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6 Shock & FluidResuscitation

Lesson

Prehospital Trauma Life Support

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Developed by the

National Association ofEmergency Medical Technicians

In cooperation with

The Committee on Trauma,American College of Surgeons

This slide presentation is intended for use only

in approved PHTLS courses. 6-1B

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Lesson 6 Objectives

Correlate perfusion, hypoperfusion, hypoxia,hypovolemia and hypotension to the signs andsymptoms of shock.

Differentiate between early and late signs of shock.

Describe the pathophysiological changes of shock.

Identify the management of shock, includingconservation of heat, fluid replacement and thepneumatic anti-shock garment.

6-2

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Shock:

6-3

A rude unhinging of

the machinery of life.

Samuel Gross, 1852

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Shock Redefined:

6-4

Lack of end-tissue

perfusion.

Pitfall: Defining shock as

decreased blood pressure.

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Scenario

You are caring for the sole victim of a

motorcycle crash. He is lying on the

ground next to his motorcycle. The

scene appears safe.

6-5

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Findings

A

- Open, clear. B- RR fast. BS clear. Bruising noted over

sternum; no other chest deformity.

C- Radial pulse weak & rapid.

D- PEARL. Anxious & confused. Normalmovement & sensation.

E- No deformity noted. Skin cool &diaphoretic.

6-6

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Is this patient in shock?

Why?

What is the patients real problem?

Discussion

6-7

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Cell Perfusion

6-8

Aerobic metabolism requiresadequate oxygenation.

Cells require oxygen and sugar toproduce energy and carbon dioxide.

Is the patient in this scenario

adequately perfusing his cells?

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Anaerobic Metabolism

6-9

Inadequate oxygenation for

metabolism.

By-products: Less energy.

More acid.

Potassium.

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Cellular Death

6-10

SHOCKCellular Hypoxia - AnaerobicMetabolism

Hypotension

Hypoperfusion

Cellular Hypoxia

Anaerobic Metabolism

Cell DeathIf cellular death is notprevented, organismdeath will follow.

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Staged Death

Organism death:

May be quick - prior to EMS.

May be prolonged - 2 to 3 weeks later.

Occurs in stages:

Stages occur as the body tries tocompensate.

We see the stages through signs &symptoms.

6-11

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Recognize shock early.

Restore cellular perfusion.

Restore aerobic metabolism.

Prevent Cellular Death

6-12

Pitfall: Waiting until it is too late

to restore perfusion to cells.

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Early Recognition

6-13

Signs & Symptoms of Uncompensated Shock

Description Compensated Decompensated

Pulse

Skin

BP

LOC

Tachycardia

White, cool,and moist

Normal range

Unaltered

Marked tachycardia;can progress tobradycardia

White, waxy, cold,marked diaphoresis

LoweredAltered, ranging fromdisoriented coma

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What are the earliest signs ofshock?

What is a late sign of shock?

Early vs. Late

6-14

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Maintain chemical balance.

Maintain fluid balance.

Restore Cellular Perfusion

6-15

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Chemical Balance

Decrease in oxygen.

Detected by chemical receptors in the carotidarteries and in the arch of the aorta.

Respirations increase in rate & depth.

Rise in acidity.

Buffer system converts acid to CO2 & water. Medulla senses increased CO2.

Respirations increase; lungs blow off CO2.

6-16

continued...

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Chemical Balance

Key: increase in respiratory rate is anearly sign of shock.

What signs or symptoms indicate that thepatients body is trying to restore itschemical balance?

What steps could you take to help thebody restore balance and aerobic

metabolism?

6-17

contd.

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Fluid Decrease

6-18

Fluid volume decreases

Baroreceptors note change

Epinephrine and norepinephrine released

Vasoconstriction Increased rate &strength of cardiac

contractions

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Fluid Decrease

Hormonal response:

Various hormones are released,causing vasoconstriction and fluid

retention.

Compensation:

Blood vessels constrict.

Heart increases strength & rate.

Fluid is retained.6-19

continued...

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In the scenario, which signs suggestthat the patients body is trying torestore its fluid balance?

Is the patient compensating well? Why?

What steps could you take to help thebody restore balance?

6-20

contd.Fluid Decrease

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Defines what is necessary toachieve end-tissue perfusion: On-loading oxygen to the RBCs. Delivering the RBCs to the tissue. Off-loading oxygen to the tissue.

As part of the process, patient musthave an adequate number of RBCs

to transport oxygen.

The Fick Principle

6-21

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Scenario

You are responding to a patient that has

fallen from a 40-foot cliff while rock climbing.

He is awake. He tells you that he cant move

his legs, and has no feeling below his waist.

Pulse 119, RR 20, and BP 104/72.

6-22

How does the Fick Principle apply here?

How well is this patient compensating?

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Scenario

You are called to the scene of a house

fire, where firefighters have just removed

one patient. He is unresponsive. Pulse

102, RR 6, and BP 104/76.

6-23

How does the Fick Principle apply here?

How well is this patient compensating?

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Scenario

You respond to a scene where a skier has

struck a tree at high speed. Exam reveals pain

on palpation of the right lateral chest, absent

breath sounds on the right and labored

breathing. Pulse 142, RR 40, and BP 88/70.

6-24

How does the Fick Principle apply here?

How well is this patient compensating?

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Scenario

You are dispatched to an MVC. On arrival, you

find a 47-year-old male driver still in the

vehicle. There are 10-15 inches of intrusion to

the front of the vehicle. The patient is

unresponsive as you approach.

6-25

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Findings

A

- Blood & vomitus in airway. B- Slow & labored. BS absent on left.

C- No palpable radial pulse. Cool, wet

skin. No external bleeding.

D- Pupils equal but reacting slowly.

E - Obvious fracture of left femur.

6-26

How does the Fick Principle apply here?

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Shock Summary

Shock is staged death...

6-27

catch it in the first act!