Overarching Concepts

We spend so much focus on timeless in stroke and STEMI to prevent cellular death, in shock its all the cells in the body. 

Respect and  respond to the shock

A fluid bolus is not the only EMS response to shock

The only common pathway to death is shock

"Patients don't suddenly deteriorate, healthcare providers suddenly notice"

Few excuses this day in age to show up to the hospital with a hypotensive patients

Types of shock

Hypovolemic Shock - 2 types

Volume depletion (Dehydration) Body water loss (Urination, diarrhea, vomiting, sweating) - STILL in shock

Hemorrhagic (Bleeding)

Treated very differently - Lots of volume (Dehydration) vs fluid limiting (permissive hypotension) 

30% blood loss before you see hypotension in hemorrhagic shock. If you wait until BP drops, your waiting too long

Bolus 20ml/kg crystalloid - providers sees pressure come up and "feel better". Just a moment in time. Crystalloids don't stay in the intravascular space, they will drop again. If they don't respond to crystalloids, then they have over 40%. These patients need blood.

Stage 1 Hemorrhagic Shock - Less than 15%

Stage 2 Hemorrhagic Shock - 15 - 30% Tachycardia

Stage 3 Hemorrhagic Shock - 30 - 40% First time BP drop

Stage 4 Hemorrhagic Shock - Irreversible shock

Kids need more aggressive treatment than adults, compensate more... .then don't.

Obstructive Shocks

Neck veins tell a story

Flat neck veins = Volume issue

Distended neck veins = Pressure issue (tension pneumothorax, PE, pericardial tamponade)

Lack of air movement with TRAUMA  (not due to medical problems, asthma, COPD) - high pressure due to tension pneumothorax - needle decompress

Triggers for decompression 1. GOOD Story (Almost always trauma, not asthma or COPD) 2. Diminished lung sounds 3. LACK of radial pulses = chest decompression

One is rarely enough, add additional if there are return of signs

Distributive Shocks

Shocks with a WIDE Pulse pressure

Respond with pressors

Septic 

High mortality rate but not "attacked" like other shocks, but needs to be. Patients are not "just septic"

They cannot be left in shock

20ml/kg IV fluids, but one needs to be smart about  that administration. You are unlikely to get that entire volume in the patient before arrival at the hospital. That is entire goal, but you need to escalate sooner if the patient is not responsive to first part of the bolus.

Example, if the BP does not improve after first 300ish ml's, ADD push dose epinephrine

Anaphylactic  SHOCK (not reaction)

If people die, its due to lack of epinephrine

"They don't die in the ER" they either are already dead, or EMS has an opportunity to save them.

Come heavy with epinephrine, its a fast moving shock, the time to mike push dose will kill the patient

The faster the reaction the worse its going to be

Use CARDIAC EPINEPHRINE (0.1mg/ml) this is 100mcg 

1ml per min is 100mcg -ATTACK!

If you don't come heavy with the cardiac epinephrine in anaphylactic shock, the dose will be 1mg when they arrest... prevent the arrest. 

Is it anaphylactic shock or reaction? Radial pulses (Reaction) use IM epi, No radial pulses (shock) use IV CARDIAC epi

Convert shock to reaction with IV epi, then you can consider PDE or IM

Neurogenic

Cord injury dictates level of response

Hypotension and bradycardia - both vasodilation and lack of sympathetic tone

Hint here is the paralysis - these patients will be neurologically devastated with hypotension and / or bradycardia

The higher on the spinal core the injury the more damage to the sympathetic ganglia 

Push dose epinephrine very effective here. Supplant the sympathetic that cannot be released naturally. 

Cardiogenic Shock

Is the pump working?

Not just lack of squeeze, not all cardiogenic shock is heart failure - although alot presents like it

Could be arrhythmic - to fast or slow to create forward blood flow

Could be  hyperkalemia - heart can't contract cant get calcium to move to get the heart to contract. Need to attack with calcium! Serial albuterol to hide 

Many other reasons, not an exhaustive list

Weakened heart muscle need to increase contractility with a vasopressor (push dose epinephrine)

 as reference materials

Push Dose Epinephrine Pearls

Push the initial 10mcg, push the NIBP button, by the time you get the result back, that 10mcg is metabolized, if the BP is still low you have to increase subsequent doses. This is generally not additive to the previous dose, so you repeat the previous dose, plus the addition. Example; first dose 10mcg, second dose may be 20mcg, the first 10mcg plus the second 10mcg, if more is needed the previous dose needs added in.

You do not have to go in linear order. If first dose of 10mcg is given for a MAP of 46, and the MAP only increases to 48, the next dose could be 30, 40, or 50 mcg of epinephrine to get a bigger result. The protocol max is 50mcg / dose, however there is no repeat timing constraints, give as needed.  

Volume Resuscitation Pearls

Does the choice of fluid influence acidosis? In large volumes yes. Normal saline isn't normal

Short and wide catheters flow faster

Consider pressure infuser for IV's or IO's where you need to get fluid in (or use BP cuff in a pinch)

Start multiple IV's.... Not just reserved for trauma. Especially if you can only come up with small gauge sets

Pay attention to you extension set! If you are using  a microbore extension set, no matter what size bag, pressure infuser, drop set, or catheter size you have a 22 gague IV. 

Remember, Extension sets are a courtesy, put the IV tubing directly on the IV/IO if no extension set available or it is a microbore and going to be a hinderance to resuscitation. 

Conscious awake IO's, don't forget the intraosseous lidocaine. Success here is the time the lidocaine is left to dwell in the intraosseous space. Longer dwell more effect in "numbing" the pain response of the following fluid resuscitation

Assessment

Capnography is great overall view of the patient condition - Single value review of breathing, perfusion, and metabolism

Basic vital signs will indicate shock first, without technology. 

Breathing fast = compensation for acidosis

Tachycardia = volume loss (cautions about medications that control rate)

Still must touch the patient despite all the technology

Treat the patient not the computer - there is time to chart later

View from the door gives you the sick/not sick understanding one needs - scene size up 

The story  (history) makes the case - 90% of figuring out what's going on

Technology has evolved - are we sending mixed message basics and tech. Both have a place. Tech validates what the vitals and presentation are telling you.

Teamwork - National Registry testing today may help promote seeking input during patient care. In practical test out, you are given a partner to seek input from as well