CH APTER

Hypotension and Shock
7
Ronald N. Roth
Ahamed H. Idris
Raymond L. Fowler

INTRODUCTION blood pressure ⫽ cardiac output ⫻ peripheral
vascular resistance
Shock is an important life-threatening emergency and
cardiac output ⫽ heart rate ⫻ stroke volume
must be recognized early and intervention started to
prevent progression, morbidity, and mortality. Unfor-
Any condition that lowers cardiac output and/or
tunately, the identification and treatment of shock in
peripheral vascular resistance may decrease blood
the out-of-hospital setting is fraught with many dif-
pressure. Alterations of heart rate (very low or very
ficulties and potential pitfalls. For example, patient
high) can lower stroke volume and hence blood pres-
assessment is often limited by the challenging out-
sure. Also, decreasing stroke volume may also lower
of-hospital environment and lack of diagnostic and
cardiac output with a possible reduction in perfusion
therapeutic options. In addition, the early stages of
as well. Stroke volume may be reduced by lower circu-
compensated shock with subtle alterations in physi-
lating blood volume (e.g., hemorrhage or dehydration),
cal findings are easily overlooked or misinterpreted
by damage to the heart (e.g., myocardial infarction or
by out-of-hospital care providers. Ongoing treatment
myocarditis), or by conditions obstructing blood flow
for medical conditions, such as beta-blockers for hy-
through the thorax (e.g., tension pneumothorax, car-
pertension, may also mask the body’s compensatory
diac tamponade, or massive pulmonary embolism).
responses. As a result, the patient with severe shock
To aid in the evaluation and treatment of shock it is
may present with normal vital signs. The tools avail-
often useful for the physician and EMS personnel to cat-
able for the diagnosis and treatment of shock in the
egorize the etiology of the shock condition.2 Most EMS
field are limited.
providers are familiar with the pump-fluid-pipes model
of the cardiovascular system, with the pump represent-
ing the heart; pipes representing the vascular system;
PATHOPHYSIOLOGY and fluid representing the blood. Shock may therefore
occur from increased resistance to flow of blood into the
Shock is a complex physiologic process defined as thorax, from diminished cardiac contractility, from di-
the widespread reduction in tissue perfusion leading minished vascular resistance, and from decreased intra-
to cellular and organ dysfunction and death. In the vascular volume.3 Categorizing shock into four catego-
early stages of shock, a series of complex compensa- ries may help prehospital providers and EMS physicians
tory mechanisms act to preserve critical organ per- organize their assessment and approach (Table 7.1). Ac-
fusion.1 In general, the following relationships drive curate physical assessment is vital for the EMS provider
this process: to determine the etiology of the shock state (Table 7.2).

51

1_A_07_051-062.indd 51 12/3/08 5:52:35 PM

tachycardia. arrhythmias. Drug or toxin induced Distributive shock states usually show flat size B. tachycardia.1 Categories of Shock Type of Shock Disorder Example Comments Hypovolemic Decreased fluids A. For Central Nervous System example. Spinal cord injury neck veins. especially 1 Hemorrhage hemorrhagic shock. Severe aortic stenosis E. tachycardia and hypotension in an elderly • Agitation. TABLE 7. tachycardia. Pulmonary embolism B. • Tachypnea. and dyspnea may represent • Alterations in level of consciousness pneumonia with septic shock. Of- ten historical features and clinical findings can pro- • Tachycardia. mottling. Acute valvular incompetence E. and an urticarial rash in Skin a victim of a recent bee sting strongly suggest dis- • Pallor. normal or low pulse rate. Myocardial contusion F. tachycardia. Myocardial infarction TABLE 7. Obstruc- • Cyanosis (in obstructive shock cases). Anoxia neck veins. dyspnea Hypotension. Venacaval obstruction Cardiogenic “Pump” problems A. Anaphylaxis spinal cord injury tends to show flat E. tive shock precipitated by a tension pneumothorax should be suspected in a hypotensive trauma patient 52 SECTION A Time/Life-Critical Events 1_A_07_051-062. produce flat neck 2 Gastrointestinal losses veins. Cardiac tamponade D. Internal fluid loss 1 Fractures 2 Intestinal obstruction 3 Hemothorax 4 Hemoperitoneum Distributive Increased “pipe” A. and cyanosis D. hypotension vide clues as to the etiologies of the shock state. and pallor 3 Renal losses 4 Cutaneous loss B. Sepsis Neurogenic shock due to a cervical D. Tension pneumothorax C. Cardiomyopathy sion. cough. Arrhythmias tend to produce jugular venous disten- C. and pink skin Obstruction Pipe obstructionA. hematemesis.indd 52 12/3/08 5:52:37 PM . Myocardial infarction Cardiogenic and obstructive shock states B.2 EVALUATION Signs and Symptoms of Shock The diagnosis of shock depends on a combination Cardiovascular of key historical features and physical findings. confusion patient with fever. External fluid loss Hypovolemic shock states. melena. diaphoresis tributive shock secondary to anaphylaxis. and hypotension. and pallor. C. Hemorrhagic shock • Coma may be suspected in a middle-aged man with epi- Respiratory gastric pain.

