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8/6/2019 Shock by Ruth
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Defined, shock is a widespread state of inadequate cellular
profusion. Shock occurs frequently and is potentially lethal. It is TIME
CRITICAL. It is for this reason all ambulance officers should be able to
recognise and treat a patient in shock early, quickly and efficiently.
Clinical shock is
NOT the same as emotional shock/distress, althoughdistress is associated with the condition.
Cell function requires a constant supply of oxygen and glucose
(glucose is the only source of food for the brain). These two
essential chemicals are supplied from the blood stream.
For this mechanism to work, there has to be adequate Blood pressure
to allow Oxygen and Glucose to cross the capillary wall and to move
to the cells. This process in referred to as perfusion.
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Fluid loss Fluid can be lost from the circulatory systemdue to injury that causes bleeding, burns that cause plasmaloss, and dehydration.
Pump Failure If the heart is damaged, e.g. M.I or
Trauma, and cannot pump enough blood to the body.
Vasodilatation In some cases the blood vessels willdilate, e.g. Spinal injuries, and the heart is unable to keepperfusion and blood pressure at normal levels.
Hypoxemia A severe chest injury, airwayobstruction, or other cause of respiratory/cardiac difficultymay prevent an inadequate amount of oxygen getting tothe blood stream. Without oxygen the bodys cells willbegin to die
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The degree of shock depends on several factors:
Amount of blood/fluid loss
Rate of blood/fluid loss
Age of patient (most elderly people are alreadydehydrated and, children do not need to lose asmuch blood as children before going into shock)
Patients overall physical condition
Patients ability to mobilise compensatorymechanisms.
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Each TYPE/CLASIFICATION of shock has its own
distinguishing signs and symptoms.
CLASSES of shock in the main refer to Hypovolemic
shock, based on blood loss.
STAGES of shock in the main refer to all other types
of shock.
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Cardiogenic
Relating to the heart and its inefficiency to act as a pump, it is unable to
pump the blood around the body.
This type of shock is seen in patients who may have had a MI, myocardialcontusions,cardiomyopathies,myocarditis,dysrhythmias,pericardial
tamponade.
Signs and symptoms; signs of MI, chest pain, nausea, syncope, ECG changes,
cardiac dysrhythmias, decreased cardiac output.
Distributive
A form of shock characterized by loss of blood vessel tone, enlargement of
the vascular compartment, and displacement of the vascular volume
away from the heart and central circulation.Seen in septic (infection), anaphylactic (allergic), and neurogenic ( general
anaesthetics, spinal injury, brain injury) shock.
Signs and symptoms; decreased cardiac output, hypocapnia, pyrexia, chills,
tremors, rigors, pink, warm dry skin, diahrrea, nausea/vomiting, rash.
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Restlessness, anxious, fearful:
Reduced oxygen levels to the brain.
Cool, clammy, pale skin, cyanotic(blue) lips:
Peripheral vasoconstriction. Vessels are constricted to maintain peripheral
resistance and blood pressure
Weak, rapid pulse (tachycardia):
Less fluid (volume) in the blood vessels, The heart speeds up to
compensate. This helps maintain cardiac output and blood pressure.
Rapid breathing (tachypnoea):
Breathing rate is increased to pack the red blood cells with oxygen.
Confusion, Altered mental status, Reduced Level of Consciousness
(L.O.C.):
Not enough oxygen to the brain. Hypoxia.
Muscle weakness:
Not enough oxygen reaching the muscles, causing loss of response
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Thirst:
A response to raise blood volume
Nausea:
Stomach and intestines are considered non-vital organs, and are shut down, causing
vomiting
Slow capillary refill (longer than two seconds):
Reduced perfusion of the skin and extremities as blood is redirected to vital organs
Dilated pupils, delayed reaction: Low perfusion and hypoxic states
Normal to slightly high blood pressure, then rapidly falling. (Going from
Compensatory shock to decompensatory shock)
As the body detects a fall in B.P with fluid volume loss ( baroreceptors in the carotid and
aortic bodies), blood vessels constrict to maintain blood pressure, then the smooth muscles
in artery walls themselves begin to suffer from oxygen depletion, and release their hold,
causing the BP to fall, This patient is in serious trouble.
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As you can see, the Human body does have defence mechanisms that it uses
when it is under attack from illness and injury. However, these mechanisms can
only be sustained for a limited time before the patient, if untreated, will die. An
understanding of the progressive stages of shock will help you determinetreatment and management of your patient.
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Classes of shock in the main refer to Hypovolemic shock
Stages of shock in the main refer to all other types of shock
Each type of shock has its own distinguishing signs andsymptom.
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Shock is progressive if untreated, and can be broken down into several stages
Pre-shock/Initial phase:
Baroreceptors detect a slight fall in BP, so the body mobilises thecompensatory mechanisms.
Compensatory: (Blood loss up to 15%, approx 500ml in a healthy adult)
In the first stage, the body is able to use its normal defences to maintainnormal perfusion and function, it can compensate. In most cases the
patient does not exhibit any signs or symptoms. As the body detects a
drop in BP, it signals the heart to increase its rate and blood vessels to
constrict in an attempt to maintain the BP. If the blood loss is stopped,the body may replenish the lost volume within 24 hours.
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Progressive or Decompensatory: (Blood loss up to 40%)
If bleeding goes on uncontrolled, then the body works tomaintain adequate perfusion to the vital organs. Blood will beshunted away from less vital organs and sent to the blood,
brain and lungs. The body cannot correct itself from this stagewithout outside assistance. The cardiovascular system is not
receiving enough oxygenated blood to maintain the
compensatory stage. The heart no longer contracts efficiently,so the blood pressure and circulatory flow drops.
Irreversible: (Blood loss over 40%)
This is a state where cell death has begun and the cardiovascular
system is no longer capable of sustaining life. Multi-system
organ damage and death of the organs has begun. If Shockreaches this magnitude, even if treated, death will result.
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Classes of shock are related to volume ofblood lost. Hence, it is important to have some
knowledge of the normal blood volumes.
Adult 5-6 Litres 65-70mls Per kg
10-11yr old child 2.5 Litres 80-85mls Per kg
3-5 yr old infant 1.5 Litres 70-76mls per kg
Infant 0.6 Litres 70-76mls per kg
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Stages of Shock compensated decompensated irreversible
Classes of Shock I II III IV
Amount of blood loss. %
TBV
40%Pulse rate Normal -slightly
increased>100 >120 >140
Pulse quality Normal Thready Thready/veryweak
No radial/ threadycarotid
Pulse pressure Normal/increased Decreased Decreased decreased
Capillary refill Normal Delayed. 3-5 sec Delayed >5 sec Delayed >5 sec
Resp rate 14 20 20 30 30 40 >35
SBP Normal Normal Decreased < 80mmHg
Greatly decreasedapprox 60mmHg
Skin colour Pink Pale Whiteextremities/ashengrey
Whiteextremities/ashengrey/ cyanotic
Skin temp Cool Cool/clammy/moist
Cool extremities Cold extremities
Mental status Normal/ slightlyanxious
Anxiety/fright/mildly anxious
Severeanxiety/confused
Lethargic/confused/ unconscious
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Task
In groups, choose a lead crew member.
Working as a team and your given scenario, what isyour management and treatment of your patient?
What type, stage of shock is your patient in?
What is the expectation and tasks asked of the secondcrew person.
You have 20 mins to complete the task, if notcompleted, your patient will be pronounced dead.
Presentation of your task with rationale to be presentedto all those present.