All Shock Types in One Video | NREMT Shock Review

0:00This topic is so important. It has its

0:03own chapter inside the EMS textbooks.

0:06Today, we're talking everything shock.

0:08By the end of this video, everything

0:10that I know about shock, I'm going to

0:12give to you. There's also a free study

0:14guide and quiz after you watch this

0:16video. It's going to be down in the

0:18description, so make sure to get access

0:20to that. We're going to start by going

0:22over the four types of shock. There's

0:26four main types of shock you have to

0:29know about.

0:33Hypoalmic shock. Okay, it's the most

0:36common type of shock when we think about

0:39shock in the patient, bleeding out,

0:41chaotic scene, right? Hypoalmia

0:45is shock that is caused by a loss of

0:49circulating blood or fluid. So you need

0:52to remember this

0:54hypoalmia

0:56means low hypoalmia

1:00volume of blood or fluid in the body and

1:03that is why the patient has a low blood

1:05pressure because there's not enough

1:08fluid blood or fluid in this case for

1:11the body to continue on. That's

1:13hypoalmic shock. So you can see here a

1:17loss of circling border fluid volume. So

1:21the heart has nothing to pump.

1:23So what happens? Okay, there's not

1:26enough preload mean there's not enough

1:28blood return coming back to the heart.

1:30Okay, stroke volume goes down, cardiac

1:33output goes down and there's poor tissue

1:35profusion in hypoalmia. Now here's the

1:39big thing to remember. A patient that is

1:43severely dehydrated

1:46can also have this type of shock. Okay.

1:51So, look here. There's hemorrhagic like

1:54I'm bleeding out and there's

1:57non-hemorrhagic causes. So, don't forget

2:00when you go to that patient and they're

2:03vomiting for days or they had diarrhea

2:06for days, they're very dehydrated that

2:09they may also be in hypoalemia.

2:12Hypoalemia. It's not just patients that

2:15got shot or got stabbed or for example

2:19have a GI bleed or internal bleeding

2:21that we don't know about. Okay, I'm

2:24going to give you a big pearl. Hit the

2:26bell right here. Big pearl alert. And

2:29here it is.

2:31When you go to a patient with

2:33unexplained

2:36unexplained low blood pressure, okay,

2:39it's right here. unexplained low blood

2:43pressure and they got abdominal pain.

2:46They don't look very they don't look

2:47very good. It's going to be a triple A.

2:51Okay. An acute abdominal aortic

2:54aneurysm. It's happening right now in

2:56front of her eyes. An abdominal aortic

2:58aneurysm happening right before our

3:00eyes. A triple A. Okay, remember that.

3:03Unexplainable tension. I got abdominal

3:06pain. Triple A until proven otherwise.

3:08Okay. Now, trauma with external or

3:11internal bleeding, a GI bleed, think

3:13ulcer or esophageal veraces. They're

3:17basically throwing up but coughing up.

3:20Okay. Bright red blood uncontrollably.

3:22That's in alcoholics. Ruptured ectopic

3:25pregnancy. Okay, that's obviously again

3:28severe abdominal pain in a female of

3:31childbearing age. And we don't know

3:33what's going on. Are you pregnant? I

3:34don't know. They could be. Maybe they're

3:36early trimester. really don't know yet.

3:38Watch out for that. Okay.

3:41Non-hemorragic, severe vomiting or

3:43diarrhea, dehydration, heat illness,

3:46poor intake, or burns. Everyone forgets

3:49burns. So remember this the rest of your

3:52career.

3:54Why do we give IV fluids and burns?

3:58Because right here that plasma loss,

4:00burns of plasma loss. In severe burns,

4:04the patient essentially loses a lot of

4:07fluid and it can actually become

4:08hypoalmic due to severe burns. So burn

4:12patients get fluids. Okay? So don't

4:15forget that burns can cause here. Make

4:18sense? Now with every one of these, you

4:21know, if you don't know my one, two,

4:23three, four method, we have to

4:25understand first number one, what causes

4:28this? Okay, who gets it? What are the

4:30risk factors? the signs symptoms three

4:32and number four how we treat it stay to

4:34the end of this video I'm going to go

4:36over all the treatment for all the

4:37shocks okay let's continue okay now

4:41hypoic shock sign and symptoms okay we

4:44have anxiety restlessness feeling of

4:48impending doom like you see in the

4:49movies okay now this is key what you're

4:52going to notice with the majority of

4:55shocks they have high heart rates and

4:58low blood pressure high rates Low blood

5:01pressure, alter mental status. Okay.

5:05Cool, clammy skin, diaphoretic. That's

5:08classic. Well, this hypoimmia is our

5:12classic type of shock that we always

5:13think about. That's why I'm going over

5:14it first. But you're going to notice

5:17that some of the types later on this

5:19video

5:21don't appear that way, okay? They can be

5:24sneaky. I'm going to explain, so hang

5:27with me for that. But let's go over our

5:29classic hypoalmia. Okay, the hashtardia.

5:33Remember the remember this. I got

5:35another big hit that bell. Another big

5:38pro alert. Here it is.

5:41The body when we enter shock, the first

5:45thing the body does to try and

5:47compensate for, wow, I don't have enough

5:50blood volume. I don't have enough fluid

5:52in my body. What am I going to do? Okay,

5:54the heart isn't like this. Okay, cardiac

5:57output's going down.

