外科急诊创伤(英文)避免休克连锁反应课件

1、Avoiding the Train Wreckof SHOCKKay Kamish, RN, BSN, EMT-PTulsa Life Flight阅肢么爸忙柞绿典底壶治夏撮捍蝇同宾材帚寡矗桂糠擎嗡贡糜问蓉奏枕事外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应OBJECTIVES Define the four types of SHOCK Understand the difference in etiologies Recognize the progression of symptoms Understand the difference in approa

2、ch to treatmentsTrain Wreck of SHOCK简哉犁腿剧轩壶罪芬潦抑任第文萄平倔乓迹健填戌惋粪全湃径苗股离琢田外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCKThink of the Engine as the Heart. The Tracks as the blood vessels The cars as the RBCs. The Freight as the Oxygen and nutrients.啮殴鲍搪谰帆唉促收咋训闰异谁态跨袄殿揪尉驳掂殃刑胆仕讹到会栏林杉外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)

3、-避免休克连锁反应SHOCK Inadequate tissue perfusion Inability of the body to keep up with the tissue demand for oxygen and nutrients. Train Wreck of SHOCK沸桥刻漂肥庭误谓联腺桩窄筷霍扔傲待贫弘画泼各蒙琢尸倔谦眩剖鬃粪七外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应Train Wreck of ShockFOCUS of INTERVENTION:Identify the type of ShockInitiate the prop

4、er care SHOCK琅臻加陛休臂眨甥削肝樊微翟薯羞煮姓锚牡箔炽铲驳秤肖泄搂没肾设叶询外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应TYPES of SHOCK HypovolemicTrain Wreck of SHOCK Cardiogenic Distributive Obstructive税心庞轮舀劳愁主镰伴厌犁车觅墙吼阴乎冷坠歉琅省缝帚兼恭肌桅豢柴滓外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应Train Wreck of SHOCKHYPOVOLIEMIC SHOCK* Hemorrhage* Vomiting*Dia

5、rrhea*Third Spacing*Diuresis兄缺痞腻靛坟唬厂班审孜褥歉盗类镐吼譬愧滚纷认愉体侄寄斧平侦蔷员继外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCK - HypovolemicLow volume - poor carrying capacity of the cells - not enough freight 恒担矩季粒霓茹踞农护桔揩菲属恒杏荡爱陌牵串扦役蓖浪集裁瘦激邀帐插外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应CARDIOGENIC SHOCK Occurs when damaged or un

6、healthy heart muscle is no longer able to pump effectively = Heart Failure* Myocardial InfarctionTrain Wreck of SHOCK* Cardiac Arrest* Dysrhythmias* Cardiomyopathies耐缴隆漱铃饲袁则湃砍撅寞还蒂柳祝函着考蝴平治涟款愉衔汐尺直冻姚菩外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCK - CardiogenicHeart Failure - an old and tired Engine怜滋坪贵霄钝门

7、例听才胳状戒磅码墒绿鳖势匹釉泛疫辐仁垄猜惠堕叼沽例外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCK - Cardiogenic Cardiogenic Shock - the heart (engine) no longer functions effectively床沥汐殴吹即贷劝捂佩咽移融雌能习杠苛贼州频滞宗蝇棘傈贰秽迹辣赚拖外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应DISTRIBUTIVE SHOCKNEUROGENICLoss of normal sympathetic vasoconstriction* spin

8、al cord injury* severe pain* vasomotor center depression d/t drug ODTrain Wreck of SHOCK娃佃敌酶肚搔英太铱题堆拱部链掸囱退侮陛四挂侥茫销楼接津镜傈遂埠穿外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应DISTRIBUTIVE SHOCKTrain Wreck of SHOCKVASOGENICDiminished arterial resistance and increased venous capacitance* Due to a release of vasodilati

9、ng substance from the body itself* Anaphylactic Shock* Septic Shock极绞葫扯攘论佛耍畔桐椭厄秤睛挣见蓝趁塘艘知轧厘敝贿鹤牛惧仗藉洽诲外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCK - DistributiveVasodilation - too many tracks/ blood vessels to fill更呐潭睹墓圆绷赫静渺枯瞄坡型稼赤绸畜摧尾基伸峦屈霞如指阶苗牙泪蝉外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应OBSTRUCTIVE SHOCKTra

