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The passage of red blood from the rectum is called:

Hematochezia

The early physiological response to hemorrhage, including vasoconstriction, formation of a platelet plug, and coagulation is called:

Hemostasis

If mechanisms of hemostasis fail, the result is:

Hypotension

Shock might best be defined as:

Inadequate tissue perfusion

relation to cardiovascular physiology, heart rate multiplied by stroke volume equals:

Cardiac output

The Fick Principle is used to estimate:

Perfusion to an organ or the body

Black "tarry" stools are called:

Melena

Serious internal hemorrhage generally occurs in the chest cavity, abdominal cavity, pelvic cavity, and:

Retroperitoneal cavity

The peripheral vascular vessels are lined with smooth, low-friction cells called the

Endothelium

Fluid flows through a tube such as a blood vessel in response to the:

Pressure gradient between the two ends of the tube

The pressure differential between systemic systolic and diastolic readings is called:

Pulse pressure

The tone of the arterial system is best reflected by the:

Pulse pressure

total resistance against which blood must be pumped is called:

Peripheral vascular resistance

The primary factor affecting resistance to blood flow in healthy humans is:

Vessel diameter

The abnormal narrowing of an artery is called:

Stenosis

Arterial blood pressure is regulated primarily by:

Vasoconstriction and vasodilation

The majority of the blood in the human body is contained in the:

Veins and venules

You are evaluating a 78-year-old male with a 4-day history of fever and chills. On your arrival, the patient is hypotensive, tachycardic, and flushed. He has had no vomiting, diarrhea, or blood loss, but is obviously in a state of shock. His possible sepsis has produced:

Relative hypovolemia

As the body compensates for shock with peripheral vasoconstriction, oxygen delivery to the capillaries decreases, causing:

Anaerobic metabolism to replace aerobic metabolism

"Leaky capillary" syndrome occurs when the capillaries:

Permit protein-containing fluids to leak into the interstitial space

Stage 1 shock is compensated for by:

Vasoconstriction

You are treating a healthy 20-year-old male who has lost approximately 350 mL of blood. Which of the following vital signs would you expect with this amount of blood loss?

Normal blood pressure

As shock progresses from stage 1 to stage 2:

The precapillary sphincters relax and the postcapillary sphincters remain closed

During stage 2 shock, arterial hypotension and opening of AV shunts cause:

Stagnation of blood flow in the capillaries

Stage 2 shock is noted by:

Capillary and venule opening

patient has lost approximately 800 mL of blood. You expect her ventilatory rate to be:

Fast - she is compensating by releasing carbon dioxide

Stage 2 shock occurs with a 15% to 20% decrease in intravascular blood volume, leading to:

Increased capillary refill time, normal blood pressure, tachypnea, tachycardia

42 yr. F, in a unrestrained car crash head on 45mph dbl.femur fracture,unresponsive, tachypneic, Hypotensive. Based on Vitals what stage of shock is she in?

Stage 3

42 yr. F, in a unrestrained car crash head on 45mph dbl.femur fracture,unresponsive, tachypneic, Hypotensive. What does she need to reverse her stage of shock?

Blood replacement

42 yr. F, in a unrestrained car crash head on 45mph dbl.femur fracture,unresponsive, tachypneic, Hypotensive. What is likely her celluar response?

Disseminated intravascular coagulation

Water and sodium leaking into cells, potassium leaking out of cells, and cellular swelling typically occur in which phase of shock?

Stage 3

Stage 4 shock is noted by:

Multiple organ failure

Which of the following organs is most likely to fail first due to cellular necrosis?

Liver

Your patient has been hypotensive for 3 hours. Following transport to a trauma center, adequate blood flow and blood pressure are restored. Cells affected by the hypotension are likely to:

Die due to inadequate capillary perfusion

Which of the following does not produce actual or relative hypovolemic shock?

Cardiac failure

In the United States, hypovolemic shock is most commonly caused by:

Hemorrhage

You are treating a patient in decompensated shock. On physical exam, you note that the patient has hypotension, tachycardia, tachypnea, and crackles. What type of shock do you suspect?

Cardiogenic

The mortality rate of patients with this type of shock is:

High - approaching 80%

You are treating a patient in decompensated shock. On physical exam, you note that the patient has hypotension, tachycardia, tachypnea, and crackles.Initial management for most patients in shock is:

Fluid boluses

Which of the following causes obstructive shock?

Tension pneumothorax

Neurogenic shock due to head injury creates:

Peripheral vascular dilation

A severe allergic reaction due to histamine release from exposure to an antigen is called:

Anaphylactic shock

A severe anaphylactic reaction may cause:

Upper and lower airway constriction

Peritonitis and endocrine disorders might produce what type of shock?

Hypovolemic shock

A serious systemic bacterial infection most commonly causes what type of shock?

Septic shock

Between inmates,nursing home residents, immunosuprressd transpant pt., and a sickle cell disease pt. Which of the following would not statistically be prone to septic shock?

