What is one of the first signs that would indicate a patient is experiencing hypovolemic shock?
EDITOR'S NOTE: Thanks to our guest blogger this week, Dean Meenach, MSN, RN, CNL, CEN, CCRN, CPEN, EMT-P. ** Show
The effects of shock due to major blood loss rapidly become irreversible, so quick identification and intervention are critical.Shock is not a disease, but a clinical manifestation of the body’s inability to perfuse its tissues adequately. [1] Shock is considered a systemic response to an illness or injury resulting in inadequate tissue perfusion and decreased oxygen to the cells. Hypovolemic shock is the loss of volume, which can include:
The effects of shock are initially reversible, but rapidly become irreversible. For prehospital professionals to improve shock outcomes, these interventions must begin early in the prehospital setting. [2,3] Here are 10 things you need to know to help you identify hypovolemic shock early and manage it effectively to save lives. 1. TWO MAJOR TYPES OF HYPOVOLEMIC SHOCKHypovolemic shock is caused by a decrease in the amount of circulating volume (absolute hypovolemia). In trauma patients, one type of hypovolemic shock, this is usually caused by hemorrhage. Volume loss in non-trauma patients, the other type of hypovolemic shock, it can be caused by hemorrhage, vomiting, diarrhea, excessive perspiration, fever, medication induced diuresis, etc. [1,10,18,19] 2. SCOPE OF THE PROBLEMAvailable studies suggest that 2% of EMS calls present with traumatic or nontraumatic hypotension and 1-2% with hypovolemic shock. Hypovolemic is the second leading type of shock experienced. [6] Hemorrhage is the second leading cause of death in trauma patients, making hemorrhagic shock the most common cause of preventable trauma death within 6 hours of admission. [7,8,9] According to the literature, 1.9 million people die per year worldwide due to hemorrhagic shock. [6,10] It is no surprise that trauma is the most frequent condition leading to hemorrhagic shock. [10,11] Finally, patients with trauma-related hemorrhagic shock have better outcomes when transported to specialty trauma centers. [12,44,47] 3. THREE MAJOR STAGES OF SHOCKIn the early stages of shock, the body is unable to meet the demand for oxygen and cellular nutrients. To maintain perfusion to the organs, the body reacts by activating various compensatory mechanisms that result in shunting perfusion away from other organs. If the shock state is unrecognized, prolonged or untreated, it will progress to a terminal stage. The pathophysiologic changes that occur during shock can be divided into three stages: compensated, uncompensated, and irreversible. [1,13]
4. UNDERSTAND THE TRAUMA TRIAD OF DEATHResuscitation-associated coagulopathy in hemorrhagic shock has been recognized as the major cause of the trauma triad of death. [15] These three lethal complications include: Resuscitation-associated coagulopathy in hemorrhagic shock has been recognized as the major cause of the trauma triad of death. At present, this can only be treated with blood product replacement.(image/EMS1)
5. THE VARYING SIGNS AND SYMPTOMS OF SHOCKVital signs are important indicators of the patient's physiologic status.
6. PHYSICAL EXAM FINDINGS IN SHOCKThe physical examination of the patient presenting in shock can be expedited by applying the ABCDE approach:
7. SUMMARY OF CURRENT MANAGEMENT STRATEGIESThe evidence-based guidelines for treating all types of shock are constantly evolving as new research is accepted. Management of shock varies greatly due to age, pre-existing conditions, comorbidities, causes and numerous other factors. Here is a summary of some of the recent evidence-based guidelines and recommendations: For hemorrhagic hypovolemic shock:
For nonhemorrhagic hypovolemic shock:
8. CONSIDERATIONS FOR PREGNANT PATIENTS WITH SHOCKHemorrhagic shock and head injury remain the leading causes of maternal death. The most common cause of fetal death is maternal death. In the presence of maternal shock, fetal mortality rates may be as high as 80%. [36,37] Therefore, identifying maternal shock early is paramount in improving outcomes. When pregnancy and shock intersect, there are unique challenges to consider. Normal physiologic changes in pregnancy can make it more difficult to identify the early signs of shock. These include:
These physiologic changes can result in a blood loss of 30-35% (about 1,500 ml) before a significant change in the pregnant patient’s blood pressure is measured. [18] The prehospital professional must remain vigilant in identifying and treating maternal shock early. 9. CONSIDERATIONS FOR PEDIATRIC PATIENTS WITH SHOCKIn children, differences in total percentage body water, metabolic rate, oxygen consumption and compensatory mechanisms make early identification of shock challenging. The main mechanisms for compensation include significant increases in heart rate and systemic vascular resistance, but minor changes in stroke volume. [38] Children can appear surprisingly well in early shock with only minimal changes in blood pressure because of their strong compensatory mechanisms. However, when they deteriorate, they do so rapidly. 10. CONSIDERATIONS FOR GERIATRIC PATIENTS WITH SHOCKMany geriatric patients present with comorbidities and pre-existing conditions that impair the ability of compensatory mechanisms to respond to hemorrhage and shock. [39,40] Congestive heart failure, high blood pressure, coronary artery disease, cirrhosis, malignancy, diabetes, COPD and renal disease all increase mortality risk in older adults. [41,42] In addition, polypharmacy can alter vital signs and mental status, impair compensatory mechanisms to shock, confuse physical exam findings and responses to trauma and alter blood clotting mechanisms. [43] Because of these factors, elderly patients are less likely to handle the physiological stresses of hypovolemic shock and may decompensate more quickly. It’s important for EMS providers to stay informed about the latest skills and strategies for saving lives. 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Critical Care,18(6). doi:10.1186/s13054-014-0648-0 ABOUT THE AUTHOR ** Dean Meenach, MSN, RN, CNL, CEN, CCRN, CPEN, EMT-P, has taught and worked in EMS for more than 24 years and currently serves as director of EMS Education/Paramedic Instructor and co-teacher in the Paramedic to RN Bridge Program at Mineral Area College. He has served as a subject matter expert, author, national speaker and collaborative author in micro-simulation programs. Dean continues to serve patients part-time as a member of a stroke team and in a pediatric and adult trauma center. He can be reached at . What are 5 signs and symptoms that your patient is going into hypovolemic shock?Hypovolemic shock symptoms include:. Breathing faster than normal.. Feeling confused or anxious.. Sweating a lot.. Passing out.. Having skin that feels cool.. Feeling weak.. Having a low temperature and low blood pressure.. Having a fast pulse.. What is the first indicator of shock?Cool, clammy skin. Pale or ashen skin. Bluish tinge to lips or fingernails (or gray in the case of dark complexions) Rapid pulse.
What is the first priority for hypovolemic shock?Three goals exist in the emergency department treatment of the patient with hypovolemic shock as follows: (1) maximize oxygen delivery—completed by ensuring adequacy of ventilation, increasing oxygen saturation of the blood, and restoring blood flow, (2) control further blood loss, and (3) fluid resuscitation.
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