Shade et al.: Mosby’s EMT-Intermediate Textbook for the ...brainspew.com/advanced/emt/notes/intChapter_010.pdfmembrane in the function of the cell ... Revised Edition PowerPoint

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Copyright © 2006 by Mosby, Inc. All rights reserved.

Chapter 10Chapter 10Assessment and Management of ShockAssessment and Management of Shock


ObjectivesObjectives

Explain the difference between aerobic and Explain the difference between aerobic and anaerobic metabolismanaerobic metabolism

Describe the importance of tissue perfusionDescribe the importance of tissue perfusion

List the four elements of the Fick principleList the four elements of the Fick principle

List the primary components of the List the primary components of the cardiovascular system and their rolescardiovascular system and their roles


ObjectivesObjectivesDiscuss the role of water in its relationship Discuss the role of water in its relationship with body functionwith body function

Discuss the fluid compartments of the bodyDiscuss the fluid compartments of the body

Identify the significant anions and cations in Identify the significant anions and cations in the bodythe body

Explain the role of the Explain the role of the semipermeablesemipermeablemembrane in the function of the cellmembrane in the function of the cell

Shade et al.: Mosby’s EMT-Intermediate Textbook for the 1985 National StandardCurriculum, Revised Edition PowerPoint Lecture Notes Chapter 10: Assessment and Management of Shock

Copyright© 2006 by Mosby, Inc. All rights reserved.

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ObjectivesObjectivesDiscuss the concepts of diffusion, facilitated Discuss the concepts of diffusion, facilitated diffusion, osmosis, osmotic pressure, and diffusion, osmosis, osmotic pressure, and active transportactive transport

Give examples of isotonic, hypotonic, and Give examples of isotonic, hypotonic, and hypertonic solutionshypertonic solutions

Explain the function of plasma, erthrocytes, Explain the function of plasma, erthrocytes, platelets, hemoglobin, and hematocrit in platelets, hemoglobin, and hematocrit in bloodblood


ObjectivesObjectivesDescribe the role of antigens and antibodies Describe the role of antigens and antibodies in the bodyin the body

Explain the Rh factor in bloodExplain the Rh factor in blood

Describe acids and bases in relation to pHDescribe acids and bases in relation to pH

Explain how the buffer systems, respiration, Explain how the buffer systems, respiration, and kidney function help to maintain acidand kidney function help to maintain acid--base balance in the bodybase balance in the body


ObjectivesObjectivesDescribe the three principal stages of shockDescribe the three principal stages of shock

List the five types of shockList the five types of shock

Discuss the proper assessment and Discuss the proper assessment and management of the patient in shockmanagement of the patient in shock

Describe fluid replacement in the Describe fluid replacement in the management of the patient in shockmanagement of the patient in shock


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Pathophysiology of ShockPathophysiology of Shock

PerfusionPerfusion

Anaerobic metabolismAnaerobic metabolismWithout OWithout O22

Aerobic metabolismAerobic metabolismWith OWith O22

HypoperfusionHypoperfusion

Insert fig 10-1



FickFick principleprincipleAdequate ventilationAdequate ventilationOO2 2 binds with binds with hemoglobinhemoglobinOO22 transported via transported via circulatory systemcirculatory systemOO22 offoff--loaded in loaded in capillariescapillaries



Cellular metabolismCellular metabolismCellular respirationCellular respirationPyruvicPyruvic acidacid


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Aerobic metabolismAerobic metabolismPerson breathes OPerson breathes O22

OO22 binds with binds with hemoglobinhemoglobin



Anaerobic metabolismAnaerobic metabolismShock patientShock patient


The Cardiovascular SystemThe Cardiovascular System

Closed system of blood Closed system of blood vesselsvessels


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Stroke volumeStroke volume

Dependent on:Dependent on:ContractilityContractilityPreloadPreloadAfterloadAfterload



ContractilityContractilityExtent and velocity of muscle fiber shorteningExtent and velocity of muscle fiber shorteningInfluenced byInfluenced by

•• OO22 supply and demandsupply and demand•• Degree of sympathetic stimulationDegree of sympathetic stimulation•• Electrolyte balanceElectrolyte balance•• Drug effectsDrug effects•• DiseaseDisease



