path of shock

PATHOPHYSIOLOGY OF SHOCK : 

1 PATHOPHYSIOLOGY OF SHOCK

FLUIDS AND ELECTROLYTES : 

2 FLUIDS AND ELECTROLYTES WATER Most abundant substance in the body Accounts for 60% of total body weight Distributed among compartments separated by cell membranes

INTRACELLULAR COMPARTMENT : 

3 INTRACELLULAR COMPARTMENT Fluid within body cells Represents 75% of all body water

EXTRACELLULAR COMPARTMENTS : 

4 EXTRACELLULAR COMPARTMENTS Fluid found outside body cells Represents 25% of all body water Has two divisions Intravascular Fluid found outside of cells within the circulatory system Represents 7.5% of body water Interstitial Fluid outside of cells and not in circulatory system Represents 17.5% of body water CSF, intraocular fluid

HYDRATION : 

5 HYDRATION Water is the universal solvent Most substances dissolve in water, producing various chemical changes Water is critical for most of body’s biochemical processes Normal hydration balance

INTAKE : 

6 INTAKE Defined as the water coming into the body From digestive system (liquids, solid foods,) and metabolic sources.

OUTPUT : 

7 OUTPUT Defined as all water excreted from the body From lungs, kidneys, skin, intestines water vapor, urine, perspiration, and feces

HOMEOSTASIS : 

8 HOMEOSTASIS The body’s tendency to maintain a constant, stable internal environment.

HOMEOSTASIS : 

9 HOMEOSTASIS When fluid levels drop ADH (Anti-diuretic hormone) secreted Kidneys reabsorb more water back into the blood and excrete less urine Thirst sensation stimulates urge to drink

HOMEOSTASIS : 

10 HOMEOSTASIS When fluid levels rise Kidneys activated to excrete more urine Water shifts from one compartment to another

DEHYDRATION : 

11 DEHYDRATION An abnormal decrease in total body water (loss of water and electrolytes)

CAUSES OF DEHYDRATION : 

12 CAUSES OF DEHYDRATION GI losses Vomiting Diarrhea Malabsorption disorders

CAUSES OF DEHYDRATION : 

13 CAUSES OF DEHYDRATION Increased insensible loss Fever Hyperventilation High environmental temperatures

CAUSES OF DEHYDRATION : 

14 CAUSES OF DEHYDRATION Increased sweating Medical conditions High environmental temperatures

CAUSES OF DEHYDRATION : 

15 CAUSES OF DEHYDRATION Internal loss - loss of fluids into various body compartments, especially from intravascular into interstitial. Illness - peritonitis, pacreatitis, bowel obstruction Poor nutritional states

CAUSES OF DEHYDRATION : 

16 CAUSES OF DEHYDRATION Plasma losses Burns Surgical drains Fistulas (Abnormal tubelike passage from a normal cavity to another cavity or free standing surface). Open wounds

CLINICAL PRESENTATION : 

17 CLINICAL PRESENTATION Dry mucous membranes Poor skin turgor Excessive thirst If severe, tachycardia and hypotension In infants, sunken fontanelles, absence of tears, dry diaper, concentrated urine

MANAGEMENT - DEHYDRATION : 

18 MANAGEMENT - DEHYDRATION Fluid replacement - isotonic crystalloid (100-200 ml/hr)

OVERHYDRATION : 

19 OVERHYDRATION Excess of total body water

CLINICAL PRESENTATION : 

20 CLINICAL PRESENTATION Peripheral edema Heart failure, lung congestion

MANAGEMENT : 

21 MANAGEMENT Remove excess fluid IV D5W TKO Diuretic therapy

ELECTROLYTES : 

22 ELECTROLYTES BASICS Defined as substances that dissociate into charged particles when placed in water Positively charged particles are cations Negatively charged particles are anions Usually measured in milliequivalents per liter ( mEq/L)

MOST FREQUENTLY OCCURRING CATIONS : 

