Cardiogenic Shock

Shock can be classified into 3 different types: Hypovolaemic Shock, Cardiogenic Shock, and Septic Shock. Whilst the management of shock varies based on the type of shock it is, the resulting effect of all 3 types of shock is the same – decreased tissue perfusion.

Cardiogenic Shock

  • impaired ability of the heart to pump blood as it should (left or right ventricle dysfunction), causing systemic hypoperfusion and tissue hypoxia
  • may be caused by cardiac injury (eg. cardiac tamponade), cardiopulmonary arrest, following cardiac surgery, dysrhythmias (severe tachycardia or bradycardia), myocardial tissue necrosis following a Myocardial Infarction, or structural problems (eg. valvular damage or regurgitation, pulmonary embolus, acute myocarditis, papillary muscle rupture, intracardiac tumour, and congenital defects
  • compensatory mechanisms may worsen the situation…eg. reduced cardiac output due to myocardium death causes increased contractility which further increases the heart’s workload and oxygen demand; reduced blood pressure causes the release of catecholamines which leads to vasoconstriction, subsequently leading to a further increase in cardiac workload and oxygen demand

Cardiogenic Shock Signs & Symptoms

  • chest pain or chest trauma
  • altered level of consciousness
  • cool, pale moist skin
  • weak thready pulse
  • tachycardia possibly with dysrhythmias
  • tachypnoea
  • SBP <90mmHg and MAP 30mmHg less than normal
  • urine output <30ml/hr
  • jugular venous distension
  • reduced cardiac output and cardiac index
  • increased PAWP (Pulmonary Artery Wedge Pressure), increased RA (right atrium) pressure & increased SVR (systemic vascular resistance)
  • signs of pulmonary oedema eg. hypoxaemia, crackles, and frothy sputum

Management

  1. Treat Underlying Cause to Prevent Further Damage & Preserve Healthy Myocardium
  2. Enhance Pumping Effectiveness by Increasing Cardiac Output
  3. Improve oxygen perfusion in the heart as well as other organs and tissues
  4. Increase oxygen supply and reduce oxygen demand of the heart
  • provide oxygen therapy through supplementary oxygen or mechanical ventilation due to cardiac ischaemia and chest pain
  • administer morphine for analgesia and sedation, and promote rest
  • if patient has pulmonary oedema, administer diuretics eg. furosemide or bumetanide, and oxygen whilst monitoring haemodynamic status and ABGs of the patient; diuretics reduce fluid accumulation which causes a decrease in preload – monitor for fluid and electrolyte imbalance
  • provide mechanical reperfusion through PCI (percutaneous coronary intervention) eg. angioplasty and coronary stents, or a coronary artery bypass graft (CABG)
  • provide thrombolytic therapy through pharmacologic agents eg. streptokinase, urokinase, tissue plasminogen activator TPA, which dissolve clots in coronary artery BEFORE cardiogenic shock sets in; ATTENTION: watch out for bleeding!
  • provide drug therapy that helps improve cardiac output by increasing cardiac contractility, decreasing preload and afterload, and stabilising the heart rate
  • provide fluids with great caution since this increases risk of pulmonary oedema
  • administer inotropes (eg. dobutamine or milrinone) to improve contractility and reduce afterload, and vasopressors (eg. adrenaline or noradrenaline) to increase contractility, vasoconstriction, blood pressure, and heart rate NOTE: inotropes and vasopressors can be given in combination
  • administer vasodilators eg. nitrates to reduce oxygen demands by reducing preload through venous dilation, reducing afterload by arterial dilation due to less resistance, increasing oxygen supply to the myocardium due to coronary vasodilation, but ATTENTION – vasodilators cause hypotension!
  • treat arrhythmias with anti-arrhythmic drugs eg. amiodarone to help increase time for ventricular filling
  • make use of the intra-aortic balloon pump – a long balloon attached to a large bore catheter inserted through the femoral artery to the descending aorta, with the balloon tip placed just below the aortic arch, and the bottom tip above the renal artery; the attached machine helps by inflating the balloon with helium at the start of diastole when the aortic valve closes, and rapidly deflating it at the start of ventricular systole, just before the aortic valve opens; ATTENTION to possible complications eg. dislodgement of clots, limb ischaemia / neuropathy (check pedal pulses), bleeding (check clotting time before insertion and removal), infection, balloon rupture, and improper position
  • if indicated, the Left Ventricular Assist Device may be used – flow pump which is placed across the aortic valve into the left ventricle; it draws blood continuously from the left ventricle to the proximal aorta; may be used prior to transplantation or long term for transplantation-ineligible patients
  • the VA-ECMO is a device through which deoxygenated blood is drained through the central vein; blood is then oxygenated outside of the patient’s body, before being returned through the large artery; it helps improve aortic flow and organ perfusion, however, it may increase afterload and worsen pulmonary oedema; note increased risk of acute kidney injury, severe bleeding, lower limb ischaemia, and stroke
  • if indicated, a patient with cardiogenic shock may undergo surgical interventions such as human heart transplantation, repair of septal, ventricular, or papillary muscle rupture, or valve repair or change
Retrieved from https://www.magonlinelibrary.com/doi/abs/10.12968/bjca.2021.0055?journalCode=bjca on 20th January 2023
cardiogenic shock
Retrieved from https://www.facebook.com/jamajournal/photos/a.10158814898548341/10158814906348341/?type=3&locale=zh_HK on 19th January 2023

Cardiogenic Shock and Intra-aortic Balloon Pump => https://www.youtube.com/watch?v=mADxD7C8jBw


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The Definition, Classification and Pathophysiology of Shock

In order to understand how to care for a patient in shock, we must first understand the pathophysiology of shock, as well as how to assess, diagnose, and manage it through appropriate nursing interventions. The most common types of shock are the Hypovolaemic Shock, Cardiogenic Shock, and Septic Shock. Throughout this blogpost we will be looking in detail at the definition, classification, and pathophysiology of shock.

What is Cardiac Output?

