all so don't delay your transport for that trauma patient in shock to split when treating a trauma patient again that hypothermia is probably one of the worst things that could happen to that person in shock we want to always put a blanket on them always even if it's hot for you we want to put a blanket on them my medical director used to say tongue-in-cheek if you're patient sweating you should be sweating because if they're sweating there's something wrong with the body now we should be sweating worrying about what the problem is the other thing that we should do too when we prevent this hypothermia is we never turn the air conditioner on in the back of the ambulance to for our to make us feel better we should be turning the air conditioning off to make the patient feel better with keeping them warm potential causes of cardiogenic shock include all of the following except inadequate heart function decrease in muscle tissue severe bacterial infection and impaired electrical system so what are the causes of the pump shock now which one is not that yep it's that bacterial infection is not what we're concerned about with the cardiogenic shock you have a 60 year old woman who presents with a blood pressure of 80 over 60. her pulse rate is 110 she has modeled skin remember that model skin we talked about she has a temperature of 103.9 she's most likely experiencing septic shock neurogenic shock profound heart failure or a severe viral infection her blood pressure is low her pulse is fast she has poor perfusion by looking at her skin the only thing that's weird is she has that increased temperature so she's most likely experiencing septic shock with septic shock you're always going to have a temperature i know my medical director will frown on that because he used to say sometimes you can see septic shock with normal temperature but typically that's going to be one of those signs that you're going to see is there having an elevated temperature a patient with neurogenic shock would be least likely to present with tachypnea hypotension tachycardia or an alternation least likely in a neurogenic patient c is correct so again the hormones are going to increase not necessarily in that neurogenic shock hypotension yes fast breathing yes altermentation yes but that neurogenic shock would be least likely to have tachycardia a 20 year old male was kicked numerous times in the abdomen during a fight an assault his abdomen is rigid and tender his heart rate is 120 his respirations are 30. we should treat this patient for a lacerated liver a ruptured spleen respiratory failure or hypovolemic shock hopefully you all said hypovolemic shock now we're not really sure what's probably damaged in there and you know you're not going to be able to treat that lacerated liver you're not going to be able to treat that ruptured spleen even though those could be a problem but we're going to treat for hypovolemic shock because that's the only thing we can treat for we can treat for hypovolemic shock by uh the oxygen by putting a blanket on them you can turn up the heat in the back of the ambulance those are the simple treatments you can get them to a trauma center as quickly as possible that's your treatments [Music] 33 year old woman presents with generalized rash facial swelling hypotension after 10 minutes excuse me about 10 minutes after being stung by a hornet her blood pressure is 70 over 50. her heart rate is 120 in addition to high flow oxygen this patient is most in most immediate need of epinephrine rapid transport and antihistamine or iv fluids most immediate that means the very next thing yes anaphylactic shock still needs epinephrine now let's go back to this you notice that you've already done your patient assessment and you have your vital signs before you give the epinephrine you always always always need to have a vital signs before you give a medication or a drug yes after we do that or we could give the epi in route to the hospital even but oxygen is the other treatment now an antihistamine or iv fluids that's when we call als and they come on board and they help us or they meet us and help us all of the following are potential causes of impaired tissue perfusion except an increased number of red blood cells pump failure low fluid volume or poor vessel function all of them are causes of impaired tissue perfusion except i hope this one really sticks out big and large yeah increased red blood cells now if we have an increase in red blood cells we're going to have good tissue perfusion so all of the others are incorrect i really hope that this kind of helped you understand how shock works and how we can find shock early treat shock early so that we can help our patients the most