Prison inmates

You are dispatched to a 22-year-old male patient who has reportedly been struck with a ball bat at the midshaft right femur. The area is contused, swollen, and angulated. The patient is conscious, alert, and normotensive, but tachycardic. He is in what stage of shock?

Compensated shock

Clinical signs of irreversible shock include:

Frank hypotension

The management and treatment of a patient in any stage of shock must be directed to:

Management of oxygenation and perfusion of organs

If internal bleeding is suspected, after securing the airway and providing oxygen, the paramedic's highest priority must be:

Initiating rapid transport to an appropriate facility

The circulatory status assessment should begin with:

The control of arterial bleeding

Unless proven otherwise, shock is assumed to be _____ in nature.

Hypovolemic

A patient with noted hypotension, bradycardia, and jugular venous distention would lead you to suspect what type of shock?

Cardiogenic shock

You are treating a patient who presents with signs of shock. No trauma is noted, and the only pertinent history is a leg fracture 6 weeks earlier. What type of shock do you suspect?

Septic shock

You are treating a patient who presents with signs of shock. No trauma is noted, and the only pertinent history is a leg fracture 6 weeks earlier. Treatment for this patient includes:

Normal saline

A patient complains of a "racing heart" when she stands up. You note that her heart rate increases from 90 to 104 after standing up, leading you to suspect:

Volume depletion of at least 10%

Orthostatic vital-sign changes include a pulse rate:

Rise of 10 beats per minute when the patient stands

Hypovolemic shock due to any cause is first treated with:

Crystalloid fluid volume replacement

Tamponade of pelvic or abdominal internal hemorrhage may be aided by:

PASG application

situation that is generally a contraindication to the application of the PASG is: (A.) Internal bleeding into the abdomen (B.)Lung sounds indicating pulmonary edema (C.) Lower extremity fracture (D.) Obvious pelvic fracture

Lung sounds indicating pulmonary edema

An increase in ambient temperature will cause the pressure in the PASG to:

Increase the applied pressure

An IV solution with an osmotic pressure greater than that of the body's cells is a(n):

Hypertonic solution

How much normal saline would you expect to administer to a patient who has lost 500 mL of blood?

1500 mL

Which of these IV solutions can help to combat systemic acidity in the body's tissues?

Lactated Ringer (LR)

Blood transfusion reactions may occur up to how long after an infusion has been completed?

96 hours (4days)

If aggressive fluid resuscitation is indicated, you should use:

A pressurized IV system

The treatment of choice for an acute anaphylactic reaction is to administer:

Epinephrine

Your patient was the unrestrained driver in a head-on vehicle collision. The windshield is starred, and the steering column collapsed. The patient has a GCS of 11. Her vital signs are BP 106/70 mmHg, P 116, R 20/min. SaO2 is 94% and breath sounds are clear. ETA to the trauma center is 5 minutes. You have immobilized the spine and the patient is in the ambulance. What is the next appropriate course of action?

Administer oxygen by non-rebreather mask as you initiate transport

Aerobic metabolism is

energy using oxygen into cells

Anaerobic metabolism is

energy not using oxygen and is 18 times less effective than aerobic and produces acids (results in accumulcation of lactic acid)

Hemorrhage

disruption or leak in the vascular system that results in internal or external bleeding

Cardiac output

the amount of output per minute, heart rate times stroke volume is cardiac output

Stroke volume

the amount ejected in one contraction of heart

Perfusion

movement

Hypoperfusion

inadequate movement of blood (shock)

Hypotension

low BP

Pulse Pressure

the difference between the systolic and diastolic numbers

Fick Principle

Getting O2 into lungs, into body, into cells, back into lungs and out. If one is not working, we fall apart

Afterload

Peripheral vascular resistance (what the heart pumps against) and is a measure of friction between the vessel walls and fluid (viscosity)

Frank Starling Law

More pre-load results in a greater filling of the ventricles which result in better stretching of fibers to get a better ejection factor

Why is blood pooling concerning?

Becuase 60% of blood volume is in the venous system and pooling indicates shock and inadequate perfusion

Which vessel is most muscular?

artery

What vessels are the smallest?

capillaries

What vessels return to the heart and has a valve to prevent backflow?

vein

Four steps to control bleeding:

Step 1 - Direct pressure to reduce bleeding into the area.
Step 2 - Elevate to reduce blood flow to the area.
Step 3 - Pressure point - pressing down on major artery to the area to reduce blood flow. (brachial in arm and femoral in legs).
Step 4 - Tourniquet - LAST EFFORT WHEN ALL ELSE FAILS.

What are the new PHTLS/NREMT standards in bleeding control?

For a localized trauma injury with major bleeding follow the step by step approach to control bleeding. For Multi-system trauma patients with major bleeding not controlled by direct pressure go to tourniquet to save red blood cells.

Indications of internal hemorrhage?

Blunt or penetrating trauma or acute and chronic illness, blood collects most commonly in one of 4 cavities: chest, abdomen, pelvis or retroperitoneum, melena is black, tarry stools, hematochezia is red blood passing through the rectum.

