CHAPTER 13

Shock

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National EMS Education Standard Competencies (1 of 2)

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Shock and Resuscitation
Applies a fundamental knowledge of the causes, pathophysiology, and
management of shock, respiratory failure or arrest, cardiac failure or arrest, and
postresuscitation management.
National EMS Education Standard Competencies (2 of 2)

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Pathophysiology
Applies fundamental knowledge of the pathophysiology of respiration and
perfusion to patient assessment and management.
Introduction

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 Shock (hypoperfusion) is defined as inadequate cellular perfusion.
 Any compromise in perfusion can lead to cellular injury or death.
 In the early stages, the body attempts to maintain homeostasis.
Pathophysiology (1 of 12)

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 Diffusion is a passive process in which molecules move from an area with a
higher concentration of molecules to an area of lower concentration.
 Oxygen and carbon dioxide move across the walls of the alveoli.
Pathophysiology (2 of 12)

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 In cases of poor perfusion (shock):
 Transportation of carbon dioxide out of tissues is impaired.
 Results in a dangerous buildup of waste products, which may cause cellular
damage
Pathophysiology (3 of 12)

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 Shock is a state of collapse and failure of the cardiovascular system that leads
to inadequate circulation.
 Early recognition can save lives.
 Requires immediate recognition and rapid treatment
Pathophysiology (4 of 12)

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 Cardiovascular system consists of three parts:
 Pump (heart)
 Set of pipes (blood vessels or arteries)
 Contents (the blood)
Pathophysiology (5 of 12)

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FIGURE 13-1 The cardiovascular system consists of three parts: the pump (heart), the container (vessels),
and the contents (blood). The blood carries oxygen and nutrients through the vessels to the capillary
beds, where they diffuse into the tissue; in exchange, waste products diffuse into the bloodstream.
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Pathophysiology (6 of 12)

 “Perfusion triangle.”
 When a patient is in shock, one or

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more of the three parts is not working
properly.

FIGURE 13-2 The heart, the blood vessels, and the blood
represent the three parts of perfusion (the perfusion triangle).
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Pathophysiology (7 of 12)

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 Blood pressure is the pressure of blood within the vessels at any moment in
time.
 Systolic: peak arterial pressure
 Diastolic: pressure in the arteries while the heart rests between heartbeats
Pathophysiology (8 of 12)

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 Pulse pressure is the difference between the systolic and diastolic pressures.
 It signifies the amount of force the heart generates with each contraction.
 A pulse pressure less than 25 mm Hg may be seen in patients with shock.
Pathophysiology (9 of 12)

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 Blood flow through the capillary beds is regulated by the capillary sphincters.
 Under the control of the autonomic nervous system
 Regulation of blood flow is determined by cellular needs.
Pathophysiology (10 of 12)

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 Perfusion also requires adequate:
 Oxygen exchange in the lungs
 Nutrients in the form of glucose in the blood
 Waste removal, primarily through the lungs
Pathophysiology (11 of 12)

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 Mechanisms are in place to help support the respiratory and cardiovascular
systems when the need for perfusion of vital organs is increased.
 Includes the autonomic nervous system and hormones
Pathophysiology (12 of 12)

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 Hormones are triggered when the body senses pressure falling.
 Cause an increase in:
 Heart rate
 Strength of cardiac contractions
 Peripheral vasoconstriction
 This response causes all the signs and symptoms of shock.
Causes of Shock (1 of 3)

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 Many different shocks result from three basic causes:
 Pump failure
 Poor vessel function
 Low fluid volume
Causes of Shock (2 of 3)

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FIGURE 13-3 There are three basic causes of shock and impaired tissue perfusion. A. Pump
failure occurs when the heart is damaged by disease or injury, or when an obstruction
prevents it from functioning. B. Low fluid volume, often a result of bleeding. C. The blood
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vessels can dilate excessively so that the blood within them is inadequate to fill the system.
A, B, C: © Jones & Bartlett Learning.
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Causes of Shock (3 of 3)
Cardiogenic Shock (1 of 2)

