Prehospital Trauma Life Support

Lesson
Shock & Fluid
6 Resuscitation
 Developed by the
National Association of
Emergency Medical Technicians
In cooperation with
The Committee on Trauma,
American College of Surgeons

This slide presentation is intended for use only

in approved PHTLS courses. 6-1B
Lesson 6 Objectives

 Correlate perfusion, hypoperfusion, hypoxia,

hypovolemia and hypotension to the signs and
symptoms of shock.

 Differentiate between early and late signs of shock.

 Describe the pathophysiological changes of shock.

 Identify the management of shock, including

conservation of heat, fluid replacement and the
pneumatic anti-shock garment.

6-2
Shock:
A rude unhinging of the
machinery of life.

Samuel Gross, 1852

6-3
Shock Redefined:

Lack of end-tissue perfusion.

Pitfall: Defining shock as

decreased blood pressure.

6-4
Scenario
You are caring for the sole victim of a
motorcycle crash. He is lying on the
ground next to his motorcycle. The
scene appears safe.

6-5
Findings
 A - Open, clear.
 B - RR fast. BS clear. Bruising noted
over sternum; no other chest
deformity.
 C - Radial pulse weak & rapid.
 D - PEARL. Anxious & confused.
Normal movement & sensation.
 E - No deformity noted. Skin cool &
diaphoretic.
6-6
Discussion
 Is this patient in shock?

 Why?

 What is the patient’s real

problem?

6-7
Cell Perfusion

 Aerobic metabolism requires

adequate oxygenation.

 Cells require oxygen and sugar

to produce energy and carbon
dioxide.
Is the patient in this scenario
adequately perfusing his cells?

6-8
Anaerobic Metabolism

Inadequate oxygenation
for metabolism.
 By-products:
 Less energy.
 More acid.
 Potassium.
6-9
 Leads to Acidosis
• Inadequate oxygen delivery, cellular
extraction, and consumption result in
cellular conversion to anaerobic
metabolism for energy substrate
production (ATP production)

• Increased production and

release of lactate
 Shock
Definition – Decreased utilization
of oxygen by the tissues

If prolonged - downward spiral

Tissue injury

Organ dysfunction syndrome

Multiple organ failure

Death
Cellular Death
SHOCK
Cellular Hypoxia - Anaerobic
Metabolism

Hypotension

Hypoperfusion

Cellular Hypoxia

Anaerobic Metabolism
If cellular death is not
Cell Death prevented, organism
death will follow.

6-10
Staged Death
 Organism death:
 May be quick - prior to EMS.
 May be prolonged - 2 to 3 weeks later.

 Occurs in stages:
 Stages occur as the body tries to
compensate.
 We see the stages through signs &
symptoms.
6-11
 What Organs Fail?
Combination of respiratory
failure (ARDS) with renal
failure, metabolic failure,
or cardiac failure
– Poor prognosis

Mortality rate
– One organ/systems 40%
– Two organ/systems 60%
– Four or more 100%
Prevent Cellular Death
 Recognize shock early.
 Restore cellular perfusion.
 Restore aerobic metabolism.

Pitfall: Waiting until it is too late

to restore perfusion to cells.

6-12
3 Phases of Shock

Compensatory

Progressive

Irreversible
Early Recognition
Signs & Symptoms of Uncompensated Shock

Description Compensated Decompensated

Pulse  Tachycardia  Marked tachycardia;
can progress to
bradycardia

Skin White, cool, White, “waxy,” cold,

and moist marked diaphoresis

BP Normal range  Lowered

LOC Unaltered Altered, ranging from

disoriented  coma

6-13
Early vs. Late
 What are the earliest signs of
shock?

 What is a late sign of shock?

6-14
Restore Cellular Perfusion

 Maintain chemical balance.

 Maintain fluid balance.

6-15
Chemical Balance continued...

 Decrease in oxygen.
 Detected by chemical receptors in the carotid
arteries and in the arch of the aorta.
 Respirations increase in rate & depth.

 Rise in acidity.
 Buffer system converts acid to CO2 & water.
 Medulla senses increased CO2.
 Respirations increase; lungs “blow off” CO2.

6-16
 Common Shock Pathways
 Mechanisms  Compensation
 Oxygen deficiency  ↑ Catecholamines
 Cellular hypoxia ↑ HR, contractility
 Ischemia Vasoconstriction of
 Anoxia both arterial and
venous beds
– ↑ oxygen delivery
↑ Cellular extraction
of oxygen
Chemical Balance cont’d.

 Key: increase in respiratory rate is

an early sign of shock.
 What signs or symptoms indicate
that the patient’s body is trying to
restore its chemical balance?
 What steps could you take to help
the body restore balance and
aerobic metabolism?
6-17
Fluid Decrease
Fluid volume decreases

Baroreceptors note change

Epinephrine and norepinephrine released

Vasoconstriction Increased rate &

strength of cardiac
contractions

6-18
Fluid Decrease continued...

 Hormonal response:
 Various hormones are released,
causing vasoconstriction and fluid
retention.

 Compensation:
 Blood vessels constrict.
 Heart increases strength & rate.
 Fluid is retained.
6-19
Fluid Decrease cont’d.

 In the scenario, which signs

suggest that the patient’s body is
trying to restore its fluid balance?
 Is the patient compensating well?
Why?
 What steps could you take to
help the body restore balance?
6-20
The Fick Principle
 Defines what is necessary to
achieve end-tissue perfusion:
 On-loading oxygen to the RBCs.
 Delivering the RBCs to the tissue.
 Off-loading oxygen to the tissue.

 As part of the process, patient

must have an adequate
number of RBCs to transport
oxygen.
6-21
Scenario
You are responding to a patient that has
fallen from a 40-foot cliff while rock climbing.
He is awake. He tells you that he can’t move
his legs, and has no feeling below his waist.
Pulse 119, RR 20, and BP 104/72.

How does the Fick Principle apply here?

How well is this patient compensating?

6-22
Scenario
You are called to the scene of a house
fire, where firefighters have just removed
one patient. He is unresponsive. Pulse
102, RR 6, and BP 104/76.

How does the Fick Principle apply here?

How well is this patient compensating?

6-23
Scenario
You respond to a scene where a skier has
struck a tree at high speed. Exam reveals pain
on palpation of the right lateral chest, absent
breath sounds on the right and labored
breathing. Pulse 142, RR 40, and BP 88/70.

How does the Fick Principle apply here?

How well is this patient compensating?

6-24
Scenario
You are dispatched to an MVC. On arrival, you
find a 47-year-old male driver still in the
vehicle. There are 10-15 inches of intrusion to
the front of the vehicle. The patient is
unresponsive as you approach.

6-25
Findings
 A - Blood & vomitus in airway.
 B - Slow & labored. BS absent on
left.
 C - No palpable radial pulse. Cool,
wet skin. No external bleeding.
 D - Pupils equal but reacting slowly.
 E - Obvious fracture of left femur.

How does the Fick Principle apply here?

6-26
Shock Summary

Shock is staged
death...
…catch it in the first act!

6-27