Impact of Shock on the Body

Steve Powell

It is important to understand by what is meant by shock. Shock in a physiological is a life threatening condition, and must be taken lightly.

Shock as a definition is: “failure of the circulatory system to maintain adequate perfusion of vital organs”. (1) Mitch Taylor. (2010). Multi-Organ Dysfunction Syndrome Available: http://acls4u.homestead.com/MultOrganDysfunctionSyndromeVoiceOver.pdf. Last accessed 01/06/2014

Shock comes used to be classified as separate types:

1. Cardiogenic
2. Hypovolaemic
3. Anaphylactic
4. Neurogenic
5. Toxic

Recently this has been condensed in three types:

1. Cardiogenic
2. Hypovolaemic
3. Distributive

The definitions of these types of shock are:

1. Cardiogenic –pump failure resulting in the blood cannot get to where it’s supposed to go i.e. the tissues, hence a low cardiac output.
2. Hypovolaemic –a low volume of blood in the body as a result of major trauma or massive haemorrhage
3. Distributive (Vasogenic) –this type of shock relates to changes in the body’s blood vessels, vascular changes, as a result of Anaphylactic, Neurogenic or toxic insult on the body.(2)

Mitch Taylor. (2010). Multi-Organ Dysfunction Syndrome Available: http://acls4u.homestead.com/MultOrganDysfunctionSyndromeVoiceOver.pdf. Last accessed 01/06/2014

In Cardiogenic shock we have ascertained that it is down to pump failure and the bodies in ability to circulate adequate blood around the body to meet its metabolic needs. We have seen that it can be caused by a low cardiac output that is caused by, massive haemorrhage trough trauma or pathophysiological reason (dissected aortic aneurysm). It can also be caused by: a myocardial infarction (heart attack), dysrhythmias, and heart failure. A second cause is obstruction to the pump flow, that is to say conditions such as: valve dysfunction, pulmonary embolism, and tamponade (pericardial effusion that effects the normal action of the heart in pumping).

Question 1 cont….

Hypovolaemic shock as the name suggests is “low volume”, causes range from massive haemorrhage through trauma or pathophysiological reasons (triple A). Burns victims are at particular risk as it affects these types of patients at a cellular level, the loss of fluid out of vascular spaces.

Technically shock in burns victims a combination of distributive and hypovolaemic shock. In as much as it is seen as volume depletion within the intravascular system, lowered pulmonary artery pressure and an elevated systemic resistance, resulting in a low cardiac output.

The low cardiac output is a direct result of an increased after load, a reduced contractility, and a lowered level of plasma volume. (3) Barbara A. Latenser, MD, FACS. (2009). Critical care of the burn patient: The first 48 hours Society of critical and medicine. 37 (10), p2819-p2826

Multiple organ dysfunction syndrome or MODS as it’s also known is a condition where two or more of the body’s systems have failed. MODS can be described as a “systemic activation of an adaptive host stress response to a catastrophic event”. (4) Sat Sharma and Gregg Eschun (2008) Hypotension and multiple organ dysfunction syndrome Journal of Organ Dysfunction 4 (1), p130-p144

Once a state of prolonged shock has been induced an over the top bodily response takes place. This is known as a “systemic inflammatory response”. Once this stage has started, the body releases inflammatory mediators that are intrinsic to the pathogenesis of SIRS (systemic inflammatory response syndrome.

Where sepsis is not a key trigger, hypotension through hypovolaemic will contribute to the onset of SIRS and eventually MODS.

The combination of these three conditions, Sepsis, SIRS, and MODS, combine conditions that have a massive impact on haemodynamic abnormalities, coagulation problems, and systemic issues.(5) Sat Sharma and Gregg Eschun (2008) Hypotension and multiple organ dysfunction syndrome Journal of Organ Dysfunction 4 (1), p130-p144

Any insult to the body and normal function (haemostasis) will initiate a cycle of metabolic chaos that includes an increase for oxygen versus an inadequate supply at a molecular level.

Question 1 cont

Inadequate blood supply to the tissues and cells in hypovolaemic shock and associated hypotension is the key to MODS in this instance.

(6) Mitch Taylor. (2010). Multi-Organ Dysfunction Syndrome Available: http://acls4u.homestead.com/MultOrganDysfunctionSyndromeVoiceOver.pdf. Last accessed 01/06/2014

What we can say about the timeline for MODS is:

1. The event that starts the cascade off, infection, hypoxia, trauma, in our case hypovolaemic shock via traumatic infarct trauma.
2. Increase in levels of cytokines (immune system signalling cells).
3. Leads to a release of ELAM and ICAM that induce leukocyte adhesion.
4. This in turn triggers a multiple release of chemicals and compounds resulting in endothelial damage
5. Resulting oedema eventually leading to organ dysfunction.

