Transcript ch08b - SchultzMedic

Paramedic Care:
Principles & Practice
Volume 1
Introduction to Advanced
Prehospital Care
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Chapter 8
General Principles of
Physiology and
Pathophysiology
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Chapter 8, Part 2
Disease—Causes and
Pathophysiology
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Part 2 Topics
Genetic and Other Causes of Disease
Hypoperfusion
Types of Shock
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Genetic and Other
Causes of Disease
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Genetic and Other
Causes of Disease
Many diseases result from genetic causes.
Many diseases result from a combination of
genetic and environmental factors as well as
age and gender.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Genetics, Environment,
Lifestyle, Age, and Gender
Inherited traits are determined by molecules
of deoxyribonucleic acid, or DNA.
– Form genes that reside on chromosomes
– Somatic cells (all the cells except the sex cells)
contain 46 chromosomes
– Sex cells contain 23 chromosomes
Offspring receive 23 from mother and 23 from father
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Genetics, Environment,
Lifestyle, Age, and Gender
Abnormal genes or chromosomes may
cause a congenital disease or a propensity
toward acquiring a disease.
Some diseases are thought to be purely
genetic.
Other diseases are caused by a
combination of genetic and environmental
factors.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Disease Effects on Individuals
Related to Host, Agent, and Environment
– Host
Genetic predisposition, gender, and ethnic origin are
determinants related to the host.
– Agent
Bacterium, toxin, gunshot, or other pathophysiological
process
– Environment
Local climate, socioeconomic or demographic features,
culture, religion, and associated factors
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Disease Effects
on Populations
Epidemiologists generally report disease
data with three basic measures: incidence,
prevalence, and mortality.
Morbidity is reported as incidence and
prevalence.
– Incidence is occurrence of disease
– Prevalence is the proportion of total population
effected
Mortality is the occurrence of death.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Family History and
Associated Risk Factors
Immunologic
disorders
Cancer
Endocrine
disorders
Hematologic
disorders
Cardiovascular
disorders
Renal disorders
Rheumatic
disorders
Gastrointestinal
disorders
Psychiatric
disorders
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Immunologic Disorders
A number of immunologic disorders are
more prevalent among those with a family
history of the disorder.
– Rheumatic fever, allergies, and asthma
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cancer
Some types of cancer tend to cluster in
families and seem to have a combination
of genetic and environmental causes.
– Breast cancer
– Colorectal cancer
– Lung cancer
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Endocrine Disorders
The most common endocrine disorder is
diabetes mellitus.
Both Type I and Type II diabetes can be
family related.
Causes of diabetes are complex and still not
well understood.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hematological Disorders
There are many causes of hereditary
hematological disorders such as gene
alteration and histocompatibility (tissue
interaction) dysfunctions.
– Hemophilia
– Hemochromatosis
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cardiovascular Disorders
The cardiovascular system can be greatly
affected by genetic disorders.
–
–
–
–
–
Elongation of the QT interval
Mitral valve prolapse
Coronary artery disease
Hypertension
Cardiomyopathy
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Renal Disorders
Caused by a variety of factors, primarily
hypertension
May eventually require a patient to receive
dialysis treatment several times a week
– Problems with vascular access devices
– Localized infection and sepsis
– Electrolyte imbalances
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Rheumatic Disorders
Gout is a disorder both genetic and
environmental characterized by the deposit
of crystals in the joints, most commonly the
great toe.
The crystals form as a result of abnormally
high levels of uric acid in the blood.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Gastrointestinal Disorders
Lactose intolerance
Crohn’s disease
Peptic ulcers
Cholecystitis
Obesity
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Neuromuscular Disorders
Diseases of the nervous and muscular
systems include:
– Huntington’s disease
– Multiple sclerosis
– Alzheimer’s disease
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Psychiatric Disorders
Genetic and biological causes of these
disorders are being studied and increasingly
understood.
– Schizophrenia
– Manic-depressive illness (bipolar disorder)
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hypoperfusion
Progressive cycle of pathophysiological
events
– Fatal if not corrected
Although causes differ, all forms of shock
have the same underlying pathophysiology at
the cellular and tissue levels.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Progression of Shock
Cellular Death
Tissue Death
Organ Death
Organ System Death
Organism Death
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Physiology of Perfusion
Body cells require a constant supply of
oxygen and other essential nutrients.
– Accomplished by the passage of blood through
the capillaries.
The constant and necessary passage of
blood through the body’s tissues is called
perfusion.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Components of the
Circulatory System
The pump (heart)
The fluid (blood)
The container
(blood vessels)
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Pump
The heart is the pump of the cardiovascular
system.
