外科急诊创伤(英文)-避免休克连锁反应.ppt

Train Wreck of SHOCK,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Avoiding the Train Wreckof SHOCK,Kay Kamish,RN,BSN,EMT-P,Tulsa Life Flight,OBJECTIVES,Define the four types of SHOCK,Understand the difference in etiologies,Recognize the progression of symptoms,Understand the difference in approach to,treatments,Train Wreck of SHOCK,SHOCK,Think of the Engine as the Heart.The Tracks as the blood vessels The cars as the RBCs.The Freight as the Oxygen and nutrients.,SHOCK,Inadequate tissue perfusion,Inability of the body to keep up,with the tissue demand for oxygen,and nutrients.,Train Wreck of SHOCK,Train Wreck of Shock,FOCUS of INTERVENTION:,Identify the type of Shock,Initiate the proper care,SHOCK,TYPES of SHOCK,Hypovolemic,Train Wreck of SHOCK,Cardiogenic,Distributive,Obstructive,Train Wreck of SHOCK,HYPOVOLIEMIC,SHOCK,*,Hemorrhage,*,Vomiting,*,Diarrhea,*,Third,Spacing,*,Diuresis,SHOCK-Cardiogenic,Heart Failure-an old and tired Engine,SHOCK-Cardiogenic,Cardiogenic Shock-the heart(engine)no longer functions effectively,DISTRIBUTIVE SHOCK,NEUROGENIC,Loss of normal sympathetic vasoconstriction,*,spinal cord injury,*,severe pain,*,vasomotor center depression d/t drug OD,Train Wreck of SHOCK,DISTRIBUTIVE SHOCK,Train Wreck of SHOCK,VASOGENIC,Diminished arterial resistance and increased venous capacitance,*,Due to a release of vasodilating substance from,the body itself,*,Anaphylactic Shock,*,Septic Shock,SHOCK-Distributive,Vasodilation-too many tracks/blood vessels to fill,OBSTRUCTIVE SHOCK,Train Wreck of SHOCK,*,Arterial Stenosis,*,Pulmonary Embolism,*,Pulmonary Hypertension,*,Cardiac Tamponade,*,Tension Pneumothorax,Train Wreck of SHOCK,Review:Four Types of SHOCK,HYPOVOLEMIC,Volume Loss,CARDIOGENIC,Heart Failure,DISTRIBUTIVE,Vasodilation,OBSTRUCTIVE,SHOCK,You have the engine(the heart)but no cars(volume)and too many tracks to fill up(excess venous capacitance).,Train Wreck of Shock,STAGES of SHOCK,*,Whatever the type of shock,the signs and,symptoms are the result of diminished blood flow,*,Symptoms follow a predictable path,YOUR GOAL:,Identify the type of shock and intervene at the earliest stage possible,STAGES of SHOCK,Train Wreck of Shock,Early Stage,Pathophysiology,Decrease in MAP,Results in reduced or uneven,microcirculatory blood flow,and decreased O2 delivery,to cells,Clinical Signs,Usually there are,few at this point,STAGES of SHOCK,Train Wreck of Shock,Early Stage,Pathophysiology,Compensatory mechanisms can restore MAP to reasonable levels.,Clinical Signs,Therefore:There are few clinical signs,AND:,No disruption of,vital organ function,STAGES of SHOCK,Train Wreck of Shock,*,Important Point*,VITAL ORGAN,FUNCTION,Now drops 10-15 mmHg,*,Compensatory Mechanisms are put in motion,Heart rate increases,Respirations increase,STAGES of SHOCK-Compensatory,Train Wreck of Shock,Cardiac Output,CO,=,Heart rate,X,Stroke volume,Normal CO =4 to 6 Liters/minute,Normal SV =60 to 100 cc,Normal HR =60 to 100 bpm,STAGES of SHOCK-Compensatory,Train Wreck of Shock,Cardiac Output Increases,WHY?,To perfuse,Vital,Organs,:,heart,lungs,brain,kidneys,STAGES of SHOCK-Compensatory,Train Wreck of Shock,Pathophysiology,Renal&Chemical Compensation,Renal vasoconstriction,decreased perfusion,stimulates release of:,*,ADH,*,Aldosterone,*,Catecholamines,Clinical,Signs,Decreased urinary output,Skin cool,clammy,mottled,Pupils dilated,Decreased bowel sounds,Hyperglycemia,WHY?,STAGES of SHOCK-Compensatory,Train Wreck