Shock and Fluids

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Shock and Fluids
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What is Shock

• Shock is lack of tissue oxygenation that leads to
  anaerobic metabolism
• Low blood pressure, rapid pulse, rapid
  respirations are only SIGNS of shock
• The true mechanism of shock happens at the
  cellular level

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Metabolism

• What is metabolism
• The process of every cell in the body using
  oxygen and sugar to make energy
• When both sugar and oxygen are present AEROBIC
  METABOLISM takes place
• During aerobic metabolism the body efficiently
  makes energy, and CO2 is the by product
• The complex process of aerobic metabolism is
  called the KREBS CYCLE

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The Back-up System

• If oxygen is not available the body will go into
  ANAEROBIC METABOLISM to produce power
• Anaerobic metabolism is much less efficient one
  nineteenth the amount of ATP (energy units)
  produced
• By products are much more harmful to the body,
  and may cause irreversible damage
• As cells start to die, other cells in tissue have
  to work harder, increasing oxygen demand
• Not uncommon for cellular damage caused in the
  first few minutes of injury to cause death 2-3
  weeks later

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Ischemia

• Lack of oxygenated blood
• Either Hypoxia (insufficient oxygen available),
  or Hypoperfusion (inadequate blood passing by
  cells)
• The amount of time an organ can be ischemic
  before damage occurs is Ischemic Sensitivity
• Ischemic sensitivity for heart/brain/lungs4-6
  min, kidneys/liver/G.I.45-90min,bone/skin 4-6
  hrs

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FICK PRINCIPLE

• Describes components necessary for oxygenation of
  body cells
• On loading of 02 onto red blood cells (working
  lungs, O2 available, RBCs except O2)
• Delivery of RBC to cells (enough blood, pump
  moving fast enough, enough RBCs)
• Off loading of 02 from RBCs to organ cells

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Components of PerfusionThe Heart

• The right side is presented with blood, it is
  pumped at low pressure through the lungs where it
  ideally will be oxygenated
• Blood comes out of the lungs to the left side of
  the heart were it is pumped at high pressure to
  rest of body
• The atria (top part of the heart) is like the
  first stage of a two stage pump - accounts for
  30 of volume/pressure

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Components of PerfusionThe Heart

• As the heart rate increases the atria becomes
  ineffective and at approximately 150 bpm the 30
  is lost
• Heart ends up doing more work with less blood
  output
• More blood presented to heart, the more blood it
  will pump
• More time blood has to fill the heart, the more
  it will pump, as heart rate increases filling
  time decreases
• Heart is perfused between contractions, as heart
  rate increases myocardial perfusion time shortens

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Components of PerfusionThe Blood Vessels

• Blood vessels, highway to the cells
• Vessels progressively get smaller, arteries
  become capillaries, tiny vessels that run against
  the cells
• Vessels constrict and dilate changing the volume
  and resistance

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Components of Perfusion Blood

• Blood has many components including RBCs, WBCs,
  Platelets, and Glucose
• Must have enough RBC in the blood to carry
  adequate oxygen
• Must have enough volume for RBCs to get around
  to all cells of the body

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Components of Perfusion Other Players

• Lungs must be exchanging enough oxygen to keep up
  with bodys demand
• Effective respiration causes milking effect on
  vena-cava to present more blood to the heart
• Nervous system controls all functions, must be
  working correctly to allow compensatory
  mechanisms to take place
• Baroreceptors (pressure), chemoreceptors
  (chemical, O2, CO2) sensors in body give nervous
  system info on how things are going

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Causes of Shock

• Volume failure, dehydration, rapid loss of volume
  (hemorrhagic)
• Container failure, size of container enlarges
  rapidly, spinal injury (neurogenic), Vagal
  stimulation (psychogenic),baroreceptor
  malfunction, infection (septic)
• Pump failure, caused by muscle failure
  (cardiogenic), Arrhythmia (heart is not efficient
  pump), no room to pump (pericardial tamponade)

