Chapter 15

Shock and Resuscitation

Copyright ©2010 by Pearson Education, Inc.All rights reserved.

Prehospital Emergency Care, Ninth EditionJoseph J. Mistovich • Keith J. Karren

Objectives

1. Define key terms introduced in this chapter.2. Explain the pathophysiology of shock (hypoperfusion),

including the consequences of cellular hypoxia anddeath (slide 16).

3. Describe the physiology of maintaining adequateperfusion (slide 17).

4. Describe how inadequate vascular volume, inadequateheart function, and decreased peripheral vascularresistance can lead to shock (slide 18-22).

5. Give examples of conditions that can lead to (slides 18-22, 25-47):a. Loss of vascular volumeb. Inadequate heart functionc. Decreased peripheral vascular resistance

Objectives

6. Explain the mechanisms and pathophysiology of eachof the following categories and types of shock (slides23-50):a. Hypovolemic (hemorrhagic and nonhemorrhagic)b. Distributive (anaphylactic, septic, neurogenic)c. Cardiogenicd. Obstructivee. Metabolic or respiratory

7. Explain how compensatory mechanisms to shock aremaintained through (slides 53-56):a. Direct nerve stimulationb. Release of hormones

8. Explain the body’s compensatory responses tohypoperfusion and how they manifest in the early signsand symptoms of shock (slides 51-56).

Objectives

9. Differentiate between early (compensatory) and late(decompensatory/irreversible) signs of shock (slide 58).

10. Describe the progression of shock through thecompensatory, decompensatory (progressive), andirreversible stages (slide 58).

11. Explain how to identify the patient who is in a shockstate and demonstrate the assessment of patients toidentify shock (slides 59-64).

12. Explain the influence of age on the assessment andmanagement of patients with shock (slides 65-66).

13. Discuss the goals of prehospital management ofpatients with shock (slides 67-69).

Objectives

14. Describe the pathophysiology of cardiac arrest (slides70-73).

15. Differentiate between the electrical, circulatory, andmetabolic phases of cardiac arrest (slide 73).

16. Identify situations in which resuscitative attemptsshould be withheld (slides 76-77).

17. Explain each of the links in the Chain of Survival ofcardiac arrest (slides 78-79).

18. Explain the importance of early defibrillation in cardiacarrest (slides 80-81).

19. Explain the rationale for the “push hard and push fast”approach to cardiopulmonary resuscitation (CPR)(slides 82-83).

Objectives

20. Describe the features, functions, advantages,disadvantages, use, and precautions in the use ofautomated external defibrillators (AEDs) (slides 84-87).

21. Compare and contrast ventricular fibrillation, ventriculartachycardia, asystole, and pulseless electrical activity(slides 88-92).

22. Given a series of cardiac arrest scenarios involvinginfants, children, and adults, demonstrate appropriateassessment and resuscitative techniques, including theintegrated use of AEDs (automated andsemiautomated), ventilation, and CPR, and explain thepurpose and procedure for reassessment of thecardiac arrest patient (slides 94-101).

Objectives

23. Demonstrate assessment and management of a postcardiac-arrest patient with return of spontaneouscirculation (slides 98-101).

24. Given a cardiac arrest scenario, make decisionsregarding obtaining advanced cardiac life support(ACLS) (slide 105).

25. Describe the safety precautions to be taken to protectyourself, other EMS providers, the patient, andbystanders in resuscitation situations (slides 93, 107-108).

Objectives

26. Explain the importance of AED maintenance, EMTtraining and skills maintenance, and medical directionin the Chain of Survival of cardiac arrest (slides 109-115).

27. Discuss special considerations in the use of an AED inpatients with cardiac pacemakers and automaticimplanted cardioverter-defibrillators (slides 118-121).

28. List the advantages and disadvantages of automatedchest compression devices, impedance thresholddevices, and other circulation-enhancing devices(slides 122-129).

Multimedia Directory

Slide 22 Etiology of Shock AnimationSlide 50 Types of Shock AnimationSlide 69 Bleeding Control/Shock Management Video

Topics

ShockResuscitation in Cardiac ArrestAutomated External Defibrillation and CardiopulmonaryResuscitationRecognizing and Treating Cardiac ArrestSpecial Considerations for the AED

CASE STUDYCASE STUDY

Dispatch

Respond to 46 Hillman Street. You have a 26-year-old male patient who has been stabbed in

the leg and is bleeding profusely. Lawenforcement is en route.

EMS Unit 102

Time out 2102

• A police officer leads you into the basement• Patient is supine on the floor with a large pool of

blood around his right thigh• Patient is not alert, does not respond to voice,

and appears extremely pale

Upon Arrival

How would you proceed with theassessment of this patient?

