Transcript
Yep.
So a couple of quick housekeeping items before we get started.
Just I'll go through the as far as we've done for every day, if you have a question for Doctor Heath, then just drop it into q and a, box will get to it or even better if you have a question, you'd like to talk with doctor Doctor Heath And just now in that conversation, we hope you take advantage of that.
It's just simply raise your hand in the chat, and then I will unmute your audio and video, and you just have that conversation with the audience as well.
So we encourage that versus the regular chat feature, but nonetheless, We want you to we want to hear your questions today as we get started.
I also want to thank Doctor.
Heath for serving as a curator for this special session today.
He has lined up a fantastic group of presenters that'll follow him this morning.
And though you're gonna I'm excited about hearing their topics.
I've spoke with them.
On several times over the last couple of weeks, and they are just their rock stars don't write their own world in their in the realm what they do.
So the couple of things we'd like to do is, but here's a quick introduction to Doctor Heath.
If you don't know him, he was on our first symposium and there's a reason why we brought him back again.
So he's one of the, I believe and correct me if probably one of the only osteopathic physician slash d a t trained clinicians in the country.
He is well 1st, if you look on the webpage for the symposium, his full bio was there.
His his residency trained in emergency medicine, He did that at the Cleveland Clinic, and currently serves as an EMS medical director, and he can go more into some of the things that he does as well.
But has received a number of accolades, including during his formal training as well.
He's been recognized at outstanding resident faculty, of the year during his residency training.
He was also nat naturally recognized in 2014 with American naturopathic foundation, outstanding resident of the year.
He's done he's complete this undergraduate education, athletic training at Lincoln Memorial.
Also, he got his doctorate degree at a t Steel University.
He's out of several degrees, including University of Tennessee at Chattanooga.
Also, for I mean, he's been credentialed as a athletic trainer for over 20 years.
Has extensive experience.
And and if you talk to Doctor Heath enough, you recognize not only that what he does for a living, but he is truly passionate about this area of health care and emergency medicine.
So with that, Doctor Heath, I'm gonna give it over to you, and This presentation is now yours for the next 30 minutes or 40 minutes.
Great doc.
I appreciate that.
I get a thumbs up, you can hear me alright?
Yes.
I can hear you.
I think everybody else can everybody on it.
Let us know if you can hear you on the audience.
Excellent.
Alright.
Well, greetings to everybody.
Pleasure to be your day for specialty topic curator here.
And as Doctor Cassel mentioned, I'm David Heath.
So I kinda have the unique training as both an athletic trainer and an emergency physician.
So I've been in a a t for over 20 years.
So hopefully, I can bring some insight on our journey into compensatory shock here.
So we're gonna kinda move on.
Now it's not really going to be like this guys.
I'm not gonna give you a lot of information.
You're gonna have to try to drink out of a fire hydrant for It's kinda basically distilled everything down to need to know topics.
So you can take whatever you find here in the presentation to the bedside with you.
Now as a matter of course, I am giving you my disclosures potential conflicts of interest.
I have none.
I would be happy to have some.
If you folks wanna contact me, I always need, you know, some income.
One thing to mention, I will have a few things in this presentation that are red and underlined.
So those are really important.
And there will be some purposeful redundancy here as well.
So I'm gonna keep telling you what I tell you after I tell you, then I'll tell you again.
So I used to be a teacher.
So that's just a habit I have.
So, hopefully, you can learn it.
And what I'm hoping is you can take some of the stuff right out into your clinical practice to improve your emergency action plans and actually save some lives in the field.
So educational objectives, I won't really go over those with you.
You can read those.
But, essentially, we're gonna go over the types of shock.
So just real quick, we're gonna just think about a case or 2 here.
So this is Will.
He ate some peanuts about 10 minutes ago, and now he's got facial swelling, and we're gonna find out what type of shock he's suffering from a little bit later on.
And to your right, This is Fred.
He's had 2 heart attacks before.
He's got about 9¢, and now he's getting some chest pain.
So what type of shot could he be in?
Well, stay tuned.
We will find out.
So first off, what is shock?
I think it's good to kinda get on the same page with everybody and know what we're talking about, but it is essentially a life threatening condition.
And it causes 3 big things Whenever you decrease your tissue perfusion, you're gonna get hypoxia because you're not getting oxygen.