5:59I I have low preload. What do I do? Ah,

6:03I'll raise my heart rate. So, tic cardia

6:05is an early compensation. That's how we

6:07always say up at the heart rate, down

6:09the blood pressure. Okay. They're also

6:11going to increase their breathing rates

6:13and then may appear short of breath.

6:15Cool, pale, clammy skin, delayed cap

6:19refill, a sign of shock. That's a big

6:21one. Could be narrow pulse pressure or

6:24weaker 3D pulse. Sure. Hypotension, a

6:26late finding. Yes. Cuz they're going to

6:29get into when they're really, really

6:31ill. They're going to get into injured,

6:34get into low blood pressure, high heart

6:37rate, low blood pressure. Decreasing or

6:39altered level of consciousness or, you

6:42know, mental status. If monitored in the

6:45hospital or if they're monitored at

6:47home, which you never know, decrease

6:49urine output. Obvious signs of fluid

6:51loss would be bleeding. Remember these.

6:54These are the big four. Bleeding,

6:57vomiting, diarrhea, oh, and burns.

7:00You're never going to forget for the

7:01rest of your career because you watch

7:02this video. Let's go. Okay, let's go.

7:05You got this. I'm excited for success.

7:08Smash that like button, hit subscribe,

7:10and let's continue to our next type of

7:12shock. Come on.

7:17Now, I always say with cardiogenic

7:18shock, cardiogenic shock is the heart's

7:23fault. Say it with me if you're watching

7:25this video right now. Cardiogenic shock

7:28is the heart's fault. Why? Something in

7:32the heart, some damage is going on in

7:34the heart right now that's messing with

7:37our entire circulating system in our

7:39body. The heart pumps blood around the

7:42body. If I damage my heart, I can't get

7:44blood to my tissues all over my body.

7:46and we enter shock. So cardiogenic shock

7:49is shock from pump failure. The heart

7:52has failed as a pump. The heart is too

7:54weak or too damaged to circulate blood

7:57effectively. So think right now two

8:00reasons why this might happen. Think

8:02right now. Okay.

8:06One, you had a heart attack. At a heart

8:09attack, your heart muscle is literally

8:11dying.

8:13Too weak, too damaged.

8:15What about congestive heart failure?

8:17Right. Someone has a heart a heart

8:19failure flare up. It's too weak. Okay.

8:24All right. Now, in this case with

8:26Kajjang shock, the blood volume, I'm not

8:30losing blood. I'm not losing fluid. My

8:33volume's normal, but I have a severely

8:37decreased cardiac output because my

8:39heart is too weak or my heart is too

8:41damaged. Common causes here. There they

8:44are. Okay. A QMI myioardio infarction.

8:48That's our medical term. Okay. Myioardio

8:52heart muscle infarction means death.

8:55Okay. Especially a large interior MI.

8:59Well, of course that's true. But any

9:02MIMIs

9:04are to cause heart muscle damage. Okay.

9:07Okay. Now, severe heart failure or acute

9:11pulmonary edema. pulmonary edema. I got

9:15fluid in the base of my lungs filling up

9:17my lungs, filling up my avoli, which are

9:20my lily pads for my oxygen to come into

9:23the body and my carbon dioxide to

9:24eventually leave the body. Severe heart

9:27failure will cause this sentiment to

9:29occur and we'll hear that on lungs with

9:32rails. I hear rails bilaterally. Okay,

9:35don't want to hear that. Now if we have

9:39a significant dysriythmia what about if

9:41we have VT VF ventricular tic cardia

9:46ventricular fibrillation and put you

9:47under cardiac arrest okay rapid AIB

9:50rapid atrial fibrillation right extreme

9:53brada cardia right some heart blocks can

9:57cause your heart to be the pump to fail

10:01too weak not too weak to damage in this

10:04case but eventually but because the EKG

10:06is uh abnormal we have pump failure. The

10:09heart can't pump effect effectively if

10:11the electrical system of the heart is

10:14not moving effectively. Okay. And also

10:17just a note some cardiomyopathies and

10:20myocarditis. Okay. Inflammation of the

10:22heart muscle can cause pump failure and

10:24we can go into this. Okay. Make sense?

10:27Okay. Beautiful work. Let's continue.

10:29Now here are signs and symptoms and

10:32remember stay tuned end this video.

10:34Okay. Get your free study guide and free

10:36quiz of all this whole video in the

10:39description. Don't forget about that.

10:40Watch the end. Watch this video over

10:43two, three, four, five times. It's here

10:44for you. Go through the freestake. I go

10:47through the quiz and you will have shock

10:49down cold just as good as me. I promise

10:52you're going to love this. Okay. And

10:53also the we're going over treatments. So

10:55hang tight for that. Now cardiogenic

10:58shock sign symptoms. Chest pain or

11:01pressure. Okay. So this is classic.

11:04Think about it folks. How does a heart

11:06attack presents? Chest pain, shortness

11:09of breath, right? Rails bilaterally.

11:13Okay, these are all signs that our heart

11:15has failed as a pump. And here they are.

11:17Okay, shortness of breath, right?

11:19Remember, pink frothy sputum. One more

11:24time. Pink frothy sputum. That's a CHF

11:28flare up you're going to see on NRMT.

11:31Okay. crackles, rails in the lungs

11:33bases. Okay, again, there it is. Cool,

11:37pale, clammy skin, weak pulses. There it

11:40is. Shock, shock, shock. Hypotension

11:43with possible narrow pulse pressure.