– Receives blood from the venous system, pumps
it to the lungs for oxygenation, and then pumps
it to the peripheral tissues.
The amount of blood ejected by the heart in
one contraction is referred to as the stroke
volume.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Stroke Volume
Factors affecting stroke volume:
– Preload
Amount of blood delivered to the heart during diastole
– Cardiac contractile force
The strength of contraction of the heart
– Afterload
The resistance against which the ventricle must
contract
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cardiac Output
Cardiac output is the amount of blood
pumped by the heart in one minute.
An increase in stroke volume or an increase
in heart rate can increase cardiac output.
SV x HR = CO
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Blood Pressure
Peripheral vascular resistance is the
pressure against which the heart must
pump.
Increasing cardiac output or peripheral
vascular resistance will increase blood
pressure.
CO x PVR = BP
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Blood Pressure
Peripheral Vascular Resistance
– Blood pressure maintained by compensatory
mechanisms and negative feedback loops
– Baroreceptors
Increased pressure causes a decreased heart rate,
preload, and peripheral vascular resistance
Decreased pressure stimulates vasoconstriction and
adrenal hormone release
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Fluid
Blood is thicker and more adhesive than
water.
Blood consists of plasma and the formed
elements.
– Red cells, white cells, platelets
Nutritional function
An adequate amount of blood is needed for
perfusion, and volume must be adequate to
fill the container.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Fluid
Natriuretic Hormone
– Endocrine function of the heart
– Involved in the long-term regulation of sodium
and water balance, blood volume, and arterial
pressure
– Natriuretic peptides
Atrial natriuretic peptide (ANP)
Released by atrial muscle cells in response to such
things as atrial distension and sympathetic stimulation
Brain natriuretic peptide (BNP)
Released by ventricular muscle cells in response to
ventricular dilation and sympathetic stimulation
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Fluid
Natriuretic Hormone (cont.)
– Counterregulatory system to the reninangiotensin system
Decreases aldosterone release
Produces natriuresis (sodium loss) and diuresis (water
loss)
Decreases renin release
– BNP levels are elevated in congestive heart
failure
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Container
Blood vessels
– A continuous, closed, and pressurized pipeline
by which blood moves throughout the body
Autonomic regulation
Microcirculation
– Comprised of the small vessels: arterioles,
capillaries, and venules
– Responsive to local tissue needs
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Container
Capillaries
– The precapillary sphincter opens in response to
local tissue demands such as acidosis and
hypoxia.
– The postcapillary sphincter opens when blood is
to be emptied into the venous system.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Blood Flow Regulation
Blood flow through the vessels is regulated
by two factors:
– Peripheral vascular resistance
– Pressure within the system
Vessels with larger inside diameters offer
less resistance.
Vessels with smaller diameters offer more
resistance.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Blood Flow Regulation
Click here to view an animation on capillary pressure.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Blood Flow Regulation
A significant change in peripheral resistance
occurs at the arterioles and precapillary
sphincters.
– Local tissue needs and sympathetic stimulation
Contraction of the venous side of the
vascular system
– Decreased capacitance and increased cardiac
preload
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Oxygen Transport
Surrounding the alveoli are capillaries that
are perfused by the pulmonary circulation.
– Alveolar air is far richer in oxygen than blood
that enters the pulmonary capillaries.
– Oxygen from the alveoli diffuses across the
alveolar-capillary membrane.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Oxygen Transport
Oxygen binds to the hemoglobin molecules
of the red blood cells.
– 97% of oxygen is transported reversibly bound
to hemoglobin.
– 3% of oxygen is transported as a gas dissolved
in the plasma.
Oxygen-enriched blood is pumped
throughout the body via systemic circulation.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Oxygen Transport
The oxygen-rich blood interfaces with the
tissues in capillary beds.
– Cells in tissue are oxygen-deficient.
– Partial pressure of oxygen is greater in the
bloodstream than in the cells.
– Oxygen will diffuse from the red blood cells
across the capillary wall.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Oxygen Transport
The movement and utilization of oxygen in
the body is dependent upon the following
conditions:
– Adequate concentration of oxygen
– Appropriate movement of oxygen across the
alveolar/capillary membrane
– Adequate number of red blood cells
– Proper tissue perfusion
– Efficient off-loading of oxygen at the tissue level
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Waste Removal
The waste products of cellular metabolism
are expelled from the cells and carried away
by the blood.