You're gonna private stuff in oxygen, and you're gonna get this waste accumulation of lactic acid.
It's going to damage your organs leading to death.
This inadequate tissue perfusion is going to inevitably lead to ischemia throughout the entire body.
And the ultimate outcome here is primarily low blood pressure.
I mean, that's the shock part of it.
And that kinda leads me to the bottom right hand corner of your screen there is that is kind of the key of the presentation.
Meaning arterial pressure equals cardiac output times your stroke volume or systemic vascular resistance rather.
That's the squeezing of your peripheral tissues.
That's gonna squeeze everything back into your systemic circulation.
And as a note there, you know, you probably don't wanna remember from your undergraduate times because it's so so scarring.
But cardiac output equals heart rate times stroke volume.
So those two those two equations are gonna be pretty important when we're talking about shock.
So what are the compensatory phases of shock?
Well, I guess, specifically, there are compensatory mechanisms.
So there your body has to counter this tissue perfusion problem by number of ways, and you're gonna try to get the body to shunt all of the blood to the vital organs like your brain, heart, kidney, liver, not necessarily your skin.
And your body does that by doing a few things.
You're gonna increase your preload.
So that blood coming into the right part of your heart, which we'll see a little bit later.
Your body is gonna increase its heart rate and the potential squeeze of the heart.
So it's gonna squeeze the left ventricle, right ventricle to try to get the the blood coming out of the heart a little bit faster.
And then as I mentioned before, part of that equation is systemic vascular resistance.
So the actual squeeze of your arterioles and your peripheral vasculature to try to clamp down to increase your blood pressure.
It's gonna also increase your cardiac output, so your squeeze and your stroke volume, the amount of blood you're squeezing out of your heart.
And overall, your body's trying to keep the cardiac output up to perfuse your organs.
Because bottom line, if you don't perfuse your organs, you're gonna die.
And hopefully, that's where we come in to try to recognize some of those things.
3 basic stages of shock.
The initial stock presentation that, you know, you're gonna get is you're gonna get the anaerobic metabolism.
It's like an early sign.
Your body is going to start to respond by increasing the heart rate, increasing the stroke volume, increasing the preload, different things like that, which we'll talk about later.
Now these mechanisms may not work.
So that's when they start to fail and you get into the progressive compensatory mechanism failure.
And when they start to trickle off and fail, Lactic acid starts to climb in the blood, and then you start getting profoundly hypertensive profoundly hypoxic.
Your organs die, and ultimately, you die.
And that's what we don't want.
So that's kind of the setup here to where we talk about the classifications of shock, and that's actually how we're going to end our time together our journey talking about both cold and warm shot.
So, basically, shot comes in 2 flavors.
And as you notice there, red, and it's underlined.
So it's important.
But when I talk about cold and warm shock, I'm actually talking about the skin.
And you can actually tell a lot by palpation.
You know, again, I'm an orthopedic physician as an athletic trainer, and we use our hands to help us diagnose diseases.
And in fact, shock is no different.
I mean, we have special things that we use like stethoscopes and things, but, you know, old fashioned physical exam, it hasn't gone the way at the dodo yet.
You gotta use it.
So cold shock.
Cold shock actually comes in 3 different flavors.
You got cardiogenic, hypovolemic, and obstructed.
And when we're talking about cardiogenic shock, that is where the actual heart is compromised.
So there's a problem, essentially.
And it can be from a number of things.
And it's actually things that both I see in the ER and things that you can see on the field.
Mean, you can have heart attacks that cause pump problems, valvular problems, congestive heart failure, trauma, So somebody gets struck in the chest with a baseball or a back football.
Anything that can have struck and prevent the heart from pumping enough blood to the rest of the body.
So that's gonna cause high hypotension.
And essentially, I'm kinda probably getting ahead of myself, but you're gonna get bare receptors in your aorta.
And your carotid arteries that induce a sympathetic response that squeeze everything down, and it causes vasoconstriction.
And the peripheral arterioles are gonna try to increase your systemic vascular resistance to increase your blood pressure.
So that's what basically happens with cardiogenic shock.
And when you shunted all the blood from your nonvital organs, nonvital organ, skin.
So you're gonna get cold and clammy skin.
So that's the basics of cardiogenic hypovolemic.
