Chapter 13

Introduction

• Shock (—-) is defined as inadequate cellular perfusion.

  • Any compromise in perfusion can lead to cellular —- or —-.

  • In the early stages, the body attempts to maintain homeostasis.

hypoperfusion, injury, death 

Pathophysiology

• Diffusion is a passive process in which molecules move from an area with a —- concentration of molecules to an area of —- concentration.

  • This is how oxygen and carbon dioxide move across the walls of the alveoli.

• In cases of poor perfusion (shock): 

  • Transportation of carbon dioxide out of tissues is —-.

  • Results in a dangerous buildup of —- products, which may cause cellular damage

    • — — is the main waste product causing cell injury and death

• Shock is a state of —- and failure of the —- system that leads to inadequate circulation.

  • Early recognition can save lives.

  • Requires —— recognition and rapid treatment

• Cardiovascular system consists of three parts:

  • Pump (—)

  • Set of pipes (—- —— or arteries)

  • Contents (the —-)

  • “Perfusion triangle.”

    • When a patient is in shock, —- or —- of the three parts is not working properly.

higher, lower impaired, waste, lactic acid, collapse, cardiovascular, immediate, heart blood vessels, blood, one, more

Pathophysiology

• Blood pressure is the pressure of blood within the —— at any moment in time.

  • Systolic: —- arterial pressure

  • Diastolic: pressure in the arteries while the heart —- between heartbeats

• Pulse pressure is the —- between the —- and —- pressures.

  • It signifies the amount of —- the heart generates with each contraction.

  • A pulse pressure less than —- mm Hg may be seen in patients with shock.

• Blood flow through the capillary beds is regulated by the capillary sphincters.

  • Under the control of the —- nervous system

  • Regulation of blood flow is determined by cellular needs.

  • In cases of shock, the sphincters may shut to divert and conserve blood flow to more important areas 

• Perfusion also requires adequate:

  • — exchange in the lungs

  • — in the form of glucose in the blood

  • — removal, primarily through the lungs

vessels, peak, rests, difference, systolic, diastolic, force, 25, sphincters, autonomic, oxygen, nutrients, waste

Pathophysiology 

• Mechanisms are in place to help support the respiratory and cardiovascular systems when the need for perfusion of vital organs is increased.

  • Includes the — nervous system and —

• Hormones are triggered when the body senses pressure falling.

  • Cause an increase in: 

    • Heart —- 

    • — of cardiac contractions

    • Peripheral —-

  • The hormone that causes this is —/—-

  • This response causes all the —- and —- of shock.

autonomic, hormones, rate, strength, vasoconstriction, epinephrine adrenaline, signs symptoms

Causes of Shock

• Many different shocks result from three basic causes:

  • Pump —-

  • — vessel function

  • — fluid volume

failure, poor, low

 

Cardiogenic Shock

• Caused by inadequate function of the —-

• A major effect is the backup of blood into the —- —-.

  • Resulting buildup of pulmonary fluid is called pulmonary —-.

• Cardiogenic shock develops when the heart cannot maintain sufficient —— to meet the demands of the body.

• Cardiac output depends on adequate:

  • — of the heart muscle

  • — of blood to pump (—)

  • — to flow in peripheral circulation (—)

heart, pulmonary vessels, edema, output, contractility, amount, preload, resistance, afterload 

Obstructive Shock

• Caused by a —- obstruction that prevents an adequate volume of blood from —- the heart chambers.

• Three of the most common examples: 

  • Cardiac tamponade

  • Tension pneumothorax

  • Pulmonary embolism

1. Cardiac tamponade

   • Collection of —- between the pericardial sac and the myocardium (pericardial —-) becomes large enough to prevent ventricles from —- with blood.

   • Caused by —- or —- trauma

   • Signs and symptoms are referred to as —- —-

     • JVD, muffled heart sounds, narrowing blood pressure.

2. Tension pneumothorax

   • Caused by damage to —- tissue

   • Can be a result of an untreated spontaneous or traumatic pneumothorax

   • Air normally held within the lung —- into the chest cavity.

   • The lung —-, and air applies —- to the organs, including the heart and great vessels.

3. Pulmonary embolism

   • A blood —- that blocks the flow of blood through —- vessels

   • If massive: 

     • Can result in complete backup of blood in the —- ventricle

     • Leads to catastrophic —- shock and complete —- failure

mechanical, filling, fluid, effusion, filling, blunt, penetrating, Beck triad, lung, escapes, collapses, pressure, clot, pulmonary, right, obstructive, pump

Distributive Shock

• Results from widespread —- of small arterioles, small venules, or both

• The circulating blood volume —- in the expanded vascular beds.

• Tissue perfusion ——.

• 4 causes are septic, neurogenic, psychogenic, and anaphylactic shock

dilation, pools, decreases

Septic shock

• Occurs as a result of severe —- in which —- are generated by bacteria or by infected body tissues

• Toxins damage vessel —-, causing increased cellular —-.

• Vessel walls —- and are unable to —- well.

• Widespread —- of vessels, in combination with —- (volume) loss through the vessel walls, results in shock.

