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Shock

Shock can be seen at three different phases. Compensated shock; which just maintains that the patient, through compensatory mechanisms, is able to maintain a blood pressure. It doesn’t mean that they are able to maintain perfusion to the tissues. It just means that they are not yet hypotensive. A de-compensated shock means that they are no longer able to maintain a blood pressure and at some phase your patient is going to enter irreversible shock.

What are the shock patterns that you can see in patients? We are going to talk about these a little bit, each individually; hypovolemic shock, cardiogenic shock, septic shock and distributive shock. Hypovolemic shock; you would like to have some sort of a history suggesting that your patient is hypovolemic. Lack of intake, vomiting, diarrhea, something that would decrease their volume status. Tachycardia is very sensitive for hypovolemia.

Cardiogenic shock; typically, although not always, there is a suggestive medical history. When you look at the patient you may in fact see a big scar running down the middle of their sternum. Always a warning sign that something has happened to their heart. So get a medical history. Tachycardia will essentially always be present unless the cause of their shock.

Septic shock; again, history may be very helpful. Certainly if somebody is very febrile it’s one of the things you will entertain. The findings will be similar in that you will be tachycardic. The thing that will be different oftentimes about septic shock, especially early on, is that you will have systemic vasodilation which will make your skin look very well perfused.

A pure distributive shock will be a shock state where your blood flow is not appropriate for your body. You may have a history - if someone has a knife wound to their spinal cord, you might suspect that they’ve lost all their sympathetic innervation.

So overall, what is going to be the therapy for your shock state? You are going to treat the underlying cause. If you are suspicious that somebody has septic shock, some antibiotics might be a good thing to do. You are going to stabilize their airway and breathing, that is, if they have quit breathing you are going to breathe for them, and you are going to administer fluids.

If the fluid is not being effective, regardless of the form of shock, or if you are dealing with cardiogenic shock you are going to want to move on to inotropic agents and vasoactive agents. Some of them that are utilized include epinephrine, which affects all of your receptors - alpha, beta receptors - and maybe your first drug of choice in septic shock because of it’s nice effects on the vasculature. Norepinephrine is a potent vasoconstrictor and something you may lean towards with a severe distributive shock.

Trauma; the scenario I’m going to present to you is kind of an abbreviated advanced trauma/life support scenario. What you want to do is pick up injuries that are likely to be life threatening or cause long term morbidity quickly and treat them effectively and resuscitate each problem as you discover it. After the patient has been stabilized, you are going to go back and do a little more thorough exam with a secondary survey, and then begin definitive therapy.

The primary survey; it’s very easy to get distracted by the fractured femur sticking out of the thigh, the foot that’s twisted on backwards. Other than blood loss, that’s not going to kill them. What’s going to kill them is the fact that while you are looking at their ankle they quit breathing. So be very systematic in your assessment; airway, breathing, maintain cervical spine precautions with the airway. Cervical spine injuries in children with survivable injuries are relatively uncommon. That doesn’t mean you should ignore them. I would not let someone asphyxiate because you are concerned about intubating them. Breathing; listen to the lungs for asymmetry. Think about pneumothorax, hemothorax. Circulation; IV access and fluid resuscitation. Remember you can put interosseus needles in, using bone marrow needles, up to the age of six and maybe even a little bit beyond. It may be very effective in initial fluid resuscitation. If somebody has a crushing chest injury, be suspicious of pericardial effusions and the need for pericardial centesis. In keeping with the ABC’s, we end up with D which stands for disability, which really reflects the neurologic status. Advanced trauma life support talks about the AVPU system of assessing the level of consciousness. A, being alert, V means that they respond to verbal commands, P to painful, and U means they are unresponsive.

Pupillary response and lateralizing weakness; you are looking for very gross neurologic changes. You are not writing letters in the palm of their hand and asking them what they are. This is a very quick neurologic survey to make sure that they don’t have any potentially life threatening or long term morbidity-threatening problems.

The Glasgow coma scale is used frequently to assess trauma victims in the field, through the EMS system, through the emergency department, oftentimes to the anesthetic suite if the patient is at all awake, and into the ICU. It is nice because it is relatively simple, it’s relatively consistent between observers and it provides a numerical scale that can be followed between multiple different people who are assuming and maybe passing on care to another team. If consists of three different systems; eye-opening, you get a total of four points, verbal you can get five points, and motor you can get six points, for a total of 15 points. In your handout they have the complete Glasgow coma score. Of some note is that if someone calls you to admit a patient to you or transport a patient, and they tell you that the Glasgow coma score is zero, they’ve told you two things. One is that the child is probably pretty sick, and two that they don’t know what the Glasgow coma scale is all about, because as you can see, dead people and inanimate objects have three points. The table in front of you gets a Glasgow coma score of three, so if someone gives one of your patients a lower score, you know they are in a heap of trouble.

Okay, you’ve stabilized your patient, you’ve done your primary survey. As you’ve discovered problems, such as a pneumothorax, hemothorax, respiratory arrest, you’ve dealt with it, you’ve moved on. Now you are going to go back for a secondary survey and look for a little bit more subtle findings, generally in a head-to-toe approach. You are going to look at the head, palpate it, look for hematomas, other signs that may lead you to suspect emerging intracranial pathology. Cranial nerves. Repeat your primary survey, that is, make sure they are moving both sides of their body.