It's just what it is.
You can have hemorrhagic.
So let's say somebody cuts their leg, cuts their wrist, cuts their neck, they're bleeding out onto the field, they can suffer from hypovolemic shock.
Non hemorrhagic can be fluid loss.
So we've all seen this practices and such, people can't.
Either they don't drink or, you know, they've had excessive vomiting.
Diarrhea, all their fluid is getting lost, or even they have conditions like I see in the ER, like diabetic ketoacidosis.
Where they can't keep their fluid because they basically pee it all out.
All those are important causes hypovolemic.
Shock.
And finally, the 3rd cold type of shock is going to be obstructive shock.
When we think about obstructive shock, that's something that's going to obstruct the heart itself from pumping blood.
So we're talking about things like tension pneumothorax or pericardial tamponade.
So if somebody collapses their lung, those type of things.
That happens, I've seen that a few times on a field in football.
And even blood clots in the lung, pulmonary emboli can cause that.
So something that's preventing the heart from pumping blood.
So that's a brief overview of cold shock, which will go into detail here in a couple minutes.
Kinda switching topics to warm shock.
Warm is actually also known as distributive shock.
Which is under the umbrella the 3 under the umbrella distributed shock is septic anaphylactic and neurogenic.
Now septic is just what it is.
Someone is infected.
Maybe you have an athlete that gets meningitis.
Maybe they have pneumonia.
Some type of infection that's causing vasodilation.
They get hypertensive and they go into shock.
Anaphylactic.
Super duper common.
You get a reaction to an antigen like a bee sting or peanuts, and then you get this mast cell big granulation.
Histamine release and bradykinin.
Folks get hypotensive, and they crash.
And that's why we have our epiPen.
So that's gonna counteract that.
So we're gonna talk about that here in a couple of minutes as well.
Neurogenic, very, very important cause of distributed shock.
I don't see it so much anymore, but I saw it a couple times in my early days in athletic trainer.
This is a injury to the CNS, so spinal cord injury.
You're gonna have sympathetic nervous system tone decrease.
So the parasympathetic's take over, and then you get vasodilation.
It's actually pretty pretty interesting type of phenomenon.
But we're gonna go over some of these in-depth, and, hopefully, you'll learn something.
That's what we'll talk about these.
Now just as I'm a visual type of learner, I like to give you stuff you can use.
So this is going to be Basically, our entire presentation talking about the 4 different types of shock here.
And as you see down there in the distributive part, that's separated into the 3 types of warm shock.
So this basically explains what happens with the compensatory mechanisms And for those of you who like pictures, animated pictures like like me, I'm pretty visual, I created this.
Now on the left side of your screen, it's gonna be your total volume, which for most individuals, it's gonna be about 5 liters of stuff, fluid blood, you know, introsculate volume, that type of thing.
Now coming into your right heart, Everything's gonna be dumping into your right atrium, which is your preload.
It's preloading your heart to pump out to your body.
And then it goes to your lungs to get oxygenated, and then it goes into your periphery, into the systemic vascular part of your body.
And that's where you get your blood pressure.
You know, it's gonna clamp down if you're hypotension.
And then it basically comes to a crossroad.
It's gonna decide whether it goes upward toward your skin, your nonvital organs, or it gets shunted over to your vital organs like your heart, your brain, your kidney.
And then after that, after everything happens in the preferring all all the oxygen extracted, then it goes back in your venous system, dumps back in your total volume, and it all happens again.
So first off, let's talk about cardiogenic shock.
We mentioned this before, but when you get your cardiac output compromised because of some problem, like heart failure, heart attack, contusion to your heart, that's going to induce your aorta and your carotid to squeeze you down and cause your beta receptors to squeeze down in your periphery.
That's gonna cause vasoconstriction of your arterioles.
And if you notice there, your blood is gonna be shunted toward your brain and liver and heart.
And not so much for your tissues.
So your hands are gonna feel cold and clammy.
Pretty common with cardiogenic shock.
And if you also notice there, your was actually gonna back up into your your lungs.
So you're gonna get pulmonary edema, and you're gonna get crackles in the lungs and shortness of breath.
Now you can basically see this, like, on the field when someone has a heart attack.
I've I've had it in the stands before, and that's, you know, an immediate emergency.
