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Initial Assessment and Management Shock Shock
Initial Assessment and ManagementShock
Declaracin del capituloEl diagnstico de shock se basa en el reconocimiento clnico de la presencia de una perfusin tisular inadecuada y la oxigenacin; el primer paso en el tratamiento inicial del shock es reconocer su presencia.
Caso clinico28-aos de edad en MVC Paciente era desenfrenada Pulso: 126; BP: 96/70; RR: 28 Confundido y ansioso
ObjetivosDefinir y reconocer los golpes y correlacionar signos clnicos agudos de un paciente con el grado de dficit de volumen. Explicar la importancia de la identificacin temprana y el control de la fuente de la hemorragia. Describir el manejo inicial y permanente del shock hemorrgico. Reconocer las respuestas fisiolgicas a la reanimacin con lquidos y evaluar las complicaciones. Explicar la funcin de reemplazo de sangre. Describir las consideraciones especiales en el diagnstico y el tratamiento de choque.
Definicin de ShockQu es el shock?
El shock es una anormalidad del sistema circulatorio que resulta en la perfusin de rganos inadecuada y la oxigenacin del tejido.Definicin de ShockQu es el shock?
Estado generalizado de hipoperfusinEl suministro de oxgeno insuficiente Las catecolaminas y otras respuestas El metabolismo anaerbico La disfuncin celular La muerte celularDefinicin de Shock
Reconocimiento del ShockEsta el paciente en shock?
La alteracin del nivel de conciencia, la ansiedad Piel fra, sudorosa taquicardia Taquipnea, respiraciones superficiales Hipotensin Disminucin del gasto urinarioReconocimiento del ShockEsta el paciente en shock?
Causas del ShockCul es la cause del shock?
Perdida sanguneaPerdida de FluidosHipovolemicoNo hemorrgicoNeumo- trax a tensinTaponamiento CardiacoCardiogncioNeurognicoSpticovsCausas del ShockCul es la cause del shock?
En la gran mayora de los pacientes de trauma, shock se debe a la prdida de sangre.Causas del ShockCul es la cause del shock?
Evaluacin del ShockMtodos de Localizacin de la hemorragiaExamen fsicoDiagnostico adjuntos en la evaluacin primariaRadiografa de TraxRadiografa PlvicaFAST / DPL
IntervencionesQu puedo hacer con respecto al shock?
Presin directa/ torniqueteReducir el volumen plvicoOperacinAgentes HemostticosEnferulado de fracturasAngio-embolizacinResucitacinHemostticoIntervencionesQu puedo hacer con respecto al shock?
La reanimacin con lquidos El acceso vascular? Tipo? Volumen? BalanceMonitorear la respuesta !Prevenir hipotermia!IntervencionesQu puedo hacer con respecto al shock?
Balance de la ResucitacinLa aceptacin de una presin arterial ms baja de lo normal, Concentrados de hemates, FFP, plaquetas No es un substituto para el control quirrgico definitivo de la hemorragia
El exceso puede ser tan malo como demasiado poco.IntervencionesQu puedo hacer con respecto al shock?
Respuesta del pacienteCul es la respuesta de la paciente?
Identificar la funcin del rgano mejoradaPiel: caliente relleno capilar Renales: aumento de la produccin de orina Los signos vitales SNC: la mejora del nivel de concienciaRespuesta del pacienteCul es la respuesta de la paciente?
En relacin con el volumen o la persistencia de la hemorragiaRespuesta rpida Respuesta transitoria No responderRespuesta del pacienteCul es la respuesta del paciente?
750-1500 mL Perdida del volumen sanguneo (15-30%)Ansioso La presin arterial normal La frecuencia cardaca> 100 / min Disminucin de la presin del pulso La respiracin 20-30 / min La produccin de orina de 20-30 ml / horaHemorragia Clase II
Cristaloides
1500-2000 mL Perdida del volumen sanguneo (30-40%)Confusin, ansiedad Disminucin de la presin arterial La frecuencia cardaca> 120 / min Disminucin de la presin del pulso La respiracin 30-40 / min La produccin de orina de 5-15 ml / hora
Cristaloides, Componentes sanguneos, control definitiva de la hemorragiaHemorragia Clase III
> 2000 mL Perdida del volumen sanguneo (> 40%)Confundido, letrgico Hipotensin La frecuencia cardaca> 140 / min Disminucin de la presin del pulso Respiraciones> 35 / min La produccin de orina insignificante Componentes sanguneos, control definitiva de la hemorragiaHemorragia Clase IV
Edad avanzada Atletas Embarazo Medicamentos MarcapasosConsideraciones especialesComplicaciones del Shock Factores del paciente
HipotermiaCoagulopatia tempranaAcidosisComplicaciones del Shock y Manejo del ShockConsideraciones especiales
La equiparacin de TA con el gasto cardaco Engaosa los niveles de hemoglobina y hematocritoEvaluacin y Manejo del ShockConsideraciones especiales
Caso clinico28-aos de edad en MVC Paciente era desenfrenada Pulso: 126; BP: 96/70; RR: 28 Confundido y ansioso
Questions??
