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U.S. ARMY MEDICAL DEPT.

CENTER & SCHOOL CORRESPONDENCE PHASE 91B BNCOC TECHNICAL TRAINING Shock Evaluation and Management I. REFERENCE.

M C2000194 0797

Campbell, J.E. (Ed.), Basic Trauma Life Support (Advanced). (3rd Ed.) Englewood Cliffs, N.J.: PrenticeHall, Inc. 1995. II. OBJECTIVES. A. Terminal Learning Objective. Given a patient in posttraumatic shock, evaluate and manage the patient IAW cited reference. B. Enabling Learning Objectives. 1. 2. 3. 4. 5. 6. 7. Given a list, identify the four components necessary for normal tissue perfusion IAW cited reference. Given a list, identify the symptoms and signs of hemorrhagic shock IAW cited reference. Given the pathophysiology of hemorrhagic shock compare to the pathophysiology of high-space shock IAW cited reference. Given a list, identify the four common clinical shock syndromes IAW cited reference. Given a list, identify the management of controlled and noncontrolled hemorrhage IAW cited reference. Given a list, identify the management of nonhemorrhagic shock syndromes IAW cited reference. Given a list, select the current indications and contraindications for the use of the antishock garment in the treatment of traumatic shock IAW cited reference.

M C2000194 0797 III. EXPLANATION.

Objective 1. Given a list, identify the four components necessary for normal tissue perfusion IAW cited reference. A. Basic Pathophysiology. 1. Body tissue perfusion requires four intact components: a. b. c. d. 2. A vascular system to deliver oxygenated blood throughout the body. Adequate air exchange in the lungs to allow oxygen to enter the bloodstream. An adequate volume of fluid in the vascular system, to include plasma and blood cells. A pump that functions properly - the heart.

These components and their maintenance can be related to the basic concepts of emergency care: a. b. c. d. Airway maintainance. Control ventilation and oxygenation. Control bleeding. Maintain circulation.

REMEMBER: Oxygen is required for all body tissues. 3. Definition of shock: A condition that occurs when tissue perfusion with oxygen becomes inadequate. Less oxygen is transported to body tissues when a patient is hemorrhaging and loosing red blood cells. The cells of the body become shocked, and grave changes in body tissue begin to occur - eventually, death of the cell.

M C2000194 0797 4. Cells that are deprived of oxygen begin to use backup (anaerobic) processes that inefficiently utilize energy sources and produce toxic by-products which can poison certain cellular functions. Eventually, lactic acid spills over into the bloodstream and creates systemic acidosis that disrupts cellular activity. Respiratory muscle function that is weakened leads to the development of respiratory failure with worsening hypoxia. Due to inadequate oxygen delivery, the body reacts with increased sympathetic tone and release of circulating catecholamines (epinephrine and norepinephrine thus increasing the heart rate, vasoconstricting peripheral blood vessels, and increasing the respiratory rate. Shock - a cellular process with clinical manifestations. The patient may be pale, diaphoretic, and tachycardic. Cells starving for oxygen with poor tissue perfusion may permanently and severely damage the organs of the body.

5.

6.

NOTE: Symptoms and clinical signs of the patient in shock imply critical processes threatening every vulnerable cell in the patients body, particularly those in vital organs. Objective 2. Given a list, identify the symptoms and signs of hemorrhagic shock IAW cited reference. B. Assessment: Signs and Symptoms of Shock. 1. Classic signs and symptoms associated with hemorrhage-associated shock include: a. b. c. d. Weakness - caused by tissue hypoxia and acidosis. Thirst - caused by hypovolemia (especially with low fluid amounts in the blood vessels). Pallor - caused by catecholamine-induced vasoconstriction and/or loss of red blood cells. Tachycardia - caused by catecholamines effect on the heart.

M C2000194 0797 e. f. g. h. i. j. k. Tachypnea (elevated respiratory rate) - caused in response to stress, catecholamines, acidosis, and hypoxia. Diaphoresis (sweating) - caused by catecholamines effect on sweat glands. Decreased urinary output - caused by hypovolemia, hypoxia, and circulating catecholamines. Diminished peripheral pulses - the thready pulse, caused by vasoconstriction, fast heart rate, blood volume loss. Hypotension - caused by hypovolemia, either absolute or relative. Altered sensorium (confusion, combativeness, restlessness, unconsciousness) caused by decreased cerebral perfusion, acidosis, and catecholamine stimulation. Cardiac arrest - caused by critical organ failure secondary to fluis or blood loss, hypoxia, and occasionally arrhythmia caused by catecholamine stimulation.