11:47CHF gets what? JVD. JVD. If it's right

11:51side heart failure, we can get tag

11:54cardio or brada cardia depending how

11:55sick the patient is. You get irregular

11:57rhythms, right? signs of poor profusion,

12:01alter their mental status, diapharesis

12:04and low urine output. We see a pattern

12:07here where the patients end up in the

12:09same spots but for different reasons.

12:12This is why we learn the different

12:13reasons so we know how to treat them

12:15which we're going to talk about later.

12:16Make sense? Okay, beautiful work. Let's

12:18continue.

12:22Now obstructive shock means blood flow

12:25in the body is being obstructed through

12:28our circulatory system for some reason.

12:31There is some medical or traumatic

12:34emergency as stopping blood flow and

12:37it's messing with the body's functions

12:40and it end up in shock. Now I'm going to

12:43go over here the main reasons. Okay,

12:45obstructive shock is shock where the

12:47heart is okay, but the heart isn't doing

12:50anything wrong. The heart's like, "What

12:52is going on here? I'm not having a heart

12:54attack. I'm not having heart failure.

12:57I should I should be pumping just fine.

13:01Why? Why? What? What's going on?

13:05But but blood flow is physically

13:08blocked. Is physically blocked. How?

13:12Well, either mechanical obstruction to

13:16filling of the heart

13:19or emptying of the heart

13:23lowers cardiac output. I want to say one

13:25more time. Mechanical obstruction to

13:28filling of the heart because the heart

13:30needs to fill with blood and then push

13:32it forward. Emptying of the heart lowers

13:35cardiac output. So there's three how

13:39many? three main emergencies you have to

13:42know. If I say, "Hey, right now tell me

13:45about obstructive shock." Well, you'd

13:48say the heart's okay, but somewhere

13:50along the chain blood flow is being

13:52blocked. In some case, the heart is

13:54can't pump effectively. It's it's being

13:57blocked. Why? There's three main

13:59reasons. Tension thorax. In tension

14:03thorax, let's say I am tricked by a

14:05bullet here or a stab wound here inside

14:07of my chest. This lung starts to get

14:09smaller and smaller and smaller because

14:12air is pressing here. As it gets worse

14:16when we get to under tension, our blood

14:19pressure goes down. We put pressure on

14:21right here the great vessels and the

14:24heart. So now the heart's like there's

14:26no more room. I can't really pump

14:28effectively, right? So air under

14:30pressure compresses the lung and the

14:32great vessels.

14:34Tension thorax. Okay. In that we're

14:37going to go over in a second sign and

14:38symptoms. So remember tension numero

14:40thorax you're going to have what?

14:44Unilateral

14:45one side one side unilateral one-sided

14:50absent lung sounds. Okay cardiac

14:52tampenade this is a big one and this can

14:54be very very very hard in the back of

14:56moving ambulance to go I think it's

14:58cardiac tampenade but we're gonna go

15:01over in a moment but cardiac tampenad is

15:03fluid in the paricardium. paricardium

15:06around the heart compresses the heart.

15:10So if I have fluid around the heart, the

15:13heart cannot squeeze effectively like

15:15it's supposed to. It's kind of like

15:16this. So we get low cardiac output

15:20because it is in this case we're not

15:23able to squeeze like we're supposed to,

15:25right? That's cardiac tampenade. Massive

15:27pulmonary ambolism. The sneakiest

15:30emergency of all. You go to a patient. I

15:33got chest pain. I can't breathe. Okay,

15:36that's okay. We listen to lung sounds.

15:39They're clear. We look at their vitals.

15:42Tacardia,

15:44but the SBO2 is down, but they have

15:46pretty lung sounds. Huh? Think about a

15:49PE.

15:51We're going to talk more about PE on the

15:52next slide. Just hang with me is very

15:54important. But look, a PE is a clot that

15:57break that blocks blood flow through the

16:00pulmonary circulation. Look here down

16:02here in my calf. Let's say I have a DVT

16:05and let's say I have a little bit of

16:07clot that goes in my Venus system. The

16:10Venus system in the body goes up into

16:13and feeds eventually into the SVC IVC.

16:16Let's get in the IVC into my heart. And

16:20now I'm in what? Because if you know

16:24heart blood flow, we know I'm on the

16:26right side of my heart. Right atrium

16:29drops down the right ventricle. right

16:31ventricle takes that little bit of clot

16:32and pushes it up to my pulmonary artery

16:36tracts and I have a pulmonary embolism

16:40which is a little clot or a big clot in

16:43my pulmonary artery tracts. Okay, that

16:46is a major life threat. Now let's go

16:48over our signs and symptoms here. Okay,

16:51tensionothorax

16:53is going to be shortness of breath. Yes,

16:56that feeling of impending dune. Okay, we

16:58think about trauma. We think about car

17:01accidents, but don't forget a

17:02numoththorax could be in very very tall,

17:06lanky individuals that are young, young,

17:09tall, lanky individuals. You have a

17:12medical numoththorax. Don't forget about

17:14a traumatic assault victims, uh, motor

17:17vehicle accidents, right? Stabbing,

17:19shootings, hetronumothorax.

17:21Okay? Remember, it's unilateral.