Cardiac Output (CO) is the volume of blood ejected from the heart over 1 minute. In adults, normal Cardiac Output is between 4-6L/min.

Cardiac Index (CI) is a haemodynamic parameter related to the cardiac output from the left ventricle in 1 minute to body surface area (BSA). In adults, normal Cardiac Index should be between 2.5-4L/min/m2.

Stroke volume (SV) is the volume of blood pumped out of the left ventricle during each systolic cardiac contraction.

Mean Arterial Pressure (MAP) is the average arterial pressure throughout one cardiac cycle, systole, and diastole.

Systemic Vascular Resistance (SVR) is the resistance in the circulatory system which affects the blood pressure and the flow of blood. SVR is also a component of cardiac function, eg. vasoconstriction leads to an increased SVR.

Formulas:

Cardiac Output (CO) = Heart Rate (HR) X Stroke Volume (SV)

Cardiac Index (CI) = Cardiac Output (CO) / Body Surface Area

Mean Arterial Pressure (MAP) = Cardiac Output X Systemic Vascular Resistance (SVR)

Cardiac Output Determinants

  • HEART RATE – influenced by both the sympathetic and parasympathetic system, as well as by intrinsic regulation
  • STROKE VOLUME – determined by cardiac preload (PL), afterload (AL), and cardiac contractility (CC).

Preload determinants

Preload (PL) is the stretching force exerted on the ventricle by the blood contained within at the end of diastole.

The Starling’s Law of the Heart indicates that increased volume returned to the heart causes an increase in Cardiac Output, however, following a certain increase in volume returned causes a decrease in Cardiac Output.

Retrieved from https://ecgwaves.com/topic/pressure-volume-curves-preload-afterload-stroke-volume-wall-stress-frank-starlings-law/ on 10th January 2023

Preload determinants include:

  • VOLUME OF BLOOD RETURNED TO LEFT VENTRICLE – influenced by venous return, total blood volume, and atrial kick
  • LEFT VENTRICLE COMPLIANCE (stretching ability) – influenced by the stiffness and thickness of the muscle wall

Examples: in Hypervolaemia, preload is too low, whilst in Congestive Heart Failure, preload is too much.

Afterload Determinants

Afterload (AL) is the resistance (a.k.a. Systemic Vascular Resistance SVR) that the heart must overcome to push blood into the systemic circulation.

An increase in Afterload causes an increase in the required effort and oxygen demand by the heart, eg. vasoconstriction increases Systemic Vascular Resistance, total blood volume and viscosity.

To reduce the heart’s workload we can provide therapeutic nursing management, including the administration of vasodilators.

pathophysiology of shock
Retrieved from https://www.studypk.com/articles/nursing-mnemonics-preload-vs-afterload/ on 10th January 2023

Cardiac Contractility Determinants

Cardiac Contractility (CC) is the force by which the heart contracts. CC is determined by:

  • VENOUS RETURN – Starling’s Mechanism
    • STIMULATION OF THE SYMPATHETIC NERVOUS SYSTEM
    • INCREASE IN INTRACELLULAR CALCIUM (Ca++) – such as after use of Digoxin
    • PHARMACOLOGICAL INTERVENTIONS – eg. administration of Inotropes
Retrieved from https://step1.medbullets.com/cardiovascular/108003/cardiac-output-and-variables on 11th January 2023

Shock Definition

Shock can be defined as an acute widespread process of impaired tissue perfusion resulting in cellular, metabolic and haemodynamic changes, causing an imbalance between cellular oxygen supply and demand. Shock leads to death if not controlled in time.

Normal tissue perfusion requires:

  • adequate blood volume
  • adequate cardiac pump
  • effective circulatory system

Impairment of any of the above, thus, impairment in normal tissue perfusion, may lead to SHOCK…

Impaired oxygen perfusion causes:

  1. inadequate blood flow reaching the tissues
  2. inadequate delivery of oxygen and nutrients to the cells
  3. cell starvation due to oxygen and nutrient deprivation
  4. cell death
  5. multiple organ failure
  6. death

Classification of Shock

Shock can be classified into 3 different types. Whilst the management of shock varies based on the type of shock it is, the resulting effect of all 3 types of shock is the same – decreased tissue perfusion.

Hypovolaemic Shock

Hypovolaemic shock is the most commonly occurring type of shock, which is also easily reversible if treated in a timely manner. Features of a hypovolaemic shock include:

  • loss of circulating or intravascular volume
  • impaired tissue perfusion
  • inadequate delivery of oxygen and nutrients
  • may be caused by relative and absolute hypovolaemia, or loss of blood or other fluids
Retrieved from https://twitter.com/misirg1/status/1382458804995035144 on 19th January 2023

Cardiogenic Shock

  • impaired ability of the heart to pump blood as it should (left or right ventricle dysfunction), causing systemic hypoperfusion and tissue hypoxia
  • may be caused by cardiac injury (eg. cardiac tamponade), cardiopulmonary arrest, following cardiac surgery, dysrhythmias (severe tachycardia or bradycardia), myocardial tissue necrosis following a Myocardial Infarction, or structural problems (eg. valvular damage or regurgitation, pulmonary embolus, acute myocarditis, papillary muscle rupture, intracardiac tumour, and congenital defects
  • compensatory mechanisms may worsen the situation…eg. reduced cardiac output due to myocardium death causes increased contractility which further increases the heart’s workload and oxygen demand; reduced blood pressure causes the release of catecholamines which leads to vasoconstriction, subsequently leading to a further increase in cardiac workload and oxygen demand
Retrieved from https://www.facebook.com/jamajournal/photos/a.10158814898548341/10158814906348341/?type=3&locale=zh_HK on 19th January 2023

Distributive Shock

  • impaired distribution of circulating blood volume
  • vasodilation
  • capillary leaks

Distributive Shock is further sub-classified into 3 other types of shock:

SEPTIC SHOCK:

While sepsis is defined as a life-threatening organ dysfunction caused by dysregulated host response to infection, a septic shock is defined as a subset of sepsis in which underlying circulatory, cellular and metabolic abnormalities and profound enough to substantially increase the risk of mortality.