ResumenChoque conduce a la perfusin de rganos inadecuada y oxigenacin de los tejidos; hipovolemia es la causa en la mayora de los pacientes de trauma. Diagnstico y tratamiento de choque deben ocurrir simultneamente. Evaluacin inicial requiere un cuidadoso examen fsico; manejo inicial incluye la hemostasia rpida y reanimacin equilibrada con cristaloides y sangre. Reemplazo de la sangre se reanuda la capacidad de transporte de oxgeno del volumen intravascular.
*3-1Title SlideIntroduce the topic and explain to students that, based on their preparation for the course, a series of questions will be asked throughout the lecture. Their active participation and responses are expected.Emphasize that this lecture summarizes the information provided throughout the course, and that all major components will be covered in depth during individual lectures, skill stations, and demonstrations.Because you will use the slide show to emphasize key points, it is important to be familiar with every slide. Proper sequencing of questions and responses facilitates an interactive presentation. Be sure to carefully manage the time allotted for this lecture. *3-2Chapter Statement
*3-3Case ScenarioEmphasize organ perfusion deficit as indicated by confusion.Changes in the LOC and vital signs indicate shock.Internal bleeding must be suspected.*3-4Objectives 1-3Review the objectives as provided on the slide.Emphasize the clinical and other important aspects of the approach to the injured patient who is in shock.These objectives relate to the lecture/interactive discussion. There may be additional objectives related to this topic that will be covered in the skill stations and the initial assessments. Please refer to the Student Manual for the complete list of objectives related to this topic.
*3-5Definition of Shock: What is shock?*3-6 Definition of Shock: What is shock? *3-7Definition of shock Encourage active student discussion to arrive at the required definition. Query the students about the effects of hypoperfusion on cellular function and microcellular alterations.*3-8Recognition of Shock: Is the patient in shock?*3-9Recognition of Shock: Is the patient in shock?Clarify that initially, recognition of the shock state is related to the patients signs and symptoms. You may need to remind the students of the definition of shock and the effects of hypoperfusion on organs available for assessment, e.g., brain, kidney, skin, heart, etc. Emphasize that altered level of consciousness does NOT equate with LOSS of consciousness and is a late sign.*3-10Cause of Shock: What is the cause of shock?*3-11Cause of Shock: What is the cause of shock?Explain that cardiogenic shock can be caused by myocardial infarction, dysrhythmia, and cardiac failure.Remind the students that bradycardia is not a constant finding in neurogenic shock. Explain that cord lesions below the T4 level may lead to shock with a well perfused periphery and reflex tachycardia. Shock can be caused by medical conditions, such as adrenal insufficiency or diabetes.
*3-12Cause of Shock: What is the cause of shock?Ask the students for the most common cause of shock in the injured patient. The students should respond with hemorrhage as the most common cause. *3-13Shock Assessment: Methods of Locating Bleeding Ask the students to identify possible sites of blood loss in injured patients. The students should identify possible external sources of bleeding, as well as the thorax, abdomen, pelvis and long bone fractures as internal sources of bleeding.Query the students as to how these sites can be assessed for the presence of hemorrhage. The students should respond with physical examination and diagnostic adjuncts to the primary survey, including chest x-ray, chest tube insertion, DPL, FAST (focused assessment ultrasonography in trauma), CT scan, pelvic x-ray, etc.Emphasize that, as soon as shock has been diagnosed and a tension pneumothorax has been excluded during B, a focused search should be made for the cause of the blood loss. Remember, Blood on the floor x four more. *3-14Interventions: What can I do about shock?*3-15Interventions: What can I do about shock?Ask a student to recall the most common cause of shock in the injured patient, emphasizing the need to identify and stop the hemorrhage by the most direct and simplest means available while avoiding blind clamping. These might include direct pressure to control external hemorrhage, reducing pelvic volume, and splinting fractures.In civilian circumstances, applying a tourniquet is a matter of last resort (things may be different in the military arena).Emphasize that fractures of the smaller long bones are also accompanied by, albeit smaller, blood loss. Students responses to this question also should include controlling hemorrhage with operative intervention, such as laparotomy and/or thoracotomy.
