23: Shock
Cognitive and Affective Objectives
5-1.9 List signs and symptoms of shock
(hypoperfusion).
5-1.10 State the steps in the emergency medical
care of a patient with signs and symptoms of
shock (hypoperfusion).
5-1.11 Explain the sense of urgency to transport
patients who are bleeding and show signs of
shock (hypoperfusion).
Psychomotor Objectives
5-1.16 Demonstrate the care of the patient exhibiting
signs and symptoms or shock (hypoperfusion).
5-1.17 Demonstrate completing a prehospital care
report for the patient with bleeding and/or shock
(hypoperfusion).
Shock
• State of collapse and failure of the
cardiovascular system
• Leads to inadequate circulation
• Without adequate blood flow, cells cannot
get rid of metabolic wastes
• The result of hypoperfusion to cells that
causes the organ, then organ systems, to
fail
Perfusion
• The cardiovascular system’s
circulation of blood and oxygen
to all the cells in different tissues
and organs of the body
Perfusion Triangle
Heart
(Pump Function)
Damage to the heart by
disease or injury.
It cannot move blood
adequately to support
perfusion.
Blood Vessels
(Container Function)
If all the vessels dilate at once,
the normal amount of blood
volume is not enough to fill the
system and provide adequate
perfusion to the body.
Blood
(Content Function)
If blood or plasma is lost, the
volume in the container is not
enough to support the perfusion
needs of the body.
Capillary Sphincters
• Regulate the blood flow through the capillary
beds.
• Sphincters are under the control of the
automatic nervous system.
• Regulation of blood flow is determined by
cellular need.
Perfusion and Neurogenic Shock
Cardiovascular Causes
of Shock (1 of 4)
• Pump failure (cardiogenic shock)
– Inadequate function of the heart or pump failure
– Causes a backup of blood into the lungs
– Results in pulmonary edema
– Pulmonary edema leads to impaired ventilation
Cardiovascular Causes
of Shock (2 of 4)
• Poor vessel function (neurogenic shock)
– Damage to the cervical spine may affect control
of the size and muscular tone of blood vessels.
– The vascular system increases.
• Blood in the body cannot fill the enlarged
system.
• Neurogenic shock occurs.
Cardiovascular Causes
of Shock (3 of 4)
• Content failure (hypovolemic shock)
– Results from fluid or blood loss
– Blood is lost through external and internal
bleeding.
– Severe thermal burns cause plasma loss.
– Dehydration aggravates shock.
Cardiovascular Causes
of Shock (4 of 4)
• Combined vessel and content failure
– Some patients with severe bacterial infections,
toxins, or infected tissues contract septic
shock.
– Toxins damage vessel walls, causing leaking
and impairing ability to contract.
– Leads to dilation of vessels and loss of plasma,
causing shock
Noncardiovascular Causes
of Shock (1 of 3)
• Respiratory insufficiency
– Patient with a severe chest
injury or airway obstruction
may be unable to breathe
adequate amounts of
oxygen.
– Insufficient oxygen in the
blood will produce shock.
Noncardiovascular Causes
of Shock (2 of 3)
• Anaphylactic shock
– Occurs when a person reacts violently to a
substance.
– Four categories of common causes:
• Injections
• Stings
• Ingestion
• Inhalation
Noncardiovascular Causes
of Shock (3 of 3)
• Psychogenic shock
– Caused by sudden reaction of the nervous
system that produces a temporary, generalized
vascular dilation
– Commonly referred to as fainting or syncope
– Can be brought on by serious causes: irregular
heartbeat, brain aneurysm
– Can be brought on by fear, bad news,
unpleasant sights
Progression of Shock
• Compensated shock
– When the body compensates for blood loss
• Decompensated shock
– The late stage of shock when blood pressure is
falling
• Irreversible shock
– The terminal stage
Compensated Shock
•
•
•
•
Agitation
Anxiety
Restlessness
Feeling of impending
doom
• Altered mental status
• Weak pulse
•
•
•
•
•
•
•
Clammy skin
Pallor
Shallow, rapid breathing
Shortness of breath
Nausea or vomiting
Delayed capillary refill
Marked thirst
Decompensated Shock
• Falling blood pressure
(<90 mm Hg in an adult)
• Labored, irregular
breathing
• Ashen, mottled, cyanotic
skin
• Thready or absent pulse
• Dull eyes, dilated pupils
• Poor urinary output
Irreversible Shock
• This is the terminal stage of shock.