  • microorganism entry into the patient’s body
  • dysregulated host response characterised by excessive peripheral vasodilation, causing maldistribution of blood volume, over-perfused peripheral areas and under-perfused central areas
  • is the major cause of admission in the critical care setting

Septic Shock may originate from the community (>80% of cases) or during a stay in a healthcare facility.

ANAPHYLACTIC SHOCK:

  • severe antigen-antibody reaction causing histamine release
  • signs & symptoms include vasodilation, hypotension, bradycardia, increased capillary permeability, bronchospasm, laryngeal oedema, and stridor

NEUROGENIC SHOCK:

  • disruption of sympathetic nerve activity below the level of a spinal cord injury or disease
  • signs & symptoms include vasodilation, hypotension, bradycardia, warm dry skin, and loss of thermoregulation

Obstructive Shock

  • obstructive shock is often classified with cardiogenic shock
  • obstructive shock is mechanical obstruction which impedes the heart from generating adequate cardiac output
  • examples of obstructive shock include Tension Pneumothorax, Pericardial Tamponade and Pulmonary Embolus
pathophysiology of shock
Retrieved from https://www.pinterest.com/pin/34762228362737082/ on 11th January 2023

The Pathophysiology of Shock

pathophysiology of shock
Retrieved from https://slideplayer.com/slide/17204705/ on 11th January 2023

Initial Stage

Within the initial phase of shock, effects are very subtle and at cellular level. An increase in serum lactate indicates metabolic acidosis due to cells switching from aerobic to anaerobic respiration.

  1. Decrease in Cardiac Output
  2. Decrease in tissue perfusion
  3. Cells switch from aerobic to anaerobic respiration
  4. Accumulation of Lactic Acid
  5. Lactic Acidaemia (Low pH)
  6. Cellular Damage

Compensatory Stage

During the compensatory stage of shock, the patient’s body attempts to improve tissue perfusion through neural, chemical, and hormonal compensation, mediated by the sympathetic nervous system.

NEURAL COMPENSATORY MECHANISMS

  • increased Heart Rate and Cardiac Contractility
  • arterial and venous vasoconstriction
  • circulation lessens within the peripheries and becomes more focused on vital organs perfusion

CHEMICAL COMPENSATORY MECHANISM

  • chemoreceptors detect acidosis and stimulate hyperventilation so more Carbon Dioxide is exhaled

HORMONAL COMPENSATORY MECHANISMS

Hormonal compensatory mechanisms aim to increase the blood pressure to cause an increase in tissue perfusion.

  • the anterior pituitary gland is stimulated, causing secretion of ACTH (Adrenocorticotropic Hormone), which then stimulates the adrenal cortex to produce glucocorticoids (glucagon), which causes an increase in blood glucose level
  • the adrenal medulla is also stimulated, causing the release of adrenaline and noradrenaline, which result in vasoconstriction, leading to an increased Blood Pressure and increased Heart Rate
  • renin response is activated, which facilitates the conversion of Angiotensinogen into Angiotensin II; this conversion causes vasoconstriction, release of aldosterone (which leads to sodium retension), and release of antidiuretic hormone (ADH) by the posterior pituitary gland (which leads to water retention)
pathophysiology of shock
Retrieved from https://en.wikipedia.org/wiki/Renin%E2%80%93angiotensin_system on 11th January 2023

SYMPTOMS EXPERIENCED DURING THE COMPENSATORY PHASE:

  • cold, clammy skin
  • drop in urine output
  • tachycardia
  • tachypnoea
  • hyperglycaemia

Progressive Stage

  • compensatory mechanisms start failing
  • shock cycle continues indefinitely
  • anaerobic respiration causes energy exertion within the cells
  • cells are unable to function, and irreversible damage occurs (Mitochondria become unable to use oxygen for the production of energy, and Lysosomes release digestive enzymes which then cause further cellular damage)
  • utilisation of the limited oxygen delivered into the cells becomes problematic

During the progressive stage, organ systems start to fail…

  • Myocardial Hypoperfusion causes decreased Cardiac Output leading to ventricular failure, enabling shock to progress further
  • Decreased Cerebral Blood Flow causes CNS dysfunction, causing failure of the sympathetic nervous system, failure of the thermoregulation mechanism, cardiac and respiratory depression, and altered mental status
  • Impaired Coagulation leading to microclot formation, which may cause Disseminated Intravascular Coagulation (DIC)
  • Renal Vasoconstriction & Hypoperfusion causes decreased urine output and increased creatinine, which may also lead to Acute Tubular Necrosis (ATN)
  • GastroIntestinal Tract Hypoperfusion causes decreased peristalsis (decreased bowel sounds), release of Gram-negative bacteria (which worsens shock), and liver hypoperfusion due to deranged LFTs
  • Pulmonary Vasoconstriction along with microemboli, parenchymal inflammation, and alveolar oedema all lead to respiratory failure (Acute respiratory distress syndrome ARDS)

SYMPTOMS EXPERIENCED DURING THE PROGRESSIVE PHASE:

  • electrolyte imbalance
  • metabolic acidosis
  • respiratory acidosis
  • peripheral oedema
  • tachycardia
  • arrhythmias
  • hypotension
  • pallor
  • cool clammy skin
  • altered level of consciousness
  • reduced bowel sounds

Refractory Stage

In the final stage of shock, the patient becomes unresponsive to treatment, experiences multiple organ failure, eventually leading to death.


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Sudden Acute Illness

Illness can be categorised under either acute or chronic. Whilst chronic illness is long-lasting, potentially worsening over time, sudden acute illness happens suddenly with immediate or rapidly developing symptoms, which is why it usually requires immediate care.

