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EMT91
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Thank you!
Types of Shock and other charts
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325Medic
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What he said..
325.
325.
I'm a basic student, and we haven't covered shock yet, but from my understanding...
As BLS, I don't believe I'd treat any differently based on the type of shock, EXCEPT anaphylactic or diabetic.
I'd place the pt. on the gurney, elevating their legs (pillows or whatever), keep them warm, put them on high flow oxygen (NRB), call ALS and when we intercept with them assist starting a line. Any form of shock is a priority call and we're going to load and go. Their best chance for survival is getting to definitive care as quickly as possible.
For anaphylactic... if the patient has their own prescribed epi I can assist in the administration (so long as it isn't expired, it is the patient's, etc). We also carry epi which we can administer but it is an absolute online and ALS must have been dispatched (either on the initial or as per our request). If we do intercept with ALS, they must ride with us if epi has been administered (they cannot release it to BLS).
For diabetic (know Hx), I can administer oral glucose or any other available sugar (non-diet soda, etc). BGL is a BLS skill in my state, but it is not in my agency.
That is my limited understanding, would definitely be interested in hearing any feedback.
As BLS, I don't believe I'd treat any differently based on the type of shock, EXCEPT anaphylactic or diabetic.
I'd place the pt. on the gurney, elevating their legs (pillows or whatever), keep them warm, put them on high flow oxygen (NRB), call ALS and when we intercept with them assist starting a line. Any form of shock is a priority call and we're going to load and go. Their best chance for survival is getting to definitive care as quickly as possible.
For anaphylactic... if the patient has their own prescribed epi I can assist in the administration (so long as it isn't expired, it is the patient's, etc). We also carry epi which we can administer but it is an absolute online and ALS must have been dispatched (either on the initial or as per our request). If we do intercept with ALS, they must ride with us if epi has been administered (they cannot release it to BLS).
For diabetic (know Hx), I can administer oral glucose or any other available sugar (non-diet soda, etc). BGL is a BLS skill in my state, but it is not in my agency.
That is my limited understanding, would definitely be interested in hearing any feedback.
JPINFV
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Hypoglycemia is not a form of hypoprofusion ("shock").
I'm not going to get nit picky on the lack of evidence supporting trendelenburg for hypoprofusion besides pointing out that the studies done are small, poor and quality, but consistent with showing no benefit from trendelenburg.
As far as "definitive care," for shock it isn't necessarily the hospital as paramedics can use a variety of interventions to help support the patient's cardiovascular status. Getting to the hospital is important, but getting competent paramedics to the patient is also important. Depending on the type of shock, this is one of the few times where saline can save lives.
DesertMedic66
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Which is why I am extremely surprised that my county actually went away with trendelenburg, seeming how we have a horrible rep for EMS lol
Rettsani
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The treatment of shock is very simple ...
For this requires that you need only a look at the shock cascade.
--> Decrease in cardiac output -
-> blood pressure drops
--> Compensatory counter regulation including catecholamine mediated by sympathetic activation and stress response: Increase in heart rate, constriction of peripheral vessels = Centralization to ensure the circulation of the heart and brain influx of fluid from the interstitial space into the vascular system.
-> Later failure of the counter-regulation
-> vascular atony
-> Migration of fluid from the vasculature into the interstitial space
-> Gain of hypovolemia
-> Hypoperfusion of the organs
-> stasis - capillary damage - microthrombi formation
-> Propagation of the clotting activity of the entire organism
-> Depletion of clotting potential, with increased bleeding tendency
-> Gain of hypovolemia
-> tissue hypoxia
-> anaerobic metabolism
-> metabolic acidosis
Consequence of the cascade of shock
-> Acute renal failure
-> heart failure
-> Adult Respiratory Distress Syndrome
-> liver failure
-> Decompensation of the circulation
-> death
Task of any shock treatment should be the shock to stop or prevent cascade.
-> Shock position in hypovolemic shock or vasovagal syncope
-> Upper body elevated in cardiogenic shock or anaphylactic ( except for cardiogenic shock)
-> Flatness in neurogenic shock
-> Stop bleeding in trauma
-> Administration of low molecular infusions
so and now you are to write to it .......^_^
->I am a Cruel EMT or whatever.
For this requires that you need only a look at the shock cascade.