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Manifestations of Shock

• Assuming systems are all working normally
• Compensated shock, rapid heart rate/respirations,
  mild anxiety, normal blood pressure, cool/pale
  skin
• Decompensating shock, dropping blood pressure,
  decreased level of consciousness
• Irreversible shock, dropping heart rate, coma,
  waxy cold skin

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Progression of Shock

• Injury to system (or a taxing on the system)
  causes cells to start making energy anaerobicly
• Body senses increased acid in body from anaerobic
  byproducts
• Body starts breaking down acid into water and CO2
  (CO2 in a much higher concentration than with
  normal metabolism)
• CO2 has an immediate effect on the brain, causing
  confusion, brain increases respirations and heart
  rate to get rid of CO2

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Progression of Shock

• Early compensatory mechanisms usually corrects
  things and body goes back to aerobic metabolism
• If the kidneys detect a drop in blood pressure,
  they release enzymes that cause vasoconstriction,
  and the kidneys start retaining sodium to keep in
  fluid
• The enzymes released by the kidneys last approx 1
  hour. This shunts blood away from skin, kidneys,
  GI tract, and muscles - increasing the amount of
  blood to the heart and lungs

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Progression of Shock

• If adequate perfusion is not restored quickly
  (within a few minutes) the cells in the shunted
  areas become ischemic and convert to anaerobic
  metabolism
• This Ischemic phase is the first of the 3
  phases that lead to irreversible harm
• Due to the decreased blood flow the acid and CO2
  is not effectively carried away from the shunted
  cells, this is the Stagnant phase - this
  becomes very toxic to the cells and eventually
  the Lysosomal packets (suicide packs) in the cell
  rupture

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Progression of Shock

• The Washout phase starts when the enzymes from
  the kidneys causing vasoconstriction wear off
• During the washout phase the returning blood
  picks up all the stagnant CO2 /acid and carries
  it to the brain and heart
• The high concentrations of CO2 and acid cause
  failure of the heart, lungs and brain
• The high concentrations of acid also cause the
  RBCs to stack up and clog the small passage ways
  to the cells (rouleaux), causing further ischemia

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Progression of Shock

• In the tissues that are still being perfused
  fluid from the increased blood pressure moves out
  of the blood vessels, and into the space between
  capillaries and cells this EDEMA makes it very
  hard for the oxygen to cross into the cell
• Even if blood is returned death will often occur
  if the lysosomal packets were ruptured
• -If heart failure and brain damage do not prove
  lethal, ARDS will often kill the patient weeks
  after the injury

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BLS Tx of Shock

• Rapid transport to trauma center/operating room
  is most important
• Provide good airway with oxygen
• Keep pt. supine or trendelenberg
• Control bleeding

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Addendum from SCEMS(not recommended)

• REMEMBER C-COLLARS ARE MORE IMPORTANT THAN
  AIRWAY
• IF ITS MORE CONVENIENT TO LET PATEINT DIE THAN
  TO TRANSPORT, LET THEM DIE

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SCEMS Trauma Code Black Protocol
Is this a trauma call
Yes
No
Find a way to make it one, much less work
Have you eaten yet
No
Yes
No
Pass the buck
Are you the mentor
Contemplate triage over hot bag of long John
Slivers
I have 6 months of service
Yes
Move Pt to warmer local to speed demise
Refuse to run call, let someone else worry about
it
Yes
Is Pt talking to you
Are you in a soccer field
Yes
Yes
No
Yes
No
Get refusal form ready
If ABCs neglected long enough will they die
Have you known someone who died in similar manor
Will a WFD Paramedic or member of station 5 call
you on it
Duh
No
Reposition Pt ie. Lay down, put head under water
etc.
No
Will transporting pt be much more work for you
No
Yes
Yes a couple of times
Code Black
Has your medic captain misdiagnosed people dead
before
No I am truly incompetent
Can I turn it around and make it look like their
fault
Can you hide it from the media when it comes out
No
No
Yes
No
Yes
Are you not sure what to do treatment wise, and
are generally confused about what is wrong with pt
Screw it, code black
Can you show this as an example of too many
paramedics diluting the system
Code Black
Yes
No