17:24Unilateral. I listen here, I hear

17:27nothing. I listen here, I hear

17:28something. Okay. Absence or marketably

17:32decreased lung sounds. Okay. In school,

17:35you're going to learn about this. I just

17:37wanted to put it up here, but hyper res

17:40hyper resonance on the affected side if

17:43assessed. So, if we're doing a

17:45percussion, it' be hyper resonance on

17:47the affected side. Okay. Hypotension,

17:51teocardia, and JVD.

17:54Everyone knows about tracheal deviation.

17:57Tracheal deviation. shaky actually

17:59moving over. Okay, it's that'll be seen

18:02because it's so late. It's so late, but

18:06you shouldn't know it because NRMT NT

18:08exams love to talk about trigger

18:10deviation even though it's a late sign.

18:12Okay, hypotension, tic cardia, JVD. Now,

18:16what about cardiac tampenon? Cardiac

18:18tampenon is our friend good old Dr.

18:20Beck. Beck's triad. Okay, Beck's triad.

18:24Cardiac tampenot. Think Beck's triad. It

18:27is a triad of hypotension,

18:30JVD, and muffled heart sounds. Okay,

18:33again, it's hard to appreciate prehosp,

18:35but muffled heart sounds, JVD, big

18:39honking JVD. Okay, pumping that vein up

18:42in your neck. And then hypotension,

18:44okay, that is cardiac tampon, okay? And

18:47also a narrow pulse pressure, okay?

18:49Think about that, too. Now, inside of

18:52PE, inside of pulmonary embolism, I'm

18:56going to go through I'm going to read

18:57this all to you and we're going to talk.

18:58Here it is. The sudden onset of

19:01shortness of breath and pleuritic chest

19:04pain. Chest pain, shortness of breath,

19:05but they got clear lung sounds. Okay,

19:08they got tacicardia. They got increased

19:11respiratory rates, but they got SPBO2 is

19:14low. Don't forget that clear lung

19:16sounds. They may have the key to this.

19:20Let me see here first, but I have a lot

19:21to share with you. It's a possible

19:23history of DVT, recent surgery,

19:27immobility,

19:29cancer, pregnancy. Folks, this comes

19:31down to one word. It's hyper coagulable

19:36states. You want to ask your patient,

19:38have you had any recent surgeries? Have

19:40you been on bed rest? Okay. Have do you

19:43have you had or do you have cancer right

19:45now? Are you pregnant? Right? We're

19:48talking about hypercoagulable states.

19:50These are some of the hyper coagulable

19:52states. Long plane rides, long train

19:55rides, long bus rides, elderly people,

19:58they're not moving around. DVT recently.

20:01Have you had blood clots in the past in

20:03the body? Don't forget this because

20:05everyone wants to think about the fancy

20:07stuff like centinumothorax

20:10in trauma and you forget this when you

20:12go see a patient

20:15who's middle-aged and they're having a

20:16life-threat Please don't forget PE. We

20:19talk about a lot in this channel. PE,

20:21don't forget it. Re-watch this section

20:24if you never heard about it before.

20:25Super important.

20:30With distributive shock, we have how

20:32many? We have three three subtypes. So,

20:37three subtypes in aactic,

20:40septic shock, and neurogenic shock

20:43underneath distributive shock. Remember

20:46early on in the video I was talking

20:47about shocks that present weird. These

20:51are the shocks that present very weird.

20:54Okay, so do not forget about these.

20:57Okay, here we are. Here they are. Now,

21:00anaphylactic shock is caused by a

21:04life-threatening allergic reaction

21:06causing widespread vasoddilation,

21:10capillary leakage, and airway swelling.

21:14Folks, there is a high risk of airway

21:18swelling with anaphilaxis, which is why

21:22we give epinephrine. You want to use

21:25epinephrine for its alpha one, okay?

21:28It's going to cause vasoc constriction,

21:30okay, in the body.

21:33Beta one, it's going to increase the

21:35heart rate. Beta 2 effect of epinephrine

21:38is going to do what? Bronco dilate the

21:41lungs. Okay? thus saving the patient

21:44from having a swollen airway and swollen

21:46lungs. Okay, so this is what this is why

21:50patients that are allergic to like bees

21:52for example, okay, carry an epi pen and

21:55why the ambulance when you walk up to

21:58someone having allergic reaction, the

22:00first thing we do epi lateral thigh,

22:04boom, epinephrine, it's the first line.

22:06It's the most important. We can save all

22:08the benadryil for later. First thing,

22:11boom, epinephrine is most important.

22:14Okay, you're not going to forget that

22:15now. Okay, now look what we end up

22:18happening here is we have again airway

22:21compromise. Okay, decreased SVR and

22:25relative hypoalmia.

22:28Okay, now here are triggers.

22:32Foods, medications, and insects. So if

22:35you remember food, medications and

22:38insects, you're pretty much on the

22:40money. I do mention here latex. I do

22:43mention here environmental exposures.

22:45Antibiotics

22:47are very very people talk about pen. You

22:50have an allergy to penicellin like

22:51penicellin allergies. NSAIDs contrast

22:54die. Right now let's talk about immune

22:58mechanism in anaphilaxis.

23:02a rapid release of histamine and other

23:05mediators from the mass cells and

23:08basilopils

23:10after exposure to an allergen. Okay,

23:13what's happening in the body is the

23:15beast stings you boom. What do we get? A

23:18rapid release of histamine and other

23:20mediators from the mass cells and the

23:22basils after the exposure to an

23:25allergen. Okay, causing you to

23:28essentially puff up, right? So again

23:33in anaphilaxis the airway swelling and

23:36the swelling of the lungs this is very

23:39very very very scary for the patient.