You gotta take them to the ER.
But you can also have people that have aortic bowel dysfunction or the trauma, like I mentioned.
That's also pretty common.
So as you notice there on the bottom right hand corner, it's gonna decrease your cardiac output, and it's gonna increase your systemic vascular resistance.
Everything is going to clamp down.
So very important to summarize with cardiogenic shock, you're gonna get fluid in the lungs, You're gonna get cold, clammy skin, and you're gonna get hypotension.
Cardiogenic shock.
Now what I'm probably more familiar with is high poevolemic shot.
Folks that don't drink, they haven't decreased intravascular volume.
They're gonna have to decrease cardiac output.
So their heart's gonna try to compensate.
Their heart rate's going to go up.
And again, their their receptors are gonna clamp down.
Their sympathetic are gonna clamp down by their flight.
Everything's gonna be shunted from the nonvital organs to the vital organs.
And you're gonna get cold and clammy skin.
But in this case, you're not going to get fluid in the lungs.
You just have decreased volume.
As you see on there on the left.
Gonna be dehydrated and since you don't have enough fluid to pump into your right heart, to preload your heart.
That's where you're gonna get high potential.
And you get the compensatory mechanism to try to increase your heart rate, which should try to help increase your stroke volume.
So that's pretty important.
Now two types, remember, you can have hemorrhagic, so they're bleeding.
Or you can have non hemorrhagic.
Now this is interesting.
On type of non hemorrhagic, can also be severe burns.
I've had people come in, and they've had burns over 70% of their body, and they're profoundly hypotensive.
They're losing all of their fluid through their skin.
That is a big one for a non hemorrhagic cause of high poepilemic shock.
And you'll see that the schools here, guys, vomiting diarrhea.
People that are sick, they may try to practice.
They're gonna further decrease their body volume.
So you're gonna get that hypotension.
Okay?
So all these are pretty important to realize.
Cold and clammy skin, increased heart rate.
K?
So so far, we've went over cardiogenic, hypovolemia.
Both have cold and clammy skin.
Alright.
So the last type of cold shock we're gonna go over is obstructive shock.
Now now this is actually pretty interesting to me.
Because with obstructive shock, you're gonna have something that's going to actually obstruct the heart and prevent it from pumping blood out.
And so if you're preventing blood from getting out of your heart, your preload, which is preloading your right atrium here on or outside your screen, it's gonna keep continuing to try to fill your heart, but it can't get out of your heart.
It can't get out.
So you're gonna have increased preload, but your cardiac output is gonna go low.
Because you can't squeeze anything out of your heart.
So remember what I talked about, pericardial tamponade.
It's the classic one for this.
You have fluid around your heart.
It's squeezing.
It's killing your heart.
Your lungs are trying to push fluid into your heart.
Can't go anywhere.
Your sympathetic are going crazy.
Your hands are gonna be cold and clammy.
Right?
Because it's gonna be shunting all your blood to your vital organs, not your skin.
Classic.
Pericardial tamponade.
Sometimes you'll see it with stab victims.
They get fluid around your heart.
You can get it with pericarditis.
People have viruses, and here's one for you guys out there in the schools is tension pneumathorax.
Sometimes you'll have people that just get spontaneous tension and look alike from maybe they inhale to heart.
They're real tall and skinny people.
They can get spontaneous one.
And now you have basically inability of the heart to pump.
So that is an obstructive shot.
So so so important.
Now we went over the cold type of shocks.
Now let's finish up with distributive shock.
I have about 10 minutes here.
When I talk about septic shock, Cepic shock is kind of an interesting animal because, again, you're gonna have a warm skin.
And you're you're probably thinking yourself, what's going on with this specific shock?
It's a gradual process.
So the person doesn't get a chewy pill immediately.
So the problem is that the systemic vascular resistance is decreased due to peripheral mesodilation.
Okay?
And because of the dilation, that warm and flush skin is gonna be present.
So to compensate for this, the heart tries to pump faster.
So cardiac output is going to be increased.
And consequently, your preload is going to be a little bit decreased.
It's gonna be normal initially, but it's gonna be decreased eventually.
So kind of intuitively, one would think, well, the the vasodilation increases blood flow, and therefore, she should actually increase the delivery of oxygen to your tissues.
Well, that's a good point.
