We're talking about shock. Shock by definition is one of the worst states that we can be in. Why is that?
It's because all the cells in our body need blood, need perfusion, need nutrients like oxygen in order to survive. In shock, we have something called hypoperfusion. Simply put, your body is not getting enough oxygen to the cells.
So here it is. Shock is inadequate cellular perfusion. The cells are starving for what they need. Oxygen, blood, nutrients. This process is called hypoperfusion.
Now, the next part, there are three components to adequate, good perfusion in the body. So I'm standing in front of you now. If I'm saying, I have good perfusion right now. There are three main things my body's doing. Number one, my heart as a pump.
What this means. Now, the main function of the heart as a pump is to pump blood around the body. The heart allows all the nutrients, all the oxygen, all the blood to be pumped around the body. That's what the heart's primary job is.
So in order to have adequate, good perfusion. I need my heart to be working properly. If my heart is in heart failure, a heart attack, I'm at risk of going into shock because I can't get nutrients around my body because my pump is failing.
Second piece, the blood vessels themselves. So you may have heard about the blood vessel as the container. Well, it is. The blood vessel is the container for our blood, our circulatory system, right? So what this means, if I am abnormally vasodilated, which is one type of shock that we're going to talk about, right?
If that happens, my blood pressure is going down. And my ability to get blood to where I need it to go is not going to be as strong, right? Right. So the blood vessels themselves as the container, are they constricted?
Are they dilated? That can be part of the issue of are we in shock or not? And the last step is the blood itself. Do we have enough volume in our body? What is the integrity of the blood that we have?
Is it lacking oxygen, for example, right? Are we bleeding out, right? Do we have enough volume in the body?
So the way I like to look at it is how is our ability to get blood around the body? What's going on inside my blood vessels? And how is the blood itself? These three facts will determine... If you are hypo perfused or not.
Now we're just getting started. Come on, let's go. Cardiogenic shock is pump failure. So what are the two main things? We can have a heart attack.
That is called in medicine a myocardial infarction. Myo, that's going to be muscle. Cardio, they cardiac the heart. Infarction means death.
That's a heart attack. That can cause. cardiogenic shock the other thing we think about is diseases right we've had acute injury we talked about that but diseases so the disease like you can have in your history congestive heart failure and have a flare-up of that cause you need to cause 911 right so what this means cardiogenic shock inadequate heart function pump failure can be caused by disease see jeff or acute injury for example now what do we get when we have an acute injury, and we have CHF occur.
What is it we get? We're going to hear rails, aka crackles, bilaterally because the heart is failing as a pump. This is what heart failure looks like.
We get pulmonary edema. What that is? Pulmonary edema is fluid accumulating on the same area, the alveoli, where a gas exchange occurs, where carbon dioxide leaves and oxygen comes in.
So we have poor gas exchange. Well, think about it. we know that our SpO2 is going to be much lower, right?
The other thing we see is, again, this is the big key. We talk about heart blood flow. Remember this, blood backs up.
Blood is backing up into, in this case, the fluid on the alveoli, poor gas exchange, JVD, some other signs you'll see, right? Now, remember this here. When this happens, cardiogenic shock, we're having a decrease in our cardiac.
output. And when we look at cardiac output, we're thinking about how good is our preload, what's going on with our afterload, and also the contractility. What is the strength of the heart?
In this case, we have a failing heart. Obstructive shock means we have a process, an event going on in the body that is causing circulation to be obstructed. That's all it is. There's three main events, three main emergencies that cause obstructive shock, you got to know. The first is cardiac tamponade.
Cardiac tamponade is when we have an accumulation of fluid of injury around the outside of the heart where the heart basically it doesn't have enough room to make its normal contraction. It's being squeezed, being tight. So instead of pumping normally, it has less space and it can't pump effective.
If we fix the cardiac tamponade, the injury, the event, then guess what? Blood flow will go back to normal. Next. the adenomyotorax.
In adenomyotorax, we have one of our lungs that is collapsed, and there's air around due to injury, due to trauma, usually, due to trauma, we have air surrounding our collapsed lung, and this is causing circulation issue in our body. Now, the next one under obstructive is pulmonary embolism, which is a large obstruction to our pulmonary artery tracts. So with these, if we can fix these, then our blood flow will be restored. We don't fix it, shock will continue.
So the main thing with obstructive, remember, it is obstructing blood flow of the normal circulation. There it is. Now, distributive shock is the one with the four Subtypes. So here it is.
Distributive shock has four main subtypes. I'm going to break them down for you. The biggest thing to remember about distributive shock is this is the type of shock with vasodilation.
Abnormal, extensive vasodilation. This is why you may have heard about a patient who is septic and they're going to give them epinephrine to help raise their blood pressure because the body cannot compensate like in other shocks like a hypovolemic when it has a distributive shock problem going on this is the big key the blood vessels just picture the blood vessels going and then what happens blood pressure down right so let's get into more some details here four subtypes you Septic shock, neurogenic, anaphylactic, psychogenic shock. So let me explain these. First, septic shock has to do with a widespread infection in your body.