23:42Epinephrine can help combat that. Now

23:44here we have the signs and symptoms.

23:46Okay.

23:48What is the textbook definition of

23:51anaphilaxis?

23:53Two or more body systems are affected by

23:56an allergen. How many? Two. So if I have

24:01hives on my skin and I can't breathe, I

24:04got a repatory system and I got our

24:07skin, that's two, call it anaphilaxis.

24:11Okay, if I just have hives, maybe you're

24:15having allergic reaction. But if I have

24:17if I have hive and I'm vomiting, I got

24:20two or more body systems. Call me

24:22anaphilaxis. Okay, look here. These are

24:25the four main body types that are

24:27affected. Okay, I've seen patients like

24:30this. There is a great sense of doom and

24:33anxiety because their airways literally

24:35closing up. Now look here, folks. Skin,

24:39itching, flushed skin, hives, angio

24:43edema is the big one. They swell up.

24:46They swell up. Lips, tongue, and face.

24:50Airway breathing, throat tightness,

24:53horarsseness, strider. You can hear

24:55across the room, folks. When you see

24:58this patient, you're gonna walk on scene

25:00and boom, you're gonna know I got an

25:02llaxis. Hit him with epi. Okay.

25:05Wheezing, uh, bronco spasm. Now, hang

25:08on. Wheezing and bronco spasm

25:12is we have tight tight tight tight

25:15bronchioles.

25:17Strider is an upper airway sound.

25:21Wheezing is a lower airway sound. I can

25:25hear wheezing bilaterally in

25:27anaphilaxis.

25:29But strider is a partial airway

25:31obstruction. Your airway is starting to

25:34close. And you can have patients where

25:37the airway does close if they are not

25:41treated with an EpiPen fast enough,

25:44which is why they carry an EpiPen. Okay,

25:47beautiful work. Circulation. What do

25:50they get, folks? What do you think they

25:52end up with? hypotension because every

25:55type of shock is gonna end in one place.

25:58Hypotension, hypotension,

26:01tacicardia, there it is. Heart rate up

26:05and the blood pressure goes down. Okay,

26:07but hang with me. Dizziness and syncopy

26:11can be other signs you might see. Signs

26:13of shock, warm flush skin early that go

26:17later on gets cool and clammy.

26:20I I don't want to say every case, but a

26:24lot of times when someone's anaphilaxis,

26:27there's nausea and vomiting, diarrhea. A

26:30lot of the times, a lot of times there's

26:32nausea, vomiting, many times. So, just

26:35remember skin, airway, circulation, GI

26:39are the four body systems. Underneath

26:41anaphilaxis, you're going to be golden.

26:43Okay. Now with septic shock is shock

26:46caused by disregulated

26:50response to infection. Hang with me. I'm

26:52going to explain. Leading to

26:55vasoddilation,

26:57capillary leakage and cellular and

27:00metabolic dysfunction. We have a

27:03decreased systemic vascular response.

27:07Hang with me. and a relative hypoalmia

27:11and impaired oxygen use at the cellular

27:13level. Whoa, that sounds crazy. I'm

27:16going to simplify it for you because it

27:18really is this simple, folks. You got

27:21bacteria in your blood. Sepsis equals

27:24bacteria in your blood. And what happens

27:30when there's this bacteria in your blood

27:32is we get what we talked about here

27:34which is an abnormal vasoddilation.

27:38An abnormal vasoddilation.

27:41These patients inside of sepsis and

27:45later on we were talking about

27:46neurogenic shock. They don't compensate

27:50very well and they very much need

27:53vasopressors like norepinephrine

27:56epinephrine to save their life very

27:59badly. This is given by paramedics via

28:02IV drip. Also given in hospital same

28:05thing but hang with me here, okay?

28:08Septic shock. Remember this. Bacteria in

28:12the blood, abnormal vital dilation.

28:15They're going to need pressers to keep

28:17their blood pressure up. Now

28:21you as a EMT, a AMT paramedic

28:26or kind of like a detective,

28:29what are some clues? I'm going to talk

28:31about in the next slide, but I want to

28:33preface this with this. What are some of

28:35the main routes that you're going to

28:39find in sepsis?

28:41Pneumonia,

28:43UTI,

28:45those are my top two of all time. Not

28:48only are not only are they the most

28:49common routes to get septus, but in my

28:52own practice, this is what I've seen.

28:55Pneumonia, UTI. Now, I put some other

28:57ones in here. I want to talk about

29:00abdominal infections.

29:03Okay? Peritis, infl remember this folks.

29:08Anything you see in medicine that ends

29:10in itis is an inflammation or infection

29:14of what I'm talking about. This is like

29:16medical language, right? So itis,

29:18paritinitis, the the lining of your

29:21abdomen is called the paritinium and

29:23that gets inflamed, right? Pancreatitis,

29:27an inflame or infected pancreas, bowel

29:30perforation, the bowel is popped open.

29:33Okay, skin soft tissue infections,

29:36cellulitis,

29:38okay, a necrotising infection that can

29:41happen. Okay, and this is actually

29:44another one is very very very common.

29:46You could even put it as number three.

29:48You could even put it as number three

29:50honestly is line related or device

29:53infection. So if someone has uh uh

29:56certain lines in their body, right? Uh

29:59certain um medical procedures that were

30:02done to their body right again

30:04infections infections do with that. Now

30:07there's always going to be a higher risk

30:08in the very young and the very old.