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References

1. Mitch Taylor. (2010). Multi-Organ Dysfunction Syndrome Available: http://acls4u.homestead.com/MultOrganDysfunctionSyndromeVoiceOver.pdf. Last accessed 01/06/2014
2. Mitch Taylor. (2010). Multi-Organ Dysfunction Syndrome Available: http://acls4u.homestead.com/MultOrganDysfunctionSyndromeVoiceOver.pdf. Last accessed 01/06/2014
3. Barbara A. Latenser, MD, FACS. (2009). Critical care of the burn patient: The first 48 hours Society of critical and medicine. 37 (10), p2819-p2826
4. Sat Sharma and Gregg Eschun (2008) Hypotension and multiple organ dysfunction syndrome Journal of Organ Dysfunction 4 (1), p130-p144
5. Sat Sharma and Gregg Eschun (2008) Hypotension and multiple organ dysfunction syndrome Journal of Organ Dysfunction 4 (1), p130-p144
6. Mitch Taylor. (2010). Multi-Organ Dysfunction Syndrome Available: http://acls4u.homestead.com/MultOrganDysfunctionSyndromeVoiceOver.pdf. Last accessed 01/06/2014

Reflection

As far as a reflective piece of work goes, I find myself having to reflect on skills that I learnt 10 years ago and have been employing on a regular basis.

Although reflection should take place on a regular basis, it is never too late to reflect on things. Even though the skills were learnt 10 years ago there is 10 years scope to develop bad habits if not identified and rectified.

The four skills in question inspection, auscultation, percussion, and palpation form part of the primary and secondary surveys for healthcare professionals worldwide.

The initial primary survey should take seconds. I can remember when I first started doing patient inspections/assessments, it would be very text book orientated, not a bad thing you would have thought. However when you’ve exhausted all the text book questions you suddenly come to stand still and there is a period of silence then between yourself and the patient and sometimes the relatives.

What I started to do, on the advice of a colleague, was, as i approached the patient I would assess their “colour posture and behaviour”. These three things would give me an idea of the state of the patient.

If the patient answered the door and looked well and was ambulatory (as happens) then I would be off to a fairly good start. The patient had spoken to me (airway was clear); they looked well perfused and were mobile, no obvious life threatening conditions.

If for instance the patient answered the door and was pale, sweaty, breathless and complained of chest pain then that would put a completely different slant on the primary survey. The patient would then have to be sat down immediately and further cardiac assessment undertaken. So by employing this little method (colour, posture, and behaviour) I was able, at a glance to do a quick assessment of the patient. Other aspects, such as scene safety etc…. soon became second nature as was the ability to do rapid risk assessments at the scene’s of RTC’s and other scene’s where there may be hazardous.

There is a lot to take into consideration when carrying out an assessment, it is however a rolling concept where you question as you asses or treat.

For non life threatening conditions then there no need to rush and miss your history taking, if you stick to the AMPLE model of:

• Allergies
• Medicine
• Past medical history
• Last meal/oral intake
• Events that lead to calling 999.

These questions are limited and can take 1-2 minutes to ask and be answered. This is where you can expand on the history take and delve further in to the patient’s medical, social, familial history.

When I first qualified I was encouraged by work colleagues to use all my extended skills.

The auscultation side of the assessment was a little difficult at first because I just didn’t know what I was listening for; it wasn’t long before we started getting quite a few patients with respiratory problems. This enabled me to match the condition with what I was listening to. I remember also listening to chest sounds on the internet, a useful exercise, but not like the real thing.

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One thing that stick s out, and is still relevant o this day, is that its well and good listening to chest sounds on the computer and in the back of a relatively quiet ambulance, that it is at the side of a road with traffic rushing by and the sound of the fire service’s generators going at full tilt.

Auscultation is a tool that I use frequently in my patient assessment.

The percussion side of my assessment, I have to be honest and say that I do it for respiratory cases and trauma cases, but not for every patient that I see. It’s probably an area where i could do with more practise if I’m being hypercritical. Would I know a hyper/hypo-resonant chest? I believe so, however if I were to do a SWOT analysis then this would probably be in my weak box.

Palpation I tend to use a lot more, whether it is because I get far more abdominal calls than critical chest’s I don’t know. The fact remains that I use palpation far more than percussion.

Palpation is an extremely useful tool in the ballpark when it comes to abdominal complaints. However what I have learnt about abdominal related problems over the years, is that, as well as not being in my scope of practise to diagnose and discharge (without referring to a gp first), more analytical tools are needed. Tools such a doctor, ultrasound and bloods to name (various other scans can be utilised at DGH).

Looking back or reflecting over the past 10 years, I feel i took on board the training that I received both EMT and Paramedic, and have built on them to a point where I more than comfortable treating an 80 year old gentleman in his living room with chronic emphysema to a road traffic collision where it’s quite a challenging environment. I have however identified a possible weakness in my practise that I will be address at the soonest opportunity.