16-year-old female with lower from the lying to the standing positions. the shock state. in- (e. use of orthostatic vital signs is in moving the patient tion. In some patients with intra-abdominal bleeding timates may influence therapeutic interventions.g. found an error rate sion to the later stages of shock that can result in the of more than 20% for vital signs obtained by EMTs in death of potentially salvageable patients. with normal cardiovascular status. partment.2).9. Orthostatic with significant epistaxis may be hypertensive due to blood pressure checks are sporadically performed catecholamine release and vasoconstriction despite in the field. Early recognition and sis of shock is the frequent inaccuracy of field assess. Despite their variable value. patients. in convincing the patient to allow treatment and trans- tated diastolic pressure. such as cold temperatures with up to 25% blood volume loss. and suffers a syncopal episode. standing. for mild to moderate hypovolemia. noted a 30% higher mortal- sures should be performed. and adverse lighting conditions. However. the field provider measuring only palpated sys. clammy skin (see Table 7.1 Sympathetic ner. Occasionally orthostatic vital signs are being relatively volume depleted. patients with evidence of hypovolemia. such as tachycardia. orthostatic response with normovolemia.7 a nonemergency setting. and other concurrent treatments. with unilateral decreased breath sounds and tracheal if the early signs of shock are overlooked. hospital providers should Overall. suggests that the de- may be lulled into a false sense of security initially tection of hypoxia in the prehospital setting without a CHAPTER 7 Hypotension and Shock 53 1_A_07_051-062. rescuers should not equate absence of between systolic and diastolic pressure) cannot be cal. A petite 45-kg. In a study of shock.3 The field team However.5 Without an auscul. and cool. a study by Brown et al. caught off guard when the patient’s condition dramat- An important problem in the prehospital diagno. ectopic pregnan. Cayten et al.12 Moreover.13 EMS personnel may equate “normal” vital signs Hypoxia is a common theme for many shock states.1 Baraff found that capillary refill was not a useful test Previously healthy victims of acute hypovole. of on-scene blood loss for trauma victims. An elderly patient would also be considered a positive test. The most sensitive must be correlated with the overall clinical presenta. Blood pressure by palpation provides only onstration of orthostatic hypotension is often helpful an estimate of systolic pressure. orthostatic vital tions. a recent study cy) the pulse may be relatively bradycardic despite suggests that these blood loss estimates are not accu- significant blood loss.6 rate at estimating spilled blood volumes. or she may normally have a sys.11 Symptoms of lightheadedness or dizziness tolic blood pressure of 88 mm Hg. signs are often evaluated in the emergency depart- Vital signs that fall outside of expected ranges ment. the clinical presentation of shock depends on consider any episode of prehospital hypotension as the patient’s degree of compensation. envi- mic shock may maintain relatively normal vital signs ronmental considerations. Schriger and tolic blood pressure may miss this important clue. the etiology of evidence of significant shock and illness. providers often treatment while lying down. even sue perfusion. increased cardiac contractility may result in normal Out-of-hospital personnel often provide estimates blood pressure in the face of decreasing vascular vol.8 Other studies have shown similar findings signs and symptoms of system-wide reduction in tis. ruptured abdominal aneurysm. These es- ume. the existence of other clinical condi. performed serendipitously by the patient who refuses In the noisy field environment. multiple assessment mea.4 The researchers suggest that Prehospital hypotension may predict in-hospital when critical medical decisions will be based on the morbidity and mortality in both trauma and medical data gathered in the field. and occasionally in the field. Because a decrease in the pulse pressure may Capillary refill testing as a clinical test for shock provide an early clue to the presence of hypovolemic has variable support in the literature.8–10 Jones et al. also affect the accu- vous system stimulation with vasoconstriction and racy of this technique of shock assessment. aggressive treatment of shock may prevent progres- ment. culated. However. the scene. ity rate for medical patients with prehospital hypo- Out-of-hospital care providers should look for the tension.indd 53 12/3/08 5:52:37 PM . tachypnea. ically worsens during transport. cluding fluid administration.. the pulse pressure (difference port.10 Therefore. in trauma patients with prehospital hypotension. For example. then stands up to leave measure blood pressure by palpation rather than aus. A positive abdominal pain and a reported blood pressure of orthostatic vital sign test for pulse rate would show a 88 mm Hg systolic by palpation may have a ruptured pulse increase of 30 beats per minute after 1 minute of ectopic pregnancy. mental with subsequent normotension in the emergency de- status changes. This dem- cultation. only to be deviation to the opposite side.