30:11Okay, those that are imunocmpromised

30:13recent surgery and chronic illness. So

30:15remember folks, these are our big our

30:18big five right here for risk factors

30:21really of just getting ill in general.

30:25The very young, the very old,

30:28imunocmpromised, recent surgery, chronic

30:31illness. If you should really write

30:32these five down, these are the

30:34populations that are most at risk of

30:36getting even for example, let's say they

30:38say very young, very old, heat

30:40emergencies. Okay, just something to

30:42remember when we're talking about NRMT

30:44and exams. Okay, it's good to know

30:46about. Now, when I think of the signs

30:47and symptoms of septic shock, of sepsis,

30:50I think of one word, fever. They got a

30:53fever. If you ever seen a patient with

30:56sepsis, they got a high fever. So, if we

30:59can check that, check that out. They had

31:01takia and they have a increased

31:05respiratory rate. So, their heart rate

31:07goes up, their respiratory rate goes up.

31:09But what do they get? They get that

31:12abnormal vasoddilation, sepsis, and they

31:15get hypotension. And remember this

31:18folks,

31:19we want to be a what,

31:23detective, here are the clues I promised

31:25you. Recent infection,

31:28are they taking antibiotics currently?

31:31Have they been hospitalized recently? Do

31:33they have immunosuppression in their

31:35history? Like are they a cancer patient,

31:37for example? on the uncertain

31:39medications that might make them more

31:41amunocmpromised. Right? These are our

31:44history clues. You want to write those

31:46down for your septic workup. Now, skin

31:49earlier on is more warm and flush with

31:52bounding pulses. Later is more cool,

31:54mild skin as it gets worse. Alter mental

31:58status is big in sepsis is very big. So

32:02I would say in my practice and what I've

32:06seen septic patients of all the shocks

32:10it is very very easy to jump in and

32:13alter mental status because they're

32:15already have infection. Okay. So also

32:18again if monitor decrease urine output

32:21do you notice that? Jot that down in

32:23your head. Okay. As you learn more about

32:25medicine you decreased urine output is a

32:28very ominous sign. Okay make sense? Okay

32:31cool.

32:32Now, neurogenic shock. Neurogenic shock.

32:37What do we think about first? Well, we

32:39think about trauma or neurogenic shock.

32:42Okay, it's shock from loss of

32:45sympathetic tone after a significant

32:48spinal cord injury. So, I want you to

32:50think right here. Neurogenic shock is

32:53going to be from trauma, a spinal cord

32:58injury. Okay? usually at or above T6.

33:02That can be a punk question on NRMT. Now

33:05we know it. Okay. What's the deal? The

33:08most important thing in this whole

33:09slide, sudden vasoddilation. You're

33:13going to need vasopressors for this.

33:16You're going to need norepinephrine,

33:17epinephrine, paramedic drips it in.

33:20Right? We're going to need this for

33:22neurogenic shock if we're going to save

33:24the patient. Just like sepsis, they're

33:26going to have an abnormal visual

33:29dilation with no compensation. Okay.

33:32Primary cause. Primary cause

33:36more vehicle accidents, falls, diving

33:39injuries, sports injuries, penetrating

33:41trauma. Now, I got two big pearls for

33:43you on this slide before I move on. So,

33:46listen to me here.

33:49Sudden visual dilation. We just talked

33:51about that.

33:53unopposed veagal tone. Okay, they are

33:58the vascular is wide open. Wide open

34:01their blood pressure just to drop like a

34:03rocket. Now this is interesting. What is

34:07a shock that gets brada cardia and gets

34:12hypotension?

34:13Ding ding ding. Neurogenic shock. That

34:16is probably the most important thing to

34:18remember. What's a shock to get the

34:20brada cardia and hypotension? Ding ding

34:22ding. Neurogenic. Do not confuse spinal

34:26shock. You might hear about that. Loss

34:29of reflexes with neurogenic shock. And

34:32what's the difference? Neurogenic is

34:35hemodynamic. Meaning neurogenics cause

34:38hypotension and brada cardia. It's going

34:41to mess with your vitals, not just your

34:43reflexes. Make sense? Okay. Beautiful

34:46work. Now, check me out here.

34:49Neurogenic

34:52hypotension

34:53with breda cardia. It's a unique combo.

34:56That's why we're covering it. It starts

34:58with warm and dry skin below the level

35:01of injury. There's no vas constriction.

35:04There's no compensation. Okay, there

35:07they're in this abnormal vasa dilation

35:10and they need pressers if the blood

35:12pressure to go back up. Now, it is

35:15possible to have a normal or a low heart

35:17rate despite the blood pressure. We

35:19talked about that that hypotension brada

35:21cardia mix. Okay. Motor and sensory loss

35:25below the level of the injury and no

35:28signs of hypoalmia. No sweating, no cool

35:31clammy extremities. They have warm dry

35:33skin.

35:35This is if you notice this is a real

35:37outlier

35:39for shock neurogenic. It's got warm dry

35:42skin below the level of the injury. It's

35:45got hypotension brada cardia. This is

35:47unlike all the other shocks. This is why

35:50it's neurogenic shock from a spinal cord

35:54injury. Now, we're going to go over

35:55treatments. Don't forget in the

35:58description you have your free study

35:59guide and quiz as you're watching this

36:01video. This video is here on YouTube.