Altered Level of Consciousness

Retrieved from https://www.nursingtimes.net/roles/hospital-nurses/patient-narratives-4-the-meaning-behind-communication-04-04-2016/ on 2nd October 2022

When normal brain activity is interrupted, a casualty may experience loss of awareness of their surroundings. At times the casualty may only show responsiveness when stimulated eg. through shaking, shouting, or pain stimulus.

Causes

  • hypoglycaemia – most common cause of unconsciousness
  • any issue with the airway, breathing or circulation leading to brain hypoxia
  • neurological issues (eg. CVA)
  • serious infection (eg. meningitis or infection in relation to the brain)
  • brain injury following trauma to the head
  • poisoning which affects the brain directly, or which leads to ABC compromise that induces brain hypoxia
  • other sudden acute illness eg. myocardial infarction

Signs & Symptoms of Neurological Issues

  • dizziness
  • disorientation
  • confusion
  • lethargy
  • drowsiness
  • low level of response
  • unequal pupil size
  • abnormal pupil reaction
  • limb weakness
  • unresponsiveness
  • seizures

NOTE: in CVA, limb weakness is commonly experienced on one side of the body.

A casualty’s level of consciousness is typically tested using the Glasgow Coma Scale, while the level of response is tested using the AVPU score.

Cerebrovascular Accident CVA

sudden acute illness
Retrieved from https://www.netmeds.com/health-library/post/strokecerebrovascular-accident-causes-symptoms-and-treatment on 2nd October 2022

A cerebrovascular accident is considered to be a sudden acute illness. It can happen in 2 ways:

  1. Haemorrhagic Stroke – a stroke which happens when weakened or deceased blood vessels rupture, causing blood leaks into the brain tissue
  2. Ischaemic Stroke – a stroke caused by a blood clot that stops the normal flow of blood to a part within the brain

Signs & Symptoms of Cerebrovascular Accident

  • sudden headache
  • blurred vision
  • facial asymmetry
  • drooling
  • slurred speech
  • numbness and/or weakness focused on one side of the body

First Aid for CVA

Retrieved from https://www.cedars-sinai.org/blog/stroke-strikes-act-fast.html on 2nd October 2022

In an unresponsive casualty:

  1. maintain ABCs
  2. assist into recovery position
  3. call 112
  4. monitor & provide reassurance

In a responsive casualty:

  1. assist in a comfortable position, preferably on a bed if available
  2. elevate head and shoulders to promote comfort and to minimise pressure
  3. incline head towards affected (drooling) side to avoid aspiration pneumonia
  4. loosen any tight clothing
  5. call 112
  6. monitor & provide reassurance

Hypoglycaemia

sudden acute illness
Retrieved from https://www.dailypioneer.com/2016/health-and-fitness/hypoglycaemia-cases-increased-by-39-per-cent-study.html on 2nd October 2022

Hypoglycaemia, which can be considered as a sudden acute illness, can be defined as a glucose concentration of 3.9mmol/l or below.

Signs & Symptoms of Hypoglycaemia

  • history of Type 1 Diabetes
  • weakness
  • fatigue
  • hunger
  • pale, cold, clammy skin (this side effect helps differentiate between hypoglycaemia and a CVA)
  • aggressiveness or unusual behaviour
  • possible speech slurring

First Aid for Hypoglycaemia

In an unresponsive casualty:

  1. maintain ABCs
  2. assist into recovery position
  3. call 112
  4. monitor & provide reassurance

In a responsive casualty:

  1. give sugary drink (you may mix 2 tsp sugar in a little bit of water) or assist with own medication if available (eg. glucose gel)
  2. provide privacy (casualty may become incontinent)
  3. provide reassurance
  4. monitor
  5. if condition improves encourage casualty to seek medical advice; if condition deteriorates call 112

Seizure

sudden acute illness
Retrieved from https://www.jems.com/special-topics/jems-con/know-differences-between-seizures-epilep/ on 2nd October 2022

A seizure is considered to be a sudden acute illness, however, it is not exactly an illness by itself, but a sign of another illness affecting the activity of the brain eg. fever, head trauma, cerebral hypoxia, epilepsy, etc.

Signs & Symptoms of a seizure

  • face twitching
  • lip smacking
  • individual limb spasm
  • uncontrollable muscle spasms
  • convulsions
  • staring spell
  • drooling or frothing at the mouth
  • abnormal sounds
  • tongue biting
  • incontinence

First Aid for Seizures

During a seizure:

  1. notice starting time of seizure and time its duration
  2. reduce injury risk – provide protection for the casualty’s head and remove any nearby items which may be of danger
  3. DO NOT RESTRAIN
  4. DO NOT PUT ANYTHING INTO THE CASUALTY’S MOUTH
  5. ensure casualty’s privacy especially due to possible incontinent episode
  6. apply tepid sponging in case of casualty being febrile

After a seizure:

  1. perform primary assessment and assist if necessary
  2. perform secondary assessment and assist if necessary
  3. manage ABCs
  4. assist in recovery position
  5. call 112
  6. monitor casualty’s condition

Fainting Episode

Retrieved from https://onewelbeck.com/cardiology/symptoms/blackouts-fainting/ on 2nd October 2022

Fainting is a circulatory condition affecting consciousness. Fainting can present as follows:

  • possible brief loss of consciousness
  • slow pulse
  • pale, cold, clammy skin

First Aid for Fainting

  1. remove tight clothing
  2. increase air circulation (eg. by opening windows)
  3. assist to the floor to prevent casualty from getting hurt in case of a fall
  4. elevate legs (approximately 30cm)
  5. maintain casualty’s body temperature so as to help keep a stable blood pressure
  6. provide privacy and reassurance
  7. monitor
  8. call 112 if required

Cerebral Infection

sudden acute illness
Retrieved from https://www.momjunction.com/articles/common-symptoms-of-meningitis-in-toddlers_0098491/ on 3rd October 2022

Signs & Symptoms

  • fever
  • stiffness in the neck area
  • sensitivity to light
  • signs of shock
  • non-blanching rash – press area covered by rash and let go…a rash that still shows points to a neurological infection eg. meningitis

First Aid for Cerebral Infection

Seek medical advice immediately by calling 112!