Once these basic principles are addressed. one study showed (DMO) physician must be cautioned on placing too that pulse oximetry falsely alerted three or four times much emphasis on a single set of vital signs or a lim- per patient transport.3 per patient transport. and pulmonary embolism.27 catheter with signs of shock. of the criticality of the patient.e. ECG. the current evaluation of the potential blood volume to adequately perfuse the body with oxy. Protect the patient from the environment. virtually immediate when the airway is obstructed or 2.g. An elderly man cused Assessment by Sonography in Trauma (FAST) from a nursing facility with an indwelling urinary examination. healthy college student with hypotension secondary sound scanning in the field. diminished ETCO2 should be a warning 9.24–26 ETCO2 is 5.24 Under these conditions. cardiac sive elderly patient with ventricular tachycardia (VT) tamponade.18.28 In the emergency de. All treatment approaches to shock must include the els vary inversely with minute ventilation. pulse oximeter may prove difficult. Attempt to determine the etiology of the shock changes in ETCO2 levels reliably indicate changes in state.indd 54 12/3/08 5:52:38 PM . to severe vomiting and diarrhea includes IV fluids. and tachycardia Serum lactate may reflect anaerobic tissue metabo. fever. and capnography. Establish and maintain ABCs. Exhaled end-tidal carbon dioxide (ETCO2) lev.16 In the prehospi. elevated lactate in the setting of infection in. fluids. ventilation is held constant (e. Control blood and fluid losses..17–20 Capnography reflects the expiration of carbon dioxide from the TO SHOCK lungs. Monitor vital signs. fluids and vasopressors (epinephrine). when mechanical 6.21.23 ETCO2 94%) and ensure adequate ventilation. Prevent additional injury or exacerbation of most useful as an indicator of perfusion when minute existing medical conditions. perfusion. ETCO2 levels are reduced 4. pulse when blood flow is reduced. whereas the capnography alert ited assessment. Occasionally. inotropic 54 SECTION A Time/Life-Critical Events 1_A_07_051-062. For example. ists.29 tions in the out-of-hospital setting (i. Pulse oximetry may fail to detect a this environment as well as fewer diagnostic tools. Selected air medical agencies have pioneered from severe anaphylaxis after an insect sting requires the use of ultrasound for field care. shock victim in the out-of-hospital setting is chal- gen.. Less frequent. Maintain adequate oxygen saturation (SaO2 ⬎ the endotracheal tube becomes dislodged. hypovolemia. concentration may be influenced by factors other than 3.15. is likely experiencing septic shock. the lism in acute sepsis and shock. Ultrasonography may po. Often the etiology and the initial manage- Assessment of Shock ment options are clear from the history. but most difficult to manage. Pulse oximetry alone cannot detect the adequacy lenging due both to limited assessment capability in of oxygen delivery. is sepsis therapy. diac arrest. but the correlation with arterial or venous lactate With the understanding of the limited treatment op- levels remains unclear. 7.. changes in ETCO2 are 1. readily treatable in the field (e.22 In addition. oxygen saturation. car. In any patient suffering from a potential 8. the field team should attempt to identify the etiology of the Future Technologies in the shock state. shock state. ventilation is applied). Both the provider and the direct medical oversight tal setting in nonintubated patients.15 Like pulse oximetry. In summary. pulmonary embo- dicates septic shock and the need for early goal-directed lism).g. For example. the out-of-hospital treatment of a young previously Preliminary work has been performed using ultra.14 Patients in vari. providing following basic principles: feedback regarding the effect of changes in ventilato- ry parameters. rate was 0. when pulmonary perfusion decreases in shock. capnography may also serve as an important tool in the evaluation and treatment GENERAL APPROACH of shock in the prehospital setting. including the Fo. the patient in shock without an obvious cause. although technology may be the fu- ous stages of exsanguination may not have sufficient ture solution. Notify and transport to an appropriate facility. A handheld fingerstick lactate meter ex. ventilation. primary problem may be strongly suspected but not partment. A patient suffering eurysm. Determine need for early definitive care. requires prompt cardioversion. or an abdominal aortic an. tentially assist in shock resuscitation by facilitating The treatment of cardiogenic shock in an unrespon- recognition of intra-abdominal hemorrhage.