*3-16Interventions: What can I do about shock?Explain that shock should be treated as if it were hemorrhagic in nature until proven otherwise. Emphasize that the patient should be reassessed frequently for response to therapy as well as other causes of shock.Students should indicate the role of adequate intravenous access with a short, large-caliber IV catheter. They also should identify the need to prevent hypothermia by administering warmed intravenous fluids and assessing the patients body temperature with an appropriate type of thermometer.Before proceeding, the students need to state that the patients response to therapy must be frequently reassessed to determine the accuracy of diagnosis and plan for further management.
*3-17Interventions: What can I do about shock?Explain that shock should be treated as if it were hemorrhagic in nature until proven otherwise. Emphasize that the patient should be reassessed frequently for response to therapy as well as other causes of shock.Students should indicate the role of adequate intravenous access with a short, large-caliber IV catheter. They also should identify the need to prevent hypothermia by administering warmed intravenous fluids and assessing the patients body temperature with an appropriate type of thermometer.Before proceeding, the students need to state that the patients response to therapy must be frequently reassessed to determine the accuracy of diagnosis and plan for further management.
*3-18Patient Response: What is the patients response?Ask the students to recall the definition of shock and the signs of organ hypoperfusion before asking this question. The students should respond by stating that the patient needs to be assessed for return to hemodynamic normalcy, i.e., heart rate, level of consciousness, skin perfusion, and urinary output.
*3-19Patient Response: What is the patients response?Ask the students to recall the definition of shock and the signs of organ hypoperfusion before asking this question. The students should respond by stating that the patient needs to be assessed for return to hemodynamic normalcy, i.e., heart rate, level of consciousness, skin perfusion, and urinary output.
*3-20Patient Response: What is the patients response?Emphasizes that a transient or absent response should lead to immediate surgical intervention, and not to endless infusion (thereby avoiding yo-yo resuscitation). Ask the students what the normal blood volume is based on (weight and age).Relate blood loss to the classes of hemorrhage, vital signs, and requirements for intravenous fluid administration and/or operation. This discussion leads to the next three slides (Classifications of Hemorrhage), including a summary of the signs and symptoms and appropriate therapy associated with each class of hemorrhage.*3-21Class I HemorrhageUse this slide to summarize the type of physical findings associated with a blood loss of up to 15% or 750 mL. Emphasize that normal vital signs, urinary output, and mild tachycardia are associated with this class of hemorrhage.
*3-22Class II HemorrhageUse this slide to summarize the type of physical findings associated with a blood loss of up to 30% or 1500 mL. Summarize this class of hemorrhage by noting an increase in tachycardia, confusion, beginning oliguria, and maintenance of the systolic blood pressure while pulse pressure is decreased.
*3-23Class III HemorrhageUse this slide to summarize the type of physical findings associated with a blood loss of up to 40% or 2000 mL. Summarize this class of hemorrhage by noting increasingly somnolent, worsening renal perfusion with oliguria, increased respiratory rate, increased heart rate, and decreased blood pressure with a further decrease in pulse pressure.*3-24Class IV HemorrhageUse this slide to summarize the type of physical findings associated with blood loss of greater than 40% or 2000 mL. Summarize the changes in clinical signs, including unconsciousness, oliguria and hypotension, and the need for an operation. *3-25Special Considerations: Complications of Shock Patient FactorsDiscuss the hemodynamic changes related to athletes and elderly patients.Explain the necessary precautions to take in patients with pacemakers and their inability to increase their heart rate.Some medications can affect the patients hemodynamic status (e.g., beta blockers).Discuss the effects of pregnancy on the hemodynamic status of injured patients.
*3-26Special Considerations: Complications of Shock and Shock Management Discuss the effects of hypothermia on the hemodynamic status of injured patients. *3-27Special Considerations: Evaluation and Management of ShockExplain the unreliability of blood pressure as an early sign of shock.Discuss the role of early hemoglobin analysis.
*3-3Case ScenarioEmphasize organ perfusion deficit as indicated by confusion.Changes in the LOC and vital signs indicate shock.Internal bleeding must be suspected.*3-29QuestionsAsk for questions from the students and then pause, allowing the students adequate time to form and ask their questions. *3-30Case ScenarioSpecial considerations in the diagnosis and treatment of shock include equating blood pressure with cardiac output, advanced age, athletes, pregnancy, medications, hypothermia, and pacemakers that need to be considered in the diagnosis and treatment.These summary points relate to the lecture/interactive discussion. Please refer to the Student Manual for the complete Summary related to this topic.