REMEMBER: Symptoms of classic hemorrhage-associated shock are caused by the release of catecholamines. When the brain senses that there is not enough oxygen perfusion to the tissues, it sends messages down the spinal cord to the sympathetic nervous system and to the adrenal glands, which release circulating catecholamines (epinephrine and norepinephrine). The circulating catecholamines cause the tachycardia, diaphoresis, anxiousness, and vasoconstriction. The vasoconstriction shunts blood away from the skin to the vital organs, causing an initial rise in the blood pressure and causing the skin to be pale. Decreased perfusion causes weakness and thirst initially, a decreased level of consciousness (confusion, restlessness, or combativeness), hypotension, worsening pallor, and unconsciousness followed by cardiac arrest. 2. As shock continues, the prolonged tissue hypoxia leads to worsening acidosis which can cause a loss of response to catecholamines. A drop in blood pressure can occur. Subsequently, the hypoxia and acidosis cause cardiac dysfunction and death. Early and late shock - classic patterns. a. Early shock. (1) Depletion of approximately 15 to 25% of the blood volume - enough to stimulate slight to moderate tachycardia, pallor, narrowed pulse pressure, weakness, thirst and possibly delayed capillary refill. (2) b. Presents as a fast pulse with pallor and diaphoresis during primary survey.

3.

Late shock. (1) (2) Loss of approximately 30 to 45% of the blood volume) - loss is enough to cause hypovolemic shock. Patient may present as weak pulse or loss of the peripheral pulse during primary survey.

M C2000194 0797 NOTE: Capillary refill test - if the blanched area remains pale for longer than 2 seconds the patient is suspicious for shock. This test is of little value for early shock detection but there is a high correlation with late shock. Objective #3. Objective #4. C. Given the pathophysiology of hemorrhagic shock compare to the pathophysiology of high-space shock IAW cited reference. Given a list, identify the four common clinical shock syndromes IAW cited reference. Shock Syndromes. 1. Low-volume shock (absolute hypovolemia - caused by hemorrhage, or other major body fluid loss). a. When minor blood loss occurs, the sympathetic system can shrink the space enough to maintain blood pressure. If the blood loss is severe, the vascular space cannot be shrunk down enough to maintain blood pressure, and hypotension occurs. The artery shrinks in width, becoming more threadlike in size and referred to as thready pulse in shock.

b.

M C2000194 0797 2. High-space shock (relative hypovolemia) - caused by spinal injury, syncope, vasomotor injury from hypoxia, severe head injury. a. Loss of normal vasoconstriction - the vascular space becomes much too large for the usual amount of blood. If vessel dilation occurs, the 5 liters or so of blood flowing through the normal adults vascular space may not be sufficient to maintain blood pressure and vital tissue perfusion.

NOTE: Although several types of high-space shock exist (e.g., sepsis syndrome and drug overdoses), neurogenic shock, referred to as spinal shock, will be addressed in this portion of the instructional material. b. Neurogenic shock - occurs after an injury to the spinal cord. The disruption of the sympathetic nervous system outflow from the spinal cord results in the inability of the body to compensate for any accompanying hemorrhage, and the loss of the normal vascular tone. (1) Patients will have warm dry skin (due to vasomotor paralysis and vasodilatation) and no accompanying increases in blood pressure or heart rate. Patients may also have sensory deficit corresponding to the spinal cord injury and/or paralysis. Chest wall movement may be non-existant and only simple diaphragmatic movements occur when the patient is asked to take a deep breath.

(2) (3)

REMEMBER: When associated with severe bleeding, this form of shock does not have the typical picture of hemorrhagic shock. The neurological assessment is very important and should not rely on typical shock signs and symptoms to suspect internal bleeding or accompanying hemorrhage-associated shock. Although low blood pressure and normal heart rate may be an indication, tachycardia and normal blood pressure often is observed. A neurogenic shock patient may appear or look better than his/her actual condition. Repeated patient assessments and clinical suspicion are very important. c. Drinking alcohol and other overdoses can result in vasodilation and relative hypovolemia. Injuries frequently result after such intoxication and the effects on typical clinical signs and symptoms (like spinal shock) should be considered.

3.

Obstructive or mechanical shock - any traumatic condition that slows or prevents the venous return of blood can cause shock by lowering cardiac output and therefore reducing oxygen delivery to the tissues. Any obstruction restricts the flow of blood to or through the heart can cause shock. Traumatic conditions that can cause mechanical shock: a. Tension pneumothorax - high air tension (pressure) that develops in the pleural space which is between the lung and chest wall. This high positive pressure is transmitted back to the right heart thus preventing the venous return of blood. Shifting of mediastinal structures can also lower venous return. Cardiac or pericardial tamponade - blood fills the space around the heart, squeezing and preventing the heart from filling or pumping adequately. The 6

b.

