PHTLS - Shock

Class __ hemorrhage represents a loss of up to 15% of blood volume in the adult (up to 750 milliliters [ml]

1 pt has Tachycardia

The level of _____function is an Important and measurable prehospital sign of shock

cerebral function

A patient who tries to remove an oxygen mask, particularly when such action is associated with anxiety and belligerence, is displaying another sign of ?

cerebral ischemia

Noimal saline is another isotonic crystalloid solution that can be used for volume replacement, but its use may produce _______(marked increase in the blood chloride level), leading to acidosis

hyperchoremia

patient with a brain injury with hypo tension should be assumed to have ?

hypovolemia

Decreased systolic and diastolic pressures and a narrow pulse pressure characterize ________ shock.

hypovolemic shock.

In the prehospital setting, external sources of bleeding should be identified and directly controlled ?

immediately

The best crystalloid solution for treating hemorrhagic shock is________solution.

lactated Ringer's solution.

eucapnic state

normal blood carbon dioxide level

A tourniquet should be applied just ______ to the hemorrhaging wound.

proximal

the most common cause of death in shock is the failure of early?

resuscitation

A fast ventilatory rate is a concern and should serve as an impetus to?

search for the cause of shock.

A good sign of adequate resuscitation is a warm, dry, pink?

toe

Traditionally, a tourniquet has been devised from a cravat folded into a width of about 4 inches (10 centimeters) and wrapped ____ around the extremity—the "Spanish windlass

twice

Measurement of an accurate set of vital signs is one of the first steps in the _____

secondary assessment

is a lack of tissue perfusion (oxygenation) at the cellular level that leads to anaerobic metabolism and loss of energy production needed to support life

shock

In the primary assessment, time is not taken to measure a ventilatory rate. Instead, ventilations should be estimated to be ?

slow, normal, fast, or very fast.

Class ___ hemorrhage represents a loss of 15% to 30% of blood volume (750 to 1,500 ml).

2 Clinical findings include increased ventilatory rate, tachycardia, and a narrowed pulse pressure.

three products were 100% effective in occluding distal arterial blood flow:

1. Combat Application Tourniquet (C-A-T, 2.Emergency Military Tourniquet (EMT), and 3.Special Operations Force Tactical Tourniquet (SOFTT,

Steps in the management of shock

1. Ensure oxygenation 2. Identify any hemorrhaging. 3. Transport the patient to definitive care. 4. Administer fluids en route as appropriate

At least five conditions can produce an altered LOC or change in behavior (combativeness or belligerence) in trauma patients;

1. Hypoxia 2. Shock with impaired cerebral perfusion 3. TBI 4. Intoxication with alcohol or drugs 5. Metabolic processes such as diabetes, seizures, and eclampsia

Patients in need of immediate management of their airway include those with the following conditions, in order of importance:

1. Patients who are not breathing 2. Patients who have obvious airway compromise 3. Patients who have ventilatory rates greater than 20 breaths/minute 4. Patients who have noisy sounds of ventilation

shock may be classified as.

1. hypovolemic shock 2. Distributive shock 3. Cardiogenic shock

Cardiogenic Shock 2 catigories

1.intrinsic 2. extrinsic

A rate of 20 to 30 breaths/minute indicates a borderline abnormal rate; it suggests the onset of shock and the need for supplemental oxygen

A rate greater than 30 breaths/minute indicates a late stage of shock and the need for assisted ventilation.

Fluid leak =Transmural pressure x Size of hole in vessel wall

Bernoulli's principle

what is one of the least sensitive signs of shock

Blood pressure is one of the least sensitive signs of shock

Survival depends on immediate control of hemorrhage (surgery for internal hemorrhage) and aggressive resuscitation, including blood and plasma transfusions with minimal crystalloid

CLASS IV

is a helpful diagnostic sign that can also be used to monitor the progress of resuscitation.

Capillary refilling time

________ shock is related to interference with the pump action of the heart.

Cardiogenic shock

is the initial technique employed to control external hemorrhage.

Direct hand pressure or a pressure dressing, applied directly over a bleeding site,

_____ shock (or vasogenic) shock is related to abnormality in vascular tone arising from several different causes.

Distrubutive shock

Hypotension in a pregnant female that persists after performing this maneuver typically represents life-threatening blood loss.

Elevation of the pregnant patient's right side

Three Critical Points # 1

First, when managing a wound with an impaled object, pressure should be applied on either side of the object rather than over the object

_______ shock is primarily hemorrhagic in the trauma patient and is related to loss of circulating blood cells with oxygen-carrying capacity and fluid volume. This is the most common cause of shock in the trauma patient.

Hypovolemic shock

Three Critical Points #3

Third, applying direct pressure to exsanguinating hemorrhage takes precedence over insertion of IV lines and fluid resuscitation.

______ pressure is the difference between the pressure within the vessel and the pressure outside the vessel

Transmural pressure

If external bleeding from an extremity cannot be controlled by pressure, application of a ______is the reasonable next step in hemorrhage control

a tourniquet

normal metabolic functions by producing and using energy in the form of adenosine triphos phate (ATP). The most efficient method of generating this needed energy is via ?

aerobic metabolism

The prehospital assessment of the trauma patient is directed at preventing or reversing _____

anaerobic metabolism

During pregnancy, a woman's blood volume may increase by ?.

by 45% to 50%.