PreloadPreloadAffected by volume of Affected by volume of blood returningblood returningMore blood More blood ↑↑ preloadpreloadLess blood Less blood ↓↓


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AfterloadAfterloadAffects stroke volumeAffects stroke volumeDictated by arterial blood Dictated by arterial blood pressurepressureFactors that increase Factors that increase afterloadafterload

•• Obstruction of aortic Obstruction of aortic valvevalve

•• Circulatory fluid Circulatory fluid overloadoverload



Blood pressureBlood pressureForce exerted against Force exerted against arterial wallsarterial wallsCardiac output times Cardiac output times peripheral resistanceperipheral resistance



Blood vesselsBlood vesselsArteriesArteriesArteriolesArteriolesCapillariesCapillariesVenulesVenulesVeinsVeins


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Microcirculation systemMicrocirculation systemArteriolesArteriolesCapillariesCapillariesVenulesVenules




Fluid and ElectrolytesFluid and Electrolytes

WaterWater

SolventSolventSolutesSolutes

•• ElectrolytesElectrolytes•• NonelectrolytesNonelectrolytes


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Intracellular fluidIntracellular fluid

Extracellular fluidExtracellular fluidIntravascular fluidIntravascular fluidInterstitial fluidInterstitial fluid



HomeostasisHomeostasis



ElectrolytesElectrolytesSaltsSalts

•• IonsIons——electrical currentelectrical currentCationsCations——positive chargepositive chargeAnionsAnions——negative chargenegative charge


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Cations (+ charge)Cations (+ charge)Sodium (NaSodium (Na++))Potassium (KPotassium (K++))Calcium (CaCalcium (Ca2+2+))Magnesium (MgMagnesium (Mg2+2+))

Anions ( Anions ( -- charge)charge)Chloride (CI Chloride (CI --))Bicarbonate (HCOBicarbonate (HCO33

--))Phosphate (HPOPhosphate (HPO44

22--))


Cellular MembranesCellular Membranes

SemipermeableSemipermeableAllows substances to Allows substances to pass throughpass through

PermeabilityPermeabilityDegree to which Degree to which substances are allowed substances are allowed to pass throughto pass through

Insert fig 10-15



DiffusionDiffusionMovement of particlesMovement of particles

•• SolutesSolutesPassive processPassive process


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Facilitated diffusionFacilitated diffusionTransport proteinTransport proteinPassive transportPassive transport



OsmosisOsmosisMovement of water across Movement of water across semipermeablesemipermeable membranemembrane



Active transportActive transportAcross membrane from Across membrane from ↓↓ concentration to concentration to ↑↑ concentrationconcentration

Faster than diffusionFaster than diffusion


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Isotonic solutionIsotonic solutionOsmotic pressure equal to normal body fluidOsmotic pressure equal to normal body fluid09% normal saline, 09% normal saline, lactated Ringerlactated Ringer’’ss

Hypotonic solutionHypotonic solutionOsmotic pressure less than body fluidOsmotic pressure less than body fluid

Hypertonic solutionHypertonic solutionOsmotic pressure greater than body fluidOsmotic pressure greater than body fluid


Fluid and ElectrolytesFluid and ElectrolytesThe effects of tonicity on a red blood cellThe effects of tonicity on a red blood cell


BloodBlood

Three functionsThree functionsTransportationTransportationRegulationRegulationProtectionProtection


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BloodBloodPlasmaPlasma

Fluid portionFluid portion

Erythrocytes (E)Erythrocytes (E)

Leukocytes (L)Leukocytes (L)

HemoglobinHemoglobin

HematocritHematocrit

PlateletsPlatelets


BloodBlood

AntigenAntigenProtein that triggers formation of antibodiesProtein that triggers formation of antibodies

AntibodyAntibodyProtein developed in response to an antigenProtein developed in response to an antigen

Rh factorRh factorAntigen factor considered during blood typingAntigen factor considered during blood typing


BloodBloodBlood type is determined by the antigens present on blood cell mBlood type is determined by the antigens present on blood cell membranesembranes