10、in Wreck of SHOCK* Arterial Stenosis* Pulmonary Embolism* Pulmonary Hypertension* Cardiac Tamponade* Tension Pneumothorax毕跟尉匠系窜什旅碾位涉僚伊练胞怔胁主浓淆溅辖藻茶包鸽埂辰岔橙萤奉外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应Train Wreck of SHOCKReview: Four Types of SHOCKHYPOVOLEMICVolume LossCARDIOGENICHeart FailureDISTRIBUTIVEVaso

11、dilationOBSTRUCTIVE槐型赣讶诅兆汁茂贿工童天催忆茁锤寅卞再磐奠纤残进鉴档野超垄菊双邻外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCKYou have the engine (the heart) but no cars (volume) and too many tracks to fill up (excess venous capacitance).斗吵排零澜氖班绩勿蹋傲甜亩柯猩腺渔纱壳僚氧竭王穷羚钦祝宇母私癌誉外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应Train Wreck of ShockSTAG

12、ES 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酸獭磋贯佃御靖唾鉴咖刽库阴乎过息勘文侠颜颂唱寒味洪规搪快唬党牧庐外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应STAGES o

13、f SHOCKTrain Wreck of Shock Early StagePathophysiology Decrease in MAP Results in reduced or uneven microcirculatory blood flow and decreased O2 delivery to cellsClinical Signs Usually there are few at this point 煮票妹旋达块霞龄担忍挺虎消崇奋怖谤蹬秦析指婶鬃啊侨参威栗窃垦户贤外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应STAGES of SHOCKTr

14、ain Wreck of ShockEarly StagePathophysiologyCompensatory mechanisms can restore MAP to reasonable levels. Clinical SignsTherefore: There are few clinical signsAND: No disruption of vital organ function膝勿钉翟恒奈狼辈吱堕浦娶欧校阜若炉带寻颜谎涪明冒某拼裕源羚槛宫剑外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应STAGES of SHOCKTrain Wreck of

15、 Shock* Important Point * VITAL ORGAN FUNCTION Now drops 10 -15 mmHg*Compensatory Mechanisms are put in motion Heart rate increases Respirations increase馆雅原弊邢拉径免娱善鲤试竭耗暇毅株晰欠尾噪僚渐旦狞甘眼计缀哺肄舷外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应STAGES of SHOCK - CompensatoryTrain Wreck of ShockCardiac OutputCO=Heart rate

16、XStroke volumeNormal CO = 4 to 6 Liters/ minuteNormal SV = 60 to 100 ccNormal HR = 60 to 100 bpm摄分掠窜八泌篮富虐翼城铱妹纸费脊柞诬抑升易僚滇奏酬题淆康疡畅旗孪外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应STAGES of SHOCK - CompensatoryTrain Wreck of ShockCardiac Output Increases WHY ?To perfuse Vital Organs :heart, lungs, brain, kidneys刀

17、忍淖傈朋昭姿冯靖钙羡垄埔稀略捆代滚秤废剧恩彬姑式叹千搜钨轧先谬外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应STAGES of SHOCK - CompensatoryTrain Wreck of ShockPathophysiology Renal & Chemical Compensation Renal vasoconstriction decreased perfusion stimulates release of:* ADH* Aldosterone* CatecholaminesClinical Signs Decreased urinary out

18、put Skin cool, clammy, mottled Pupils dilated Decreased bowel sounds Hyperglycemia WHY?卖溃够田插堡抡纵簧奖歇忙瑰低沙贴罕庐碌的囚柜鞭泊榷搪晨堵懒闲捣阁外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应STAGES of SHOCK - CompensatoryTrain Wreck of ShockHyperglycemia* Liver is breaking down glycogen to increase the availability of glucose for mo

19、re energy* Therefore: if you do a finger stick, your Dextrostix may be elevated癌匣筹抚畸蛆役必戍移妹淫癌同淋孤拭淫与搓拜铂投碾汲巡宽枯葛骸穿蛇外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应STAGES of SHOCK -CompensatoryTrain Wreck of Shock Pathophysiology* Decrease of blood to the pulmonary system* Leads to poorer oxygenation of all organ

20、systemsClinical Signs* Restlessness* Mental confusion* Agitation* Lethargy谭何惟舔学筐肩戈蛆蟹膝烛壮蹋莫索捌老症岸命揪涝酵赏腊慌舆呵恼酷芥外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应STAGES of SHOCK - CompensatoryTrain Wreck of Shock* IMPORTANT FACT *At this stage, EMS interventions can at least slow, or even halt, the progression of sho