• Will usually see mottling and a fever as well

infections, toxins, walls, permeability, leak contract, dilation, plasma

Neurogenic shock

• Usually the result of —— —- —- injury

• Nerve impulses to blood vessels —- the level of the injury are ——.

• All vessels cut off from nerve impulses will ——, causing the blood to ——.

• Affects the —— nervous system so you will not see the results of —-  response (no tachycardia, no diaphoresis, and no pale skin due to vasodilation) 

high spinal cord, below, blocked, dilate, pool, sympathetic, epinephrine 

Anaphylactic shock

• Occurs when a person reacts violently to a substance to which he or she has been —-

• Sensitization means becoming sensitive to a substance that did not —- cause a reaction.

• Each subsequent exposure tends to produce a more —— reaction.

sensitized, initially, severe

Psychogenic shock

• Caused by a sudden —- of the nervous system

• Produces temporary, generalized vascular —-

• Results in —- (——)

• Life-threatening causes include —- heartbeat and brain —-.

• Non–life-threatening events include receipt of bad news or experiencing fear or unpleasant sights (such as blood).

reaction, dilation, fainting, syncope irregular, aneurysm

Hypovolemic Shock 

• Result of an inadequate amount of —- or —- in the circulatory system

• Have —- causes and —- causes

• Occurs with severe —- burns as well as severe external —-

fluid, volume, hemorrhagic, nonhemorrhagic , thermal, bleeding

The Progression of Shock

• Stages in the progression of shock:

  • Compensated shock: early stage when the body can still —— for blood loss

    • Pale cool clammy skin, restlessness, anxiety, feeling of impending doom, tachycardia 

  • Decompensated shock: —- stage when blood pressure is ——

  • No way to assess when effects are irreversible

  • Must recognize and treat shock —-

• Blood pressure may be the —— measurable factor to change in shock.

  • When a drop in blood pressure is evident, shock is well developed (—-)

  • Particularly true in infants and children

  • When blood pressure drops in infants and children in shock, they are close to death.

• Also expect shock if a patient has any one of the following conditions:

  • Multiple severe fractures

  • Abdominal or chest injury

  • Spinal injury

  • A severe infection

  • A major heart attack

  • Anaphylaxis

compensate, late, falling, early, last, decompensated, 

Primary Assessment for Suspected Shock

• Perform a —- exam.

• Determine the ——

• Identify and manage — —- concerns.

• Determine —- of the patient and transport.

• Provide high-flow —- to assist in perfusion.

• For hypoperfusion, treat —- and provide —- transport.

• Request advanced life support (ALS) as necessary.

• An —— respiratory rate is often an early sign of impending shock.

• A —- pulse suggests —— shock.

• In shock or compensated shock, the skin may be —-, —, —- or ashen, and the patient may be — or —- and feel impending —-

• Assess for and identify any life-threatening —- and treat it at once.

• Determine if patient is —- priority, if ALS is needed, and which facility to transport to.

• Trauma patients with shock or a suspicious MOI generally should go to a trauma center.

Treat for shock early and aggressively by:

• Providing —-

• Keeping the patient ——

rapid, LOC, life threatening, priority, oxygen, aggressively, rapid, increased, rapid, compensated, pale cool clammy, restless, anxious, doom, bleeding, high , oxygen, warm

Emergency Medical Care for Shock

• As soon as you recognize shock, begin treatment. 

  • Follow —- —-.

  • Control all obvious —-.

  • Make sure the patient has an open —-.

  • Maintain manual in-line stabilization if necessary, and check breathing and pulse.

  • Comfort, calm, and reassure the patient.

  • Never allow patients to eat or drink anything prior to being evaluated by a physician.

  • If spinal immobilization is indicated, splint the patient on a backboard.

  • — position

  • Provide —- and monitor patient’s breathing.

  • Place blankets under and over the patient (keep them —-)

  • Consider the need for ALS.

  • Accurately record the patient’s vital signs approximately every —— (reassess) throughout treatment and transport.

standard precautions, bleeding, airway, supine, oxygen,warm, 5 minutes 

Treating Cardiogenic Shock

• Patient cannot generate the necessary —- to pump blood throughout the circulatory system.

• Patients may present with —- pain.

• Patients in cardiogenic shock should NOT receive —-; they are —-.

  • Remember, we can only give nitro for patients with systolic —— or greater

• Patients usually have:

  • — blood pressure 

  • —, — pulse

  • — about lips/underneath fingernails

  • Anxiety 

  • Nausea

• Place the patient in a position that — breathing as you give high-flow oxygen (—-)

• Assist ventilations as necessary.

• Provide prompt transport.

• Consider meeting ALS en route to hospital.

contraction chest, nitroglycerin, hypotensive, 120, low, weak irregular, cyanosis, eases, Fowler, 

Treating Obstructive Shock

• For cardiac tamponade:

  • — cardiac output is the priority.

  • Apply high-flow —.

  • — is the only definitive treatment.

• For tension pneumothorax:

  • Apply high-flow — to prevent hypoxia.

  • Chest —- is required.

