Hypoperfusion and Shock. © 2009 NAEMT Hypoperfusion Common problem Extent makes resuscitation...

Hypoperfusion and ShockHypoperfusion and Shock

HypoperfusionHypoperfusion

Common problem Extent makes resuscitation

difficult Shock due to hypoperfusion Start fluid resuscitation as soon

as possible

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

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

LifeART

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

Anaphylaxis Septic Neurogenic

Categories of ShockDistributive

Pulmonary embolus Tension pneumothorax Cardiac

tamponade

Categories of ShockObstructive

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 (Uncommon)

Medications required to Medications required to restore perfusionrestore perfusion

Spinal cord injury Cardiac failure

Severity of HypoperfusionCompensated

Compensated Decompensated

Signs are due to inadequate

tissue perfusion

Compensated shock is

reversible with fluids

Volume

Altered Mental Status

Severity of HypoperfusionCompensated Shock Signs

Decompensated

Breathing

BloodPressure

Compensated

Volume

Severity of HypoperfusionCompensated Shock Signs

Decompensated

Compensated

Weak peripheral

pulses, strong central pulses

Weak or absent peripheral

pulses, weak central pulses

DecompensatedCompensated

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Severity of HypoperfusionDehydration Testing

Hypovolemic patientHypovolemic patient’’s skin s skin will will ““tenttent””

Severity of HypoperfusionDecompensated Shock

Compensated Decompensated

Body is unable to continue

compensation

Inadequate tissue perfusion

to all organs

Volume

Severity of HypoperfusionDecompensated Shock Signs

Volume

Altered Mental Status

Decompensated

Breathing

BloodPressure

Weak or absent peripheral pulses, weak central pulses

Compensated

Severity of HypoperfusionDecompensated Shock Signs

AssessmentAssessment

Scene SurveyScene Survey

Hazards to you, your partner, Hazards to you, your partner, the patient and bystandersthe patient and bystanders

First ImpressionPediatric Assessment Triangle

Compensated or decompensatedCompensated or decompensated

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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

First ImpressionGeneral Appearance

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Muscle tone Spontaneous movements Skin color Other signs of distress

First ImpressionWork of Breathing

First ImpressionCirculation to the Skin

Skin color, capillary refill, Skin color, capillary refill, distal vs. central pulsesdistal vs. central pulses

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

Not SickNot Sick

Loss of airway may occur in

decompensated shock

Initial AssessmentAirway

Identify and treat life Identify and treat life threatsthreats

Administer OAdminister O22 and and

treat causetreat cause

Initial AssessmentBreathing

Rate effort and volume

Abnormal sounds

Assess for chest trauma

Initial AssessmentCirculation

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CompensatedWeak peripheral pulses,

strong central pulses

DecompensatedWeak or absent peripheral pulses, weak central pulses

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

Initial AssessmentCirculation Management – Intraosseous

Can be used on any age Can be used on any age childchild

Intraosseous SpaceBlood Flow

AnatomyNeonate Leg Cross Section

Subcutaneous Fat

Intraosseous Catheter

Fibula

Posterior Compartment

Anterior Compartment

Lateral Compartment

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

IO Insertion Anatomical Landmarks

Patella

TibialTuberosity

MedialTibia

IO Insertion Unable to Palpate Tibial Tuberosity

Finger Width

Often difficult or impossible Often difficult or impossible to palpateto palpate

IO Insertion Able to Palpate Tibial Tuberoisty

Finger Width

AnatomyNeonate Leg Cross Section

Fibula

Traditional IO Catheter

Left Leg

Anatomy11 y.o. Tibia Cross Section

Left Leg

Fibula

Insertio

n Site

PainSomatic and Visceral

Initial AssessmentCirculation Management – Crystalloids

Reassess patient after Reassess patient after each fluid boluseach fluid bolus

20 mL/kg, < 20 minutes20 mL/kg, < 20 minutes

Initial AssessmentNever Administer D5W

D5W can lead to D5W can lead to hyperglycemia hyperglycemia

Initial AssessmentCirculation Management – Medications

SepsisPressers and

antibiotics

Cardiogenic Shock

Pressers, furosemide, morphine and

antiarrhythmics

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AnaphylaxisEpinephrine,

diphenhydramine, Solu-Medrol

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

Bleeding

Vomiting

Diarrhea

Fluid intake / urine output

Anaphylaxis signs

Focused HistoryQuestions to Determine Type of Shock

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Head to Toe Physical ExamDone En Route

Ongoing AssessmentDone Frequently

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

Hypoperfusion and Shock. © 2009 NAEMT Hypoperfusion Common problem Extent makes resuscitation...

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