“Pump failure” is often difficult to diagnose may be the result of inadequate volume replacement. response to fluid challenges should dictate sive pulmonary embolus or cardiac tamponade). other etiologies for the hypo- be treated with appropriate chemical or electrical tension must be considered. should be used. remains controversial. though epinephrine is easily administered via several routes (intramuscular [IM]. norepinephrine.. field treatment may be indi. not to give fluids.indd 55 12/3/08 5:52:38 PM . en or whether a trial of a sympathomimetic agent rarily overcoming the obstruction. the drug has significant side effects. beta-blocker and calcium channel blocker toxicity. and to treat without invasive monitoring. External butamine. crystalloids are the fluid of choice for closely.30–38 These agents block sympathomimetic receptors. The principal treatment decision is whether or tain without special infusion pumps. rotomy). Fluids are be resolved. Norepi- Shock of Unclear Etiology nephrine and dopamine have side effects similar to In a few disconcerting conditions the primary etiol- epinephrine and must be administered via drip infu. Adult pa. An appropriate drug agent is IV gluca- dilated vasculature. and cardiogenic. flu- Obstructive causes of shock are often difficult to di. myocardial infarction. distributive. tors. treatment and fluid challenges due to the receptor bination of vasoactive medications. the obstruction should shock with profound pulmonary edema. often refractory to sympathomimetic The treatment of distributive shock involves the com. cases. CHAPTER 7 Hypotension and Shock 55 1_A_07_051-062. Some cases of cardio- genic shock will respond to fluids. distributive.g. fluids are an appropriate initial Obstructive Shock treatment for hypotension.g. Fluid replacement and DMO physician must realize that drips are often via vascular access is a mainstay of treatment. inadequate oxygenation. as previously discussed. would be more appropriate. If after vigorous field treatment the patient Cardiogenic shock from severe dysrhythmias should remains hypotensive. the initial field resuscitation of the hypovolemic pa. flu. and which many EMS agencies carry for use in clude epinephrine. however. In the difficult to manage in the field and must be monitored United States. Among the causes of cardiogenic shock are tient. However.. treatment with The treatment of hypotension and shock caused by inotropic agents or pressors. eficial. mas. In other cannot be treated successfully in the field (e. Refractory hypotension therapy. and dopamine.30 The amount of fluids that should be provided. ids should not be given to patients in cardiogenic agnose and treat. An improvement in the patient’s condi- vidualized for the four categories of shock: hypovole. or from fluid challenges of approximately 150 to 300 ml medications. thoracotomy. such as by decompression of a tension also not appropriate when cardiogenic shock has pneumothorax. ogy for the patient’s shock state may not be obvi- sion. Occasionally shock will be refractory to initial at- Cardiogenic Shock tempts at resuscitation. ous. If possible. whether additional fluid challenges should be giv- ids may be helpful in increasing preload and tempo. A worsening of the patient’s condition with a fluid challenge or the presence of obvious pulmonary edema on initial evaluation suggests that fluid therapy Hypovolemic Shock would not be helpful. The provider bleeding should be controlled. lapa- Cardiogenic shock requires individualized treatment. which fill the expanded gon. This may reflect the need for definitive care in the hospital (e. of crystalloid. hypoglycemic patients. which constrict the blockade. which facilitates heart rate stimulation and vascular tree. when the primary problem been precipitated by a treatable arrhythmia. Al. These patients present with profound bradycardia Distributive Shock and shock. endotracheal. tion suggests that enhancing preload would be ben- mic. im- pairing the body’s normal compensatory responses. and vasopressors). or IV bolus or drip). obstructive. Commonly used vasoactive medications vasoconstriction through alternative cellular recep- in the out-of-hospital setting for distributive shock in. acidemia. Continuous infusions may be difficult to main. In such settings. tension tients without obvious pulmonary edema may benefit pneumothorax. and obstructive shock. However. cardiac tamponade. such as dopamine or do- hypovolemia is relatively straightforward. agents. In hypovolemic. and fluids.