Back to Topics

Shock

Inadequate tissueperfusion

Back to Objectives

Review of Respiratory Pathophysiology

Back to Objectives

Etiologies of Shock

Back to Objectives

Inadequate Volume

Fig. 15-01

Don’t have artyet - WDS

Fig. 15-02

Inadequate Pump Function

Don’t have artyet - WDS

Fig. 15-03

Inadequate VesselTone

Don’t have artyet - WDS

Etiology of Shock

Return to Directory

Click here to view an animation on the etiology of shock

Categories of Shock

Back to Objectives

Fig. 15-04

Don’t have artyet - WDS

Categories of Shock

Hypovolemic Shock

Back to Objectives

Fig. 15-05

Don’t have artyet - WDS

Categories of Shock

Distributive Shock

Fig. 15-06

Don’t have artyet - WDS

Categories of Shock

Cardiogenic Shock

Fig. 15-07

Don’t have artyet - WDS

Categories of Shock

Obstructive Shock

Fig. 15-08

Don’t have artyet - WDS

Categories of Shock

Metabolic orRespiratory Shock

Inability of thebody to use,

transport, and/oroffload oxygen

Specific Types of Shock

Specific Types of Shock

HemorrhagicHypovolemic Shock

Fig. 15-05a only(trim outnonhemorrhagichypovolemicshock)Don’t have art

yet - WDS

Specific Types of Shock

NonhemorrhagicHypovolemic Shock

Fig. 15-05bonly (trim outhemorrhagichypovolemicshock)

Don’t haveart yet -WDS

Specific Types of Shock

Burn Shock

Fluid is pulled from thevascular space to the

interstitial space,causing hypovolemia.

Specific Types of Shock

Anaphylactic Shock

Vasodilation movesblood from the centralcore to the periphery,causing distributive

shock.

Specific Types of Shock

Septic Shock

Bacteria or toxinsthroughout the body

cause the bloodvessels to dilate and

to become permeable.

Specific Types of Shock

Neurogenic Shock

Spinal cord traumacauses a loss of bloodvessel tone and results

in widespreadvasodilation.

Specific Types of Shock

Cardiogenic Shock

Depressed pump function reduces the force ofthe left ventricular contraction, stroke volume,cardiac output, systolic blood pressure, and

perfusion.

Types of Shock

Return to Directory

Click here to view an animation on types of shock.

The Body’s Response toShock

Back to Objectives

The Body’s Response to Shock

Direct NerveStimulation

Back to Objectives

• Increased heartrate

• Increasedcontractile force

• Vasoconstriction• Release of

epinephrine andnorepinephrine

The Body’s Response to Shock

Release of Hormones

Hormonesreleased

stimulate alphareceptors inperipheral

blood vessels,returning bloodto the central

core.

Stages of Shock

Back to Objectives

Shock Assessment

Back to Objectives

Shock Assessment

History

• Pay particularattention tochief complaintand SAMPLE

• Somemedicationsmay preventcompensation

Shock Assessment

Physical Exam

• Altered mental status• Pale, cool, and

clammy skin• Delayed capillary

refill• Decreased urine

output• Weak or absent

peripheral pulses

• Skin color,temperature, andcondition

• Pulse oximeterreading

• Blood pressure (bothsystolic and diastolic)

• Heart rate• Pulse character• Respiratory rate and

tidal volume

Age Considerations inShock

Back to Objectives

Childrencompensate well

and then suddenlydecompensate.

Medications andadvanced age

decreasecompensation

ability.

General Goals ofPrehospital Management of

Shock

Back to Objectives

• Secure and maintain an airway• Assure adequate ventilation• Provide high-flow, high-concentration oxygen• Avoid hyperventilation• Stop any external bleeding• Splint fractures to reduce bleeding• Leave impaled objects in place• Keep the patient warm• Apply PASG if indicated and local protocol

allows• Provide rapid transport and perform other

interventions en route• Consider an ALS intercept

Bleeding Control/Shock Management

Return to Directory

Click here to view a video on the topic of bleeding control and shockmanagement.

Resuscitation inCardiac Arrest

Back to Topics

Sudden Death:the patient dieswithin one hourof the onset of

symptoms

Cardiac Arrest:cardiac output is

completelyineffective and nopulse can be felt

Resuscitation:bringing the

patient back froma potential or

apparent death

Back to Objectives

Pathophysiology ofCardiac Arrest

Electrical PhaseLess than four minutes following arrest, the cardiac

muscle uses its sugar/oxygen stores.

Circulatory PhaseFrom four to ten minutes following arrest, the cardiac

muscle switches to anaerobic metabolism.

