Treat for Shock

INTRODUCTION

Shock is a life-threatening condition that may result from any number of primary causes.  As a medic, you must be aware of the physiologic effects of shock to be able to detect and report what may be the development or worsening of this very serious condition. 

Identify types of shock

Definition of shock

Shock is a state of inadequate tissue perfusion resulting in decreased amount of oxygen to vital tissues and organs leading to reduced removal of waste products of metabolism

Causes of shock

(1)        Heart attack

(2)        Severe or sudden blood loss from an injury or serious illness

(3)        Large drop in body fluids, such as following a severe burn or severe vomiting and/or diarrhea

(4)        Blood poisoning from major infections

(5)        Exposure to extreme heat or cold for too long

Hypovolemic shock

(1)        Hemorrhage is the most common cause of hypovolemic shock after injury

(2)        Volume of fluid is reduced because of loss of blood, plasma, or body fluids or volume of vascular system has increased (vasodilation)

(3)        Adequate circulation cannot be maintained to all parts of the body

(4)        Can be caused by:

(a)        Severe burns

(b)        Protracted vomiting and diarrhea

(c)        Hemorrhage

(5)        Internal or external hemorrhage due to trauma such as crush injuries (hemorrhagic shock) - loss of whole blood

(6)        Clinical signs of acute hemorrhagic shock include:

(7)        Other common signs:

(a)        Progressive fall in systolic and diastolic blood pressure

(i)         Organ blood flow and tissue perfusion are the critical determinants

(ii)        Systolic blood pressure 80mmHg or below can indicate shock for normotensive patients

(iii)       Any fall in systolic blood pressure below 100mmHg or any fall of 20mmHg or more below patient's usual systolic blood pressure must be brought to the attention of the physician

(iv)       In early stages of shock, blood pressure may not fall because of body's attempt to compensate

(b)        Skin is cold, clammy and pale, caused by:

(i)         Constriction of peripheral blood vessels (cold)

(ii)        Activation of sweat glands (clammy)

(iii)       Ischemia of the cells (pale)

(c)        Cyanosis

(i)         Nail beds, lips, and ear lobes

(ii)        Lack of cyanosis may not prove absence of hypoxia

(d)        Rapid, weak, thready pulse

(i)         Rapid heart rate is a compensatory mechanism to increase cardiac output

(ii)        Narrow pulse pressure due to fall in systolic blood pressure and rise in diastolic blood pressure causes weak and thready pulse

(iii)       In later stages, pulse may be imperceptible

(e)        Shallow, rapid breathing, and grunting may be heard

(i)         Air hunger evident in earlier stages

(iii)       Rate decreases in profound shock

(f)         Subnormal temperature due to depressed heat regulating mechanism (except in bacteremic shock)

(g)        Oliguria - caused by vasoconstriction associated with diminished cardiac output resulting in a reduction in renal blood flow

(h)       Listlessness, stupor, and loss of consciousness as condition deteriorates

Non-hemorrhagic shock

Cardiogenic shock

(a)        A decrease in the contractions/contractile ability of the myocardium.  Heart fails to circulate blood efficiently to the tissues. From MI etc.

(b)        A reduction in cardiac output results in:

(i)         Decreased circulating blood supply

(ii)        Decreased oxygen delivery

(c)        Assess for blunt trauma to the chest.  Can be caused by:

(i)         Cardiac tamponade

(ii)        Cardiac dysrhythmias

(iii)       Myocardial infarction

(iv)       Cardiac contusions

(d)        Also assess for:

(i)         Tachycardia

(ii)        Muffled heart sounds

(iii)       Engorged neck veins with hypotension

(iv)       Dyspnea

(v)        Edema in feet and ankles

Septic shock

(a)        Overwhelming bacterial infection

(i)         Result of vasodilation of small blood vessels in wound area

(ii)        General vasodilation if infection has entered the bloodstream

(b)        Major cause - endotoxin release by these microorganisms

(c)        Most common cause - gram negative organisms

(d)        Common conditions that predispose to sepsis

(i)         Diabetes

(ii)        Cirrhosis

(iii)       Post partum

(iv)       Post abortion infections

(e)        Septic shock usually does not develop for 2 to 5 days after an injury and the medic will not often see it in a first aid situation

(f)         This type of shock carries a poor prognosis and must always be treated under the direct supervision of a medical officer.