--> Decrease in cardiac output -
-> blood pressure drops
--> Compensatory counter regulation including catecholamine mediated by sympathetic activation and stress response: Increase in heart rate, constriction of peripheral vessels = Centralization to ensure the circulation of the heart and brain influx of fluid from the interstitial space into the vascular system.
-> Later failure of the counter-regulation
-> vascular atony
-> Migration of fluid from the vasculature into the interstitial space
-> Gain of hypovolemia
-> Hypoperfusion of the organs
-> stasis - capillary damage - microthrombi formation
-> Propagation of the clotting activity of the entire organism
-> Depletion of clotting potential, with increased bleeding tendency
-> Gain of hypovolemia
-> tissue hypoxia
-> anaerobic metabolism
-> metabolic acidosis
Consequence of the cascade of shock
-> Acute renal failure
-> heart failure
-> Adult Respiratory Distress Syndrome
-> liver failure
-> Decompensation of the circulation
-> death
Task of any shock treatment should be the shock to stop or prevent cascade.
-> Shock position in hypovolemic shock or vasovagal syncope
-> Upper body elevated in cardiogenic shock or anaphylactic ( except for cardiogenic shock)
-> Flatness in neurogenic shock
-> Stop bleeding in trauma
-> Administration of low molecular infusions
so and now you are to write to it .......^_^
->I am a Cruel EMT or whatever.
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Why does everyone keep equating Trendelenburg's with what actually get's done? There is a difference between simply raising the legs while the body stays flat and actually tilting the entire body so that the head is lower than the feet.
As far as studies looking at passive leg raising, there are quite a few, mostly looking at something besides it's direct usefullness, but all do point out that it works, though possible only transiently. Didn't see any that pointed out any major drawbacks, though I'm not saying there aren't any.
To the OP: Perhaps if you made your own chart you'd learn a lot more than if you simply copied someone else's work.
Different things work for different reasons on different patients.
Everyone like to point out studies that show "statistically" significant benefits and drawbacks, but rarely are they profound.
Numbers needed to treat and harm are seldom reported.
Epidemiological diagnosis and treatment is one tool in the bag, medicine is not one size fits all, the patient you are treating doesn't care and it doesn't matter if the treatment works in 10, 20, 30, or 90% of patients.
He only cares what works for him.
There are indications for both passive leg raising and lowering. The key is to know when.
I agree with JP though, the use of elevating the legs while keeping the body flat, does not work by the mechanism originally postulated and isn't likely to work very well for acute treatment of hypovolemic shock.
Depends I think. I agree with the first part; even studies that have a wide margin for showing a specific effect can still be interpeted differently, depending on how the information is looked at. For the ones I referenced, none that I've seen really said that a passive leg raise was a good treatement, just that it was a good indicator that the patient would respond to fluid, and caused an increase in cardiac output and aortic blood flow; close to what a 500cc bolus of saline did for them.
The don't say anything about if that was sustained or not, or if there were any drawbacks to the increase.
I'm not saying that lifting the legs is the best treatement for hypovolemic shock, or even neccasarily a good, or long lasting one. Just that it's what is more commonly done than actually placing someone in Trendelenburg's, it doesn't have all the drawbacks, and can be beneficial for some.
I was thinking more along the lines of surgical positioning than actual hemodynamics.
JPINFV
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1. Because I'm including the studies that do just look at passive leg raising.
2. Because if trendelenburg, an intervention that would also move blood in the abdominal cavity doesn't work, then passive leg raising, which would recruit much less blood and spread it out over a wider area, is also not going to work.
Unfortunately it would appear that passive leg raising does work, though probably only transiently. And since it lacks some of the problems associated with dropping the patient's head...not a definitive treatement, but, depending on the situation, also not as potentially harmful as trendelenburg's.
JPINFV
Gadfly
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Oh, and also I'm not talking about something where it's just barely off of the critical P value ([soapbox] P values as a dividing line is stupid and useless [/soapbox]). I'm talking "Let's measure 15 people who just gave blood. Oh look only 1 person saw a mild increase in blood pressure."
JPINFV
Gadfly
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There is hope.
Fair enough.
I never said trendelenburg. That would be slightly different. I said I would elevate the legs, by placing pillows etc under them to support them.
Certainly, Paramedics are useful, but I'm not going to wait for them in these cases. If we can intercept, or if they were on the initial dispatch, awesome. If not, the hospital will be able to do everything a medic can and more.
Rettsani
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Aidey
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What exactly would the point be of doing either?