Metabolic PhaseGreater than ten minutes following arrest, cardiac cells

swell, rupture, and die.Back to Objectives

Terms Related toResuscitation

SurvivalA patient who survives tobe discharged from the

hospital

Return ofSpontaneous

Circulation (ROSC)The patient regains aspontaneous pulse

during the resuscitationeffort.

Total DowntimeThe total time from when

the patient goes intocardiac arrest until you

deliver the patient to theemergency department

DowntimeThe time the patient goes

into cardiac arrest untilCPR is effectively being

performed

Withholding a ResuscitationAttempt

Back to Objectives

You may also withholdresuscitation in cases ofobvious death, such as

decapitation.

The Chain of Survival

Back to Objectives

Early Access:The quicker someone can recognize a

patient in cardiac compromise, the betterthe chance of patient survival

Early CPR:Immediate CPR can double or even triplethe arrested patient’s chance of survival

from ventricular fibrillation

Early Defibrillation:Survival rates of patients in VF SCA

decrease approximately 7–10 percent forevery minute that defibrillation is delayed

Early Advanced Care:Advanced life support (ALS) is delivered

most often by paramedics who can provideadvanced cardiac life support (ACLS).

Automated ExternalDefibrillation andCardiopulmonary

Resuscitation

Back to Topics

AHA Rationale for EarlyDefibrillation

• The most frequent initial rhythm in suddencardiac arrest is ventricular fibrillation

• The most effective treatment for terminatingventricular fibrillation is electrical defibrillation

• The probability of successful defibrillation isdirectly related to the time from fibrillation todefibrillation

• Ventricular fibrillation will, without prompt orappropriate treatment, degenerate into asystole

Back to Objectives

• “Push hard and pushfast”

• 100 compressions perminute

• 30:2 compression tobreath ratio

• Start with CPR if thedowntime is unknownor greater than four tofive minutes

• If the downtime is lessthan four to fiveminutes, use the AED

Pulse checks shouldNOT follow a

defibrillation attempt.Always resume CPR

after shocking a patientwith an AED.

Back to Objectives

AHA Rationale for Current AEDand CPR Standards

• “Push hard and push fast” will help avoidcompressions that are delivered either too slowor too shallow

• The ratio of 30:2 minimizes interruptions tocompressions for pulse checks and ventilations

• Compressions prior to defibrillation inunwitnessed arrests will make defibrillation moresuccessful

• Rarely will a perfusing rhythm be evident by apulse check immediately after defibrillation

• CPR as just described can double or triple thechance of survival

Types of Defibrillators

Back to Objectives

Manualdefibrillators

require extensivetraining prior to

use

An automatedexternal

defibrillator (AED)is much simpler to

operate.

Advantages of AEDs:•Speed of operation•Safer, more effectivedelivery•More efficient monitoring

Types of AEDs:•Fully automated AED•Semiautomated AED

Biphasic versus Monophasic

Biphasic: moreeffective with less

energy

Monophasic: lesseffective with more

energy

150 to 200 J 200, 300, 360 J

Analysis of CardiacRhythms

Back to Objectives

Ventricular Fibrillation: Shockable!

Ventricular Tachycardia: Shockable!

Asystole: NOT Shockable!

Pulseless Electrical Activity: NOT Shockable!

Organized electricalactivity with no pulse

NEVER touch thepatient, AED, or cables

when the AED isanalyzing a rhythm.

!

When and When Not to Usethe AED

Back to Objectives

Apply an AED if:

• The patient is in nontraumatic cardiacarrest

• For children one to eight years of age, anadult AED may be used, preferably with apediatric dose attenuating system

• The downtime is less than four to fiveminutes, or two minutes of CPR has beenperformed

Do not apply an AED if:

• The patient is less than one year of age• The patient is in cardiac arrest as a result

of trauma• The downtime is greater than four to five

minutes, and two minutes of CPR has notbeen performed

Recognizing andTreating Cardiac

Arrest

Back to Topics

Assessment-BasedApproach: Cardiac Arrest

Back to Objectives

Fig 15-16aAssessmentSummary Cardiac

Don’t have art yet -WDS

Performing Defibrillation

Fig 15-16b and/or15-17 I cannotdetermine withoutseeing content

Don’t have art yet -WDS

Transporting the CardiacArrest Patient

• When to transport• Transporting a patient with a pulse• Transporting a patient without a pulse

Providing for AdvancedCardiac Life Support

Request advance life support (ALS)providers as soon as possible.

Back to Objectives

SpecialConsiderations for

the AED

Back to Topics

Safety Considerations

Back to Objectives

Remember the following safetyguidelines:

• Clear the patient beforeshocking

• Water and metalconduct electricity verywell

• Never place anelectrode over amedication patch orimplanted pacemaker

If the patient has anextremely hairy chest andfirmly pressing the pad onthe chest does not work,

then consider shaving thearea with an electric

clippers or disposablerazor.

