hypoperfusion and shock. © 2009 naemt hypoperfusion common problem extent makes resuscitation...
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Hypoperfusion and ShockHypoperfusion and Shock
© 2009 NAEMT
HypoperfusionHypoperfusion
Common problem Extent makes resuscitation
difficult Shock due to hypoperfusion Start fluid resuscitation as soon
as possible
© 2009 NAEMT
OverviewOverview
Describe differences between compensated and uncompensated shock
Review differences of distributive, non-distributive and obstructive shock
Explore pathophysiology for different etiologies of shock
Discuss interventions for early and late shock
© 2009 NAEMT
PhysiologyPhysiology
BP = Cardiac Output x Systemic ResistanceCardiac Output = Stroke Volume x Heart Rate
Pre-load = Blood returned to heart
Starling’s Law = Amount of cardiac muscle stretch
After-load = Resistance to blood being ejected
NHTSA
LifeART
© 2009 NAEMT
Shock Compensation Children vs. Adults
Shock Compensation Children vs. Adults
Children Increased heart
rate Vasoconstriction Prolonged
compensation Rapid
decompensation
Adults Increased stroke
volume Vasoconstriction Tachycardia Slow, but
sustained compensation
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Hypovolemic Hemorrhagic Metabolic
Categories of ShockNon-Distributive
Categories of ShockNon-Distributive
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Anaphylaxis Septic Neurogenic
Categories of ShockDistributive
Categories of ShockDistributive
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Pulmonary embolus Tension pneumothorax Cardiac
tamponade
Categories of ShockObstructive
Categories of ShockObstructive
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Emesis and diarrhea Osmotic diuresis from diabetes Internal or external blood loss Plasma loss from sepsis or
anaphylaxis
Etiologies of Hypoperfusion (Common)
Etiologies of Hypoperfusion (Common)
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Etiologies of Hypoperfusion (Uncommon)
Etiologies of Hypoperfusion (Uncommon)
Medications required to Medications required to restore perfusionrestore perfusion
Spinal cord injury Cardiac failure
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Severity of HypoperfusionCompensated
Severity of HypoperfusionCompensated
Compensated Decompensated
Time
Signs are due to inadequate
tissue perfusion
Compensated shock is
reversible with fluids
Volume
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Volume
Altered Mental Status
Severity of HypoperfusionCompensated Shock Signs
Severity of HypoperfusionCompensated Shock Signs
Decompensated
AVPU
Time
Breathing
Pulse
BloodPressure
Compensated
© 2009 NAEMT
Volume
Severity of HypoperfusionCompensated Shock Signs
Severity of HypoperfusionCompensated Shock Signs
Decompensated
Time
Compensated
Weak peripheral
pulses, strong central pulses
Weak or absent peripheral
pulses, weak central pulses
DecompensatedCompensated
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Severity of HypoperfusionDehydration Testing
Severity of HypoperfusionDehydration Testing
Hypovolemic patientHypovolemic patient’’s skin s skin will will ““tenttent””
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Severity of HypoperfusionDecompensated Shock
Severity of HypoperfusionDecompensated Shock
Compensated Decompensated
Time
Body is unable to continue
compensation
Inadequate tissue perfusion
to all organs
Volume
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Severity of HypoperfusionDecompensated Shock Signs
Severity of HypoperfusionDecompensated Shock Signs
Volume
Altered Mental Status
Decompensated
AVPU
Time
Breathing
Pulse
BloodPressure
VP
U
Weak or absent peripheral pulses, weak central pulses
Compensated
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Severity of HypoperfusionDecompensated Shock Signs
Severity of HypoperfusionDecompensated Shock Signs
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AssessmentAssessment
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Scene SurveyScene Survey
Hazards to you, your partner, Hazards to you, your partner, the patient and bystandersthe patient and bystanders
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First ImpressionPediatric Assessment Triangle
First ImpressionPediatric Assessment Triangle
Compensated or decompensatedCompensated or decompensated
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First ImpressionGeneral Appearance
First ImpressionGeneral Appearance
Observe interactions Not sick - attentive to environment,
focus on familiar people and objects, alert for threats
Good brain function requires adequate oxygenation, ventilation, cerebral perfusion
Sick - does not care you are present or recognize parents
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First ImpressionGeneral Appearance
First ImpressionGeneral Appearance
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Muscle tone Spontaneous movements Skin color Other signs of distress
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First ImpressionWork of Breathing
First ImpressionWork of Breathing
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First ImpressionCirculation to the Skin
First ImpressionCirculation to the Skin
Skin color, capillary refill, Skin color, capillary refill, distal vs. central pulsesdistal vs. central pulses
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First ImpressionFirst Impression
Significant MOI?Significant MOI?