Causes of shock:

pump failure (MI, CHF, drugs, valve damage leaking
container failure (blood vessels)
volume failure (blood, loss of plasma)

First stage of shock:

Stage 1: Vasoconstriction - as volume decreases the precapillary arterioles and postcapillary venules constrict. As this decrease in blood flow to these areas decrease anaerobic metabolism takes over and acid develops. As a result the capillaries begin to leak resulting in more fluid loss. Also blood is shunted from the GI, skin and kidneys.

Second stage of shock

Stage 2: Capillary and Venule Opening - Precapillary sphincter relaxes. Postcapillary sphincters resist relaxation and remain closed. This causes pooling of blood.

Third stage of shock

Stage 3: Disseminated Intravascular Coagulation - (refractory shock) still considered reversible in early stage. Blood begins to coagulate in the microcirculation resulting in lack of nutrients to the cells. Anaerobic metabolism takes over and the acid buildup allows Na+ and K+ to enlarge the cells and "washout" and die.

Fourth stage of shock

Stage 4: Organ Failure results from "washout" and a delayed death. You might get the BP up but the microcirculation is destroyed.

Hypovolemic shock

loss of volume. Diarrhea, heat stroke, vomiting. Can be caused by peritonitis and endocrine disorders also. A sister shock of hypovolemic is hemorrhagic shock in which the fluid is blood specifically. Hemorrhagic shock is the most common cause of hypovolemic shock.

Cardiogenic shock

Failure of the heart to pump. Cannot keep cardiac output up. CHF, MI, damage. Most commonly has crackles or wet lungs.

Obstructive shock

a type of cardiogenic shock and is caused by cardiac tamponade, tension pneumothorax or pulmonary embolism.

Septic shock

Infection that goes systemic throughout the body. Irritates vessels and they swell and leak plasma making BP drop. Example is pneumonia not treated may go septic. Has FEVER.

Anaphylactic shock

severe allergic reaction in which vessels leak (hives) to release histamines and the BP goes down as result.

Neurogenic shock

spinal cord severed and blood vessels dilate and loose their tone and BP drops. This type of shock is unique because heart rate usually stays between 60-100BPM without adrenaline signs present.

Psychogenic shock

NO SUCH THING. THIS IN NOT A TRUE SHOCK. This is known as syncope. Transient lack of blood to the brain so you faint. Self correcting shock.

What is considered critical blood loss for an adult?

1000cc

What is considered critical blood loss for a child?

500cc

What is considered critical blood loss for an infant?

250cc

What does a radial pulse only indicate?

80 systolic

What does a femoral pulse only indicate?

70 systolic

What does a carotid pulse only indicate?

60 systolic

What are the core/central pulses?

carotid, femoral, apical

What are the peripheral pulses?

arms and legs

What is apical?

when you listen for the lub-dub of the heart pumping

How does BP define the first phase of shock?

BP above 90

How does BP define the second phase of shock?

BP less than 90

Define early (compensated) shock

release adrenaline results in - Restlessness/anxiety, heart rate fast and strong, respirations fast and deep, pupils dilated, sweaty skin. Pt may feel thirsty, and weak.

Define late (decompensated) shock

adrenaline release slows - heart rate fast but weak, respirations fast but shallow, feeling of doom, decreased level of consciousness. delayed capillary refill.

Define irreversible shock

unresponsive and death or organ failure and die a few days later

What are orthostatic vital signs?

(tilt test) - rise in pulse and decrease in BP from lying, sitting to standing. Supports lack of perfusion.

What is the care for shock?

Goal is to maintain oxygenation and perfusion of organs.
After securing airway next priority is golden hour and load and go.
First priority of trauma patient is to transport and do all skills enroute. Load and go.
IV's short and fat and start at least 2 of them. Also use a pressure bag at 300mmHg to rapid infuse if needed.
Initial management for most patients in shock is a fluid bolus. Maintain a BP of 80-90mmHg is goal.
PASG should be applied to stop hemorrhage by tamponading any bleeding vessels in the abdomen, pelvis, or lower extremities.
Lay flat or elevate legs
Cover to keep warn
Place on high flow oxygen
Keep calm

Fluid care for shock?

General guidelines warrant an isotonic crystalloid fluids only as necessary to maintain perfusion of 80-90mmHg. Try to limit amount of fluid to 3,000 mL.
Crystalloids are the most common fluid used early. lactated ringers, normal saline solutions in water. 2/3 of the fluid leaves the vascular space within 1 hour. It takes 3mL for ever 1 mL of blood lost.
Lactated ringers are the fluid of choice for shock. Well balanced and have many chemicals found in blood. LR also contains sodium chloride, potassium and calcium and 28mEq of lactate which helps to buffer the acid.
Colloids are large molecules and remain in the vascular compartment for a longer time. Examples are whole blood, packed red blood cells, blood plasma.
Note: In the exam world if a patient has a reaction to a colloid stop the infusion immediately. Fever is most common symptom.

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