The majority of carbon dioxide
(approximately 70%) is transported in the
form of bicarbonate ion (HCO3¯).
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Waste Removal
Some cellular waste products are picked up
by the lymphatic system.
Waste is cleansed from the blood by the
kidneys and excreted as urine.
Some cellular waste products are expelled
in the feces.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Waste Removal
There is some local control of both tissue
perfusion and waste removal.
Local acidosis causes nearby pre-capillary
sphincters to relax.
Increases perfusion of the affected tissues
– Provides increased capacity for waste
elimination
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hypoperfusion
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Causes of Hypoperfusion
Inadequate pump
– Decreased preload, inadequate contractile
strength, inadequate rate, or excessive afterload
Inadequate fluid
–
Hypovolemia
Inadequate container
– Dilated container without change in fluid volume
(inadequate systemic vascular resistance)
– Leak in the container
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Shock at the Cellular Level
Shock is inadequate tissue perfusion.
Ultimate outcome is impairment of cellular
metabolism.
Two characteristics of impaired cellular
metabolism:
– Impaired oxygen use
– Impaired glucose use
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Impaired Use of Oxygen
When cells don’t receive enough oxygen or
cannot use it effectively, they change from
aerobic to anaerobic metabolism.
– A far less efficient means of producing energy.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Impaired Use of Oxygen
Glycolysis
– Stage 1
Anaerobic
Inefficient
– Stage 2
Aerobic
Efficient
Hypoperfusion
does not allow
stage 2
glycolosis
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Impaired Use of Oxygen
Accumulation of lactic acid
– The acidic condition of the blood reduces the
ability of hemoglobin in red blood cells to bind
with and carry oxygen.
– Cellular stores of ATP are used up much faster
than they can be replaced.
– Cellular death then occurs.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Impaired Use of Glucose
Factors that reduce delivery of oxygen to the
cells also reduce delivery of glucose to the
cells.
– Also by:
Fever
Cell damage
The presence of bacteria or toxins
Histamine or other substances produced by the body’s
immune and inflammatory responses
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Impaired Use of Glucose
Glucose that is prevented from entering the
cells remains in the blood.
– Certain body cells can create fuel for energy
production by converting other substances to
glucose.
Glycogenolysis
Lipolysis
Waste products of metabolism build up in
the cells, further impairing cell function and
damaging cell membranes.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Compensation and
Decompensation
Usually the body is able to compensate for
metabolic processes in order to maintain
homeostasis through perfusion.
When the various compensatory mechanisms
fail, shock develops.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Compensation Mechanisms
The fall in arterial blood pressure is a
negative feedback mechanism.
– Catecholamines, epinephrine, and
norepinephrine may be secreted
– The renin-angiotensin system aids in
maintaining blood pressure
– Secretion of anti-diuretic hormone (ADH)
– Splenic discharge
– Shunting
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Variations
Compensated shock
– The early stage of shock when the body’s
compensatory mechanisms are able to maintain
perfusion
Decompensated shock
– Compensatory mechanisms may not be able to
restore normal function
– Intervention may still be able to correct the
condition
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Variations
Irreversible shock
– Correction is no longer possible
– Cardiac depression
Myocardium has a greatly increased demand for
oxygen
Coronary blood flow is reduced; cardiac output falls
more
– Cellular deterioration progresses to tissue
deterioration, which progresses to organ failure.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Types of Shock
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Types of Shock
Cardiogenic
Hypovolemic
Neurogenic
Anaphylactic
Septic
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cardiogenic Shock
The heart loses its ability to supply all body
parts with blood
Usually the result of left ventricular failure
secondary to acute myocardial infarction or
CHF
Many patients will have normal blood
volume
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cardiogenic Shock
Evaluation
– Difference between cardiogenic shock and other
types of shock is the presence of pulmonary
edema
Wheezes or crackles (rales) may be heard
There may be a productive cough with white or pinktinged foamy sputum
– Cyanosis, altered mentation, and oliguria
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cardiogenic Shock
Treatment
– Treat for shock
Assure an open airway, administer oxygen, assist
ventilations as necessary, keep the patient warm
– Elevate the patient’s head and shoulders
– Establish IV access with minimal fluid
administration
– Monitor the heart rate
– Dopamine or dobutamine may be administered
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hypovolemic Shock
Shock due to loss of intravascular fluid
Causes of hypovolemia
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Internal or external hemorrhage
Trauma
Long-bone or open fractures
Dehydration
Plasma loss from burns
Excessive sweating
Diabetic ketoacidosis with resultant osmotic
diuresis
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hypovolemic Shock
Hypovolemic shock can also be due to
internal third-space loss.
