Shock is a potentially life-threatening emergency that can be described as inadequate perfusion of necessary organs and the brain. This reduced perfusion can come from many sources both intrinsic and extrinsic but the end result is the same; your brain and other essential organs do not receive enough oxygen and begin to fail. Shock states are a progression and end in irreversible shock which results in death for the patient. It is imperative that EMTs understand and treat shock aggressively if necessary in the field as it can easily spiral out of control and lead to a negative patient outcome.
The treatment of shock in the prehospital environment has undergone significant changes in the past several years as new research has been made available which questions the efficacy of previous treatments. Previously, the Trendelenburg or modified Trendelenburg positions were used for patients in shock, but this has been moved to a local policy specific practice as the position is no longer fully recommended in the prehospital environment. Shock is a complex problem with many different etiologies; for an EMT there is little to no difference in the treatment of a shock patient but for paramedics and other high-level practitioners there can be significant changes to treatment protocols or methodologies. Treatment of shock for EMTs follows a simple algorithm: treat what you can, ensure adequate oxygenation, keep the patient warm/cool the patient if indicated, and lay the patient flat.
Treat[edit | edit source]
Medications[edit | edit source]
- Oxygen: Oxygen is the most common medication administered and is allowed for EMTs. Oxygenation is important in the shock patient as inadequate perfusion to end organs will result in significant problems up to and including death of the patient. If the patient's oxygen saturation is below 94% (excluding some special cases such as COPD patients) the patient should be placed on oxygen and their SPO2 should be titrated to between 94% and 99%. Oxygen will not fix your patient. Oxygen helps keep the patient alive until the underlying cause of the shock can be treated.
- Epinephrine: Epinephrine is only allowed to be administered by EMTs in the autoinjector form and even then only in the situation of allergic reaction, anaphylaxis, or anaphylactic shock. Epinephrine works as a histamine antagonist that helps reduce the negative effects of an allergic reaction as well as a bronchodilator that treats the respiratory components of anaphylaxis and anaphylactic shock.
Fluid Maintenance[edit | edit source]
- Tourniquets/Bandaging: EMTs may not perform IV cannulation, nor may they administer IV fluids or blood products. That being said, EMTs may absolutely stop fluid loss through use of bandages or tourniquets in a trauma patient. Stopping bleeding using appropriate BLS measures can prevent the patient from deteriorating.
Temperature[edit | edit source]
Some shock patients are at risk of hypothermia, especially patients who have lost large volumes of fluid through methods such as bleeding, diarrhea, or vomiting. Conversely, some shock patients would not benefit from warming, for example septic or anaphylactic shock. The EMT must determine the need for rewarming based upon the patient's condition.
Passive Rewarming/Cooling[edit | edit source]
- Passive temperature management refers to changing the patient's environment in a way that will promote warming/cooling. Examples of this include removing the patient from the external environment and turning the heater/air conditioner on in the ambulance and giving the patient a blanket or removing their clothes.
Active Rewarming/Cooling[edit | edit source]
- Active temperature management describes the process by which the provider takes an active role in attempting to manage the patient's thermal condition. For EMTs this is relegated to placing hot/cold packs at the groin, axilla (armpit), or neck but for more advanced providers could include temperature controlled intravenous fluid.
Position[edit | edit source]
Supine[edit | edit source]
- Current research recommends laying the patient flat in the supine position to increase ease of venous return to the heart and reduce dependent pooling.
Trendelenburg/Modified Trendelenburg[edit | edit source]
- The Trendelenburg/Modified Trendelenburg positions used to be the standard of BLS care for shock patients, however with the advent of new research use of these positions is dependent on local protocol as it is no longer fully recommended.
- The Trendelenburg position (the head-down position) is only truly able to be performed in hospitals where the entire gurney is able to be tilted so the patient's head is the lowest point of the body. In the prehospital setting, a modified Trendelenburg position consists of elevating the patient's legs above the rest of their body and lowering the head of the gurney to keep the patient otherwise flat.
Additional Resources[edit | edit source]
This article here describes a growing trend where providers are questioning the usefulness of the Trendelenburg position in shock patients.