of Shock,Hyperglycemia,*,Liver is breaking down glycogen,to increase the availability of glucose,for more energy,*,Therefore:if you do a finger stick,your,Dextrostix may be elevated,STAGES of SHOCK-Compensatory,Train Wreck of Shock,Pathophysiology,*,Decrease of blood to the pulmonary,system,*,Leads to poorer oxygenation of,all organ systems,Clinical,Signs,*,Restlessness,*,Mental confusion,*,Agitation,*,Lethargy,STAGES of SHOCK-Compensatory,Train Wreck of Shock,*,IMPORTANT FACT *,At this stage,EMS interventions can at least slow,or even halt,the progression of shock and allow the patient to escape permanent damage!,Recognition of Signs and Symptoms of this stage of shock is imperative!,STAGES of SHOCK,Train Wreck of Shock,If shock is allowed to proceed to this stage the patients condition will deteriorate rapidly,*,THIS IS A LIFE THREATENING STAGE,*/,PROGRESSIVE,SHOCK,Progressive Shock-if condition is unchecked,patient will deteriorate rapidly!,STAGES of SHOCK-Progressive,Train Wreck of Shock,Pathophysiology,Sustained drop in MAP,(more than 20mmHg below baseline),Vital organs develop hypoxia,Less vital organs become anoxic&ischemic,leads to cell damage,which leads to cell death,Clinical,Signs,Pulse may be too,rapid to count or,thready&weak,Pulmonary crackles,&wheezes,Or,may develop,atelectasis or absent BS,AVPU declines,STAGES of SHOCK-Progressive,Train Wreck of Shock,*,Patients cannot tolerate this state for long,before there is permanent damage to organs,*,Patients with a cardiac history (CAD)are at,significantly increased risk for cardiac arrest,Why?,Think about what is happening at a cellular level,*,Life can be preserved,IF,interventions are initiated,within an hour,after onset of this stage,IF NOT.,STAGES of SHOCK-Refractory,Train Wreck of Shock,By this stage the body has sustained too much cell damage and death to survive.,Even if the underlying cause of shock has been discovered and steps taken to correct it,the patient will remain unresponsive to therapeutic interventions.,MOF(Multiple Organ Failure)then leads to the patients demise.,SHOCK-Refractory,Refractory Shock-patient will remain unresponsive to resuscitation,SHOCK-Refractory,Refractory Shock-No hope of recovery,Train Wreck of Shock,What can we,in EMS,in the pre-hospital setting,do to help avoid this disaster?,SHOCK,SHOCK,ABCs,Thorough and accurate assessment,Determine what type of shock you are dealing with,so as to be sure your approach to treatment is appropriate.,Train Wreck of Shock,Dont jump to a conclusion and then be unwilling to alter your approach as needed!,SHOCK-Approaches to Treatment,Train Wreck of Shock,Hypovolemic Shock,GOAL,:,Restore Fluid Volume,SHOCK-Treatment,Train Wreck of Shock,Hypovolemic,Fluid Choices:,Crystaloids,Normal Saline,Lactated Ringers,Sodium,Chloride,Potassium,Calcium,Lactate,SHOCK-Treatment,Train Wreck of Shock,Hypovolemic,Fluid Choices:Crystaloids,Avoid D5W,especially in head injuries!,WHY?,D5W easily shifts out of intravascular space and,into the tissue,where it does little good.,This is especially true in the brain,where this would,cause elevation of intercranial pressure (ICP),SHOCK-Treatment,Train Wreck of Shock,Hypovolemic,Fluid Choices:Colloids,Protein Containing,Tend to stay in the vascular system,“,Volume Expanders”,*,PRBCs,*,Plasma,*,Serum albumin,*,Dextran,*,Hespan,SHOCK-Treatment,Train Wreck of Shock,Hypovolemic,What if the patient does not respond to fluids?,Reassess!,May need medications to:,promote