• A transfusion of any type will not be
enough to save a patient’s life.
When to Expect Shock
•
•
•
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Multiple severe fractures
Abdominal or chest injuries
Spinal injuries
Severe infection
Major heart attack
Anaphylaxis
• You and your partner respond to an MVC involving
two cars. En route you follow BSI.
• You arrive to a 25-year-old man.
• Law enforcement informs you that the other car left
the scene. Patient was restrained and is sitting
outside car. He is pale.
• The airbag has deployed and the steering wheel
has some damage.
You are the Provider
Scene Size-up
• In addition to BSI, what are some
considerations at the scene?
• What is the mechanism of injury?
• You approach the patient and introduce yourself.
He appears visibly upset but lets you take his vital
signs.
– Pulse: 115 beats/min
– Respirations: 26 breaths/min
– Blood pressure: 110 mm Hg
• He has a laceration on his knee where it hit the
dashboard.
You are the Provider
(continued)
Initial
Assessment
• Describe the steps of your initial assessment and
findings:
– General impression
– Airway
– Breathing
– Circulation
– Transport decision
•
•
•
•
•
•
•
Spinal immobilization needed.
Pallor is a sign of shock.
He is A on the AVPU scale.
Airway is open.
Breathing is rapid.
Inspect and palpate chest for DCAP-BTLS.
Observe for accessory muscle use.
You are the Provider
(continued)
•
•
•
•
Patient has rapid pulse.
Clammy skin.
Knee laceration
Priority transport
You are the Provider
(continued)
Focused History and
Physical Exam
• Would you perform a rapid physical exam or
focused physical exam?
• What is your reasoning?
Detailed Physical Exam
• If time permits, perform en route to the hospital.
Ongoing
Assessment
• Perform reassessment.
• Take vital signs every 5 minutes.
• You reassess the patient in the ambulance and
he has a pulse of 122 beats/min, respirations
of 30 breaths/min, and a blood pressure of
106/68 mm Hg.
• What do his vital sign changes indicate?
You are the
Provider
(continued)
Emergency Medical Care (1 of 3)
• Make certain patient
has open airway.
• Keep patient supine.
• Control external
bleeding.
Emergency Medical Care (2 of 3)
• Splint any broken
bones or joint injuries.
• Always provide oxygen.
• Place blankets under
and over patient.
Emergency Medical Care (3 of 3)
• If there are no broken
bones, elevate the legs
6" to 12".
• Do not give the patient
anything by mouth.
Pneumatic Antishock Garment
• Some localities allow EMTs to apply a pneumatic
antishock garment (PASG) for some patients in
decompensated shock.
• Know your local protocol regarding their usage.
Treating Cardiogenic Shock
• Patient may breathe better in a sitting or
semi-sitting position.
• Administer high-flow oxygen.
• Assist ventilations as necessary.
• Have suction nearby in case the patient
vomits.
• Transport promptly.
Treating Neurogenic Shock
• Maintain airway and assist
breathing as needed.
• Keep patient warm.
• Transport promptly.
Treating Hypovolemic Shock
• Control obvious bleeding.
• Splint any bone or joint injuries.
• If no fractures, raise legs 6" to 12".
• Secure and maintain airway.
• Give oxygen as soon as you suspect
shock.
• Transport rapidly.
Treating Septic Shock
• Transport as promptly as possible
while giving all general support
available.
• Give high-flow oxygen during
transport.