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 Caused by inadequate function of the heart
 A major effect is the backup of blood into the pulmonary vessels.
 Resulting buildup of pulmonary fluid is called pulmonary edema.
Cardiogenic Shock (2 of 2)

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 Cardiogenic shock develops when the heart cannot maintain sufficient output to
meet the demands of the body.
 Cardiac output depends on adequate:
 Contractility of the heart muscle
 Amount of blood to pump (preload)
 Resistance to flow in peripheral circulation (afterload)
Obstructive Shock (1 of 4)

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 Caused by a mechanical obstruction that prevents an adequate volume of blood
from filling the heart chambers.
 Three of the most common examples:
 Cardiac tamponade
 Tension pneumothorax
 Pulmonary embolism
Obstructive Shock (2 of 4)

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 Cardiac tamponade
 Collection of fluid between the pericardial sac and the myocardium (pericardial
effusion) becomes large enough to prevent ventricles from filling with blood.
 Caused by blunt or penetrating trauma
 Signs and symptoms are referred to as Beck triad.
Obstructive Shock (3 of 4)

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 Tension pneumothorax
 Caused by damage to lung tissue
 Air normally held within the lung escapes into the chest cavity.
 The lung collapses, and air applies pressure to the organs, including the heart and
great vessels.
Obstructive Shock (4 of 4)

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 Pulmonary embolism
 A blood clot that blocks the flow of blood through pulmonary vessels
 If massive:
 Can result in complete backup of blood in the right ventricle
 Leads to catastrophic obstructive shock and complete pump failure
Distributive Shock (1 of 8)

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 Results from widespread dilation of small arterioles, small venules, or both
 The circulating blood volume pools in the expanded vascular beds.
 Tissue perfusion decreases.
Distributive Shock (2 of 8)

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 Septic shock
 Occurs as a result of severe infections in which toxins are generated by bacteria or
by infected body tissues
 Toxins damage vessel walls, causing increased cellular permeability.
 Vessel walls leak and are unable to contract well.
Distributive Shock (3 of 8)

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 Septic shock (cont’d)
 Widespread dilation of vessels, in combination with plasma loss through the vessel
walls, results in shock.
Distributive Shock (4 of 8)

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 Neurogenic shock
 Usually the result of high spinal cord injury
 Nerve impulses to blood vessels below the level of the injury are blocked.
 All vessels cut off from nerve impulses will dilate, causing the blood to pool.
Distributive Shock (5 of 8)

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 Anaphylactic shock
 Occurs when a person reacts violently to a substance to which he or she has been
sensitized
 Sensitization means becoming sensitive to a substance that did not initially cause a
reaction.
 Each subsequent exposure tends to produce a more severe reaction.
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Distributive Shock (6 of 8)
Distributive Shock (7 of 8)

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 Psychogenic shock
 Caused by a sudden reaction of the nervous system
 Produces temporary, generalized vascular dilation
 Results in fainting (syncope)
Distributive Shock (8 of 8)

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 Psychogenic shock (cont’d)
 Life-threatening causes include irregular heartbeat and brain aneurysm.
 Non–life-threatening events include receipt of bad news or experiencing fear or
unpleasant sights (such as blood).
Hypovolemic Shock

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 Result of an inadequate amount of fluid or volume in the circulatory system
 Hemorrhagic causes and nonhemorrhagic causes
 Occurs with severe thermal burns
The Progression of Shock (1 of 4)

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 Stages in the progression of shock:
 Compensated shock: early stage when the body can still compensate for blood loss
 Decompensated shock: late stage when blood pressure is falling
 No way to assess when effects are irreversible
 Must recognize and treat shock early
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The Progression of Shock (2 of 4)
The Progression of Shock (3 of 4)

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 Blood pressure may be the last measurable factor to change in shock.
 When a drop in blood pressure is evident, shock is well developed.
 Particularly true in infants and children
 When blood pressure drops in infants and children in shock, they are close to
death.
The Progression of Shock (4 of 4)