The clinical clues to this phase are tachycardia, tachypnea, and normal systolic blood pressure. and the pt is has anxiety and fright.

class 2 and is known as compensated shock

The classic findings of shock are obvious and include tachycardia (heart rate greater than 120 beats/ minute), tachypnea (ventilatory rate of 30 to 40 breaths/ minute), and severe anxiety or confusion

class 3

characterized by marked tachycardia (heart rate greater than 140 beats/minute), tachypnea (ventilatory rate greater than 35 breaths/minute), profound confusion or lethargy, and greatly decreased systolic blood pressure, typically in the range of 60 mm Hg.

class IV

hemorrhage represents a loss of more than 40% of blood volume (greater than 2,000 ml)

class IV

what is the ultimate "stable" condition?

death

A tourniquet should be applied tight enough to block arterial flow and occlude the ?

distal pulse

A pulse in the range of 100 to 120 beats/minute identifies a patient who has _______, with an initial cardiac response of tachycardia

early shock,

Decreased ______ production is identified by sluggish body responses, cold skin, and decreased core temperature

energy

Because hemorrhage is the most common cause of shock in the trauma patient, all shock in a trauma patient should be considered to be from hemorrhage until proven otherwise. The first priority is to_____for external sources of hemorrhage and control them as quickly and completely as possible.

examine

The force exerted against thewall of the blood vessel from the outside (such as by a hand or a dressing) is called

extramural (or extraluminal) pressure.

Direct pressure on the wound increases the ____ pressure, thus slowing the leak

extramural pressure,

Of these five conditions, the easiest to treat—and the one that will kill the patient most quickly if not treated?

is hypoxia

If there is no evidence of external hemorrhage, _______ _____ should be suspected.

internal hemorrhage should be suspected.

The pressure exerted against the inside of the blood vessel walls by the intravascular fluids and blood pressure cycle is called

intramural (or intraluminal) pressure.

______a result of direct damage to the heart itself ______ related to a problem outside the heart.

intrinsic extrinsic

Young infants (less than_____ of age) are the exception to this rule because they may bleed enough inside their head to produce hypovolemic shock as a result of open sutures and fontanelles that can spread apart and accommodate large amounts of blood

6 months

the steps in managing hemorrhage are

(1) to increase external pressure (hand-pressure dressing (2) to use the teclmique of hypoten sive resuscitation to ensiue that the intraluminal pressure is not raised extensively.

3 prime goals of shock treatment in addition to ventilation

1. identifying the source or cause, 2.treating the cause as specifically as possible, and 3. supporting the circulation

6 External hemorrhage steps in the field management of external hemorrhage

1.Hand-held direct pressure 2.Compression dressings 3.Wound packing 4.Elastic wrap 5.Tourniquet—extremities 6.Hemostatic agent—torso

There are two components in the assessment of circulation:

1.Hemorrhage and the amount of blood loss 2.Perfusion with oxygenated blood

data from the military experience suggest that appropriately applied tourniquets could potentially have prevented 7 of _____combat deaths.''"®

100

Class ___ hemorrhage represents a loss of 30% to 40% of blood volume 1500 to 2000 ml

3

prime determinants of cellular perfusion 1. the heart 2. fluid volume 3. blood vessels 4.

4. cells of the body

An ______ is usually one of the first visible signs of shock.

An altered LOC is usually one of the first visible signs of shock.

It is the backup power system in the body and uses stored body fat as its energy source

Anaerobic metabolism

occurs without the use of oxygen

Anaerobic metabolism,

the goal is not to raise the blood pressure to ______ levels but to provide only enough fluid to maintain perfusion and continue to provide oxygenated RBCs to the heart, brain, and lungs.

NORMAL

Shock research has demonstrated that for lost blood, the replacement ratio with electrolyte solution should be 3 liters of replacement for each_____of blood lost

LITER

_______ shock also displays decreased systolic and diastolic pressures, but the pulse pressure remains normal or is widened

Neurogenic

Three Critical Points #2

Second, if hands are required to perform other lifesaving tasks, a pressure (compression) dressing can be created using gauze pads and an elastic roller bandage or a blood pressure cuff inflated until hemorrhage stops. This dressing is placed directly over the bleeding site.

may be associated with up to 2 to 4 units (1,000 to 2,000 ml) of blood loss into a thigh. This injury alone could potentially result in the loss of 30% to 40% of an adult's blood volume, resulting in decompensated hypovolemic shock

femoral fracture

By far the most common cause of shock in the trauma patient is?

hemorrhage

Raising the blood pressure to normal levels only serves to dilute clotting factors, disrupt any clot that has formed, and increase ?

hemorrhage

a minimum of 3 minutes of direct pressure must be applied to the wound site for most of the available agents.

hemostatic agent

This high ratio ofreplacement fluid is required because only about ________to_________ of the volume of an isotonic crystalloid solution suchas normal saline or lactated Ringer's solution remains in the intravascular space 30 to 60 minutes after infusing it.

one-fourth to one-third

A pulse above 120 beats/minute is a definite sign of shock unless it is caused by ____or _____, and a pulse over 140 beats/minute is considered extremely critical and near-death.

pain or fear,

the patient's airway is patent and that breathing and circula tion are adequate—is the major emphasis of the ?

primary assessment

A slow ventilatory rate, in conjunction with shock, generally indicates that a patient is in _____shock and may be moments away from cardiac arrest.

profound shock

______ is frequently one of the earliest signs of anaerobic metabolism and shock, even earlier than an increased pulse rat

tachypnea

The signs of decreased perfusion and energy production and the body's response include the following:

■ Decreased LOC, anxiety, disorientation, belligerence, bizarre behavior (brain and CNS) ■ Tachycardia, decreased systolic and pulse pressure (heart and cardiovascular system) ■ Rapid, shallow breathing (respiratory system) ■ Cold, pale, clammy, diaphoretic or even cyanotic skin with decreased capillary refill time (skin and extremities) ■ Decreased urine output (kidneys)