AED Maintenance

Back to Objectives

Alwaysinspect your

AED forfunction andproper stock.

The mostcommon

cause of AEDfailure is

battery failure.

Training and SkillsMaintenance

• Be prepared to use the AED at any time

• Practice your skills with the AED at leastevery 90 days

• Review incidents for quality improvement

• Keep up to date on new research on AEDprocedures

Medical Direction and theAED

Responsible for the following:

• Making sure that the EMS system has allnecessary links in the AHA Chain ofSurvival

• Overseeing all levels of EMTs• Reviewing the continual competency skill

review program• Engaging in an audit and/or quality

improvement program

Incident review may beaccomplished by:

• Written reports• Review of the voice and/or ECG tapes if

the system’s AED is equipped with thatfeature

• Review of solid-state memory modulesand magnetic tapes if the system’s AED isso equipped

Energy Levels ofDefibrillators

Typical Energy Levels

• Manual defibrillators typically range fromfive joules to 360 joules

• Most AEDs have two preset values of 200joules and 360 joules

Cardiac Pacemakers

Back to Objectives

Some patientsrequire a

pacemaker tomaintain an

adequate heartrate. They areusually placed

under a clavicle.

Automatic ImplantableCardioverter Defibrillators

Automatic ImplantableCardioverter Defibrillators (AICD)

• Implanted device that monitors the heart’sactivity

• Capable of delivering shocks directly tothe heart to correct lethal dysrhythmias

• A conscious patient can tell you when ashock is delivered

• The shock from an AICD does not pose arisk to EMS providers

Automated Chest CompressionDevices

Mechanical PistonDevice

Back to Objectives

A mechanicalpiston device in

place on a patient

Automated Chest CompressionDevices

Load-Distributing-Band CPR or Vest CPR

A load-distributing-bandCPR device

Automated Chest CompressionDevices

Impedance ThresholdDevice

An impedancethreshold device

Automated Chest CompressionDevices

Other CirculationEnhancing Devices

Other devices, likethe LUCAS, may

also activelydecompress the

chest.

CASE STUDYCASE STUDY

Follow-Up

Primary Assessment• Patient not alert and doesn’t respond

when name is called• Pale color; apply in-line stabilization• Patient moans to painful stimuli• Respirations are adequate; place

nonrebreather mask at 15 lpm• Find blood coming from right leg wound;

expose leg and apply direct pressure

CASE STUDYCASE STUDY

Secondary Assessment• You expose the patient’s body to look for

other injuries while rolling onto backboard• No other injuries found• BP: 72/58mmHg; HR: 132; RR: 26; skin

pale, cool, and clammy• Patient still responsive only to pain• No history or medical information

obtainable

CASE STUDYCASE STUDY

Reassessment• Monitor mental status, ABCs, and

bleeding en route• No change en route• Upon arrival, trauma surgeon meets you

and brings the patient to the trauma bay• Prepare written report and return to

service

CASE STUDYCASE STUDY

• Dispatch advises you are responding to aman down; CPR in progress

• You arrive four minutes after the call camein and within moments of fire and PD

• You see a small crowd gathered around amale patient; two people are in factperforming CPR

Critical Thinking Scenario

• You’ve already donned gloves and eyeprotection while en route

• You grab your AED as you exit theambulance

• Your primary assessment reveals anunresponsive man, mid-50s, supine on theground with effective bystander CPR inprogress

Critical Thinking Scenario

• Bystanders state that they began CPRimmediately upon his collapse and thencalled 911

• The patient’s skin is slightly cyanotic• You request that CPR be stopped

temporarily while you assess pulse andbreathing

• Your partner is setting up the AED

Critical Thinking Scenario

• You find no carotid pulse and detect nobreathing

• This is a priority patient for whomdefibrillation is appropriate

• You direct a firefighter to resumecompressions while you ventilate with abag-valve mask and high-flow, high-concentration oxygen

Critical Thinking Scenario

1. What assessment findings indicate that thispatient is indeed in cardiac arrest?

2. Which components of the Chain of Survivalhave already been met?

3. Why is this patient a candidate for immediateversus delayed AED use?

4. What cardiac rhythm is this patient most likelygoing to show?

Critical Thinking Questions

5. What is the compression to ventilation ratiogoing to be for this patient?

6. If the AED indicates that no shock iswarranted, what should your next action be?

Critical Thinking Questions

Reinforce and Review

Please visitwww.bradybooks.com

and follow the myBradykit linksto access content for the text.