Dyspnoea

sudden acute illness
Retrieved from https://safarmedical.com/en/medical-articles/difficulty-breathing on 3rd October 2022

Dyspnoea is otherwise known as experiencing difficulty in breathing. Dyspnoea can happen due to various reasons:

  • Airway Obstruction
  • Cardiac & Circulatory Disorders
  • Respiratory Disorders affecting either the inhalation/exhalation process (eg. asthma), the lower airways, the diffusion process across the alveolar membrane, or the uptake of oxygen in pulmonary circulation (eg. anaemic patients)

Causes of Dyspnoea

  • asthma
  • pulmonary oedema – caused either by a cardiac problem or by accumulation of fluid in the alveoli within the lungs
  • hyperventilation syndrome – stress => hyperventilation => not feeling well => anxiety => increased hyperventilation => increasing symptoms (respiration rate of more than 30 breaths per minute; numbness)
  • chest infection
  • inhalation of fumes/chemicals
  • drowning syndrome
  • choking
  • strangulation or suffocation

Dyspnoea signs and symptoms

  • inability to speak
  • use of accessory muscles to breathe
  • abnormal respiratory rate and rhythm pattern
  • noisy breathing
  • cyanosis
  • disorientation, confusion, or unusual aggressiveness – these are classic signs of cerebral hypoxia irrespective of its cause

First Aid for Dyspnoea

  1. provide reassurance to reduce anxiety and increased symptoms
  2. encourage good breathing pattern
  3. increase ventilation in casualty’s area
  4. help sit up properly
  5. release tight clothing
  6. if casualty is on medication eg. inhalers, assist with self medication
  7. call 112
  8. monitor casualty and be prepared to resuscitate if need be

Foreign Body Airway Obstruction (FBAO)

first aid for compromised airway

Foreign Body Airway Obstruction can manifest in two ways: foreign bodies may cause partial, or complete airway obstruction.

Signs & symptoms of foreign body airway obstruction

In mild (partial) airway obstruction, the casualty is able to speak and cough.

In severe (complete) airway obstruction, the casualty:

  • is unable to speak or cough
  • has noisy breathing (wheezing)
  • shows signs of severe dyspnoea
  • shows signs of distress
  • may be or become unresponsive

First Aid for Foreign Body Airway Obstruction

In a conscious patient:

  1. 5 back blows followed by 5 abdominal thrusts
  2. continue, alternating between the two methods until either foreign body gets dislodged, or else casualty becomes unresponsive

In an unconscious patient:

  1. start CPR

NOTE: in casualties who are either obese, pregnant, or children, do not perform abdominal thrusts…instead do chest thrusts; after the intervention, the casualty should be taken to hospital to be assessed for possible internal damage.

Chest Pain

sudden acute illness

Chest pain can result due to Ischaemic Heart Disease – a disease in which there is an obstruction of blood flow to an area within the heart which causes hypoxia and death of that particular area in the heart.

Signs & Symptoms of Acute Ischaemia

  • feeling generally unwell
  • pale and cold skin
  • profuse sweating
  • feeling persistent pain or heaviness in the chest
  • chest pain may radiate to the left arm, jaw and back
  • may experience palpitations
  • may experience nausea
  • dyspnoea

First Aid for Acute Ischaemia

  1. provide reassurance
  2. ensure surrounding area is well ventilated
  3. assist in a sitting position
  4. release any tight clothing
  5. assist with own medication if available on casualty eg. 300mg of aspirin
  6. call 112
  7. ask someone to get an AED
  8. monitor
  9. be prepared to resuscitate if need arises

Anaphylaxis & Anaphylactic Shock

sudden acute illness
Retrieved from https://homeopathy.ae/article/anaphylaxis-dangerous-allergy on 7th October 2022

Anaphylaxis happens when a person comes into contact or exposure to an allergen.

Signs & Symptoms of Anaphylaxis

  • changes within the skin and mucous membranes eg. rash, burning sensation, swelling of the mouth and tongue
  • sudden illness development
  • rapid ABC deterioration eg. swelling of airway structures, altered level of consciousness, dyspnoea, wheezing, cyanosis, dizziness & weakness (neurological response)

NOTE: If a casualty experiences all the above PLUS signs of shock (including pale, clammy skin), the indication would be an ANAPHYLACTIC SHOCK, which is even worse than anaphylaxis!

First Aid for Anaphylaxis & Anaphylactic Shock

  1. identify cause (eg. if cause was an insect sting, remove it)
  2. if unconscious, resuscitate
  3. if unresponsive but breathing, assist into the recovery position
  4. if patient is responsive, assist in a supine position UNLESS patient is exhibiting signs of shock, in which case, elevate legs, OR if experiencing severe dyspnoea, in which case assist in fowlers position or elevate back as much as possible
  5. administer high concentration of oxygen
  6. if an epipen is available on the casualty and the casualty is responsive, administer, assist in self injecting Epinephrine

NOTE: Epinephrine helps DECREASE severity of anaphylaxis, EASE bronchospasms due to causing bronchial airways to dilate, and REDUCE circulatory collapse through a triggered increase in cardiac contraction as well as reversal of peripheral vasodilation.


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Bleeding and Shock First Aid

In the acronym DR ABC, C stands for circulation. Signs of circulation compromise to watch out for include bleeding or shock symptoms.

The Human Circulatory System

The human circulatory system comprises of the heart, the blood vessels, and the blood. All these components need to be working efficiently so that every tissue within the body is supplied with oxygenated blood.

Shock Causes

A decrease in blood pressure and SPO2 indicate circulatory failure – the brain is slowly dying due to lack of oxygen, and so, it triggers a defense mechanism: SHOCK.

Any issue affecting the heart, the blood vessels, or the blood volume, may lead to a decrease in the body’s blood circulation, leading to a reduction in blood pressure and volume, which in return cause a decrease in tissue perfusion.