The thing is the blood flow, in this case, is too fast.
Inceptic shock, and the tissues aren't given enough time to extract the necessary oxygen.
And some exams will kinda test you on that.
And that's kind of unique for distributive shock, especially with septic shock.
So there's gonna be an increased cardiac output here.
Very, very classic Perceptic shop.
So I think it's probably very important to note that it's a gradual process with septic shock, and your hands are gonna be really Not cold, but they're gonna be warm and flushed.
I think that's pretty important to note.
Now anaphylactic, very important.
Whenever we think about anaphylactic, you're gonna See this so so common.
It's really gonna have their EpiPen, and it's gonna be a type 1 hypersensitivity reaction.
That means that you're gonna get the systemic vasodilation from histamine and the bradykinin is gonna cause all this hypertension.
And what happens is you get this fluid accumulation in the intravascular compartment, and it extrapolates into your interstitial in your lungs.
So you get this constriction of your lungs.
So you get wheezing.
You get hypotension.
And you essentially get what looks like low volume, but it's really not.
And so that's gonna increase your likelihood of going into shock here.
So your body's gonna try to clamp down, try to increase the heart rate.
But you need the epinephrine in order to do that.
So the epinephrine here is the right limiting factor and I get it so often.
People do not have their EpiPen.
It is so often.
So be sure folks.
Have your EpiPen.
Socom.
Anaphylactic shock.
So finally, we're gonna go over neurogenic shock.
And and this is it.
Then I'm gonna tidy up.
I I have about 5 minutes.
Neurogenic shock is so unique.
The last one I saw was maybe about a month ago.
He was actually a coach.
He had fell off putting some bulge in his scoreboard at one of the local high schools here.
Fell onto concrete pad, and he was in neurogenic shock.
His central nervous system lost its sympathetic nervous system tone is sympathetic tone.
So then basically, it tips the scale.
So now since your sympathetic tone goes down, your parasympathetic goes up.
So there's a out of balance thing that occurs with your organic shock.
And that's what makes it so unique because you're gonna get decreased cardiac output.
Decrease preload, decrease system and vascular resistance, but your volume is gonna be the same.
So you're not losing volume per se, like in hypovolemic shock.
And this is actually a a type of error here there's there isn't massive histamine there, but there is massive vasodilation.
So please disregard the massive histamine there.
That that was for the anaphylactic.
But there is massive vasodilation that occurs here.
Whenever you get this type of injury, you're also gonna have decreased reflexes.
So the big thing to remember with this is that trauma almost often, almost almost always.
Massive face dilation, decreased heart rate, decreased preload, and decreased reflexes.
And I will mention too is this can happen with hemorrhages.
So folks that fall out in the crowd, they can have leads in the brain, the kids that get struck on the field, they can have intracranial hemorrhages.
So if you check reflexes on people with hypotension or heart rate, that is a classic finding for neurogenic shock.
So with me having about 3 minutes here, I just wanna take an opportunity.
To emphasize the difference between warm and cold shot.
Very important just to use your entrepreneurship skills as an athletic trainer to put your hands on the patient.
I cannot emphasize enough.
Physical exam is so important these days.
I have people that come through that can't use their hands.
That was our gift as athletic trainers.
We can use our hands, use your brains to try to evaluate these people.
Warm and cold shot.
Differentiate pathophysiology and compensatory mechanisms.
Just like we talked about, it's good to know some of the potential compensatory findings of these types of shock, and I will go over them with you here.
But it's it's pretty important to know the differences, especially for exam purposes.
It's pretty common, like, on my type of exams and emergency.
And I do write BOC exam questions as well.
And, you know, I I can't really comment on question writing.
But it is important to know that these are something that you can see in the field.
Last thing is I just wanna emphasize that heart rate is gonna be decreased in neurogenic shop, and the reflexes are also going to be decreased in neurogenic shock.
It's so important.
People think that it is an important checking reflexes anymore.
And it is.
It's real simple to do.
I mean, anybody can do it, but Even me and a lot of my colleagues don't do it in the ER, and we should.
Should.
So overall, I think I have about a minute and a half left with you folks and some questions.
I am available at any time for consults, questions, email me anytime.
And with this stuff, this stuff kind of excites me because I see it a lot.
And it's kinda interesting.
So that's my story.