as overventilation is very com- uses several alternatives when treating shock. These agents increase car- been described and used for generations. However. IV access could be attempted en route if their systems to determine the most appropriate de- it did not delay delivery to definitive care. including the severity of the patient’s illness and the available cannulation sites.43 mon. Recent innovations have made intraosseous access rapid and The treatment of shock must be customized to the easy for most patients. Conversely. Extremity veins provide the typical routes of venous access. and/or vasoconstriction. a similar patient might benefit from carefully for maintaining vascular volume. extremely sensitive to increases in intrathoracic pres- al centers have studied hypertonic saline. fluids should be infused with either pressure bags or manual Ventilation pressure applied to the IV bag. a one-handed squeeze on IV administration of fluids is a gold standard treat. both brain oxygenation and brain blood flow. Administration of vasoactive medications is often re- tients.36 in an increase in airway pressure. niques (such as bag-mask ventilation. Generally speaking.39 Older trauma algo. it is supported by a position statement of the National tim of a penetrating cardiac wound probably benefits Association of EMS Physicians.48 56 SECTION A Time/Life-Critical Events 1_A_07_051-062. other hand. intraosseous wound) also exist.35 On the vice for use by their providers. raising intratho- Some air medical services carry O-negative blood for racic pressure. or any of the “alternate airways”) results for out-of-hospital resuscitation in the United States. producing ill patients. In come so important as a method of vascular access that the urban setting with short transport times. Sever. Few EMS systems use central venous access. Patients in shock from any cause are administration to victims of hemorrhagic shock. However. rithms indicate the use of 2 L IV fluid on all major Venous return requires a relative negative pressure in trauma victims. The route of IV administration depends on a minute ventilation of about 5 L/min.38 In the patient who hemostatic materials (placed directly on the bleeding presents a difficult IV access problem. usually sufficient to control external bleeding.47 and lack of demonstrated benefit versus isotonic crys. none of the alternative fluids has trol the rate of assisted positive pressure ventilation gained widespread acceptance. Direct pressure is titrated crystalloid volume infusion during the trans. especially in the EMS care is currently uncertain.indd 56 12/3/08 5:52:39 PM . SHOCK INTERVENTIONS common form of vascular access during World War II. Recent port. allergic reactions. many patients may require the right atrium to ensure return of blood to the heart. Emergency EMS personnel must carefully con- talloids. much larger volumes. Intraosseous access has be- individual EMS agency and geographic location. Ex- Vasopressor Agents ternal jugular veins are also useful sites in many pa. Fluids could be initiated while the patient is en military experience suggests that tourniquets should route to the hospital. Recent studies in a swine hemorrhagic shock artificial blood substitutes as alternatives to isotonic sa. trauma victim with uncontrolled hemorrhage. many factors. quired to reverse systemic hypoperfusion from distrib- The intraosseous route for vascular access has utive or cardiogenic shock. produced significant heat through their exothermic The ideal quantity of fluids to administer in the chemical reaction. endotracheal Isotonic crystalloids are currently the fluid of choice intubation. when rapid fluid infusion is required. thereby prolonging neither scene be used early and liberally. model showed that even modest increases in the rate line. The patient in shock may require assisted ventilation.40. the vic.44 Various devices are most from airway maintenance and rapid transport to available.41 Problems with these alternative fluids include of positive pressure ventilation significantly reduce cost. colloids. How- ever. with longer transport times in the rural The control of external hemorrhage is essential setting. coagulopathy.45 An assortment of topical time nor time until definitive care. chronotropy. the ventilation bag at a rate of approximately once ment that has a long tradition in the care of critically every 8 seconds is reasonable in the adult. some patients may Assisted ventilation using any of the typical tech- require much smaller volumes. the military in the shock patient. hypernatremia. though it became a less popular route in the post- Fluids war era with the rising use of IV cannulation. Initial versions of these products infusions may be attempted. and sure. This was a diac inotropy. and EMS medical directors must work with the hospital.46 The role of hemostatic agents in out-of-hospital setting is not known.42 As a result.