  • Ask for ALS early in call if available, but do not delay transport.

increasing, oxygen, surgery, oxygen, decompression

Treating Septic Shock

• Hospital management is required.

• Use standard precautions and transport.

• Administer high-flow —.

• Ventilatory support may be necessary.

• Use blankets to conserve body —-.

• Notify “sepsis team” if available.

oxygen, heat

Treating Neurogenic Shock 

• Emergency treatment:

  • Obtain and maintain a proper airway.

  • Provide spinal —-.

  • Assist inadequate breathing.

  • Conserve body —.

  • Ensure the most effective circulation.

• Transport promptly.

immobilization, heat, 

Treating Anaphylactic Shock

• After ensuring adequate oxygenation and ventilation, administer —— 

• Promptly transport the patient.

• Provide high-flow oxygen and ventilatory assistance en route.

• A mild reaction may —- suddenly.

• Consider requesting ALS backup, if available.

epinephrine,worsen,

Treating Psychogenic Shock

• In an uncomplicated case of fainting, once the patient collapses, circulation to the brain is ——

  • Can place in recovery position if uninjured and breathing adequately

• Psychogenic shock can —- other types of shock.

• If the patient falls, check for —-.

• If the patient reports being unable to walk after a fall, suspect —- problem.

• Transport the patient promptly.

restored, worsen, injuries, another

Treating Hypovolemic Shock

• Control all obvious external —-.

• Keep the patient —-.

• Recognize —- bleeding and provide aggressive support. 

• Secure and maintain an —-, and provide respiratory support.

• Transport as rapidly as possible.

bleeding, warm, internal, airway

Treating Shock in Older Patients

• Older patients have more —— complications than younger ones.

• Illness is not just a part of aging.

• Many older patients take medications that —- or —- signs of shock.

serious, mask, mimic

The term “shock” is MOST accurately defined as:

a decreased supply of oxygen to the brain.

cardiovascular collapse leading to inadequate perfusion.

decreased circulation of blood within the venous circulation.

decreased function of the respiratory system leading to hypoxia.

cardiovascular collapse leading to inadequate perfusion 

Anaphylactic shock is typically associated with:

urticaria. 

bradycardia. 

localized welts. 

a severe headache.

urticaria 

Signs of compensated shock include all of the following, EXCEPT:

restlessness or anxiety.

pale, cool, clammy skin.

a feeling of impending doom.

weak or absent peripheral pulses.

Explanation: In compensated shock, the body is able to maintain perfusion to the vital organs of the body via the autonomic nervous system… When the body’s compensatory mechanism fails, the patient’s blood pressure falls; weak or absent peripheral pulses indicates this.

weak or absent peripheral pulses 

When treating a trauma patient who is in shock, LOWEST priority should be given to:

spinal protection.

thermal management. 

splinting fractures. 

notifying the hospital.

Explanation: Critical interventions during shock are spinal protection, high flow oxygen or assisted ventilation, thermal management, rapid transport, and early notification to the hospital 

splinting fractures 

Potential causes of cardiogenic shock include all of the following, EXCEPT:

inadequate heart function.

disease of muscle tissue.

severe bacterial infection.

impaired electrical system.

severe bacterial infection 

A 60-year-old woman presents with a BP of 80/60 mm Hg, a pulse rate of 110 beats/min, mottled skin, and a temperature of 103.9°F. She is MOST likely experiencing:

septic shock. 

neurogenic shock. 

profound heart failure. 

a severe viral infection.

Explanation: in septic shock bacterial toxins destroy vessel walls resulting in them being unable to constrict and leaky which dec. BP, mottling and fever are common signs of septic shock.

septic shock

A patient with neurogenic shock would be LEAST likely to present with:

tachypnea. 

hypotension. 

tachycardia. 

altered mentation.

Explanation: In neurogenic shock, the nerves that control the sympathetic nervous system are compromised. This means epinephrine and norepinephrine cannot be released and therefore cannot speed up the heart rate

tachycardia

A 20-year-old man was kicked numerous times in the abdomen during an assault. His abdomen is rigid and tender, his heart rate is 120 beats/min, and his respirations are 30 breaths/min. You should treat this patient for:

a lacerated liver. 

a ruptured spleen.

respiratory failure. 

hypovolemic shock.

Explanation: this could be a ruptured liver or spleen which can directly cause an internal hemorrhage leading to hypovolemic shock 

hypovolemic shock 

A 33-year-old woman presents with a generalized rash, facial swelling, and hypotension approximately 10 minutes after being stung by a hornet. Her BP is 70/50 mm Hg and her heart rate is 120 beats/min. In addition to high-flow oxygen, this patient is in MOST immediate need of:

epinephrine. 

rapid transport.

an antihistamine. 

IV fluids.

Explanation: anaphylaxis results in bronchoconstriction and hypotension. After ensuring adequate oxygenation and ventilation the most important thing is epinephrine which dilates the bronchi and constricts the blood vessels to increase BP

epinephrine

All of the following are potential causes of impaired tissue perfusion, EXCEPT:

increased number of red blood cells.

pump failure.

low fluid volume.

poor vessel function.

increased number of red blood cells