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 Also expect shock if a patient has any one of the following conditions:
 Multiple severe fractures
 Abdominal or chest injury
 Spinal injury
 A severe infection
 A major heart attack
 Anaphylaxis
Scene Size-up

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 Scene size-up
 Be alert to potential hazards to your safety.
 Use gloves and eye protection for trauma scenes or if bleeding is suspected.
 Mechanism of injury/nature of illness
Primary Assessment (1 of 5)

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 Primary assessment
 Perform a rapid exam.
 Determine the level of consciousness.
 Identify and manage life-threatening concerns.
 Determine priority of the patient and transport.
Primary Assessment (2 of 5)

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 Primary assessment (cont’d)
 Provide high-flow oxygen to assist in perfusion.
 For hypoperfusion, treat aggressively and provide rapid transport.
 Request advanced life support (ALS) as necessary.
Primary Assessment (3 of 5)

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 Primary assessment (cont’d)
 Form a general impression.
 Assess the airway to ensure it is patent.
 Assess breathing.
 An increased respiratory rate is often an early sign of impending shock.
 Assess patient’s circulatory status.
Primary Assessment (4 of 5)

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 Primary assessment (cont’d)
 A rapid pulse suggests compensated shock.
 In shock or compensated shock, the skin may be cool, clammy, or ashen.
 Assess for and identify any life-threatening bleeding and treat it at once.
Primary Assessment (5 of 5)

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 Primary assessment (cont’d)
 Determine if patient is high priority, if ALS is needed, and which facility to transport
to.
 Trauma patients with shock or a suspicious MOI generally should go to a trauma
center.
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 Determine the chief complaint.
 Obtain a SAMPLE history.
History Taking

 History taking
Secondary Assessment

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 Secondary assessment
 Repeat the primary assessment, followed by focused assessment.
 If a life-threatening problem is found, treat it immediately.
 Obtain a complete set of baseline vital signs.
 Use monitoring devices.
Reassessment (1 of 2)

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 Reassessment
 Reassess the patient’s:
 Vital signs
 Interventions
 Chief complaint
 ABCs
 Mental status
Reassessment (2 of 2)

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 Reassessment (cont’d)
 Determine what interventions are needed.
 Focus on supporting the cardiovascular system.
 Treat for shock early and aggressively by:
 Providing oxygen
 Keeping the patient warm
Emergency Medical Care for Shock (1 of 3)

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 As soon as you recognize shock, begin treatment.
 Follow standard precautions.
 Control all obvious bleeding.
 Make sure the patient has an open airway.
 Maintain manual in-line stabilization if necessary, and check breathing and pulse.
Emergency Medical Care for Shock (2 of 3)

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 As soon as you recognize shock, begin treatment. (cont’d)
 Comfort, calm, and reassure the patient.
 Never allow patients to eat or drink anything prior to being evaluated by a
physician.
 If spinal immobilization is indicated, splint the patient on a backboard.
 Provide oxygen and monitor patient’s breathing.
Emergency Medical Care for Shock (3 of 3)

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 As soon as you recognize shock, begin treatment. (cont’d)
 Place blankets under and over the patient.
 Consider the need for ALS.
 Accurately record the patient’s vital signs approximately every 5 minutes throughout
treatment and transport.
Treating Cardiogenic Shock (1 of 3)

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 Patient cannot generate the necessary contraction to pump blood throughout
the circulatory system.
 Patients may present with chest pain.
 Patients in cardiogenic shock should not receive nitroglycerin; they are
hypotensive.
Treating Cardiogenic Shock (2 of 3)

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 Patients usually have:
 Low blood pressure
 Weak, irregular pulse
 Cyanosis about lips/underneath fingernails
 Anxiety
 Nausea
Treating Cardiogenic Shock (3 of 3)

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 Place the patient in a position that eases breathing as you give high-flow
oxygen.
 Assist ventilations as necessary.
 Provide prompt transport.
 Consider meeting ALS en route to hospital.
Treating Obstructive Shock (1 of 2)