I'm sticking to it.
Doctor Heath, great.
This is fantastic.
So we've got we've got about 8 minutes or so for for q and a session.
So you left it right on time.
And as always, you've you've narrowed it down pretty fast and and with that, I think one of the things I saw that I haven't seen it in my training and or other presentation that you simply just define that warm versus cold shock was a really nice way of putting I just wanna compliment you on that, really a easy way to think about if they're gonna have what they're presenting with.
This is it gets you down this pathway, and it's about not not about making it the diagnosis.
It's just treating the what the vital signs are at that point in time because they're gonna need more assistance.
We we keep we're only trying to give them a chance to survive and and less injury as well.
So before I know I have a 1 or 2 questions, but before I get to that, I've got one question here.
Alyssa has a excellent questions she brought up into Q And A, and it's is there a way to have an EpiPen without prescription?
I have worked with physicians and we've not been able to find a way to have one on hand at my previous school.
It is a pre k through 12 school and my concern was kids that had never been stung by me.
He's getting stung and having a reaction, and the school was thirty miles from the emergency room.
Yes.
A good question.
So we actually have them at our school.
We have 2 or 3 of them, but it's in a locked cabinet.
And this cabinet is thumbprint.
So the athletic trainer and the doctor can access it.
And, unfortunately, nobody else because it's under the doctor's license.
But the physician can order these, and you can have them under a lock and key at your venues.
So at least in Ohio, we can do that.
Alyssa, where where are you from?
I guess I may I may provide some context and that or maybe Doctor Heath may have some resources specific to your state with what that looks like.
Where But it does.
Okay.
From North Dakota.
So there may be, I guess, the one would be probably step in the state law, I guess, would be that I think the one thing would be is Alyssa, and I think for everyone, if you're not getting a concrete answer, you know, especially the emergency medicine, go with them, I would say and I think, Doctor Heath, you probably agree with this.
First, go to your supervising physician.
If that does not answer, then go to local EMS, the medical director.
If it doesn't, go to the state level or go to state law.
Those thing there is an answer sooner or later, which you wanna make sure you uncover that as well also.
Yeah.
It's an unregulated type of medicine.
I mean, I guess I'll take that back.
It is regulated in the sense it's prescription.
Right?
It's an F and F and Auto Injector.
But as like a non narcotic, a non scheduled type of vacation of your collaborating position, maybe even willing to, you know, let you put one in your pack.
I mean,
Yeah.
I think the one is just making sure you have to, you know, with DEA, with regulations, you definitely don't wanna roll into that.
Into that in that space.
That's not a good space to be in, especially if the DEA has a control.
You know, there are different types of substances and medications.
That under purview.
I think that you kinda gave that example as having having that as an option is having a lockbox with fingerprint or have limited access in the physician knows who has that.
That's a that's a great example or a way to help with that.
And as situation regardless of the state state you're in.
Woody Gaffinette, who who presented the other day, he's like, he's he's in Ohio just touch briefly on the media interventions of different types.
AED, sequential AED, tourniquets fluid versus whole blood, if you would, I guess.
Yeah.
So I I guess the question is, tourniquets in whole blood, maybe be a little bit specific there.
I apologize.
Okay.
I'm not saying he's I guess it's I guess it probably touched base on the I guess maybe the intervent maybe if you would I think what he's what what he's asking.
If you would mind for the audience, touch base on what would be the immediate intervention for I guess, using aED or sequential like a sequential aED or using tourniquets or fluid versus whole blood, in in shock.
Oh, yeah.
Fair enough.
So that this is where, you know, some of my colleagues are gonna come into a little bit later is what AED.
So, again, you can use your hands to palpate, you know, whether they're warm or cold, palpate for pulse.
Whether they have a high heart rate or low heart rate.
But the big part is gonna be putting your AED pads on them and whether a shock is advised or not.
So if the shock is advised, then they may be in V fib.
That may be why their heart rate's high.
So that's my spheal fat.
But if they're exanguinating, you know, you're gonna put the target on the extremity.
And they may need whole blood.
So it's kinda 2 different things.
I mean, can a person go into cardiac arrest to be several arrests from extanguinating, you know, needing attorney could absolutely.
But, typically, you're gonna see one or the other.
Yep.
That's the case with the with the question.