23 MOST FREQUENTLY OCCURRING CATIONS

SODIUM (Na+) : 

24 SODIUM (Na+) Most abundant extracellular cation Helps regulate water distribution Helps transmit nerve impulses Hypernatremia - increase in relative amount of sodium in body Hyponatremia - decrease in relative amount of sodium in body

POTASSIUM (K+) : 

25 POTASSIUM (K+) Most abundant intracellular cation Helps transmit electrical impulses Hyperkalemia - high potassium level Hypokalemia - low potassium level

CALCIUM (Ca++) : 

26 CALCIUM (Ca++) Helps in muscle contractions Helps in nerve impulse transmission Hypercalcemia - high calcium level Hypocalcemia - low calcium level

MAGNESIUM (Mg++) : 

27 MAGNESIUM (Mg++) Necessary for many biomechanical functions Helps in carbohydrate metabolism

MOST FREQUENTLY OCCURRING ANIONS : 

28 MOST FREQUENTLY OCCURRING ANIONS

CHLORIDE (Cl-) : 

29 CHLORIDE (Cl-) Closely associated with sodium Helps to regulate fluid balance and renal function

BICARBONATE (HCO-3) : 

30 BICARBONATE (HCO-3) Chief buffer in the body Neutralizes hydrogen (H+) ion and other organic acids

PHOSPHATE (HPO-4) : 

31 PHOSPHATE (HPO-4) Important for energy stores Intracellular buffer Helps in renal function

OTHER NEGATIVE COMPOUNDS : 

32 OTHER NEGATIVE COMPOUNDS Proteins Certain organic acids

NONELECTROLYTES : 

33 NONELECTROLYTES Molecules that do not dissociate into ions Glucose Urea

OSMOSIS AND DIFFUSION : 

34 OSMOSIS AND DIFFUSION Basic mechanics Fluid compartments are separated by semi-permeable membranes (pores) Certain materials are allowed to pass through freely ( oxygen, carbon dioxide, water) Larger compounds are restricted ( proteins, large sugars ) Natural body tendency is to keep solutions on both sides of membrane in balance (isotonic)

OSMOSIS : 

35 OSMOSIS If one side of the membrane has a higher solute concentration than the other side, a pressure gradient occurs ( pulling force) Water moves from the side of lower concentration (hypotonic) to the side of higher concentration (hypertonic) until both sides are equal

DIFFUSION : 

36 DIFFUSION If one side of the membrane has a higher solute concentration than the other side, the body again seeks to restore balance through redistribution of electrolytes Electrolytes will move from hypertonic to hypotonic side until isotonic relationship is reestablished Movement direction in diffusion is opposite that in osmosis

OTHER TRANSPORT MECHANISMS : 

37 OTHER TRANSPORT MECHANISMS

ACTIVE TRANSPORT : 

38 ACTIVE TRANSPORT Movement of molecules against the gradient e.g.. sodium - potassium pump Electrical impulses of the heart (automaticity) Faster than diffusion Requires expenditure of energy

FACILITATED DIFFUSION : 

39 FACILITATED DIFFUSION Substance transported across membranes by “helper proteins” (Glucose/Insulin relationship) May require expenditure of energy Must follow gradient

INTRAVENOUS THERAPY : 

40 INTRAVENOUS THERAPY Basics Defined as the introduction of fluids and other substances into the venous side of circulatory system Purpose Replace blood lost through hemorrhage Replace lost electrolytes or fluids Introduce medications directly into vascular system

BLOOD AND ITS COMPONENTS : 

41 BLOOD AND ITS COMPONENTS

BLOOD : 

42 BLOOD Fluid of the cardiovascular system Adequate amount required for transport of nutrients, oxygen, hormones, and heat Made up of liquid portion - plasma - and formed elements - blood cells

PLASMA : 

43 PLASMA Composition - 92% water, 6 -7% proteins Viscosity is determined by ratio of plasma to cells

FORMED ELEMENTS INCLUDE : 