venous return,enhance contractility,improve myocardial perfusion,Epinephrine,Norepinephrine(Levophed),SHOCK-Treatment,Train Wreck of Shock,Cardiogenic,Remember this is a failure in the strength of theheart-volume is not necessarily the problem,GOAL:,Improve myocardial function,SHOCK-Treatment,Train Wreck of Shock,Cardiogenic,More difficult to manage in the field,Support cardiac function,Patient tends to be hypotensive,but administer fluids cautiously so as not to overload the heart in an already compromised state,SHOCK-Treatment,Train Wreck of Shock,Common Sense,IV,O2,Monitor,Transport supine,Raise legs if necessary,Cardiogenic,SHOCK-Treatment,Train Wreck of Shock,Cardiogenic,Medications if Available:,Dopamine-,Dobutamine-,Levophed-,Low range(renal dose)increases urinary output,Mid range stimulates,b,receptors,High range stimulates,a,receptors,Direct,b,stimulator,Potent inotropic agent;predominantly,a,-adrenergic,SHOCK-Treatment,Train Wreck of Shock,Distributive,Remember,this is due to the loss of sympathetic,tone,resulting in pooling of blood in,venous and capillary beds.,SHOCK-Treatment,Train Wreck of Shock,Distributive,Septic Shock,Most common form of Distributive Shock,40%,Mortality Rate,Seen in bodys inflammatory response to overwhelming systemic infection,Produces profound hypotension,SHOCK-Treatment,Distributive,Train Wreck of Shock,Septic Shock,Provide aggressive fluid resuscitation,What will you do if blood pressure continues to drop?,Vasopressors,Inotropic drugs,SHOCK-Treatment,Distributive,Train Wreck of Shock,Neurogenic Shock,Typically the result of head injury or spinal cord injury,Initial Symptoms:,Hypotension,Bradycardia,Hypothermia,Warm,dry skin,What symptoms are present here that are opposite to other forms of shock?,SHOCK-Treatment,Distributive,Train Wreck of Shock,Neurogenic Shock,Treatment is aimed at the cause of cardiovascular instability,Eg:,Bradycardia,Atropine,Hypotension,Vasopressors,Not,a volume problem in this case,SHOCK-Treatment,Distributive,Train Wreck of Shock,Anaphylactic Shock,Hypersensitivity to an environmental exposure,Food,Venom,Medications,SHOCK-Treatment,Distributive,Train Wreck of Shock,Anaphylactic Shock,Causes large release of histamine and other vasoactive substances,This in turn causes:,massive vasodilation,increased capillary permeability,profound hypovolemia,vascular collapse,arrhythmias,decreased cardiac contractility,SHOCK-Treatment,Distributive,Train Wreck of Shock,Anaphylactic Shock,Assess ABCs -*Airway is often compromised*,Counteract the anaphylactic reaction,Remove the offending stimulus,if possible,Fluid resuscitation,Subcutaneous Epinephrine,Antihistamines (Benadryl),Corticosteroids,Vasopressors,SHOCK-Treatment,Obstructive Shock,Train Wreck of Shock,Figure out,what,is being obstructed and,why,SHOCK-Treatment,Train Wreck of Shock,Obstructive Shock,What,is obstructed?,Airway?,(,As if no oxygen is loading onto the train),Tension Pneumothorax,Circulation?,(,Something is hampering the engine.),Cardiac Tamponade,SHOCK-Treatment,Train Wreck of Shock,Obstructive Shock,*,Treatment is emergent in both cases*,Needle decompression,Pericardiocentesis,SHOCK-Summary,Train Wreck of Shock,TYPES of SHOCK,HYPOVOLEMIC,CARDIOGENIC,DISTRIBUTIVE,OBSTRUCTIVE,SHOCK-Summary,Train Wreck of Shock,STAGES OF SHOCK,EARLY,COMPENSATORY,PROGRESSIVE,REFRACTORY,SHOCK-Summary,Train Wreck of Shock,SHOCK-Summary,Train Wreck of Shock,SHOCK,SHOCK-Hopefully does not need to end in disaster,