外科急诊创伤（英文）避免休克连锁反应

Avoiding the Train Wreck of SHOCK Kay Kamish, RN, BSN, EMT-P Tulsa Life Flight OBJECTIVES Define the four types of SHOCK Understand the difference in etiologies Recognize the progression of symptoms Understand the difference in approach to treatments Train Wreck of SHOCK SHOCK Think of the Engine as the Heart. The Tracks as the blood vessels The cars as the RBCs. The Freight as the Oxygen and nutrients. SHOCK g Inadequate tissue perfusion g Inability of the body to keep up with the tissue demand for oxygen and nutrients. Train Wreck of SHOCK Train Wreck of Shock * FOCUS of INTERVENTION: *Identify the type of Shock *Initiate the proper care SHOCK TYPES of SHOCK Hypovolemic Train Wreck of SHOCK Cardiogenic Distributive Obstructive Train Wreck of SHOCK HYPOVOLIEMIC SHOCK * Hemorrhage * Vomiting *Diarrhea *Third Spacing *Diuresis SHOCK - Hypovolemic Low volume - poor carrying capacity of the cells - not enough freight CARDIOGENIC SHOCK Occurs when damaged or unhealthy heart muscle is no longer able to pump effectively = Heart Failure * Myocardial Infarction Train Wreck of SHOCK * Cardiac Arrest * Dysrhythmias * Cardiomyopathies SHOCK - Cardiogenic Heart Failure - an old and tired Engine SHOCK - Cardiogenic Cardiogenic Shock - the heart (engine) no longer functions effectively DISTRIBUTIVE SHOCK NEUROGENIC Loss of normal sympathetic vasoconstriction * spinal cord injury * severe pain * vasomotor center depression d/t drug OD Train Wreck of SHOCK DISTRIBUTIVE SHOCK Train Wreck of SHOCK VASOGENIC Diminished arterial resistance and increased venous capacitance * Due to a release of vasodilating substance from the body itself * Anaphylactic Shock * Septic Shock SHOCK - Distributive Vasodilation - too many tracks/ blood vessels to fill OBSTRUCTIVE SHOCK Train Wreck of SHOCK * Arterial Stenosis * Pulmonary Embolism * Pulmonary Hypertension * Cardiac Tamponade * Tension Pneumothorax Train Wreck of SHOCK Review: Four Types of SHOCK HYPOVOLEMIC Volume Loss CARDIOGENIC Heart Failure DISTRIBUTIVE Vasodilation OBSTRUCTIVE SHOCK You have the engine (the heart) but no cars (volume) and too many tracks to fill up (excess venous capacitance). Train Wreck of Shock STAGES 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 STAGES of SHOCK Train Wreck of Shock Early Stage Pathophysiology Decrease in MAP Results in reduced or uneven microcirculatory blood flow and decreased O2 delivery to cells Clinical Signs Usually there are few at this point STAGES of SHOCK Train Wreck of Shock Early Stage Pathophysiology Compensatory mechanisms can restore MAP to reasonable levels. Clinical Signs Therefore: There are few clinical signs AND: No disruption of vital organ function STAGES of SHOCK Train Wreck of Shock * Important Point * VITAL ORGAN FUNCTION Now drops 10 -15 mmHg *Compensatory Mechanisms are put in motion Heart rate increases Respirations increase STAGES of SHOCK - Compensatory Train Wreck of Shock Cardiac Output CO=Heart rateXStroke volume Normal CO = 4 to 6 Liters/ minute Normal SV = 60 to 100 cc Normal HR = 60 to 100 bpm STAGES of SHOCK - Compensatory Train Wreck of Shock Cardiac Output Increases WHY ? To perfuse Vital Organs : heart, lungs, brain, kidneys STAGES of SHOCK - Compensatory Train Wreck of Shock Pathophysiology Renal predominantly a - adrenergic SHOCK - Treatment Train Wreck of Shock Distributive Remember this is due to the loss of sympathetic tone, resulting in pooling of blood in venous and capillary beds. SHOCK - Treatment Train Wreck of Shock Distributive Septic Shock Most common form of Distributive Shock 40 % Mortality Rate Seen in bodys inflammatory response to overwhelming systemic infection Produces profound hypotension SHOCK - Treatment Distributive Train Wreck of Shock Septic Shock Provide aggressive fluid resuscitation What will you do if blood pressure continues to drop ? Vasopressors Inotropic drugs SHOCK - Treatment Distributive Train Wreck of Shock Neurogenic Shock h Typically the result of head injury or spinal cord injury Initial Symptoms: T Hypotension T Bradycardia T Hypothermia T Warm, dry skin What symptoms are present here that are opposite to other forms of shock ? SHOCK - Treatment Distributive Train Wreck of Shock Neurogenic Shock Treatment is aimed at the cause of cardiovascular instability Eg: T Bradycardia Atropine T Hypotension Vasopressors Not a volume problem in this case SHOCK - Treatment Distributive Train Wreck of Shock Anaphylactic Shock Hypersensitivity to an environmental exposure g Food g Venom g Medications SHOCK - Treatment Distributive Train Wreck of Shock Anaphylactic Shock Causes large release of histamine and other vasoactive substances This in turn causes : massive vasodilation increased capillary permeability profound hypovolemia vascular collapse arrhythmias decreased cardiac contractility SHOCK - Treatment Distributive Train Wreck of Shock Anaphylactic Shock Assess ABCs - *Airway is often compromised* Counteract the anaphylactic reaction T Remove the offending stimulus, if possible T Fluid resuscitation T Subcutaneous Epinephrine T Antihistamines (Benadryl) T Corticosteroids T Vasopressors SHOCK - Treatment Obstructive Shock Train Wreck of Shock Figure out what is being obstructed and why SHOCK - Treatment Train Wreck of Shock Obstructive Shock What is obstructe