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 For cardiac tamponade:
 Increasing cardiac output is the priority.
 Apply high-flow oxygen.
 Surgery is the only definitive treatment.
Treating Obstructive Shock (2 of 2)

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 For tension pneumothorax:
 Apply high-flow oxygen to prevent hypoxia.
 Chest decompression is required.
 Ask for ALS early in call if available, but do not delay transport.
Treating Septic Shock

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 Hospital management is required.
 Use standard precautions and transport.
 Administer high-flow oxygen.
 Ventilatory support may be necessary.
 Use blankets to conserve body heat.
 Notify “sepsis team” if available.
Treating Neurogenic Shock

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 Emergency treatment:
 Obtain and maintain a proper airway.
 Provide spinal immobilization.
 Assist inadequate breathing.
 Conserve body heat.
 Ensure the most effective circulation.
 Transport promptly.
Treating Anaphylactic Shock

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 Administer epinephrine.
 Promptly transport the patient.
 Provide high-flow oxygen and ventilatory assistance en route.
 A mild reaction may worsen suddenly.
 Consider requesting ALS backup, if available.
Treating Psychogenic Shock (1 of 2)

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 In an uncomplicated case of fainting, once the patient collapses, circulation to
the brain is restored.
 Psychogenic shock can worsen other types of shock.
 If the patient falls, check for injuries.
Treating Psychogenic Shock (2 of 2)

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 If the patient reports being unable to walk after a fall, suspect another problem.
 Transport the patient promptly.
Treating Hypovolemic Shock

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 Control all obvious external bleeding.
 Keep the patient warm.
 Recognize internal bleeding and provide aggressive support.
 Secure and maintain an airway, and provide respiratory support.
 Transport as rapidly as possible.
Treating Shock in Older Patients

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 Older patients have more serious complications than younger ones.
 Illness is not just a part of aging.
 Many older patients take medications that mask or mimic signs of shock.
Review

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1. The term “shock” is MOST accurately defined as:
A. a decreased supply of oxygen to the brain.
B. cardiovascular collapse leading to inadequate perfusion.
C. decreased circulation of blood within the venous circulation.
D. decreased function of the respiratory system leading to hypoxia.
Review

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Answer: B
Response: Shock, or hypoperfusion, refers to a state of collapse and failure of
the cardiovascular system, or any one of its components (eg, heart, vasculature,
blood volume), which leads to inadequate perfusion of the body’s cells and
tissues.
Review

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1. The term “shock” is MOST accurately defined as:
A. a decreased supply of oxygen to the brain.
Rationale: It may be a result of inadequate perfusion, but it is not the definition
of shock.
B. cardiovascular collapse leading to inadequate perfusion.
Rationale: Correct answer
C. decreased circulation of blood within the venous circulation.
Rationale: It may be a result of cardiovascular collapse, but it is not the
definition of shock.
D. decreased function of the respiratory system leading to hypoxia.
Rationale: Decreased function of the respiratory system will lead to hypoxia,
which will cause cardiovascular collapse and eventually shock.
Review

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2. Anaphylactic shock is typically associated with:
A. urticaria.
B. bradycardia.
C. localized welts.
D. a severe headache.
Review

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Answer: A
Rationale: Urticaria (hives) is typically associated with allergic reactions—mild,
moderate, and severe. They are caused by the release of histamines from the
immune system. In anaphylactic shock, urticaria is also accompanied by cool,
clammy skin; tachycardia; severe respiratory distress; and hypotension.
Review

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2. Anaphylactic shock is typically associated with:
A. urticaria.
Rationale: Correct answer
B. bradycardia.
Rationale: Tachycardia, not bradycardia, is a symptom of anaphylactic shock.
C. localized welts.
Rationale: Welts are a raised ridge or bump on the skin caused by a lash from a
whip, a scratch, or a similar blow.
D. a severe headache.
Rationale: Altered mental status secondary to hypoxia may be a symptom, but
not a headache.
Review

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3. Signs of compensated shock include all of the following, EXCEPT:
A. restlessness or anxiety.
B. pale, cool, clammy skin.
C. a feeling of impending doom.
D. weak or absent peripheral pulses.
Review