Decreased Cardiac Output = Decreased Circulating Volume & Pressure = Reduced Venous Return

Types of shock include:

  1. cardiogenic shock
  2. obstructive shock
  3. neurogenic shock
  4. septic shock
  5. anaphylactic shock
  6. hypovolaemic shock

Causes of shock can be divided into 3 categories:

1. Decrease in the Pumping Action of the Heart

A drop in cardiac output can result in a:

  1. Cardiogenic Shock – this may happen due to a heart defect or disorder (cardiogenic = issue originating from the heart itself) eg. Congestive Heart Failure (CHF) or Ischaemic Heart Disease (IHD);
  2. Obstructive Shock – this may happen due to cardiac compression in cases such as in cardiac tamponade (bleeding within the pericardial space) and tension pneumothorax (air accumulation in the pleural space which compresses the lungs and decreases venous return to the heart).

2. Blood Vessel Dilation

Following vasodilation, which refers to the dilation of the blood vessels, a casualty can suffer a distributive shock:

  1. Neurogenic Shock – happens following a spinal injury, head injury, or opiate overdose;
  2. Septic Shock – happens following a severe infection which causes the casualty’s blood pressure to drop to a dangerously low level;
  3. Anaphylactic Shock – happens following a severe allergic reaction

NOTE: due to a biochemical process in the body, chemicals released cause vasodilation, which then causes either a septic shock or an anaphylactic shock.

3. Blood or Fluid Loss

Severe bleeding or severe dehydration can lead to a hypovolaemic shock. This happens due to the drop in blood volume.

Progressive Shock Clinical Indicators

  • initial weak rapid pulse that eventually becomes thready or absent (body increases heart rate to compensate due to lack of blood; eventually, drop in cardiac output = drop in stroke volume = weak heartbeat)
  • initial rapid irregular breathing that eventually becomes laboured and dyspnoeic
  • initial pale skin that eventually becomes cold, clammy and mottled (happens since the body compensates lack of oxygen circulation by sending it in the most important areas rather than in the extremities)
  • cyanosis – signifies established hypoxia
  • weakness and fatigue – signifies cerebral hypoxia (lack of oxygen in the brain)
  • confusion and disorientation
  • altered level of response leading to unresponsiveness…casualty is now at risk of cardiac arrest!

Shock First Aid

  1. identify cause of shock
  2. control cause of shock
  3. assist casualty in shock position – elevate legs by about 30cm to increase venous return; if casualty is conscious but dyspnoeic, a semi-sitting position helps provide better breathing
  4. maintain casualty’s body temperature – this helps in avoiding hypothermia, which would disrupt an open wound’s clotting process, leading to longer bleeding time
  5. administer high-concentrated oxygen if available
  6. increase ventilation by opening windows if inside
  7. call 112 for assistance
  8. monitor casualty for deterioration – if casualty is in recovery position, attempt to maintain shock position i.e. elevated legs, if possible
  9. provide reassurance at all times
bleeding and shock
Retrieved from https://persysmedical.com/blog/hypothermia-prevention/trauma-triad-of-death/ on 18th September 2022

NOTE: The term vasoconstriction refers to constriction of the blood vessels. It can be clinically indicated in blood pressure results that show a difference of about 20 only between the systolic and diastolic readings. In such case, the pulse is weak or not palpable.

Bleeding

Bleeding amount depends on what it is originating from:

  • ARTERIES – spurting blood, pulsating flow, bright red colour
  • VEINS – steady, slow blood flow, dark red colour
  • CAPILLARIES – slow and even flow

Bleeding severity depends on the injury body site, blood loss volume, time frame of blood loss volume, casualty’s age (worse in children and the elderly), and casualty’s health status prior to the injury.

Catastrophic bleeding refers to bleeding in which 30% of blood volume is lost. Such bleeding takes priority over Airway and Circulation in the DR ABC acronym.

The major consequence of blood loss is a hypovolaemic shock (explained further up). During this type of shock, the heart becomes unable to pump enough blood throughout the body due to severe blood or fluid loss. This leads to organs shutting down.

External Bleeding First Aid

  1. wear gloves to protect self
  2. control bleeding through direct pressure or using a pressure dressing
  3. monitor and provide first aid for shock

Notes:

  • In bleeding circumstances without signs of shock, elevation is not recommended anymore.
  • Indirect pressure (pressing on arteries eg. on femoral or brachial artery) is not a recommended bleeding control technique anymore.
  • If direct pressure method fails, you may use an emergency bandage, tourniquet, or haemostatic agents, all of which require prior specific training.
  • In catastrophic bleeding first aid, one may pack the wound with a towel. Worrying about an infection is not a primary concern at this point, since catastrophic bleeding may lead to loss of life.
  • Haemostatic Agents can be poured on wounds to stop catastrophic bleeding. Only materials specifically prepared for bleeding purposes may be used
  • A tourniquet is a device that helps apply pressure to a limb or extremity to limit the flow of blood. It may be used in emergency situations, during surgery, or in the post-operative rehabilitation period.
  • Normal use tourniquets are orange in colour, while the Combat Application Tourniquet (CAT) is usually black.

Internal Bleeding

Internal bleeding may be caused as a disease process eg. due to a stomach ulcer, or trauma.

Common sites of serious internal bleeding include the head, the chest, the abdomen and pelvis.

Internal bleeding is more difficult to diagnose, since it usually doesn’t show. The worst type of internal bleeding happens in the pelvic area, right in the retroperitoneum.

Recognition of internal bleeding may be done through:

  1. History
  2. Signs & Symptoms
  3. Pain & Tenderness
  4. Revealed Internal Bleeding (eg. internal bleeding in the head may produce trickling blood out of orifices such as from the ear)

Types of Internal Bleeding:

  • Otorrhoea – blood coming out of the ear
  • Rhinorrhoea – blood coming out of the nose
  • Haemoptysis – coughed out blood
  • Haematemesis – vomited blood
  • Haematuria – bleeding in the urine
  • Rectal Bleeding – bleeding coming out of the intestines
  • Bruising
Retrieved from https://psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device on 18th September 2022

NOTE: If there is suspicion of internal bleeding, it NEEDS TO BE ASSUMED! Monitor for ABC compromise and signs of shock, and provide first aid as needed!


