Transcript CBT-450-EMT12 Endocrine Emergencies

BLS 2015
Shock
Objectives
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Define shock and describe its pathophysiology
Describe the progression of shock from compensated
through irreversible
Identify the causes of shock and describe differences in
presentation
Identify indications for doing a postural blood pressure
Describe the treatment for shock
Appreciate special considerations for certain
populations, specifically pediatric and geriatric patients
Case study
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65-year-old male c/o feeling lightheaded
Pt is pale, skin cool to the touch
Vitals are BP 70P, HR 130, RR 22
What’s wrong with this patient?
Many possibilities!
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GI bleed, abdominal aneurysm, sepsis, anaphylaxis
However two things are clear:
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The patient is SICK
The patient is in shock
What is shock?
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Inadequate tissue perfusion
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Oxygenated blood can no longer reach the tissues to
support normal cellular metabolism
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What is required for adequate tissue perfusion to occur?
Tissue Perfusion
 Three components
How can problems with perfusion occur?
Perfusion Problems
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Regardless of the cause, inadequate tissue perfusion
causes problems!
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Anaerobic (“without air”) metabolism produces acids
and other harmful byproducts
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Blood is shunted away from skin, GI tract, and other
non-critical areas
Progression of Shock
 Body attempts to maintain normal perfusion
with “compensatory mechanisms” such as:
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Increased heart rate
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Peripheral vasoconstriction, shunting blood to the
core
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Hormones released by the kidney to conserve water
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Redistribution of blood from places like the spleen to
the vasculature
Stages of Shock
 Compensated shock
 Decompensated shock
 Irreversible shock
 What happens at each stage?
Compensated Shock
 Blood pressure is usually unchanged
 Mild anxiety, restlessness
 Increased heart rate; weak, thready pulse
 Capillary refill greater than 2 seconds (infants
and children)
 Cool, pale, clammy skin
 Nausea, vomiting, thirst
Decompensated Shock
 Decreasing blood pressure, usually 90 or less in
an adult
 Confusion, altered mental status
 Tachycardia
 Mottled, poorly perfused skin
 Faint or absent peripheral pulses
 Dilated pupils
Irreversible Shock
 Blood pressure difficult to measure, often 50 or
less
 Unresponsive
 Irregular, often faint respirations
 Absent peripheral pulses
 Dilated, non-reactive pupils
Causes of Shock
 Many ways to classify
 Most consider where the problem originates
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Pump (heart)
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Pipes (blood vessels)
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Fluid (blood)
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Inadequate oxygen
Hypovolemic Shock
 Loss of fluid due to:
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Trauma, GI bleed, AAA
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Diarrhea or vomiting
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Excessive urination
(diabetics with high
blood sugar)
Cardiogenic Shock
• Heart cannot pump effectively
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Heart attack
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Congestive heart failure
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Heart valve problem
Obstructive Shock
 Occurs when blood outside the heart is
blocked
 Cardiac tamponade
 Pulmonary embolus
Distributive Shock
 Occurs when the distribution of blood changes –
the pump and fluid are normal but the tank is
larger
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Spinal or neurogenic shock
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Anaphylactic shock
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Septic shock
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Psychogenic shock
Respiratory Shock
 Insufficient oxygen or problems with oxygen
delivery to the tissues
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Damage to lung tissue (for example a flail chest)
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Competition from carbon monoxide
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Cellular poisons such as cyanide
Presentation of Shock
 While the endpoint of inadequate perfusion is
the same, there are many ways to get there
 Consider –
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Patient with a GI bleed – pale, cool, wet skin
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Patient in anaphylactic shock – warm, red skin with
hives
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Patient in septic shock – hot, dry skin
 Important to recognize different etiologies of
shock
Case Study
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20-year-old female restrained driver in MVC
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Significant intrusion on driver’s side
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Pt c/o pain on left side
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Vitals BP 132/90, HR 144, R22
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Is this patient in shock?
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How would you treat this patient?
Case Study
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80-year-old male with decreased LOC
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Pt is normally A&OX3 but has been confused and slow to
respond for 24 hours, now is minimally responsive
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Vitals BP 88P, HR 148, RR 26
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Skin flushed, hot to the touch
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Pt has a history of strokes, HBP, UTI
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Is this patient in shock?
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How would you treat this patient?
Patient Assessment
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Many different causes of shock – trauma and medical
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No “one size fits all” approach
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General guidelines
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Ensure scene safety
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Initial assessment – SICK or NOT SICK?
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Age
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Overall appearance
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Position
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Distress
SICK or NOT SICK
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Hands-on evaluation
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Responsiveness/LOC
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ABCs
If SICK, do you need additional resources?