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AcidAcid--Base BalanceBase Balance

pHpHMeasure of relative Measure of relative hydrogen ion hydrogen ion concentrationconcentration

AcidAcid↑↑ hydrogen ion hydrogen ion concentration, pH <7.0concentration, pH <7.0

BaseBase↓↓ hydrogen ion hydrogen ion concentration, pH >7.0concentration, pH >7.0





Buffer systemsBuffer systemsFastest acting defensesFastest acting defensesAct as chemical spongeAct as chemical spongeMajor buffer systemMajor buffer system

•• Bicarbonate/carbonic acid Bicarbonate/carbonic acid


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RespirationRespirationVital roleVital roleRegulates concentration of carbon dioxideRegulates concentration of carbon dioxide

Kidney functionKidney functionRole is complexRole is complexAble to deal with alkalosis or acidosisAble to deal with alkalosis or acidosis



Primary acidPrimary acid--base imbalancesbase imbalancesRespiratory acidosisRespiratory acidosisRespiratory alkalosisRespiratory alkalosisMetabolic acidosisMetabolic acidosisMetabolic alkalosisMetabolic alkalosis


AcidAcid--Base BalanceBase Balance——Respiratory AcidosisRespiratory Acidosis


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AcidAcid--Base BalanceBase Balance——Respiratory AlkalosisRespiratory Alkalosis


AcidAcid--Base BalanceBase Balance——Metabolic AcidosisMetabolic Acidosis


AcidAcid--Base BalanceBase Balance——Metabolic AlkalosisMetabolic Alkalosis


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Stages of ShockStages of Shock

Compensated shockCompensated shock

Decompensated shockDecompensated shock

Irreversible shockIrreversible shock


Stages of ShockStages of Shock——Compensated ShockCompensated Shock




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Stages of ShockStages of Shock——DecompensatedDecompensated ShockShock


Types of ShockTypes of Shock

Primary mechanismsPrimary mechanismsFluid lossFluid lossSignificant vasodilationSignificant vasodilationPump failurePump failure


Types of ShockTypes of Shock

Hypovolemic shockHypovolemic shock

Cardiogenic shockCardiogenic shock

Neurogenic shockNeurogenic shock

Anaphylactic shockAnaphylactic shock

Septic shockSeptic shock


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Types of ShockTypes of Shock——Hypovolemic ShockHypovolemic Shock


Types of ShockTypes of Shock——Cardiogenic ShockCardiogenic Shock


Types of ShockTypes of Shock——Neurogenic ShockNeurogenic Shock


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Types of ShockTypes of Shock——Anaphylactic ShockAnaphylactic Shock


Types of ShockTypes of Shock——Anaphylactic ShockAnaphylactic Shock


Types of ShockTypes of Shock——Septic ShockSeptic Shock


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Assessment and Management Assessment and Management of the Patient in Shockof the Patient in Shock

Evaluation directed at: Evaluation directed at: assessing oxygenation assessing oxygenation perfusion of body organsperfusion of body organs

GoalsGoalsPatent airwayPatent airwayOxygenation and ventilationOxygenation and ventilationPerfusion Perfusion



Level of responsivenessLevel of responsivenessAssessed throughout surveyAssessed throughout surveyBetter indicatorBetter indicatorSignificant alteration Significant alteration Alcohol and drugsAlcohol and drugs



Airway assessmentAirway assessmentOpened and maintainedOpened and maintainedUpper airway obstructionUpper airway obstruction

•• SnoringSnoring•• GurglingGurgling•• StridorStridor


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Airway managementAirway managementAirway adjunctAirway adjunctEndotracheal intubationEndotracheal intubationSuctioning Suctioning Positioning Positioning



Breathing and oxygenation assessmentBreathing and oxygenation assessmentAdequacy of air exchangeAdequacy of air exchangeRate and depth of respirationsRate and depth of respirations



Breathing and oxygenation managementBreathing and oxygenation managementAssist breathingAssist breathing100% oxygen100% oxygenNonrebreatherNonrebreather maskmaskNasal cannulaNasal cannulaPulse oximeterPulse oximeter