SickSick
Rapid Initial AssessmentRapid Initial Assessment
Appropriate InterventionsAppropriate Interventions
Transport PriorityTransport Priority
Transport MethodTransport Method
Transport DestinationTransport Destination
RelationshipRelationship
Involve FamilyInvolve Family
Detailed HistoryDetailed History
Focused Physical ExamFocused Physical Exam
Yes
No
Not SickNot Sick
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Loss of airway may occur in
decompensated shock
Initial AssessmentAirway
Initial AssessmentAirway
Identify and treat life Identify and treat life threatsthreats
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Administer OAdminister O22 and and
treat causetreat cause
Initial AssessmentBreathing
Initial AssessmentBreathing
Rate effort and volume
Abnormal sounds
Assess for chest trauma
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Initial AssessmentCirculation
Initial AssessmentCirculation
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CompensatedWeak peripheral pulses,
strong central pulses
DecompensatedWeak or absent peripheral pulses, weak central pulses
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Initial AssessmentCirculation Management – Intravenous
Initial AssessmentCirculation Management – Intravenous
Fluid bolus if any signs of shock Early recognition of hypoperfusion
and fluid resuscitation are key Select a large bore catheter Location close to central circulation Two IVs may be needed
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Initial AssessmentCirculation Management – Intraosseous
Initial AssessmentCirculation Management – Intraosseous
Can be used on any age Can be used on any age childchild
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Intraosseous SpaceBlood Flow
Intraosseous SpaceBlood Flow
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AnatomyNeonate Leg Cross Section
AnatomyNeonate Leg Cross Section
Skin
Subcutaneous Fat
Intraosseous Catheter
Tibia
Fibula
Posterior Compartment
Anterior Compartment
Lateral Compartment
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Other IssuesIO Insertion
Other IssuesIO Insertion
Depth based on patient size and weight Gently insert catheter Advance catheter slowly Feel needle drop into medullary space Frequently monitor insertion site and
extremity Need hands-on training
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IO Insertion Anatomical Landmarks
IO Insertion Anatomical Landmarks
Patella
TibialTuberosity
MedialTibia
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IO Insertion Unable to Palpate Tibial Tuberosity
IO Insertion Unable to Palpate Tibial Tuberosity
Finger Width
Finger Width
Often difficult or impossible Often difficult or impossible to palpateto palpate
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IO Insertion Able to Palpate Tibial Tuberoisty
IO Insertion Able to Palpate Tibial Tuberoisty
Finger Width
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AnatomyNeonate Leg Cross Section
AnatomyNeonate Leg Cross Section
Fibula
Traditional IO Catheter
Tibia
Left Leg
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Anatomy11 y.o. Tibia Cross Section
Anatomy11 y.o. Tibia Cross Section
Left Leg
Fibula
Tibia
Insertio
n Site
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PainSomatic and Visceral
PainSomatic and Visceral
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Initial AssessmentCirculation Management – Crystalloids
Initial AssessmentCirculation Management – Crystalloids
Reassess patient after Reassess patient after each fluid boluseach fluid bolus
20 mL/kg, < 20 minutes20 mL/kg, < 20 minutes
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Initial AssessmentNever Administer D5W
Initial AssessmentNever Administer D5W
D5W can lead to D5W can lead to hyperglycemia hyperglycemia
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Initial AssessmentCirculation Management – Medications
Initial AssessmentCirculation Management – Medications
SepsisPressers and
antibiotics
Cardiogenic Shock
Pressers, furosemide, morphine and
antiarrhythmics
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AnaphylaxisEpinephrine,
diphenhydramine, Solu-Medrol
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Initial AssessmentCirculation Management – Medications
Initial AssessmentCirculation Management – Medications
Use medications after fluid Use medications after fluid bolusesboluses
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Transport DecisionTransport Decision
Rapid transport for Rapid transport for pediatric shock patientspediatric shock patients
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Bleeding
Vomiting
Diarrhea
Fluid intake / urine output
Fever
Anaphylaxis signs
Focused HistoryQuestions to Determine Type of Shock
Focused HistoryQuestions to Determine Type of Shock
FEMA Photo Library / Andrea Boomer
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Head to Toe Physical ExamDone En Route
Head to Toe Physical ExamDone En Route
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Ongoing AssessmentDone Frequently
Ongoing AssessmentDone Frequently
© 2009 NAEMT
SummarySummary
Recognition and rapid intervention are keys to treatment
Pulse quality and level of consciousness are key indicators
Obtain IV or IO access if shock treatment is needed
Deliver crystalloid fluids at 20 mL/kg