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Answer: D
Rationale: In compensated shock, the body is able to maintain perfusion to the
vital organs of the body via the autonomic nervous system. Signs include pale,
cool, clammy skin; restlessness or anxiety; a feeling of impending doom; and
tachycardia. When the body’s compensatory mechanism fails, the patient’s blood
pressure falls; weak or absent peripheral pulses indicates this.
Review

3. Signs of compensated shock include all of the following, EXCEPT:

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A. restlessness or anxiety.
Rationale: This indicates compensated shock.
B. pale, cool, clammy skin.
Rationale: This indicates compensated shock.
C. a feeling of impending doom.
Rationale: This indicates compensated shock and the anxiety associated
with it.
D. weak or absent peripheral pulses.
Rationale: Correct answer
Review

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4. When treating a trauma patient who is in shock, LOWEST priority should be
given to:
A. spinal protection.
B. thermal management.
C. splinting fractures.
D. notifying the hospital.
Review

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Answer: C
Rationale: Critical interventions for a trauma patient in shock include spinal
precautions, high-flow oxygen (or assisted ventilation), thermal management,
rapid transport, and early notification of a trauma center. Splinting fractures
should not be performed at the scene if the patient is critically injured; it takes too
long and only delays transport.
Review

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4. When treating a trauma patient who is in shock, LOWEST priority should be
given to:
A. spinal protection.
Rationale: Stabilization of the spine must take place during the first interaction
with a trauma patient.
B. thermal management.
Rationale: Preventing hypothermia is standard treatment.
C. splinting fractures.
Rationale: Correct answer
D. notifying the hospital.
Rationale: Trauma centers need to be notified early during patient interaction
and transport.
Review

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5. Potential causes of cardiogenic shock include all of the following, EXCEPT:
A. inadequate heart function.
B. disease of muscle tissue.
C. severe bacterial infection.
D. impaired electrical system.
Review

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Answer: C
Rationale: Cardiogenic shock is caused by inadequate function of the heart, or
pump failure. Within certain limits, the heart can adapt to these problems. If too
much muscular damage occurs, however, as sometimes happens after a heart
attack, the heart no longer functions well. Other causes include disease, injury,
and an impaired electrical system.
Review

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5. Potential causes of cardiogenic shock include all of the following EXCEPT:
A. inadequate heart function.
Rationale: This is a cause of cardiogenic shock.
B. disease of muscle tissues.
Rationale: This is a cause of cardiogenic shock.
C. severe bacterial infection.
Rationale: Correct answer.
D. impaired electrical system.
Rationale: This is a cause of cardiogenic shock.
Review

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6. A 60-year-old woman presents with a BP of 80/60 mm Hg, a pulse rate of
110 beats/min, mottled skin, and a temperature of 103.9°F. She is MOST
likely experiencing:
A. septic shock.
B. neurogenic shock.
C. profound heart failure.
D. a severe viral infection.
Review

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Answer: A
Rationale: In septic shock, bacterial toxins damage the blood vessel walls,
causing them to leak and rendering them unable to constrict. Widespread dilation
of the vessels, in combination with plasma loss through the injured vessel walls,
results in shock. A high fever commonly accompanies a bacterial infection.
Review

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6. A 60-year-old woman presents with a BP of 80/60 mm Hg, a pulse rate of 110
beats/min, mottled skin, and a temperature of 103.9°F.
She is MOST likely experiencing:
A. septic shock.
Rationale: Correct answer
B. neurogenic shock.
Rationale: Neurogenic shock is an injury to the nervous system and shows
bradycardia and hypotension—not fever.
C. profound heart failure.
Rationale: This is part of cardiogenic shock, associated with low blood
pressure, weak pulse, and cyanotic skin.
D. a severe viral infection.
Rationale: Septic shock is caused by a bacterial infection.
Review

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7. A patient with neurogenic shock would be LEAST likely to present with:
A. tachypnea.
B. hypotension.
C. tachycardia.
D. altered mentation.
Review