36:03Watch over two, three, four, five times.

36:05Smash that like button if you're loving

36:07this video and hit subscribe. And let's

36:09continue. Now, BLS treatment.

36:12BLS treatment here

36:15starts with scene safety and there are

36:18precautions. Of course, folks, we get

36:20our gloves on. We make sure the scene is

36:23safe. Now, we see the patient. We form a

36:25general impression and we start to

36:27provide care of the patient and we start

36:29with our ABCs. Now, the main thing with

36:33the ABCs and this is BLS human of all

36:37shocks. I want to you know we've talked

36:39about some scenarios but how do we treat

36:42shock any type of shock here's how we do

36:45it make sure the airway is opened and

36:48maintained suction if we need to high

36:52oxygen if the patient needs oxygen

36:55remember our goal is 94 to 99% SPO2

36:59likely all these patients are not going

37:02to be above 94 hence why we give them

37:04oxygen okay none are breather or BVN as

37:09needed for their airway, for their

37:10ventilation. Okay. Circulation. If they

37:14have an external bleed, control it. Stop

37:16the bleed. Okay. Check for pulses.

37:20Monitor mental status. Get some vital

37:23signs. Positioning. Well, folks, every

37:26patient in shock is going to be supine

37:31unless they can't breathe. Like someone

37:35anaphilaxis, I'm not going to lay them

37:37down flat. Okay? Somebody with heart

37:40failure or a heart attack, I'm not going

37:43to lay them down flat. Right? But

37:46somebody with hypoalmia

37:49because they got shot, I will lay down

37:51flat. Okay? So meaning we don't lay

37:55patients down flat who can't breathe

37:57because they have a primary breathing or

37:59heart problem. We have to get them

38:02sitting up so they can breathe better.

38:04Okay. Or at least at least sitting up

38:07like this. At least I'm not gonna lay

38:09them flat. Supine. Okay. Does that make

38:12sense? Okay. Good. Now, and I mentioned

38:15it here about allowing a position of

38:17comfort versus fever shortness of

38:18breath. Cardiogenic tension numeral.

38:20Again, that's I'm happy I put that

38:23there. Tension thorax. Same thing. We

38:25are not going to lay them flat. Okay.

38:29Spinal care again if it's trauma

38:32maintain C-spine C collar if we need to

38:35big one here in shock is keeping them

38:37warm blankets put the heat on the back

38:40of the ambulance warm environment

38:41prevent heat loss now I just went over

38:44some quick medications that you may use

38:46in a shot case at the EMT level. So

38:50first is member antifphylaxis,

38:51epinephrine, lateral thigh. Okay,

38:54epinephrine obviously uh bronco

38:57dilators. So albuterolium

39:00when we give that for? Well for

39:02anaphilaxis for example, right? Yes,

39:04exactly. Anytime we want to open the

39:06lungs we hear wheezing. Okay. Again I

39:09have here Narcan for any opiate

39:11overdose. Right. Oral glucose for

39:13hypoglycemia. Right. again some of the

39:16treatments at the EMT level that we want

39:18to cover here. Okay, these are some of

39:20our medications and then transport

39:22communications. Okay, rapid transport is

39:25the appropriate facility whether it's

39:27trauma center or cardiac center, sepsis

39:29cable hospital, a burn center, right?

39:32And the big thing here is an early radio

39:33report folks. If we have a trauma or a

39:37heart attack patient or sepsis

39:39anaphilaxis, we want the hospital to

39:41know remember anaphilaxis that airway

39:44close that airway close we want to watch

39:47out for that. So rapid transport we want

39:49to make sure we get a definitive airway

39:52in that patient okay especially if

39:54they're really really sick. Okay now ALS

39:57treatment is going to be a little more

39:59in depth. Okay. So, BLS we talk about

40:03ABCs, vital signs, recognizing that

40:06they're in shock, again, laying them

40:08flat or andor assisting their breathing,

40:12keep them warm, right? If we can give

40:15some medications EMT level, great. Epi

40:18breathing treatments, right?

40:22General ALS. Well, if we're thinking

40:25about cardiogenic shock and they think

40:26they're having a heart attack or any

40:28patient has pain from their neck to

40:30their hips, do a 12we EKG, folks, right?

40:33Establish an IV. SPBO2 between 94 and 99

40:37is our goal. Get them on end title.

40:39Remember, end title tells us the

40:41information right now. SPBO2 is more

40:45slow. Okay. So antidal CO2 is very

40:48important very important especially in

40:51very very sick or injured patients to

40:53see how stable they are. Okay. Now under

40:57hypoalmia and obviously we can also this

41:00is under BLS a pelvic binder for an

41:02unstable pelvic fracture that can be BLS

41:05too but I didn't want to mention it just

41:06under here. Okay. Under hypoalmia as

41:10paramedics we have the ability to do

41:13what? We have the ability to give fluids

41:16and some areas give blood. Okay, this is

41:18what the patient needs fluid or blood.

41:21So, we're gonna do that. All right. So,

41:23we're going to do aggressive hemorrh uh

41:26hemorrhage control with the patient.

41:28Okay. Make sure we stop the bleed. We

41:30can give fluid. We can or give blood.

41:33Okay. Now, for an uncontrolled

41:36hemorrhage without TBI, follow your

41:39local permissive hypotension targets.

41:42What does that mean?

41:44Well,

41:46it means that we're not going to just

41:49dump a bunch of fluid in the patient

41:51because they're in hypoalmic shock.