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Circulation assessmentCirculation assessmentExternal bleedingExternal bleedingPulse rate and characterPulse rate and characterSkin color, appearance, temperatureSkin color, appearance, temperatureCapillary refillCapillary refill



Circulation managementCirculation managementPositioningPositioning

•• Supine Supine •• Legs elevatedLegs elevated•• Respiratory compromiseRespiratory compromise



Fluid replacementFluid replacementCommon solutionsCommon solutions

•• Lactated RingerLactated Ringer’’ssVolume replacementVolume replacement

•• 0.9% sodium chloride0.9% sodium chlorideVolume replacementVolume replacement

•• 5% dextrose in water5% dextrose in waterTo keep vein openTo keep vein open


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Fluid replacementFluid replacementBlood preparationsBlood preparations

•• Packed erythrocytesPacked erythrocytes•• PlasmaPlasma•• PlateletsPlatelets•• Whole bloodWhole blood



Maintaining body temperatureMaintaining body temperatureFactorsFactors

•• Environmental/weatherEnvironmental/weather•• Oxygen and IV fluidsOxygen and IV fluids•• Patient locationPatient location

Protect the patientProtect the patient•• Wet clothingWet clothing•• Cover patientCover patient

Vasodilation Vasodilation



Focus history and physical examinationFocus history and physical examinationThoroughness depends on patientThoroughness depends on patient’’s conditions conditionObvious lifeObvious life--threatening problemsthreatening problemsContinual reassessmentContinual reassessmentAsk the patientAsk the patient


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SummarySummary

LongLong--term survival depends on delivery of adequate term survival depends on delivery of adequate amounts of oxygen amounts of oxygen and glucose to individual cellsand glucose to individual cells

Shock is inadequate tissue perfusion, causing lack of Shock is inadequate tissue perfusion, causing lack of tissue oxygenation, tissue oxygenation, which leads to anaerobic which leads to anaerobic metabolismmetabolism

Decreased blood flow is common in shock, may Decreased blood flow is common in shock, may occur from hemorrhage, occur from hemorrhage, pump failure, or pump failure, or inappropriate systemic vascular resistanceinappropriate systemic vascular resistance


SummarySummary

Body attempts to compensate for shock by Body attempts to compensate for shock by several mechanismsseveral mechanisms

Three stages of shock are compensatory, Three stages of shock are compensatory, progressive, and irreversibleprogressive, and irreversible

Progressive shock develops when body fails Progressive shock develops when body fails to compensate for insultto compensate for insult


SummarySummary

Signs and symptoms become more apparent Signs and symptoms become more apparent during progressive shockduring progressive shock

Survival depends on prompt recognition, Survival depends on prompt recognition, rapid care, and prompt transportrapid care, and prompt transport

As shock progresses, oxygen supply to cells As shock progresses, oxygen supply to cells decreases and cells resort to decreases and cells resort to anaerobic anaerobic metabolism; leads to production of lactic acid metabolism; leads to production of lactic acid and to acidosisand to acidosis


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SummarySummary

In irreversible stage of shock, tissues dieIn irreversible stage of shock, tissues die

Trauma victim is evaluated for shock in Trauma victim is evaluated for shock in primary surveyprimary survey

Continue assessment for shock during Continue assessment for shock during secondary surveysecondary survey

Reassess for developing shock until patient is Reassess for developing shock until patient is delivered to hospitaldelivered to hospital


SummarySummary

Treatment for shock includes adequate Treatment for shock includes adequate ventilation and oxygenation and ventilation and oxygenation and further further prevention of shock processprevention of shock process

Rapid transport is imperativeRapid transport is imperative

Low blood pressure is late sign of shockLow blood pressure is late sign of shock


SummarySummary

Evaluation of shock begins with scene Evaluation of shock begins with scene survey, mechanism of injury, and survey, mechanism of injury, and historyhistory

If these factors indicate shock is or could be If these factors indicate shock is or could be present, take measures to present, take measures to counter effects of counter effects of shockshock


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Questions?Questions?


Documents

Shade et al.: Mosby’s EMT-Intermediate Textbook for the ...brainspew.com/advanced/emt/notes/intChapter_010.pdfmembrane in the function of the cell ... Revised Edition PowerPoint