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Chapter 9

Chapter 9. Shock: A State of Hypoperfusion. Overview. Hypoperfusion Causes of Hypoperfusion Physiologic Response to Shock Assessment Management of Hypoperfusion. Hypoperfusion. Hypoperfusion means inadequate perfusion

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Chapter 9

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  1. Chapter 9 Shock: A State of Hypoperfusion

  2. Overview • Hypoperfusion • Causes of Hypoperfusion • Physiologic Response to Shock • Assessment • Management of Hypoperfusion

  3. Hypoperfusion • Hypoperfusion means inadequate perfusion • Hypoperfused tissue is no longer being given enough oxygen and will stop working optimally

  4. Hypoperfusion • The brain is the most sensitive organ in the body to decreases in blood and oxygen supply

  5. Causes of Hypoperfusion • Three basic components of the circulatory system can affect perfusion: • Fluid • Container • Pump

  6. Causes of Hypoperfusion • The fluid • Hypoperfusion will occur if • There is not enough blood in the system • The blood in the system is not carrying enough oxygen

  7. Causes of Hypoperfusion • Hypovolemic shock • When body fluids are lost and not adequately replenished, the total body fluid volume is low • When shock results from an actual loss of blood, it can be specifically called hemorrhagic shock • Other means of fluid loss are excessive vomiting, diarrhea, sweating, or urinating

  8. Causes of Hypoperfusion • The container • Blood vessels have the ability to significantly alter their diameter by contraction or relaxation of the smooth muscles in their walls • This can be harmful in some circumstances, such as anaphylactic, septic, or neurogenic shock

  9. Causes of Hypoperfusion • Anaphylactic shock • The result of a severe allergic reaction • Causes vasodilation and subsequent hypotension • Patient will have urticaria (hives), airway swelling, and hypotension

  10. Causes of Hypoperfusion • Septic shock • Severe infection may lead to generalized blood vessel dilation, with a drop in blood pressure and diminished perfusion • Certain types of bacteria can produce toxins that prevent the vessels from constricting appropriately, causing them to leak

  11. Causes of Hypoperfusion • Neurogenic shock • Is caused by a loss of control of the smooth muscles in the vessel walls • May occur as a result of spinal cord injury where the vessels no longer have the ability to constrict when appropriate • Also termed spinal shock

  12. Causes of Hypoperfusion • The pump • Inadequate pumping action of the heart can result in hypoperfusion • If the pump does not have enough power to generate adequate forward flow, the amount of blood pumped will be smaller • The smaller volume will result in a lower cardiac output

  13. Causes of Hypoperfusion • Cardiogenic shock • If the heart muscle is damaged, as during a heart attack, it does not pump to full capacity • Shock that results from inadequate cardiac pumping is called cardiogenic shock

  14. Physiologic Response to Shock • Compensated shock • The body attempts to compensate for hypoperfusion by: • Increasing the volume of blood pumped with each stroke or the heart rate • Increasing respiratory rate • Adjusting blood flow to only core areas (shunting)

  15. Physiologic Response to Shock • Compensated shock • Signs and symptoms • Pale • Cool • Clammy • Weakening peripheral pulses • Elevated heart rate • Elevated respiratory rate • Nausea • Altered mental status

  16. Physiologic Response to Shock • Decompensated shock • Systolic blood pressure drops to less than 90 mm Hg • The body is no longer able to compensate for an event • When hypotension is noted, the patient is considered to be in decompensated shock and must be aggressively managed for survival to be possible

  17. Physiologic Response to Shock • Irreversible shock • Prolonged periods of decompensated shock resulting in the failure of multiple organs • Patients with irreversible shock often do not survive

  18. Stop and Review • What is hypoperfusion? • What are the three main causes of hypoperfusion? • List the signs and symptoms associated with compensated shock. • What is the tell-tale sign of decompensated shock?

  19. Assessment • In assessing a patient, be careful to look for signs of compensated shock • If you don’t look for it, you won’t find it • It is necessary to begin to treat the patient in shock before she decompensates and becomes hypotensive

  20. Assessment • The look test • Ensure your own safety and adequate PPE • Form general impression

  21. Assessment • Mental status • Assess for AVPU • ABCs • Once ABCs have been assessed, look for signs of hypoperfusion

  22. Assessment • Vital signs • Obtain a complete set of vital signs • Orthostatic vital signs • Vital signs measured in two different positions • Positive tilt test

  23. Management of Hypoperfusion • The treatment of shock is geared toward restoring adequate oxygenation, ventilation, and circulation • The EMT must maximize perfusion while rapidly transporting the patient to a hospital, where definitive treatment will be available

  24. Management of Hypoperfusion • Oxygen • Apply high-flow 100% oxygen in any stage of shock • Control bleeding • Locate source of bleeding and control it in whatever way possible • Trendelenburg • Elevate the legs and utilize the force of gravity to increase the blood volume in the thorax and abdomen

  25. Management of Hypoperfusion • MAST/PASG • Military anti-shock trousers or a pneumatic anti-shock garment • A device that may support blood pressure in certain circumstances • MAST/PASG improves the blood supply to the upper body and vital organs

  26. Management of Hypoperfusion • MAST/PASG • Indications • Severe hypotension (systolic BP less than 50 mm Hg • Hypotension (systolic BP less than 90 mm Hg) because of severe pelvic injuries

  27. Management of Hypoperfusion • MAST/PASG • Contraindications (absolute) • Penetrating thoracic injury • Pulmonary edema

  28. Management of Hypoperfusion • MAST/PASG • Contraindications (relative) • Pregnancy • Penetrating object • Evisceration

  29. Management of Hypoperfusion • MAST/PASG • Application • Trouser method • Wrapper method

  30. MAST/PASG • Watch this video clip demonstrating the use of MAST/PASG

  31. Management of Hypoperfusion • MAST/PASG • Removal • Should never be deflated by the EMT • Physicians should be familiar with the procedure of slow deflation • Gradual process

  32. Management of Hypoperfusion • Reduce heat loss • Prevent excessive heat loss during the evaluation and treatment of the critically ill or injured patient • Cover the patient with blankets once the assessment has been completed

  33. Management of Hypoperfusion • Transport • Consider ground or air transport • Reassess patient frequently and monitor vital signs every five minutes • Consider ALS intercept • Consult local protocols

  34. Stop and Review • What can the EMT do to manage the patient presenting with shock? • What are the absolute contraindications for using PASG/MAST?

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