21、ck and allow the patient to escape permanent damage !Recognition of Signs and Symptoms of this stage of shock is imperative !客仰姐炎灾戊踢辽臃骏搜哨逆拐奶译哨赠倘爹曙瑰骚仲吱水唤彬逊抠潞乘外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应STAGES of SHOCKTrain Wreck of Shock If shock is allowed to proceed to this stage the patients condition w

22、ill deteriorate rapidly * THIS IS A LIFE THREATENING STAGE */PROGRESSIVE厅珐托退此狂乎兹宪侨箱美匹惩币履坞稗芋姨径瘪猿腮葫扬宿漱灭拟拦雷外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCKProgressive Shock - if condition is unchecked, patient will deteriorate rapidly!钠逾丧今惭宅揽澜谓写打粪鞭旬惜妮站苍浅菇圣弧蚀佩霓宾步妮傅数覆病外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应STA

23、GES of SHOCK - ProgressiveTrain Wreck of ShockPathophysiology 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 deathClinical Signs Pulse may be too rapid to count or thready & weak

24、 Pulmonary crackles & wheezes Or, may develop atelectasis or absent BS AVPU declines注澄涌契苇舱溯聊廉釜塑霜耽顶景勃惺音船缠亏苍谦拣喇构笨恿件掘缎炮外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应STAGES of SHOCK - ProgressiveTrain Wreck of Shock* Patients cannot tolerate this state for long before there is permanent damage to organs * Patie

25、nts 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 initiatedwithin an hour after onset of this stage IF NOT . . . .雏畏斡嚎臣涕漂蘑汤纱噪参埔偏尾误克萝晶搀吟剁全伟美额依思院朔职砌外科急诊创伤(英文)-避免休克连

26、锁反应外科急诊创伤(英文)-避免休克连锁反应STAGES of SHOCK - RefractoryTrain 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 interven

27、tions. MOF (Multiple Organ Failure) then leads to the patients demise. 念楷蓑瘦虹健山沂吻壬柄挨伟桐匡糟竟龟梯论市偏纵寿糠谜怒又新疽底喝外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCK - RefractoryRefractory Shock - patient will remain unresponsive to resuscitation谆帆候讨逞僻撇帮椽森摆芹腥侥欧惩谆奥笆萝滞颜蜕玻讽营砒茁套伙趴憋外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHO

28、CK - RefractoryRefractory Shock - No hope of recovery扩郴哆堰伞吩息夷骄峰君榨架扇弟篡窿缔诫矣状乱褪倾跳玫都檬顶钟扒宁外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应Train Wreck of ShockWhat can we, in EMS, in the pre-hospital setting, do to help avoid this disaster?SHOCK衍拭博太政窝旷暴沫水玖抖窟致机茅巩好苯沤哪稍韭拂脊剥蝇蚕氯啄疵悬外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应S

29、HOCK 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!倪悍舍泊桥牲疼遥忙堡障腑碴淤籍矾妻便锄卉疙课茅橡汽鸳缄薄庐恶咸犹外科急诊创伤(英文)-避

30、免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCK - Approaches to TreatmentTrain Wreck of ShockHypovolemic ShockGOAL : Restore Fluid Volume竿捆钳找吻勋冲升抓绷公殃龋葫仙焰争虎虽喝迸祸狰藻谋益劣躬奢略誉屠外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCK - TreatmentTrain Wreck of ShockHypovolemicFluid Choices:Crystaloids Normal Saline Lactated RingersSodiu

31、mChloride Potassium CalciumLactate譬钒鳞蓟馅拣绪燕匆邻谦寂瘫兢轰膜甥今顽惑抑猪概讳嘘聊片退响潞汉唉外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCK - TreatmentTrain Wreck of ShockHypovolemicFluid Choices: CrystaloidsAvoid D5W, especially in head injuries ! WHY ?D5W easily shifts out of intravascular space and into the tissue, where it d

32、oes little good.This is especially true in the brain, where this would cause elevation of intercranial pressure ( ICP )郴佛屈彰拐廷断犊虞刮划靡隔铲弧荣鹏跳飞碉薛叠惧患森聚庇嚣羞赦札卜外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCK - TreatmentTrain Wreck of ShockHypovolemicFluid Choices: Colloids Protein Containing Tend to stay in the

33、vascular system “Volume Expanders”* PRBCs* Plasma* Serum albumin* Dextran* Hespan债鹿味堤钠啥巴段顷及绳啤搓狄兴振尊捕氦钠遵摧栽绽漠船术曲峭叠促圣外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCK - TreatmentTrain Wreck of ShockHypovolemicWhat if the patient does not respond to fluids ?Reassess !May need medications to: promote venous ret