• Use blankets to conserve body
heat.
Treating Respiratory Insufficiency
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Secure and support the airway.
Clear airway of any obstructions.
Ventilate if needed with a BVM device.
Administer oxygen.
Transport promptly.
Treating Anaphylactic Shock
• Administer epinephrine.
• Provide prompt transport.
• Provide all possible support.
– Oxygen
– Ventilatory assistance
Treating Psychogenic Shock
• It is usually self-resolving.
• Assess patient for injuries from fall.
• If patient has difficulties after regaining
consciousness, suspect another problem.
Review
1. The term “shock” is MOST accurately defined as:
A. a decreased supply of oxygen to the brain.
B. cardiovascular collapse leading to inadequate
perfusion.
C. decreased circulation of blood within the venous
circulation.
D. decreased function of the respiratory system
leading to hypoxia.
Review
Answer: B
Response: Shock, or hypoperfusion, refers to a state
of collapse and failure of the cardiovascular
system, or any one of its components (eg, heart,
vasculature, blood volume), which leads to
inadequate perfusion of the body’s cells and
tissues.
Review
1. The term “shock” is MOST accurately defined as:
A. a decreased supply of oxygen to the brain.
Rationale: It may be a result of inadequate perfusion, but it is not the
definition of shock.
B. cardiovascular collapse leading to inadequate perfusion.
Rationale: Correct answer
C. decreased circulation of blood within the venous circulation.
Rationale: It may be a result of cardiovascular collapse, but it is not the
definition of shock.
D. decreased function of the respiratory system leading to hypoxia.
Rationale: Decreased function of the respiratory system will lead to
hypoxia which will cause cardiovascular collapse and eventually to
shock.
Review
2. A 20-year-old man was kicked numerous times in
the abdomen during an assault. His abdomen is
rigid and tender, his heart rate is 120 beats/min,
and his respirations are 30 breaths/min. You should
treat this patient for:
A. a lacerated liver.
B. a ruptured spleen.
C. respiratory failure.
D. hypovolemic shock.
Review
Answer: D
Rationale: The patient may have a liver laceration or
ruptured spleen—both of which can cause internal
blood loss. However, it is far more important to
recognize that the patient is in hypovolemic shock
and to treat him accordingly.
Review
2. A 20-year-old man was kicked numerous times in the abdomen
during an assault. His abdomen is rigid and tender, his heart rate is
120 beats/min, and his respirations are 30 breaths/min. You should
treat this patient for:
A. a lacerated liver.
Rationale: You cannot treat a lacerated liver in the field. You can treat
the symptoms of hypovolemic shock associated with the injury.
B. a ruptured spleen.
Rationale: You cannot treat a ruptured spleen in the field. You can treat
the symptoms of hypovolemic shock associated with the injury.
C. respiratory failure.
Rationale: If you treat the hypovolemic shock, then you will treat the
respiratory compromise as well.
D. hypovolemic shock.
Rationale: Correct answer
Review
3. Signs of compensated shock include all of the
following, EXCEPT:
A. restlessness or anxiety.
B. pale, cool, clammy skin.
C. a feeling of impending doom.
D. weak or absent peripheral pulses.
Review
Answer: D
Rationale: In compensated shock, the body is able to
maintain perfusion to the vital organs of the body
via the autonomic nervous system. Signs include
pale, cool, clammy skin; restlessness or anxiety; a
feeling of impending doom; and tachycardia. When
the body’s compensatory mechanism fails, the
patient's blood pressure falls; weak or absent
peripheral pulses indicates this.
Review
3. Signs of compensated shock include all of the following,
EXCEPT:
A. restlessness or anxiety.
Rationale: This indicates compensated shock.
B. pale, cool, clammy skin.
Rationale: This indicates compensated shock.
C. a feeling of impending doom.
Rationale: This indicates compensated shock and the anxiety
associated with it.