– Bowel obstruction, peritonitis, pancreatitis, or
liver failure resulting in ascites
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hypovolemic Shock
Evaluation
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Altered level of consciousness
Pale, cool, clammy skin
Blood pressure may be normal, then fall
Pulse may be normal then become rapid, finally
slowing and disappearing
– Urination decreases
– Cardiac dysrhythmias may occur
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hypovolemic Shock
Treatment
– Airway management, supplemental
oxygenation, assisted ventilations (if necessary),
hemorrhage control, and rapid transport
– Administer a bolus of crystalloid solution for fluid
replacement
Non-trauma or no blood loss:
Bolus crystalloid or colloid solutions
Trauma or blood loss:
“Permissive hypotension.” – SBP of 70-85 mmHg
PASG if part of local protocol
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Neurogenic Shock
Injury to brain or spinal cord causes an
interruption of nerve impulses to the arteries
– The arteries dilate causing relative hypovolemia
– Sympathetic impulses to the adrenal glands are
lost
Prevents the release of catecholamines with their
compensatory effects
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Neurogenic Shock
The arteries lose tone and dilate, causing a
relative hypovolemia
A disproportionate amount of blood collects
in the capillary bed
– Reduces venous return, cardiac output, and
arterial blood pressure
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Neurogenic Shock
Evaluation
– Warm, dry, red skin
– Low blood pressure
– Slow pulse
The lack of compensatory stimulation from
catecholamine release
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Neurogenic Shock
Treatment
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Airway control
Maintain body temperature
Immobilization of patient
Consider other possible causes of shock
IV access and medications that increase
peripheral vascular resistance
Norepinephrine (Levophed) and dopamine (Intropin)
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anaphylactic Shock
A severe immune response to a foreign
substance
Signs and symptoms most often occur
within a minute
The most rapid reactions are in response to
injected substances:
– Penicillin injections
– Stings from bees, wasps, hornets
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anaphylactic Shock
Evaluation
– Because immune responses can affect different
body systems, signs and symptoms vary widely.
Skin:
Flushing, itching, hives, swelling, cyanosis
Respiratory system:
Breathing difficulty, sneezing, coughing, wheezing,
stridor, laryngeal edema, laryngospasm
Cardiovascular system
Vasodilation, increased heart rate, decreased blood
pressure
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anaphylactic Shock
Evaluation
– Gastrointestinal system:
Nausea, vomiting, abdominal cramping, diarrhea
– Nervous system:
Altered mental status, dizziness, headache, seizures,
tearing
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anaphylactic Shock
Treatment
– Airway protection
May include endotracheal intubation
– Establish an IV of crystalloid
solution
– Pharmacological intervention:
Epinephrine, antihistamines, corticosteroids,
vasopressors, inhaled beta agonists
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Septic Shock
An infection that enters the bloodstream and
is carried throughout the body
Toxins released overcome the
compensatory mechanisms
Can cause the dysfunction of an organ
system or result in multiple organ
dysfunction syndrome
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Septic Shock
Evaluation
– The signs and symptoms are progressive
Increased to low blood pressure
High fever, no fever, or hypothermic
Skin flushed, pale, or cyanotic
Difficulty breathing and altered lung sounds
Altered mental status
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Septic Shock
Treatment
–
–
–
–
Airway control
IV of crystalloid solution
Dopamine to support blood pressure
Monitor heart rhythm
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Multiple Organ
Dysfunction Syndrome
Progressive impairment of two or more
organ systems
– An uncontrolled inflammatory response to a
severe illness or injury
Sepsis and septic shock are the most
common causes of MODS
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Multiple Organ
Dysfunction Syndrome
Stages of MODS
– Primary Stage
Results directly from a specific cause
Neutrophils and macrophages as well as mast cells
are thought to be “primed” by cytokines
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Multiple Organ
Dysfunction Syndrome
Stages of MODS
– Secondary Stage
Primed cells are activated, producing an exaggerated
inflammatory response
Inflammatory response enters a self-perpetuating
cycle
Triggers an exaggerated neuroendocrine response
A massive immune/inflammatory and coagulation
response develops
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Clinical Presentation of MODS
Usually will develop over a period of 2, 3, or
more weeks
There is no specific therapy for MODS
MODS will usually be detected in the
hospital
– EMS may encounter patient following discharge
or during transfer
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Part 2 Summary
Genetic and Other Causes of Disease
Hypoperfusion
Types of Shock
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 1: Introduction to Advanced Prehospital Care, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