41:54We're going to titrate to the patient's

41:57blood pressure and mental status of our

41:59treatments. Meaning

42:04we're going to titrate our fluids

42:05roughly to a mean arterial pressure of

42:0960 65 and above right around there. Our

42:14mean arterial pressure we want it just

42:16above that. Why? That's enough to peruse

42:19the organs. We also hear about again

42:21follow your local protocol. We also hear

42:23about systolic blood pressure of 90. So,

42:27a good rule of thumb, titrate to a

42:30systolic blood pressure of 90, the real

42:32golden one. A map of 60 65 around there.

42:36That's where we want to be. Okay. Again,

42:38you can use blood products. Some

42:40paramedics can give blood in the

42:41ambulance if your system carries it and

42:44it works with a patient. Okay. Again,

42:46titrate all your fluid around the blood

42:50pressure and the map. Very important. We

42:52don't we do not dump fluids on somebody.

42:55Now for cardiogenic shock, what do we

42:58look at? Well, we look at CPAP and

43:01nitrates. That's going to help the

43:03patient with a CHF flare up. We also

43:06want to strengthen the contractions of

43:09the heart. We can do that with

43:11inotropes, vasopressors. Okay, if that's

43:14in your protocol, we would do that.

43:16Right here are some of them here. And

43:18obviously treat any dysriythmias the

43:20patient may have as a paramedic. Under

43:22obstructive shock, we're looking at for

43:25tensioning with thorax our main main ALS

43:29skill needle decompression and with that

43:32supporting the airway. Start with a BVM

43:35if we need to and go from there. Okay,

43:37positive pressure ventilations. Cardiac

43:39tampenade is really just supportive care

43:42recognizing the sign and symptom that

43:44this could be cardiac tampenade getting

43:46him to a place I can do a

43:49paracardioentesis

43:52where they're going to put a needle in

43:53and draw the fluid out so heart can pump

43:55again pay in the hospital

43:58a massive pulmonary embolism we're going

44:00to give obviously high flow oxygen

44:03supportive care rapid transport and in

44:06some areas if you're allowed to give uh

44:09thrombolytics in the ambulance for

44:10example you're going to see in hospital

44:14you bring in a patient pulmonary ambism

44:16all of a sudden they have hepin hanging

44:18in the room hepin is a drug that can

44:20treat a pulmonary ambolism right so

44:22again if you're able to do that great

44:25but this is how it works here as far as

44:27ALS treatment now the last part here is

44:30anaphylactic

44:32septic and neurogenic okay anaphylaxis

44:38We know right here you know what I'm

44:39going to do here you see this how good

44:41you know it already epinephrine lateral

44:44thigh there it is okay we got that down

44:46you're not this is why you're here it's

44:48a study okay beautiful work epinephrine

44:51of course is our first line so I got

44:53anaphilaxis okay that's it I got anaxis

44:56what do we do epinephrine we do that

45:01then I have to start our oxygen and I

45:05want to start bronco dilation without

45:07albuterol. So we do that. Now what else

45:10can I do? Start an IV. Start a second

45:13IV. What else can I do? Give benadryil

45:16IV. What else can I do? Give straw IV.

45:19Beautiful work. That's your inflaxis as

45:22a paramedic. It's all here for you laid

45:25out. And don't forget this is all laid

45:28out for you in your free study guide

45:31down in the description. I got you.

45:33Okay, we're going to pass in our EMT.

45:35Let's go. Okay, hit that like button.

45:38Septic shock. We want to with septic

45:41shock. Remember that the vasoddilation

45:46is the big culprit. And what we have in

45:48the ambulance, vasopressors. So remember

45:51that septic shock and neurogenic shock

45:55are going to need vasopressors if

45:57they're going to survive. Okay.

45:59Norepinephrine, epinephrine. Can you

46:02follow your local protocol when you're

46:03working in the ambulance? As far as test

46:05day, it's going to be one of those vasop

46:07pressors. Okay, so that is the big pearl

46:10here. Remembering these two shocks have

46:13that abnormal vasoddilation. They're

46:16going to need pressers without a doubt

46:18to survive. Okay, these are the two big

46:20pearls. You may have a sephus alert that

46:23you may want to do as well. Okay, IV

46:26fluids with septic shock. Okay, that's

46:29very important. careful handling with

46:31neurogenic shock. Okay. And again

46:34remember that norepinephrine for example

46:36for neurogenic. This is the key. And

46:40finally anytime remember when we do

46:43fluids with a patient to stock around 90

46:47map 60 65. We do not need to go way

46:52above that. We want to stay in that

46:54realm. Permissive hypotension with these

46:56patients. Okay. get them back where

46:58they're getting their tissues and

47:00they're getting blood to their tissues

47:02and oxygen. We do not dump fluid on

47:04anybody anymore. Beautiful work. Great

47:08job. Make sure to get your free study

47:10guide. The link is down in the

47:12description. It comes with a free quiz

47:14as well. And also folks, if you're

47:16getting ready for NRMT, our flagship

47:18program is also down in description as

47:21well at every level. And that program is

47:24lifetime access EMT, AMT, paramedic,

47:28first responder. It's our flagship NRMT

47:31prep app. And folks, I will see you in

47:33the next one. Enjoy the free guide down

47:35below and let's get after it and let's

47:37pass it. Smash that like button and

47:39let's go. See you next time. Great work.