The benefit of a prehospital procedure must Intravascular access itself may present its own set be weighed against potential risks. inotropic agents. outcomes. For example. de- reasonable to administer steroids to shock victims creased oxygen-carrying capacity of the blood.32. Pan- protocols or regulations. the drugs carried by prehospital tive interventions may delay definitive care. field clinical ticosteroids.36 However. definitive care can only be provided in ed underlying pathologic process and the patient’s re. field providers in most clinical settings ating and treating these patients. and extrapolation from hospital-based other problems in the out-of-hospital setting. One international are taught to administer only enough IV or intraosse- study is examining the use of hypertonic saline for ous fluid replacement as to restore a peripheral pulse or the treatment of hemorrhagic shock due to trauma.52 As a result. and then a formal with many other potential pitfalls such as the difficulty assessment revealed that PASG actually worsens of calculating weight-based drug dosages. field. dition.54 However. Currently. thorax or abdomen. failure in susceptible individuals.36 Studies in Houston and San Diego suggest that mortality following traumatic hemorrhage is not in- CONTROVERSIES fluenced by prehospital administration of fluid. to reach a systolic blood pressure of 80 to 90 mm Hg. The ad. and dex. associated with shock treatment is that resuscita- able in the hospital.indd 57 12/3/08 5:52:40 PM . victims with isolated head injuries who receive excess sy exists with respect to many areas of the treatment fluids may develop worsened cerebral swelling. Accurate medication Treatment of Hemorrhagic Shock administration may be facilitated through portable IV infusion pumps. for example. In general. regional. Based on animal studies.32. albumin. hemorrhage. Excess fluid administration can create experience. medical director without clear guidelines for evalu.33. the hospital. In ad- of shock (especially traumatic shock) in the out-of.55 ers should use calculators or templates or seek DMO when initiating drug infusions. It would be dislodgement of clot. and with known adrenal insufficiency or chronic steroid exacerbation of bleeding from injured vessels in the use and refractory hypotension. Unfortunately. A major pitfall of challenges.50 The role of these agents in out-of-hospital Possible mechanisms for worse outcomes include shock management remains undefined. of definitive care. trials have suggested that volume resuscitation before recombinant human activated protein C. in the out-of-hospital delays delivery of definitive care must have proven setting.36. Any field procedure that significantly sponse to therapy.34 Survival to hospital discharge rates were not signifi- Shock Science cantly different for patients receiving fluids versus patients not receiving fluids in the field. controlling hemorrhage may be detrimental. antibiotics. Trauma pathways. nor. personal mains undefined.37 tran. excess fluids may precipitate congestive heart hospital setting. considerable controver. Out-of-hospital treatment is largely based on an.39. dilution of clotting factors. and vasopressin may also be included in mia management. Although a wide variety of vasoactive agents are avail. can and should be delivered in the the drug armamentarium of some services.53 For services are limited by local. Hemorrhage is a common cause of shock in the trauma victim. treatment schemes Other Drug Agents for hemorrhagic shock in the past have included ag- gressive fluid resuscitation and the use of PASG to re- Other agents used for shock resuscitation include cor. the etiology of the shock state is often unclear. for trauma victims with internal The choice of vasopressor depends on the suspect. pneumatic antishock garments and close monitoring of vital signs is difficult. value. most services tridge and Geddes demonstrated that some aspects carry epinephrine and dopamine. Rescu. Several investigators have examined CHAPTER 7 Hypotension and Shock 57 1_A_07_051-062. or statewide victims of myocardial infarction.51.30–34. (PASG) were implemented in clinical EMS prac- ministration of vasoactive agents in the field is fraught tice without supporting evidence. such as defibrillation and arrhyth- epinephrine. Dobutamine. Both studies The lack of definitive studies on the treatment of were performed in systems with relatively short scene shock in the out-of-hospital setting leaves the EMS and transport times. limited scientific studies.49. store normal blood pressure. The optimum target blood pressure for these patients re- ecdotal reports.