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IV Complications – Signs & Symptoms, Prevention and Management

More than 90% of hospitalised patients receive some form of IV therapy. Unfortunately, about 1/5 of these patients experience IV complications due to lack of administration care and adequate monitoring.

Phlebitis

IV complications
Retrieved from https://casereports.bmj.com/content/2016/bcr-2016-216448.full?sid=39b2cfd9-37f2-447d-bb40-64e8335a1d3c on 2nd April 2021

Phlebitis is the inflammation of the vein which is caused whenever the used cannula is too large for the chosen vein, or when the cannula is not secured in place. Using the smallest cannula possible depending on the patient and the fluid being administered will reduce the chance of phlebitis to occur during IV therapy administration.

Signs & Symptoms:

  • warm to the touch around the insertion site
  • redness and/or tenderness at insertion site or along the vein
  • bulge over the vein

Management:

  • at first sign or symptom of phlebitis stop IV infusion immediately
  • apply warm compresses onto the area
  • if further IV infusion is required, insert a new catheter into a different vein and into a different site, preferably choosing a bigger vein and opposite arm
  • document patient condition and management

Air Embolism

IV complications
Retrieved from https://vascularaccess.com.au/2017/05/14/air-embolism-understanding-why-it-occurs-and-how-to-prevent-it/ on 2nd April 2021

Air Embolism a.k.a. gas embolism occur when one or multiple air bubbles enter the blood stream through a vein or artery and blocks it. Air embolism is one of the most dangerous IV complications as it can cause death.

Signs & Symptoms:

  • blue skin hue
  • anxiety
  • dizziness
  • nausea
  • headache
  • muscle pain
  • joint pain
  • hypotension
  • dyspnoea
  • gasp reflex
  • persistent cough
  • tachypnoea
  • respiratory failure
  • shock
  • confusion
  • syncope / loss of consciousness
  • seizures
  • stroke
  • syncope

Management:

  • if air embolism is noted, flush or infusion administration should be stopped immediately and the rotating haemostatic valve (RHV) should be fully opened
  • if patient is unresponsive administer first aid, prioritising airway (A), breathing (B) and circulation (C) and if necessary resuscitate. Once resuscitated and stabilised, patient should be administered 100% oxygen treatment through a non-rebreather mask to ensure full body oxygen perfusion.
  • document patient condition and management

IV Site Infection

IV complications
Retrieved from https://sites.google.com/site/refreshersfornurses/infection on 3rd April 2021

A localised infection around the IV cannula site can be prevented by use of veins that are not small or fragile, not in extremities, not in areas that may need to be flexed and not in veins situated in sites with oedema or neurological impairment. Adherence to IV therapy safety procedures, maintaining a clear, dry dressing and frequent monitoring can help lessen the chance of infection.

Signs & Symptoms:

  • redness
  • swelling
  • burning sensation
  • discomfort
  • discharge
  • increase in temperature

Management:

  • when noted, infusion should be stopped immediately
  • remove cannula
  • clean site of infection
  • administer antibiotics as prescribed
  • monitor patient’s vital signs
  • document patient condition and management

Flare Reaction

IV complications
Retrieved from https://www.bjmp.org/content/unusual-reaction-iv-pethidine-case-report on 3rd April 2021

Venous flare reaction is usually a localised allergic response to the administration of an irritant via IV. To minimise risk for a flare reaction, patient’s allergy history should be taken prior to therapy administration, and administration should ideally happen slowly through an infusion pump. Additionally, monitor patient during infusion administration for any pain or discomfort.

Signs & Symptoms:

  • redness along the vein or at cannula site
  • tenderness
  • itchiness
  • warm to the touch
  • swelling
  • hypotension
  • anaphylaxis

Management:

  • stop irritant administration immediately
  • administer antidote if available
  • monitor for worsening of patient condition
  • document condition and management

Extravasation

IV complications
Retrieved from https://www.researchgate.net/publication/319654406_Chemotherapy_Extravasation_Management_21-Year_Experience on 3rd April 2021

Extravasation is the unintentional leakage of vesicant fluids or medications into the vein’s surrounding tissue. It can be prevented by ensuring proper drug dilution as per recommended guidelines prior to IV administration.

Signs & Symptoms:

  • discomfort, blanching and/or burning sensation at IV site
  • cool sensation at IV site
  • swelling at or right above IV site
  • blistering
  • skin sloughing

Management:

  • stop IV therapy administration immediately by disconnecting IV tube from cannula
  • aspirate any residual drug
  • administer antidote if available
  • document patient condition and management

Infiltration

IV complications
Retrieved from https://sites.google.com/site/refreshersfornurses/infiltration on 3rd April 2021

Infiltration is the accumulation of fluid in the IV surrounding tissue caused by the needle puncturing the vein wall or by eventual needle misplacement. Stabilising chosen vein extremity and taping cannula firmly to the skin can help prevent infiltration.

Signs & Symptoms:

  • little or no flow of IV infusion or bolus
  • cool to the touch
  • hard to the touch
  • swollen and pale infusion site
  • fluid leakage from infusion site
  • pain, tenderness, irritation and/or burning sensation at infusion site

Management:

  • stop infusion immediately and remove cannula
  • elevate effected extremity
  • apply warm compresses to encourage absorption (apply ice to the swelling if noticed within 30 minutes of infiltration onset)

Thrombophlebitis

IV complications
Retrieved from https://www.gastroepato.it/en_tromboflebiti_superficiali.htm on 4th April 2021

Thrombophlebitis is an inflammation that causes the formation of a blood clot, which blocks one or more veins, usually in the legs. Superficial Thrombophlebitis occurs when the affected vein is closer to the surface of the skin, whilst Deep Vein Thrombosis (DVT) occurs when the affected vein is at a deeper level.