44 FORMED ELEMENTS INCLUDE Erythrocytes Leukocytes Thrombocytes

ERYTHROCYTES : 

45 ERYTHROCYTES Red blood cells, which make up 99% of all blood cells Contain hemoglobin to carry oxygen Make up 45% of total blood volume Hematocrit is the percentage of red blood cells in blood

LEUKOCYTES : 

46 LEUKOCYTES White blood cells, responsible for immunity and fighting infection

THROMBOCYTES : 

47 THROMBOCYTES Platelets, necessary for clotting

BLOOD TYPES : 

48 BLOOD TYPES Blood types determined by presence of antigens on erythrocytes Major classification system is ABO system

ABO SYSTEM : 

49 ABO SYSTEM Two major antigen types, A and B People can have either one or the other, both or neither People generally can receive only blood of their type Different type of blood sets off immune response Type O blood does not have antigens to type A or type B; people with it are universal donors Type AB blood does not have antibodies to either A or B; people with it are universal recipients

Rh FACTOR : 

50 Rh FACTOR Present in 85% of the population Others are sensitized through transfusion and have formed antibodies and may have fatal reactions with additional transfusions

FLUID REPLACEMENT : 

51 FLUID REPLACEMENT Whole blood Best, most natural replacement Contains hemoglobin for oxygen transport Impractical in prehospital arena Must be typed and cross-matched

FLUID REPLACEMENT : 

52 FLUID REPLACEMENT Fractionated blood parts Packed red blood cells Must be typed and cross-matched Fresh frozen plasma Does not require cross-matching

TRANSFUSION REACTION : 

53 TRANSFUSION REACTION Blood and blood products not used by EMS personnel in field Personnel must, however, recognize reaction of recipient to blood or blood products of incompatible type Clinical presentations Fever, chills, hives, hypotension, tachycardia, flushing of skin, headaches, nausea, loss of consciousness, vomiting

MANAGEMENT : 

54 MANAGEMENT Stop the infusion immediately Replace the blood with crystalloid solution Conduct rapid but adequate assessment of mental status Administer oxygen Contact medical control

Fluid overload and congestive heart failure secondary to transfusion : 

55 Fluid overload and congestive heart failure secondary to transfusion

CLINICAL PRESENTATION : 

56 CLINICAL PRESENTATION Increased dyspnea, pulmonary congestion, edema, altered mental status Management Stop infusion Administer crystalloid at TKO rate Administer oxygen Contact medical control

INTRAVENOUS FLUIDS : 

57 INTRAVENOUS FLUIDS Colloids Contain proteins or large molecules Remain longer in the intravascular compartment Increases intravascular volume through osmosis Examples: Plasmanate; salt-poor albumin; dextran; hetastarch Colloids are expensive and have a short shelf life, impractical for prehospital use

CRYSTALLOIDS : 

58 CRYSTALLOIDS Solutions containing no proteins Classified by tonicity ( number of particles present per unit volume)

CRYSTALLOIDS : 

59 CRYSTALLOIDS Isotonic Electrolyte composition similar to blood plasma Will not cause significant fluid or electrolyte shift

CRYSTALLOIDS : 

60 CRYSTALLOIDS Hypertonic Have higher solute concentration than cells Will tend to cause fluid shift out of intracellular and into extracellular compartment

CRYSTALLOIDS : 

61 CRYSTALLOIDS Hypotonic Have lower solute concentration than cells Will tend to cause fluid shift out of extracellular and into intracellular compartment

COMMON CRYSTALLOID SOLUTIONS : 

62 COMMON CRYSTALLOID SOLUTIONS Lactated Ringer’s Isotonic Used for fluid volume replacement Normal Saline Isotonic Used for fluid volume replacement

COMMON CRYSTALLOID SOLUTIONS : 

63 COMMON CRYSTALLOID SOLUTIONS D5W Hypotonic Used TKO and to supply calories for cell metabolism