M C2000194 0797 heart cannot fill properly and cardiac output falls. The only life-saving measure which is available is definitive surgical care in the nearest appropriate facility for pericardial decompression. WARNING: On-scene interventions should be avoided (if the diagnosis is suspected) - any time wasted on the scene could result in death of the patient. c. Myocardial contusion - diminished cardiac output. Due to direct injury, the heart loses pumping ability. This condition cant be differentiated from cardiac tamponade in the field - rapid transport, supportive care, and cardiac monitoring are the mainstays of therapy.

CAUTION: Patients with shock from mechanical causes can be very near death and delay on the scene may prevent salvage of the patient. It is estimated that the time from development of a tamponade to circulatory arrest may be as little as 5 - 10 minutes. Survival following traumatic circulatory arrest is unlikely if surgery is not performed within 5 - 10 minutes. 4. Hypoxemic (respiratory) shock - failure of the lungs to deliver adequate oxygen levels to the blood. Lung dysfunction is the most common cause of hypoxemia (e.g., blood or vomitus in the lungs), spinal cord injury, ventilatory insufficiency from flail chest wall segments, previous intoxication or a predisposing event (e.g., stroke), airway disruption (bronchial tear), pneumothorax, diaphragmatic tear, and other causes must also be considered. Treat an open pneumothorax, sucking chest wound, immediately. Patients with severe head injury may have hypoxemia because of inadequate respiratory patterns and can appear to be breathing normally.

Objective #5. D.

Given a list, identify the management of controlled and noncontrolled hemorrhage IAW cited reference. Management of Posttraumatic Shock States - control bleeding, give oxygen, transport. 1. Treatment of posttraumatic hemorrhage - prehospital treatment of the shock patient is controversial at this time. Recent research recommends a modified approach - patients may be placed in two categories: those with bleeding you can control and those with bleeding you cannot control. a. External hemorrhage that can be controlled - after direct control of the bleeding and the patient shows persistent clinical evidence of shock, take the following steps: (1) (2) (3) (4) (5) Place the patient in a horizontal or slightly head-down position. Administer high-flow oxygen. Transport immediately and rapidly. If local protocol approves/recommends, apply the PASG, until I.V. fluid therapy is available. Using large-bore catheters, 16g or greater, obtain intravenous access. 7

M C2000194 0797 (6) Give a bolus of 20 ml/kg I.V. rapidly and then repeat the reassessment survey. Use Ringers lactate (RL) solution or normal saline (NS),

M C2000194 0797 NOTE: In cases of severe hemorrhage, shock symptoms and signs may persist despite and intravenous volume infusion and hemorrhage control - these patients need blood transfusions. (7) (8) b. Apply pulse oximetry, if available, and monitor the heart.. Frequently reassess.

Management of the patient with external hemorrhage that cannot be controlled: (1) (2) (3) (4) (5) (6) (7) Apply direct pressure on the bleeding site (e.g., femoral artery, facial hemorrhage). Place the patient in a horizontal or slightly head-down position. To stop an extremity severe bleeding, that cannot be otherwise controlled, apply a tourniquet only as a desperate attempt or last resort. Administer high-flow oxygen. Transport immediately and rapidly. Do Not utilize the PASG in this setting. En route gain I.V. access but administer only enough RL or NS to maintain a blood pressure high enough for adequate peripheral perfusion. Peripheral perfusion maintenance is defined as: Producing a peripheral pulse, maintaining level of consciousness, and an adequate blood pressure.

REMEMBER: In severe cases, a blood transfusion initiated early is the most effective method of fluid replacement. (8) (9) Monitor the heart. Use pulse oximetry if available. Reassess frequently.

NOTE: If assistance is not available, control of hemorrhage, severe or minimal, must remain the priority. Other procedures become secondary if they interrupt hemorrhage control. c. Internal hemorrhage - classic critical trauma victim, who will probably die unless rapid transport to an appropriate facility is completed. The need for rapid operative hemostasis is critical. In shock patients, recent recommendations regarding the use of the PASG and I.V. fluids, with presumed internal bleeding,suggest the following: (1) In the setting of uncontrolled internal exsanguination due to penetrating injury, the use of the PASG may increase mortality, especially in the setting of intrathoracic hemorrhage. The PASG raises blood pressure, and raising blood pressure in bleeding vessels within the abdomen, thorax, and pelvis probably increases internal bleeding. 9

M C2000194 0797 (2) Using large volumes of I.V. fluids in the setting of uncontrolled internal hemorrhage may also increases internal bleeding and mortality. I.V. fluids increase the blood pressure, but may also dilute clotting factors. I.V. fluids carry almost no oxygen and are not a replacement for red blood cells. Early blood transfusion is critical in severe cases. Do Not delay in providing rapid transport of patients unless absolutely unavoidable. Example: Patient requiring prolonged extrication. For trauma patients in deep shock with blood pressures under 50 systolic, fluid administration or even the PASG may be indicated to maintain some degree of circulation. Treatment for this extreme amount of hemorrhage may override the concerns for increased hemorrhage secondary to the use of these interventions - these patients usually die. Ask for local medical direction for such therapy.

