Any patient with signs, symptoms, and history suggesting inadequate tissue perfusion should be considered to be in shock. Make every effort to determine and treat the underlying cause. Regardless of etiology, shock patients should be transported immediately to the nearest appropriate facility for definitive care. Provide advanced notification to hospitals on all patients with suspected shock.

EMT Standing Order

• Routine Patient Care.
• Keep the patient supine.
• prevent heat loss by covering with warm blankets if available and if the patient is not febrile
• Establish IV line
• Consider acquiring ECG

ADVANCED EMT/ PARAMEDIC - STANDING ORDERS

• Establish IV/IO access
• Administer 500 ml NS or RL warmed at 40C if possible, IV fluid administration should be based on physiologic signs to maintain SBP >90 not to exceed 2000 ml.
• If there is inadequate hemodynamic response start
  • Norepinephrine 0.1-0.5 mcg/kg/ min
  • Epinephrine infusion 2-10 mcg/min
  • Dopamine infusion 5-20 mcg/ kg /min if Norepinephrine and Epinephrine is not available.

EXTENDED CARE

A tourniquet may be used temporarily to slow major bleeding while treating other life-threatening concerns or to identify the best location for direct pressure. The tourniquet can be left in place for at least an hour. If direct pressure does not control bleeding, the tourniquet will need to be reapplied and left in place during evacuation.

Etiology of Shock

• Cardiogenic Shock: History of cardiac surgery, rhythm disturbances, or post cardiac arrest. Assess for acute MI and pulmonary edema.
  • Signs & Symptoms of cardiogenic shock: chest pain, shortness of breath, crackles, JVD, hypotension, tachycardia, diaphoresis.
• Distributive Shock:  For Anaphylaxis, see Allergic Reaction/Anaphylaxis Protocol - Adult (27 Medical), for neurogenic shock, or sepsis, see Septic Shock Protocol - Adult (52 Medical). Assess for fever and signs of infection.
  • Signs & Symptoms of neurogenic shock: sensory and/or motor loss, hypotension, bradycardia versus normal heart rate, warm, dry skin.
• Hypovolemic Shock:   Dehydration, volume loss, or hemorrhagic shock.
  • Signs & Symptoms of hypovolemic shock: tachycardia, tachypnea, hypotension, diaphoresis, cool skin, pallor, flat neck veins.
• Obstructive Shock:  Consider tension pneumothorax, pulmonary embolism, and cardiac tamponade.
  • Signs and symptoms of tension pneumothorax: asymmetric or absent breath sounds, respiratory distress or hypoxia, signs of shock including tachycardia and hypotension, JVD, possible tracheal deviation upon palpation above the sternal notch (late sign).

PEARLS:

For patients with uncontrolled hemorrhagic or penetrating torso injuries:

• Restrict IV fluids to maintain BP of 80-90 systolic. Delaying aggressive fluid resuscitation until operative intervention may improve the outcome. Operative intervention must be available within 30-45 minutes to utilize this strategy. In rural areas with longer transport times restricting fluid may result in exsanguination and irreversible shock.
• Patients should be reassessed frequently, with special attention given to the lung examination to ensure volume overload does not occur.
• Several mechanisms for worse outcomes associated with IV fluid administration have been suggested, including dislodgement of clot formation, dilution of clotting factors, and acceleration of hemorrhage caused by elevated blood pressure.