D. weak or absent peripheral pulses.
Rationale: Correct answer
Review
4. A 60-year-old woman presents a BP of 80/60 mm
Hg, a pulse rate of 110 beats/min, mottled skin, and
a temperature of 103.9°F. She is MOST likely
experiencing:
A. septic shock.
B. neurogenic shock.
C. profound heart failure.
D. a severe viral infection.
Review
Answer: A
Rationale: In septic shock, bacterial toxins damage
the blood vessel walls, causing them to leak and
rendering them unable to constrict. Widespread
dilation of the vessels, in combination with plasma
loss through the injured vessel walls, results in
shock. A high fever commonly accompanies a
bacterial infection.
Review
4. A 60-year-old woman presents a BP of 80/60 mm Hg, a pulse
rate of 110 beats/min, mottled skin, and a temperature of
103.9°F. She is MOST likely experiencing:
A. septic shock.
Rationale: Correct answer
B. neurogenic shock.
Rationale: Neurogenic shock is an injury to the nervous system
and shows bradycardia and hypotension — not fever.
C. profound heart failure.
Rationale: This is part of cardiogenic shock, associated with low
blood pressure, weak pulse, and cyanotic skin.
D. a severe viral infection.
Rationale: Septic shock is caused by a bacterial infection.
Review
5. A patient with neurogenic shock would be LEAST
likely to present with:
A. tachypnea.
B. hypotension.
C. tachycardia.
D. altered mentation.
Review
Answer: C
Rationale: In neurogenic shock, the nerves that
control the sympathetic nervous system are
compromised. The nervous system is responsible
for secreting the hormones epinephrine and
norepinephrine, which increases the patient’s heart
rate, constricts the peripheral vasculature, and
shunts blood to the body’s vital organs. Without the
release of these hormones, the compensatory
effects of tachycardia and peripheral
vasoconstriction are absent.
Review
5. A patient with neurogenic shock would be LEAST likely to present
with:
A. tachypnea.
Rationale: Respirations increase to compensate for the hypoxia
associated with shock.
B. hypotension.
Rationale: Hypotension results from massive vasodilation.
C. tachycardia.
Rationale: Correct answer
D. altered mentation.
Rationale: The patient will present with mental status changes
secondary to hypoxia.
Review
6. A 33-year-old woman presents with a generalized
rash, facial swelling, and hypotension
approximately 10 minutes after being stung by a
hornet. Her BP is 70/50 mm Hg and her heart rate
is 120 beats/min. In addition to high-flow oxygen,
this patient is in MOST immediate need of:
A. epinephrine.
B. rapid transport.
C. an antihistamine.
D. IV fluids.
Review
Answer: A
Rationale: This patient is in anaphylactic shock—a
life-threatening overexaggeration of the immune
system that results in bronchoconstriction and
hypotension. After ensuring adequate oxygenation
and ventilation, the MOST important treatment for
the patient is epinephrine, which dilates the
bronchioles and constricts the vasculature, thus
improving breathing and blood pressure
respectively.
Review
6. A 33-year-old woman presents with a generalized rash, facial
swelling, and hypotension approximately 10 minutes after being
stung by a hornet. Her BP is 70/50 mm Hg and her heart rate is
120 beats/min. In addition to high-flow oxygen, this patient is in
MOST immediate need of:
A. epinephrine.
Rationale: Correct answer
B. rapid transport.
Rationale: Rapid transport follows high flow oxygen and epinephrine
administration.
C. an antihistamine.
Rationale: This is an ALS treatment.
D. IV fluids.
Rationale: This is an ALS treatment.
Review
7. Elevating the legs of a patient who is in shock:
A. causes the blood vessels to constrict, thereby
raising the blood pressure.
B. allows blood in the lower extremities to more
rapidly return to the heart.
C. makes the patient more comfortable, which will
decrease oxygen demand.
D. returns warmed blood from the legs to the body,
preventing hypothermia.