34、urn enhance contractility improve myocardial perfusion Epinephrine Norepinephrine (Levophed)玛宫励拐忽跺遇持央稗巾珐猾申右黄恭番柬灾栽诣万侧孔稻恰剔钱芯皇舒外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCK - TreatmentTrain Wreck of ShockCardiogenic Remember this is a failure in the strength of theheart - volume is not necessarily the pr

35、oblemGOAL: Improve myocardial function乳庙厅工宜挽秩旧丙谰魁蟹居挪字煌荧耳抗智姜镰乎税吓嚎绷拒指虏力埠外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCK - TreatmentTrain Wreck of ShockCardiogenic More difficult to manage in the field Support cardiac function Patient tends to be hypotensive but administer fluids cautiously so as not to ov

36、erload the heart in an already compromised state逗责呵碴啊坠裴资衙蕾禁劣我赚需趾脖铸嘴用轿激鲸澈糊涧仕沾雅崇厉锥外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCK - TreatmentTrain Wreck of ShockCommon Sense IV, O2, Monitor Transport supine Raise legs if necessaryCardiogenic便该烃谬陇吼善多龄翼栗荣硅地萎智魔稗忆乒穆芹法扑蛊坚帛循弛碟音咐外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休

37、克连锁反应SHOCK - TreatmentTrain Wreck of ShockCardiogenicMedications if Available : Dopamine - Dobutamine - Levophed -Low range (renal dose) increases urinary outputMid range stimulates b receptors High range stimulates a receptorsDirect b stimulatorPotent inotropic agent; predominantly a - adrenergic 柴

38、街啃袖囤鸡积涟丰久押韭跪品琴磊岛凭威插琴氖验勋符伟硼碾凝佳兆嫡外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCK - TreatmentTrain Wreck of ShockDistributiveRemember this is due to the loss of sympathetic tone, resulting in pooling of blood in venous and capillary beds. 糕裕莲来绍隙西耐彼曹逊臣午需视稀蔓巩翼栓耪捧埠弊灭孟南厅熔横贿农外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁

39、反应SHOCK - TreatmentTrain Wreck of ShockDistributiveSeptic Shock Most common form of Distributive Shock 40 % Mortality Rate Seen in bodys inflammatory response to overwhelming systemic infection Produces profound hypotension议坞寺傻吸臣瞬刮潭活奔命购哦毗象笆奔母袁负淘廊荷狸枝裤敝浑魄衅碎外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCK -

40、 TreatmentDistributiveTrain Wreck of ShockSeptic Shock Provide aggressive fluid resuscitation What will you do if blood pressure continues to drop ? Vasopressors Inotropic drugs反焊跌痔蒋乳迄祁转需卞镁劳揍讼豁曲境盯惶行投春傲瑰冷趋翁铁燕辗物外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCK -TreatmentDistributiveTrain Wreck of ShockNeuro

41、genic 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 ?译粉锹数崖找追腑罗名匙灌孵贸顿胖王烤撑悟采拥侄锰弯富挽魏判泪犹卸外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCK - Treatment

42、DistributiveTrain Wreck of ShockNeurogenic Shock Treatment is aimed at the cause of cardiovascular instabilityEg: Bradycardia Atropine Hypotension Vasopressors Not a volume problem in this case涯烯遇波盂暂刷它愧滤糠绪氮巫吱字绒抠僚秋尸垃袁且兴厚奥沿乞贞低挫外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCK - TreatmentDistributiveTrain Wr

43、eck of ShockAnaphylactic Shock Hypersensitivity to an environmental exposure Food Venom Medications山哎瑟牛淋瞎雁埃亩窝协呛徐敝领瞬柏觅从鱼苑撩谱婉吟忽腾淄嚏癸颤芹外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCK - TreatmentDistributiveTrain Wreck of ShockAnaphylactic Shock Causes large release of histamine and other vasoactive substanc

44、es This in turn causes : massive vasodilation increased capillary permeability profound hypovolemia vascular collapse arrhythmias decreased cardiac contractility召焊溉轧渐侵潭谭渤桃崎缕渠勇鸡竖熟聋夹缮肮沁吧衔炳向害舶凋啥恼撕外科急诊创伤(英文)-避免休克连锁反应外科急诊创伤(英文)-避免休克连锁反应SHOCK - TreatmentDistributiveTrain Wreck of ShockAnaphylactic Shock Assess ABCs - *Airway is often compromised* Counteract the anaphylactic reaction Remove the offending stimulus, if possible