(g)        The medic should assess for:

(i)         Penetrating abdominal injuries

(ii)        Signs of infection

(iii)       Warm pink skin and dry elevated body temperature

(iv)       Tachycardia

(v)        Wide pulse pressures

Neurogenic shock

(a)        Insult to the nervous system which leads to decreased arterial resistance

(b)        Vasodilation -- as result of loss of sympathetic nervous system control over the size of the arterioles

(c)        Can be caused by:

(i)         Spinal cord injury

(ii)        Certain drugs

(iii)       Brain stem, spinal or torso trauma

(d)        Signs and Symptoms:

(i)         Hypotension without tachycardia

(ii)        Warm pink skin

(iii)       Low blood pressure

Anaphylactic shock/Vasogenic shock

(a)        Diffuse vasodilation results in an increase in the size of the vascular bed

(b)        Blood is trapped in small vessels and in viscera and is temporarily lost to total circulatory volume

(c)        Sudden severe allergic reaction to:

(i)         Drug

(ii)        Foreign substance

(iii)       Toxin

(iv)       Insect stings (i.e. wasps, bees, hornets, ants, yellow jackets)

(v)        Food

(vi)       Animal serum

(vii)      Plants (i.e. poison oak, poison ivy and sumae)

(d)        Onset usually begins within 30 minutes after exposure to causative factor

(i)         Reaction usually progresses in explosive manner

(ii)        Peak intensity within 1 hour

(e)        Primary anaphylactic shock organs - Respiratory and cardiovascular events account for a majority of mortality associated with anaphylaxis.

(i)         Cardiovascular

(ii)        Respiratory

(iii)       Cutaneous

(iv)       Gastrointestinal

(v)        Circulatory

(f)         Symptoms

(i)         Apprehension and flushing

(ii)        Tightness in chest or difficulty breathing due to bronchi constriction

(iii)       Wheezing or shortness of breath

(iv)       Rapid, weak pulse

(v)        Cyanosis

(vi)       Generalized itching or burning

(vi)       Sneezing or coughing

(viii)      Watering and itching of the eyes

(ix)       Hives

(x)        Blood pressure drops, dizziness/faintness, swelling/edema, especially of face, tongue

(xi)       Coma

(g)        Consider an epinephrine injection, if indicated and authorized under protocol

Severity of Shock

(1)        Compensated shock

(a)        First stage

(b)        Normal body defense mechanisms maintain perfusion and function

(2)        Decompensated shock

(a)        Second stage

(b)        Blood shunted from less to more vital organs

(3)        Irreversible shock

(a)        Third and final stage

(b)        Multiple system organ damage

(c)        Even with treatment, death is the result

Assess for shock

Determine history of shock

(1)        Is there internal or external hemorrhage underling cardiac problems sepsis trauma to spine cord, drugs or other sensitize substance contact?

(2)        Determine amount of blood loss

(3)        Determine how long casualty has been bleeding

Determine level of consciousness.  Report and record, using AVPU:

(1)        Alert

(2)        Verbal response to stimuli

(3)        Pain response to stimuli

(4)        Unresponsive to any stimuli

Early Signs of shock include:

(1)        Soldier must have high index of suspicion

(2)        Minimum tachycardia

(3)        No measurable changes occur in blood pressure, pulse pressure or respiratory rate

Other common signs:

(1)        Decrease in systolic and increase in diastolic resulting in narrow pulse pressure

(a)        Organ blood flow and tissue perfusion are the critical determinants

(b)        Systolic blood pressure 80mmHg or below can indicate shock for normotensive patients

(c)        Any fall in systolic blood pressure below 100mmHg or any fall of 20mmHg or more below patient's usual systolic blood pressure must be brought to the attention of the physician

(d)        In early stages of shock, blood pressure may not fall because of body's attempt to compensate

(2)        Skin is cold, clammy and pale, caused by:

(a)        Constriction of peripheral blood vessels (cold)

(b)        Activation of sweat glands (clammy)

(c)        Ischemia of the cells (pale)

(3)        Cyanosis

(a)        Nail beds, lips, and ear lobes

(b)        Lack of cyanosis may not prove absence of hypoxia

(4)        Rapid, weak, thready pulse

(a)        Rapid heart rate is a compensatory mechanism to increase cardiac output

(b)        Narrow pulse pressure due to fall in systolic blood pressure and rise in diastolic blood pressure causes weak and thready pulse

(c)        In later stages, pulse may be imperceptible

(5)        Shallow, rapid breathing, and grunting may be heard

(a)        Air hunger evident in earlier stages

(b)        Rate decreases in profound shock

(6)        Subnormal temperature due to depressed heat regulating mechanism (except in septic shock)

(7)        Oliguria - caused by vasoconstriction associated with diminished cardiac output resulting in a reduction in renal blood flow

(8)        Listlessness, stupor, and loss of consciousness as condition deteriorates

Provide medical care

Treatment for Hypovolemic Shock

(1)        The goal of treating shock is to increase tissue perfusion and oxygenation status.  The treatment will vary according to type of shock.