(3) (4)

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M C2000194 0797 (5) For a patient with probable exsanguinating internal hemorrhage secondary to penetrating injuries - management recommendations are: (a) (b) (c) (d) (e) (f) Transport immediately and rapidly. Place the patient in a horizontal or slightly head-down position. Administer high-flow oxygen. DO NOT utilize the PASG except as indicated/directed by local medical direction. Gain I.V. access with large-bore catheters. Maintain peripheral perfusion - administer sufficient RL or NS.

NOTE: Experts now recommend fluid resuscitation be kept minimal until hemorrhage control is obtained (operative intervention). (g) (h) (6) Monitor the heart - apply pulse oximetry if available. Reassess frequently.

Management of the patient with presumed internal hemorrhage from blunt injuries (falls, motor vehicle accidents, etc.).

NOTE: Patients with blunt injuries can lose a significant amount of blood and fluid from the intravascular space into the sites of large-bone fractures (hematoma and edema). This loss could be enough to cause shock, and yet the blood loss is usually self-limited. (a) Treat patient with oxygen and I.V. fluids.

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M C2000194 0797 NOTE: If the patient, with a blunt injury, has a tear of a large internal blood vessel, and/or a ruptured or avulsed internal organ, raising the blood pressure prior to surgical intervention may also result in accelerated or a secondary hemorrhage. (b) If a patient is alert, oriented and has no apparent chest, abdomen, or pelvic injuries and internal hemorrhage is not suspected, use fluids judiciously for fractures and externally controlled bleeding. Maintain peripheral perfusion by administering fluids. Assess patient frequently.

Objective #6.

Given a list, identify the management of nonhemorrhagic shock syndromes IAW cited reference. 2. Treatment of nonhemorrhagic shock syndromes (mechanical and high space) - all patients require high-flow oxygen, rapid transport, I.V. line placement (usually en route) and shock positioning. a. Mechanical shock. (1) (2) (3) Access the patient - determine the problem cause. Promptly decompress the elevated pleural pressure for the patient with tension pneumothorax. Rapidly transport a patient with suspected pericardial tamponade to an appropriate facility - the time of tamponade onset to the time of cardiac arrest can be a very few minutes. Only on the order of medical direction, and during transport, use I.V. fluids. Obtaining I.V. access must not delay direct transport or airway/oxygen support/interventions. Contraindicated, in this case, is the use of the PASG. Myocardial contusion rarely causes shock - administer high-flow oxygen and perform cardiac monitoring on the patient.

(4) b.

High-space shock - initial management: (1) I.V. fluid blouses and possible short-term use of the PASG. The patients level of consciousness is a reasonable endpoint to follow. Possible internal injuries - be aware that raising the blood pressure may increase internal bleeding. Elastic bandage wraps around the lower extremities or intravenous vasopressors may be utilized in interhospital transfers.

(2) Objective #7. E.

Given a list, select the current indications and contraindications for the use of the antishock garment in the treatment of traumatic shock IAW cited reference. Current Uses for the Pneumatic Antishock Garment (PASG or MAST). 1. Inflatable compressive device that encircles the abdomen and legs.

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M C2000194 0797 2. Exerts its effect by compression of the arteries of the abdomen and legs, and increases the peripheral vascular resistance (PVR). As PVR is a component of blood pressure (BP), BP typically rises with application and inflation. As PVR rises, cardiac output (CO) may fall. Elevate PVR in settings of low BP with caution because of the possibility of lowering the cardiac output. If uncontrolled bleeding is occurring, raising the blood pressure may increase bleeding. General consensus among informed medical personnel regarding use of PASG: a. b. c. PASG should probably not be applied in any clinical scenario in which bleeding cannot be controlled, such as in penetrating chest or abdominal trauma. The patient with spinal chock has an inability to maintain vascular tone and may benefit from the use of PASG. A patient with anaphylaxis who has vasodilation due to histamine release might also benefit.

3.

4.

NOTE: There is no documented proof that the PASG helps in these clinical situations at this time. d. PASG may be effective for the stabilization of pelvic and femur fractures. Also possible that the PASG may reduce pelvic hemorrhage. Elevation of the systolic pressure beyond 90 or 100 should be done only with caution in the setting of the patient with possible uncontrolled internal hemorrhage.

NOTE: Local medical direction should guide PASG therapy.

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