Some common ones you'll see, pneumonia, UTI, very common pathways for sepsis to occur, and when it gets really bad, we end up in... Septic shock with that abnormal evasive dilation and we have a widespread infection throughout our entire bloodstream. That's sepsis. Now the next piece we're going to talk about another type of distributive shock, anaphylactic. Anaphylactic shock is a severe allergic reaction.
If I have a simple allergic reaction, let's just say one body system gets affected. So let's just say I have hives and nothing else is bothering me. That's a simple allergic reaction. Let's say I have wheezing and I'm vomiting and I have hives.
Why talk to you about my skin, my lungs, and my GI system? That's three body systems. So the rule, two or more body systems affected by an allergen, that's anaphylaxis. When it gets bad enough to be called shock, anaphylaxis shock, right?
When we have that hypoperfusion. Which obviously, we all understand, we have a low blood pressure, obviously, with shock. Now, psychogenic, what is that?
So, psychogenic shock, these words need to be in your head. When I say psychogenic shock, I'm talking about someone who's fainted, who's passed out, who had a syncope. So what this means, usually, not always though, if we have someone who has passed out and they have a syncope, Right?
And they've fainted. We want to evaluate them for everything. Right?
Of course. Because there's so many things they can cause you to pass out. Yes. But in this particular case, psychogenic shock, it could be someone receiving bad news.
It could be someone, when they see a needle, they pass out. It's basically a flash of vasodilation and they pass out. That's psychogenic. And that's why I call psychogenic event-related.
Because usually it's... bad news, a bad event in someone's life, causing them to pass something, that flash of vasodilation. That's psychogenic. Now, neurogenic is trauma.
Neurogenic is trauma, meaning I have severe trauma to my spinal cord. I have a spinal cord injury. That's neurogenic. So that is how we define all distributive shock.
Now with hypovolemic shock, this is your classic, I'm bleeding out, hypovolemic shock. Right. Now, don't forget these sneaky ones. What if I have a GI bleed?
What if I have a trauma and I have an internal bleed? What if I am severely dehydrated? That's all under the hypovolemia pathway.
Now, here we go. Medical terminology, hypo, it's going to be low, right? Volemia, I have low volume. Hypovolemic shock, low volume shock, means our circulating blood, where is it?
More low. That's all it is. That breaks down. As long as you remember these pathways, don't always remember about, could this be an internal bleed?
Could this be dehydration? What's the history of the event? As long as you remember those, you'll be good.
Now to paint a picture for you, there's... Three main stages of shock, but we can really only see two of them. Compensated shock, then leads to decompensated shock.
Then there's something called irreversible shock. Let me explain. So our body first enters shock.
There's a compensation stage where the body tries to compensate for the bad event that's going on to the body. So what's going to happen? Our respirations increase.
We get agitated. We get anxious. We may be feeling... Doom and gloom, right? That's the business we're going through.
Restlessness, right? Now what else? Heart rate up, respirations up, right?
What's the big key here? Alter mental status. This is compensated shock.
So at this point our blood pressure hasn't completely failed us yet. We're not hypotensive yet. We're headed that way very soon. In decompensated shock, all this stuff to try to keep our blood volume together, keep the heart pumping, Wait, maintain our volume?
It fails. Decompensated shock, the big hallmark sign, is the blood pressure being hypotensive. At this stage, instead of being altered, we're starting slipping in unresponsiveness, right?
We're on that, right on the edge here in decompensated. Now, irreversible shock, there's no way to know when someone has crossed that line. One thing that I will say is, you may have a feeling this patient is going to be near arrest. or in a coma-like state, that would be irreversible shock, right? So these are the three stages of shock you're going to hear about.
I just want to give you a quick overview on that there. Now, the final point I want to make about treatment with shock, the treatment of shock is going to determine what kind of shock that you have. So for example, if we're in cardiogenic shock and someone's having a heart attack, we fix the shock by fixing the heart attack and going through that pathway.
If we're in anaphylaxis, for example, we have to do something to fix their anaphylaxis, right? So, for example, if they have anaphylaxis, we're going to need to do the EpiPen, right? We're going to give aspirin, so we're not going to have a heart attack. You see what I'm saying?
So the big thing with shock to remember is figuring out what type of shock do we think that we're in, and then try to pinpoint, well, why are they in the shock, and then using that EMS treatment plan that we have to try to fix and combat that problem. And then the shock... well then, if they're in this state of compensated or decompensated, hopefully we can get them out of it. And the biggest thing with shock is early recognition, so they don't enter here.
And there it is. Now, a lot of you asked in the comments about how to prepare for school, how to get through school, and how to pass NREMT. The first link in the description is a study tool that I give to all my students to accomplish all of that.
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