(2)        Maintain airway 

(a)        Ensure open airway using head-tilt/chin-lift or jaw-thrust

(b)        Provide oxygen therapy once at BAS

(3)        Control bleeding

(a)        Direct pressure

(b)        Elevation

(c)        Pressure points

(d)        Tourniquet if indicated

(4)        Obtain baseline vital signs and level of consciousness

(5)        Position casualty

(a)        On back with legs elevated 6 to 12 inches

(b)        Place casualty so that head is lower than the feet if possible (except in head injury)

(c)        If vomiting or bleeding around mouth, place on side or back with head turned to side (except in head injury)

(d)        If you suspect head or neck injuries, or are unsure of casualty's condition, keep them lying flat.

(6)        Keep patient at normal temperature.  Attempt to maintain normal body temperature, to prevent hypothermia and minimize effect of shock

(7)        Fluid therapy

(a)        Intravenous fluid administration is the single most important factor in treatment of any type of shock except cardiogenic shock

(b)        Two 16 gauge IV's ACF Bilateral

(c)        Normal saline is adequate until properly cross-matched whole blood can be administered

(i)         Replace lost blood volume

(ii)        Replace lost extracellular fluid

(d)        All shock is severe, immediate administration of fluids is warranted.  Delay transportation

(8)        Drug therapy

(a)        To correct specific cardiac problems, only if ordered by MD

(9)        Provide on-going assessment

(a)        Monitor level of consciousness

(b)        Monitor blood pressure

(c)        Monitor heart rate

(d)        Monitor respiratory rate

(e)        Monitor vital signs

(f)         Monitor skin response

Treatment for Septic Shock 

(1)        Securing the airway is the first priority

(2)        Administer oxygen, if available

(3)        Obtain baseline vital signs and level of consciousness

(4)        Position casualty

(a)        On back with legs elevated 6 to 12 inches

(b)        Place casualty so that head is lower than the feet if possible (except in head injury)

(c)        If you suspect head or neck injuries, or are unsure of casualty's condition, keep them lying flat.

(5)        Keep patient at normal temperature.  Attempt to maintain normal body temperature, to prevent hypothermia and minimize effect of shock.

(6)        Fluid therapy

(a)        Intravenous fluid administration is the second most important factor in treatment of any type of shock except cardiogenic shock

(b)        Two 16 gauge IV's ACF Bilateral

(c)        Normal saline is adequate until properly cross-matched whole blood can be administered

(i)         Replace lost blood volume

(ii)        Replace lost extracellular fluid

(d)        All shock is severe, immediate administration of fluids is warranted. 

(7)        Drug therapy

(a)        Dependent on source of infection

(b)        Administer empiric antibiotic as ordered by MD

(8)        Provide on-going assessment

(a)        Perform serial neurological exams

(b)        Monitor blood pressure

(c)        Monitor heart rate

(d)        Monitor respiratory rate

(e)        Monitor vital signs

(f)         Monitor skin response

Treatment for Neurogenic Shock

NOTE:            Diagnosis of Neurogenic shock is one of exclusion

(1)        Securing the airway is the first priority

(2)        Administer oxygen, if available

(3)        Obtain baseline vital signs and level of consciousness

(4)        Position casualty

(a)        On back with legs elevated 6 to 12 inches

(b)        Place casualty so that head is lower than the feet if possible (except in head injury)

(c)        If vomiting or bleeding around mouth, place on side or back with head turned to side (except in head injury)

(d)        If you suspect head or neck injuries, or are unsure of casualty's condition, keep them lying flat.

(5)        Keep patient at normal temperature.  Attempt to maintain normal body temperature, to prevent hypothermia and minimize effect of shock.

(6)        Fluid therapy

(a)        Intravenous fluid administration is the single most important factor in treatment of any type of shock except cardiogenic shock

(b)        Two 16 gauge IV's ACF Bilateral

(c)        Normal saline is adequate until properly cross-matched whole blood can be administered

(i)         Replace lost blood volume

(ii)        Replace lost extracellular fluid

(d)        All shock is severe, immediate administration of fluids is warranted. 

(7)        Drug therapy

(a)        High dose corticosteriods given intravenously over the first two – three days.  Ordered by MD.

(8)        Provide on-going assessment

(a)        Monitor level of consciousness

(b)        Monitor blood pressure

(c)        Monitor heart rate

(d)        Monitor respiratory rate

(e)        Monitor vital signs

(f)         Monitor skin response

Treatment for Anaphylactic shock

(1)        Securing the airway is the first priority

(2)        Exposure to the causative agent, if identified, must be terminated if ongoing

(3)        First-line therapies, during acute stage of anaphylaxis

(a)        Epinephrine

(b)        IV fluids

(c)        Oxygen (may be limited until reach BAS)

(4)        Second-line therapies the soldier medic may use to prevent recurrences and treat anaphylaxis refractory to the first-line treatments

(a)        Antihistamines

(b)        Corticosteroids

(5)        Evacuate

SUMMARY

Shock is a very serious condition which requires early detection and prompt medical intervention.  As a medic, you must monitor those casualties susceptible to shock and be prepared to assist with the appropriate medical management.  Early identification and treatment of shock is imperative in preventing serious injury and death.