approaches should be individualized for 1. the amount of time required to initiate interventions 4 Resources to be used in the field. Protocols for the inner city may not be Honigman. The potential benefits of 2. 58 SECTION A Time/Life-Critical Events 1_A_07_051-062. Treatment modalities for shock are limited in the PROTOCOLS field. lyzed 52 cases of prehospital multiple trauma. over one fourth of the IV attempts were unsuc- ease state. The is taking oral antibiotics and has no allergies. ease. Transport to the hospital when appropriate. studies led by Jacobs. Smith et al. SUMMARY tims and rapid transport times.9 times higher adjusted survival rate for es for the establishing of clinical protocols addressing patients receiving IV fluids in the field versus those not the evaluation and treatment of shock that optimizes receiving fluids. and only 1 L of fluid was infused in the most tions. be applied. but include bleeding control. that the EMS medical director draw from best practic- described a 3. Establishing and maintaining the status of ABCs. primarily in trauma victims. The effectiveness of Shock must be correlated with the patient’s clinical IV fluids for similar patients in the rural and wilder- condition. finding Protocols developed for the out-of-hospital treatment that IV insertion time exceeded transport time in all of shock must consider the heterogeneity of the dis- cases. evidence-based medical decision making when devel- ALS interventions did not delay transport time to the oping treatment protocols. and the environment in which the protocols will critical patients.56–58 In the study by Jacob et al. PASG applica- be considered. Paramedics report that they are caring for a and respiratory rate of 16 breaths/min. Skills of the various levels of prehospital care studies send conflicting messages. inotropic agents. fluid administra- tion. jugular vein distention (JVD) or peripheral edema. shock care interventions must be weighed against the 3. Medics note 65-year-old male complaining of abdominal pain and that he is pale and diaphoretic. Their evaluation is dizziness on standing. The medics are 25 minutes from the nearest hospital patient is alert and oriented with a blood pressure and are requesting orders from DMO.56 Other investigators have described the resources of the area of medical oversight. the feasibility of starting IV access while en route to the hospital. the limited assessment and treatment op- cessful. or IV insertion. This man has a history of an remarkable for clear lung fields and no evidence of abdominal aortic aneurysm. Providers must identify signs of decreased tissue perfusion when assessing for the presence of shock. The level of train- did not correlate with the number of prehospital proce- ing and clinical experience of the providers must also dures performed. coining the term zero-time prehospital IV. Although the mainstay of shock treatment should address the following factors: is IV fluids. potential risks of delaying definitive care. The patient monitor shows sinus rhythm at a rate of 95. The definitive care permitted for these patients. and recent prostate surgery.. including intubation. It is strongly recommended hospital as compared with BLS units. CLI NI C A L VI G NET T E S Case 1 of 60 mm Hg palpable. but these 5. pulse rate of 95 beats/min. ECG indwelling urinary bladder catheter. size. and Eckstein each found that on-scene time appropriate for the rural setting. Ideally. medical oversight would use tion.59 The majority of IV fluid studies took place in urban settings with primarily penetrating trauma vic. and he has an The abdomen is slightly distended and tender.58 Eckstein et al. ana. in the field. providers in the field. age. and careful control of assisted A treatment protocol for treating shock in the field ventilation. coronary artery dis.38 Conversely.indd 58 12/3/08 5:52:40 PM . tory. different clinical scenarios. and present and past medical his- ness settings remain undefined.