Review
Answer: B
Rationale: Elevating the shock patient’s lower
extremities 6” to 12” allows blood in the legs to
return to the heart, thus helping maintain perfusion
to the vital organs. It also helps control venous
bleeding in the lower extremities.
Review (1 of 2)
7. Elevating the legs of a patient who is in shock:
A. causes the blood vessels to constrict, thereby raising the blood
pressure.
Rationale: Vasoconstriction is accomplished by the administration of
medication and not by elevating the patient’s legs.
B. allows blood in the lower extremities to more rapidly return to the
heart.
Rationale: Correct answer
Review (2 of 2)
7. Elevating the legs of a patient who is in shock:
C. makes the patient more comfortable, which will decrease oxygen
demand.
Rationale: Oxygen demand will not be effected by elevating the
patient’s legs.
D. returns warmed blood from the legs to the body, preventing
hypothermia.
Rationale: Heat loss secondary to shock is a concern, but body heat
is maintained by placing a blanket over the patient.
Review
8. The PASG would MOST likely cause further harm
to a patient with:
A. an unstable pelvis and severe pain.
B. external bleeding from bilateral femur fractures.
C. severe, ongoing bleeding in the pelvic cavity.
D. blunt thoracic trauma with internal hemorrhage.
Review
Answer: D
Rationale: The pneumatic antishock garment (PASG)
is mainly used as a splint for patients with pelvic or
bilateral femur fractures. They should not be used
in any patient with trauma above the last rib. The
PASG causes vasoconstriction, which, in the
patient with intrathoracic hemorrhage, may worsen
the bleeding by dislodging internal clots that may
have formed.
Review
8. The PASG would MOST likely cause further harm to a patient with:
A. an unstable pelvis and severe pain.
Rationale: PASG is an appropriate device used to splint unstable
pelvic fractures.
B. external bleeding from bilateral femur fractures.
Rationale: PASG can be utilized to apply pressure to external
bleeding if the PASG is inflated to splinting pressures only.
C. severe, ongoing bleeding in the pelvic cavity.
Rationale: PASG will stabilize the pelvis and blood loss.
D. blunt thoracic trauma with internal hemorrhage.
Rationale: Correct answer
Review
9. Anaphylactic shock is typically associated with:
A. urticaria.
B. bradycardia.
C. localized welts.
D. a severe headache.
Review
Answer: A
Rationale: Urticaria (hives) is typically associated with
allergic reactions—mild, moderate, and severe.
They are caused by the release of histamines from
the immune system. In anaphylactic shock,
urticaria is also accompanied by cool, clammy skin;
tachycardia; severe respiratory distress; and
hypotension.
Review
9. Anaphylactic shock is typically associated with:
A. urticaria.
Rationale: Correct answer
B. bradycardia.
Rationale: Tachycardia is a symptom of anaphylactic shock.
C. localized welts.
Rationale: Welts are a raised ridge or bump on the skin caused by
a lash from a whip, a scratch, or a similar blow.
D. a severe headache.
Rationale: Altered mental status secondary to hypoxia may be a
symptom, but not a headache.
Review
10. When treating a trauma patient who in shock,
LOWEST priority should be given to:
A. spinal protection.
B. thermal management.
C. splinting fractures.
D. notifying the hospital.
Review
Answer: C
Rationale: Critical interventions for a trauma patient in
shock include spinal precautions, high-flow oxygen
(or assisted ventilation), thermal management,
rapid transport, and early notification of a trauma
center. Splinting fractures should not be performed
at the scene if the patient is critically-injured; it
takes too long and only delays transport.
Review
10. When treating a trauma patient who in shock, LOWEST priority
should be given to:
A. spinal protection.
Rationale: Stabilization of the spine must take place during the first
interaction with a trauma patient.
B. thermal management.
Rationale: Preventing hypothermia is standard treatment.
C. splinting fractures.
Rationale: Correct answer
D. notifying the hospital.
Rationale: Trauma centers need to be notified early during patient
interaction and transport.