DEVELOPMENT CLASSES   Notes   SHOCK   Archie Cuthbertson – Class Facilitator

 

DEVELOPMENT CLASS

 

SHOCK

DEFINITION

 

Shock is not a specific entity, but the name given to a clinical condition. It is said to exist when the functions of the body are thrown into a state of imbalance.

Shock occurs when, for any reason, there is inadequate tissue perfusion, that is inadequate blood flow in and out of the body’s tissues.

 

 

To function normally the body requires three intact mechanisms: -

 

• An efficient pump; The heart
• An adequate fluid volume; The blood and body fluids
• Intact blood vessels which contract and dilate, in response to the body’s needs

 

So shock can be caused by: -

 

• A poorly functioning heart (Cardiogenic Shock)
• Too little blood circulating in the system (Hypovolaemic Shock)
• Inefficient nervous control of blood vessels. (Neurogenic Shock)
• A reaction to an injection. (Anaphylactic Shock)

 

 

 

 PATIENTS AT HIGH RISK OF DEVELOPING SHOCK

 

• Patients with haemorrhage, injuries or fractures
• Patients with heart conditions
• Patients with burns or scalds
• The elderly
• Pregnant women

 

SHOCK

 

CONDITIONS THAT CAN LEAD TO SHOCK

 

• External Bleeding (from an open wound)
• Internal Bleeding (damage to internal organs, closed fractures)
• Crush Injuries (loss of plasma from injured tissues)
• Burns (loss of blood and/or plasma from burnt areas
• Illness (D&V, peritonitis, cardiac conditions)
• Injection or stings (an allergic reaction from the substance)

 

There are 4 stages of hypovolaemic shock. These stages only relate to adults and children over 12 years of age.

 

STAGE 1 (Up to 15% blood volume loss)

 

• Pallor of the skin
• Normal capillary refill – less than two seconds
• Increase in pulse rate – up to 100 B.P.M
• No change in systolic or diastolic blood pressure

 

At this stage the systolic pressure is being maintained by compensatory mechanisms mediated through the autonomic nervous system.

 

STAGE 2 (15% to 30% blood volume loss)

 

• Pallid, cool, clammy skin
• Capillary refill extending beyond the normal 2 seconds
• Pulse rate exceeds 100 B.P.M
• Increased respiratory rate
• Maintenance of normal systolic blood pressure, but an elevated diastolic narrows the pulse pressure

 

At this stage the body is at it’s limit of compensation.

 

STAGE 3 (30% to 40 % blood volume loss)

 

• Anxiety, restlessness and agitation
• Pulse rate greater than 120 B.P.M
• Systolic blood pressure falling to 100mm Hg or less

 

 

SHOCK

 

STAGE 4 (greater than 40% blood loss)

 

• Moribund appearance
• Central cyanosis
• Altered level of consciousness
• Marked tachycardia with weak pulse
• Signs of respiratory distress
• Systolic blood pressure of 70mm Hg or less

 

REMEMBER   - SHOCK CAN KILL

 

 

 

TYPES OF SHOCK

 

CARDIOGENIC SHOCK

Cardiogenic shock occurs when the heart is so severely damaged that it can no longer pump a volume of blood sufficient to maintain tissue perfusion. Acute myocardial infarction nearly always produces some impairment of the left ventricular function. When about 40% or more of the left ventricle has been infracted, cardiogenic shock occurs. Cardiogenic shock therefore indicates that there has been extensive injury to the myocardium, and accordingly, it carries a very high mortality.

 

HYPOVOLAEMIC SHOCK

This occurs when a significant amount of fluid is lost from the intravascular space. This loss may be in the form of blood, plasma or electrolyte solution. The form of fluid loss we see most frequently is blood loss due to haemorrhage (profuse bleeding)

 

Haemorrhage may be external or internal. External is usually recognized quite readily, but internal bleeding may be hidden. A person who has sustained blunt trauma to the abdomen, for example, may bleed to death (exsanguinations) into the abdominal cavity without a single drop of blood being spilled outside the body. Fractures of the pelvis and long bones are also often a source of significant internal bleeding. Pelvic fractures sustained in crush injury produce shock in about 40% of patients and may lead to exsanguinations; a fracture of the femur may result  in blood loss of up to 4 litres. A person need not sustain trauma, however, to bleed internally. A duodenal ulcer that erodes into a blood vessel or an ectopic pregnancy (pregnancy outside the womb) that ruptures into the abdomen can also produce severe and even fatal haemorrhage.