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Answer: C
Rationale: In neurogenic shock, the nerves that control the sympathetic nervous
system are compromised. The nervous system is responsible for secreting the
hormones epinephrine and norepinephrine, which increase the patient’s heart
rate, constrict the peripheral vasculature, and shunt blood to the body’s vital
organs. Without the release of these hormones, the compensatory effects of
tachycardia and peripheral vasoconstriction are absent.
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7. A patient with neurogenic shock would be LEAST likely to present with:
A. tachypnea.
Rationale: Respirations increase to compensate for the hypoxia associated with
shock.
B. hypotension.
Rationale: Hypotension results from massive vasodilation.
C. tachycardia.
Rationale: Correct answer
D. altered mentation.
Rationale: The patient will present with mental status changes secondary to
hypoxia.
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8. A 20-year-old man was kicked numerous times in the abdomen during an
assault. His abdomen is rigid and tender, his heart rate is 120 beats/min, and
his respirations are 30 breaths/min. You should treat this patient for:
A. a lacerated liver.
B. a ruptured spleen.
C. respiratory failure.
D. hypovolemic shock.
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Answer: D
Rationale: The patient may have a liver laceration or ruptured spleen—both of
which can cause internal blood loss. However, it is far more important to
recognize that the patient is in hypovolemic shock and to treat him accordingly.
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8. A 20-year-old man was kicked numerous times in the abdomen during an
assault. His abdomen is rigid and tender, his heart rate is 120 beats/min, and
his respirations are 30 breaths/min. You should treat this patient for:
A. a lacerated liver.
Rationale: You cannot treat a lacerated liver in the field. You can treat the
symptoms of hypovolemic shock associated with the injury.
B. a ruptured spleen.
Rationale: You cannot treat a ruptured spleen in the field. You can treat the
symptoms of hypovolemic shock associated with the injury.
C. respiratory failure.
Rationale: If you treat the hypovolemic shock, then you will treat the respiratory
compromise as well.
D. hypovolemic shock.
Rationale: Correct answer
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9. A 33-year-old woman presents with a generalized rash, facial swelling, and
hypotension approximately 10 minutes after being stung by a hornet. Her BP
is 70/50 mm Hg and her heart rate is 120 beats/min. In addition to high-flow
oxygen, this patient is in MOST immediate need of:
A. epinephrine.
B. rapid transport.
C. an antihistamine.
D. IV fluids.
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Answer: A
Rationale: This patient is in anaphylactic shock—a life-threatening
overexaggeration of the immune system that results in bronchoconstriction and
hypotension. After ensuring adequate oxygenation and ventilation, the MOST
important treatment for the patient is epinephrine, which dilates the bronchioles
and constricts the vasculature, thus improving breathing and blood pressure,
respectively.
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Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com
9. A 33-year-old woman presents with a generalized rash, facial swelling, and
hypotension approximately 10 minutes after being stung by a hornet. Her BP
is 70/50 mm Hg and her heart rate is 120 beats/min. In addition to high-flow
oxygen, this patient is in MOST immediate need of:
A. epinephrine.
Rationale: Correct answer
B. rapid transport.
Rationale: Rapid transport follows high-flow oxygen and epinephrine
administration.
C. an antihistamine.
Rationale: This is an ALS treatment.
D. IV fluids.
Rationale: This is an ALS treatment.
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10. All of the following are potential causes of impaired tissue perfusion,
EXCEPT:
A. increased number of red blood cells.
B. pump failure.
C. low fluid volume.
D. poor vessel function.
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Answer: A
Rationale: An increased number of red blood cells would allow adequate oxygen
and nutrients to be delivered to the cells.
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Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com
10. All of the following are potential causes of impaired tissue perfusion,
EXCEPT:
A. increased number of red blood cells.
Rationale: Correct answer
B. pump failure.
Rationale: Pump failure is a cause of impaired tissue perfusion.
C. low fluid volume.
Rationale: Poor vessel function is a cause of impaired tissue perfusion.
D. poor vessel function.
Rationale: Poor vessel function is a cause of impaired tissue perfusion.