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ALS
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Additional BLS resources
Rapid Assessment and Focused Physical
 Dictated by nature of illness (NOI) and
mechanism of injury (MOI)
 Vital signs
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BP, HR, RR, skin signs, blood sugar, pulse ox
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Consider how age, meds might affect vitals
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For example, how will beta blockers affect HR?
 Repeating vitals is essential to document trends
Postural Vital Signs
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Can be an important clue if used appropriately
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Can help you decide if a stable patient has sustained
volume loss
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DO NOT perform a postural test if the patient is already
hypotensive or if the patient is suffering from a medical
condition that already requires an ALS evaluation
Postural Vital Signs
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Consider posturals
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Possible GI bleed or other internal hemorrhage
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Complaint of weakness, dizziness, lightheadedness
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Prolonged vomiting or diarrhea
DO NOT perform a postural check
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Patient who is already hypotensive (supine BP below 90)
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Woman with third trimester bleeding
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Trauma patient
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Person with suspected cardiac chest pain
Posturals, yes or no?
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25-year-old male with “GI bug” – nausea, vomiting,
diarrhea for 24 hours
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Called because he felt lightheaded
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Currently supine with BP of 118/70, HR 90, RR 16
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Would you do posturals on this patient?
Posturals – GI bug
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Postural technique
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Sit patient up in bed, wait 2 minutes, take vital signs again
Postural vitals
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BP 116/72, HR 130, RR 18
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HR increase is greater than 20 beats per minute, so patient is
considered postural
Patient would benefit from further evaluation/treatment
Posturals – yes or no?
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65-year-old female c/o abdominal pain and states she
had an episode of dark liquid stools
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She felt lightheaded so she lay down on the bed
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Vitals BP 80D, HR 130, RR 20
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Posturals?
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No, because patient is already hypotensive
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No benefit or additional information from doing posturals, and
you may make the patient worse
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Consider Trendelenburg
Patient History
 SAMPLE
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Signs/symptoms
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Allergies
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Medications
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Past medical history
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Last meal
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Events leading up to present illness/event
Patient History
 Pain/signs and symptoms
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Onset
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Provocation
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Quality
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Radiation
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Severity
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Time
Treatment
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Depends entirely on the type of shock
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Determine SICK or NOT SICK
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For all shock patients
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Monitor ABCs
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Repeat vital signs
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Administer oxygen as appropriate
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Maintain body temperature
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Request ALS evaluation if indicated
Treatment – Specific Conditions
 Hypovolemic shock
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Trauma
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Control bleeding
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Splint fractures
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Consider pelvic splint depending on MOI
Medical
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Determine amount of blood loss (e.g. GI bleed)
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Determine medications that might affect clotting (e.g. coumadin)
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If no contraindications, position in Trendelenburg
Treatment – Specific Conditions
 Cardiogenic shock (resulting from MI or CHF)
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Patients may be dyspneic and not tolerate lying
down
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Administer high flow oxygen via NRB depending on
sats
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Consider assisting with BVM if patient is nearing
respiratory failure
 Obstructive shock (tamponade or embolus)
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High flow oxygen and assist ventilations as needed
Treatment – Specific Conditions
 Neurogenic shock
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Cervical collar and backboard
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Use modified jaw thrust for airway management
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Use extreme care if immobilizing and packaging the
patient
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Observe respiratory status very closely
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Assist ventilations if needed
Treatment – Specific Conditions
 Septic shock
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If temperature is normal or low, prevent heat loss
with blankets
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Early notification of emergency room
 Anaphylactic shock
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Administer oxygen as appropriate
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Place patient in Trendelenburg if hypotensive and if
no contraindications
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Administer epinephrine if criteria are met
Treatment – Specific Conditions
 Psychogenic shock
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Keep patient supine, in Trendelenburg if no
contraindications
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Remove or diminish the trigger if possible
 Respiratory shock
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Provide high flow oxygen
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Consider assisting with BVM if indicated
Special Populations – Pediatrics
 Children can transition from appearing well to
being SICK very quickly
 Children compensate well
 By the time the blood pressure falls, amount of
blood loss may be life-threatening
 Children have smaller blood volume
 Children have larger surface to volume ratio so
they lose heat easily
Special Populations – Geriatrics
 May have rapid onset of shock
 Inelastic blood vessels, poor compensatory
mechanisms
 Medications (e.g. beta blockers) prevent
compensatory mechanisms
 High risk of septic shock
Shock – Summary
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Causes and presentation vary widely
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End point is the same – loss of perfusion and tissue
death
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Definitive care happens in the hospital, BUT –
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The patient needs to survive to get to the hospital – your
actions are critical!
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Early recognition
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Appropriate treatment
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Rapid transport