You're gonna stop the you're gonna stop the part, the bleeding.
That's the first that's the first threat to the body.
I think you're talked, you know, this is the first script.
So it doesn't mean the person's going to roll.
It's gonna get better.
They're gonna get worse.
But you have to stop something first and then treat the vital treating with with perfusion using a BVM or you have oxygen.
If you don't have oxygen, have that.
Have the resources, check the vitals in in in a timely manner, are getting those trending vitals throughout.
The one question I had, I know we have a couple minutes left, is think if you discuss if if you have, like, from warm to cold, does it change?
I mean, can it that would probably be something that we may somebody may encounter is what is there a point where you would check that would that would move over, and that gets in a multisystem shock.
But you can give an example of that where it starts one one, you know, one particular type of shock, and then it moves over from the, like, from the cold, and now it's the person has a sensations are being warm and doing it moves into a whole another level of they're they're they're really decompensated.
Oh, yeah.
Good question.
So I see commonly that folks that are in hypovolemic shock.
So let's say they have bad vomiting, diarrhea, diabetic ketoacidosis, sometimes non hemorrhagic cause of hypovolemic shock.
That is a precursor sometimes to septic shock.
Because remember, hypovolemic is gonna be the cold shock, and then the septic shocks where you get warm.
So they may have an infection that's underlying.
So you can get that hypovolemic transition into a septic shock.
So I get that quite often.
The anaphylactic usually, it's a standalone thing.
Neurogenic stand alone.
Cardiogenic, sometimes you can go from between cardiogenic and obstructive.
Because, you know, that's sometimes heart problems, so you can see that sometimes.
But more than often not, it goes from obstructive to cardiogenic.
Okay.
So if somebody they may have a tension pneumothorax, for example, and then that'll progress if you don't do a needle decompression or a test tube.
Yeah.
From if if you would briefly, thank you for answering that.
I guess just to reiterate the importance of the initial assessment obtaining the vital signs sets, the trending vital signs sets, the frequency that comes into I know if I have questions.
I know I get questions a lot of way.
You know, how how often do I need to practice these skill sets to be proficient or is it twice a year or versus as a like, for example, blood pressure versus blood pressure in the field?
What what is that if you could expand on that before we get before we finish up on that?
Oh, yeah.
Good question.
So I would recommend quarterly training.
So I know a lot of our athletic trainers from a lot of our local school systems, they get together and do sometimes even mass casualty training, they get involved with the hospitals.
But a lot of times, it's scenarios, you know, simulations, you know, a patient goes down on the field, you know, what do you do?
Those type of things.
And during you're debriefing afterwards, then they go through vitals and just showing how to do those type of things.
But I think quarterly would be a great way.
I mean, I think, like, twice a year is too little.
I mean, I think quarterly is probably good.
I'm not sure what you think.
Well, I just think that it's training.
You know, you have to do that.
It's easy to do it in rope scale training like CPR.
Like, you can you can sit in front of a mannequin all you want, but until you train in that situation, and it exposes your weaknesses in very unique ways.
I mean, you get to that mini even 5 minute mini doing what you do in the first 5 minutes will dictate what happens in the next 3 days or 5 I mean, just the final sunset.
You're calling you know, you're activating 911.
You're applying the you're applying initial, you know, vinyl sunset.
Treating what that's there either a pub name to provide oxygen or, you know, putting them in an inappropriate body position or given them, you know, glucose.
If they're in for, you know, if they're high school, they're in that in that hypostate or I mean, hypoglycemic state.
So just haven't addressed that rapidly as you can, it sets the state.
It prevents them from going into the shock or they they moved out, like, for example, I think one that we don't think about a lot is, you know, in the field, it's like having an appendectomy or having an an inflamed appendix.
It starts leaking Now you're in sepsis, and now that person may be, what, 3, 4 days into this where they're having that low grade fever, but they're really they're hypoprofusing.
They've probably had other things going on.
So it's really important to get those things not to just you I think you give an example of meningitis was the one earlier.
That's a great example of they're having a fever when it's really more than just a fever or an infection.
So Getting early, getting nice.
Great.
Well, we're I'll it's time for us to move on to session too.
Doctor Heath, thank you again for a fantastic presentation leading us off on this session.
Shock and Compensatory Mechanisms
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