 

 

SHOCK

 

NEUROGENIC

Neurogenic shock (Spinal shock) occurs immediately after a significant injury to the spinal cord, as a result of widespread dilation of blood vessels. The systolic blood pressure is usually in the range of 75 to 80mm Hg. Hypotension without other signs of shock, that is, hypotension with a normal or slow pulse and warm skin is highly suggestive of Neurogenic shock.

 

ANAPHYLATIC SHOCK

Anaphylaxis is a form of allergy – a very extreme and devastating form – and allergy represents the body’s immune system gone overboard.

 

An anaphylactic reaction is the most extreme form of allergic reaction, usually effecting not just a localized tissue but the entire body. In anaphylactic response, cells patrolling the body (Mast Cells) are in a state of red alert, highly sensitized to some particular antigen (or allergen. Then along comes the allergen in question – say, penicillin or wasp sting – a substance to which the person has been exposed (whether he knows it or not). The mast cells take one look, and instead of dropping a few Histamine bombs to create a little itch, they go totally berserk and let loose a barrage of bombs all over the body. In so doing, they are very likely to kill every organism the where designed to defend.

 

AGENTS COMMONLY RESPONSIBLE FOR ANAPHYALAXIS

 

PHARMACEUTICAL

Penicillin

Mismatched blood transfusion

Animal serum products

Aspirin

Vaccines and local anesthetics

Insulin and heparin

 

FOODS

Shell fish and other seafoods

Peanuts

Milk and milk products

Egg whites

Chocolate

Some fruits

 

VENOM OR INSECT STINGS

Wasps and Bees                                  

SHOCK

 

ANAPHYLATIC SHOCK (Continued)

 

SIGNS and SYMPTOMS

 

BODY PROCESS                                                    RESULTING SIGNS/SYMPTOMS

Constriction of bronchial                                        Dyspnoea

Smooth muscle                                                         Tightness in chest

(bronchiospasm)                                                       Wheezes

 

Peripheral vasodilation                                            Flushing of skin

                                                                                    Feeling of warmth

                                                                                    Hypotension

                                                                                    Reflex Tachycardia

 

Leakage of plasma into

tissues - oedema

Oedema of subcutaneous                                         Swelling of eyelids, tongue, lips

Tissue                                                                         Relative hypovolaemia

 

Laryngeal and glottic                                                Feeling of lump in throat

Oedema                                                                      Hoarsness or stridor

Oedema of gastrointestinal                                      Nausea, vomiting, diarrhoea

 

Increased myocardial                                                Decreased cardiac output

contractility   

 

Decreased coronary blood flow                                Dysrhythmias

                                                                                     Possible acute M.I.

 

Other Histamine effects                                           Pruritus (itching)

                                                                                    Urticaria (hives)

 

 

Consider the following brief case history;

 

Little Miss Muffit

Sat on her tuffit

Eating her curds and whey

She felt her face flush

And her pulse start to rush

The funeral was held the next day              Anaphylactic shock?                                                                        

 

SHOCK

 

SIGNS and SYMPTOMS

 

4 UP                            4 DOWN

Pulse                                        Level of consc.

Respirations                            Colour

Pupils                                       Temperature

Sweating                                  B.P (late stage)

 

 

 

 

8 ACROSS

Nausea         Fear         Restlessness        Anxiety

Apathy         Thirst           Vomiting          Lethargy

 

 

 

Remember

Renal damage occurs at a B.P

Lower than:80mm Hg Systolic

  

SHOCK if not treated, CAN BE FATAL

 

SHOCK

 

MANAGEMENT

 

You cannot treat shock, but it is essential to recognize and manage it,

 

Primary Survey (AVPU – ABC)

 

If the patient is unconscious, place in recovery position. If conscious, lay them down with head and shoulders raised.

 

Administer high concentration of Oxygen via trauma mask.

 

Control any bleeding  (if present)

 

Treat other injuries, immobilize fractures, reduce pain - consider Entonox

 

Keep the patient at normal temperature, do not over heat, or let get cold

 

Raise the legs to maintain blood pressure to the vital organs, if  injuries permit

 

Secondary Survey (Place on monitor, BP, Spo2, BM, AMPLE)

 

Avoid unnecessary movement and rough handling

 

Give reassurance, keep patient calm and at rest

 

Stay with them constantly checking, pulse breathing and L.O.C.

 

 

OTHER IMPORTANT POINTS

 

Give nothing by mouth.

 

Transport to casualty as quickly as practicable, drive smoothly, speed is a secondary consideration.

 

Keep patient under constant observation

 

Note and report any relevant information, changes in condition, your estimate of blood loss and/or burns area etc.