A primary sur. and two was working on his roof on a hot. The patient should be reevaluated of pulse oximetry. The bleed- coronary artery disease. pressure. As in the previous case. the DMO physician should instruct therapy. On arrival of the paramedics at the scene. blood pressure of 60 mm Hg systolic. or arrhythmias. to be performed by the paramedics en route to the tinal bleeding. the patient was awake. and fluids should be ad- 65 beats/min. the the presence of a radial pulse and/or a palpated patient remained unresponsive and without sponta- systolic blood pressure of 80 to 90 mm Hg. On arrival Hg. However. female who cut both of her wrists in an apparent suicide attempt. gastrointes. The patient showed no shock in this patient may include a perforated ab. fluid vol- estimate a 20-minute transport time to the nearest ume should be rapidly replaced to normalize blood trauma center. but the initial evaluation and treatment is tic aneurysm. the patient was found unresponsive on the ground. distrib. and the airway was secured of the Intravenous Fluids for This Patient? by endotracheal intubation. and myocardial infarction ing is now controlled with direct pressure. merous. capnography. frequently. In this case. signs of fluid overload. of an inferior wall myocardial infarction to the emer- ceiving hospital should be notified. and therefore interventions dominal viscus. and sepsis. A secondary survey should be completed by the providers to ascertain any other conditions Paramedics have initiated transport of a 25-year-old that may be present. myocardial infarction. Additional gency department team. and dextrose Case 3 level. of the two-person paramedic crew. or obstructive shock with no signs of fluid challenge of at least 300 ml of an isotonic crystalloid. A dopamine of 300 to 500 ml of crystalloid should be rapidly drip was initiated with moderate improvement of the infused under pressure with frequent evaluation for patient’s blood pressure and perfusion. Unlike the revealed no signs of external or obvious sources of uncontrolled hemorrhage model in which aggressive internal bleeding. capnography. The field team es- A 65-year-old man with a history of hypertension. Secondary survey to the IV fluid bag to increase the flow.indd 59 12/3/08 5:52:41 PM . Therefore. a Evaluation at the trauma center revealed a cervical 12-lead ECG should be taken and evaluated. sunny day. ministered at a wide open rate with pressure applied and clear and equal lung sounds. urticaria. Suspecting an abdominal hemorrhagic Response to these interventions would direct further catastrophe. He large-bore IV catheters have been established. or external trauma. overload. IV access repeated fluid challenges (200-ml trials infused rap- should be established en route. Fluid therapy would be hospital should include large-bore IV access or in- appropriate for hypovolemic. The patient remained hypotensive despite the field personnel to expedite transport. How Would You Direct the Management How Would You Direct the Management of This Patient? of This Patient? Although the parties involved in this case were The etiologies of hypotension in this patient are nu- rightly concerned about a leaking abdominal aor. and spine fracture and ECG changes that were suggestive the operating room and surgical team at the re. traosseous access and the administration of a fluid utive. Normal saline IV lines are running wide open. standard protocol measures include the monitor- ing of pulse oximetry. How Would You Direct the Management vey was performed. but drowsy. During their report to This patient is suffering from hypovolemic shock medical oversight. The struck a beehive with his hammer and suffered a patient’s present systolic blood pressure is 60 mm fall approximately 6 feet from the roof. other etiologies of hypotension and independent of the etiology. the patient was relatively bradycardic with a heart rate hemorrhage is controlled. CHAPTER 7 Hypotension and Shock 59 1_A_07_051-062. A fluid challenge idly under pressure for a total of 1 L). additional fluid challenges may be administered according standard protocol measures include the monitoring to this plan. the paramedics noted that the and requires fluid resuscitation. and dextrose level. facial swelling. timates a 900-ml blood loss on scene. internal fluid administration may lead to increased bleeding. cardiogenic. Serial neous movement. The paramedics the bleeding here is controlled. with Case 2 active bleeding from both wrists. ECG monitoring should be started.

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