To prevent thrombophlebitis, one needs to avoid prolonged periods of standing and elevate legs when sitting down. Improving blood circulation helps. This can be done by regular exercise.

Signs & Symptoms:

  • sudden or gradual swelling in the affected area
  • tenderness and/or pain in the affected area
  • redness or discolouration in the affected area
  • warm to the touch

Management:

  • apply heat to affected area
  • elevate
  • use of NSAIDs
  • wear compression stockings

Haematoma

IV complications
Retrieved from https://www.myiv.com/category/blog/page/11/ on 4th April 2021

A haematoma is leakage of blood from the blood vessel into the surrounding soft tissue. As one of the possible IV complications, a haematoma occurs when an IV catheter passes through multiple walls of a vessel, or when not enough pressure is applied to an IV site after catheter removal.

Signs & Symptoms:

  • redness
  • swelling
  • pain
  • disfiguring bruises

Management:

  • during the first 24hrs from the formation of a haematoma apply ice packs wrapped in cloth for 20 minutes (you can repeat this multiple times)
  • after the first 24hrs from the formation of a haematoma apply warm, moist compresses to the affected site for 20 minutes (you can repeat this multiple times in the second 24hrs post haematoma formation)
  • do not massage affected area
  • compress and elevate if affected area is a limb

Electrolyte Imbalance

IV complications

Electrolytes are minerals that carry an electrical charge in the blood, tissues, organs and everywhere within the body. An electrolyte imbalance is the result of too much or too little water.

Signs & Symptoms:

  • fatigue
  • lethargy
  • nausea and vomiting
  • diarrhoea or constipation
  • dysrhythmias
  • tachycardia
  • convulsions or seizures

Management:

  • monitor for dehydration
  • monitor ECG for prolonged QT interval
  • IV fluids
  • diet changes (eating more foods containing lacking electrolyte)
  • check current drug prescriptions for any possible replacement need (eg. loop diuretics may be changed to potassium-sparing diuretics in the case of loss of potassium)

Acute Hypervolaemia

Retrieved from https://en.wikipedia.org/wiki/Edema on 5th April 2021

Hypervolaemia is a condition in which there is excess fluid in the blood. Whilst an adequate amount of water is necessary for the body to function well, excessive fluid leads to an imbalance, resulting in complications.

Signs & Symptoms:

Management:

  • watch fluid intake
  • minimise sodium intake
  • monitor weight and report any changes and swelling immediately
  • diuretics
  • if present manage other existing comorbidities such as heart failure and chronic kidney disease to minimise hypervolaemia

Anaphylaxis

Retrieved from https://www.healthline.com/health/anaphylaxis on 5th April 2021

Anaphylaxis is a severe immediate hypersensitive reaction which is usually triggered by an allergen. Identifying the signs and symptoms of an anaphylactic shock is crucial as this is a life-threatening situation requiring immediate treatment.

Signs & Symptoms:

  • hives / itching
  • flushed or pale skin
  • dizziness or fainting
  • hypotension
  • bronchoconstriction / swollen tongue and/or throat leading to wheezing and dyspnoea
  • weak rapid pulse

Management:

  • epinephrine shot administered immediately
  • maintain a patent airway
  • if required, antihistamines and / or steroids may also be administered
  • oxygen administration
  • bronchodilators
  • monitor blood pressure, heart rate and oxygen saturation

Speed Shock

Retrieved from http://www.cwladis.com/math104/lecture6.php on 5th April 2021

Speed Shock is a systemic reaction to a drug being administered rapidly, leading to toxicity onset. An infusion device ensures that a drug is administered at the recommended rate.

Signs & Symptoms:

  • headache
  • flushed face
  • chest tightness
  • irregular pulse
  • syncope
  • loss of consciousness
  • shock
  • cardiac arrest

Management:

  • Stop IV immediately
  • Monitor ABC’s (Airway, Breathing, Circulation)
  • Report reaction
  • Do not leave patient unattended
Retrieved from https://www.pedagogyeducation.com/Class-Catalog/Infection-Control/Goal-Zero-Catheter-Related-Blood-Stream-Infections.aspx on 5th April 2021

Catheter Related Bloodstream Infection (CRBSI) is a complication resulting from the use of IV catheters. Septicaemia can also result from a CRBSI, causing a prolonged hospital stay. CRBSI can be prevented using an aseptic non-touch technique (ANTT) during insertion, use of PPEs, disinfecting external surfaces of the catheter hub and connecting ports, and removing and/or replacing at the appropriate time.

Signs & Symptoms:

  • fever
  • chills
  • hypotension
  • signs of infection proximal to the insertion site of the PVC (peripheral venous cannula)

Management:

  • removing catheter immediately when a CRBSI is noted
  • administrating antibiotics
  • maintaining infection control

Adverse Drug Reactions

An adverse drug reaction (ADR) is a harmful or unpleasant reaction resulting from an IV infusion which can be caused by a single or a combination of drugs. An ADR can be prevented by avoiding consumption with alcohol, reading instructions and consuming medication only as prescribed, and taking note of any previous reactions to the same ingredients. Avoid taking over-the-counter medications with vitamins.

Signs & Symptoms:

  • phlebitis
  • infiltration
  • extravasation
  • speed shock
  • shock
  • cardiac arrest
  • venous spasms (presenting as cramping and pain above IV site)

Management:

  • stop drug administration immediately
  • do not discard syringe…keep for further investigation
  • monitor vital signs
  • provide reassurance
  • perform CPR or administer Oxygen if required

Below you can find a collection of videos that can help provide a more visual approach to IV Complications.

IV Complications

IV Complications: Phlebitis Animation

IV Complications: Air Embolism

IV Flare Reaction

Extravasation

Infiltration Animation

Infiltration

Thrombophlebitis

Anaphylaxis

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels ivWatch, Lineus Medical Channel, What Happens If ?, Chronically Jaquie, Kathryn the Educator, DrER.tv and Alila Medical Media.

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