A VOICE on the EMS radio interrupts your thoughts: "Med 2 en route with 21-year-old male involved in motorcycle accident. Patient was wearing helmet and had no loss of consciousness. At present he is conscious, alert, and oriented, but complaining of abdominal pain. Heart rate 110 bpm with BP 120/90. ETA 5 minutes."

I Moments later, your patient arrives, appearing anxious and complaining of severe abdominal pain, which he rates at 8 on a 0-to-10 pain scale. You note his skin is pale and diaphoretic. He's tachypneic, and a radial pulse check shows that he's tachycardic. As you call for the ED physician, you realize that you're seeing signs of shock. This man could die from hypovolemic shock unless the team responds quickly.

II Hypovolemia is the most common cause of shock. Although it's often due to injury and massive blood loss, it can also have non traumatic causes, such as a gastrointestinal bleed or ruptured ectopic pregnancy. Hypovolemia can also be caused by fluid losses or dehydration from frequent vomiting or diarrhea.

III A clinical syndrome of inadequate tissue perfusion, shock results in a decreased supply of oxygen and nutrients to cells. The body responds initially by activating numerous compensatory mechanisms to improve cellular perfusion. If these fail, shock leads to widespread cellular necrosis, multiple organ dysfunction and failure, and death.

IV Although there are various types of shock, including hypovolemic, cardiogenic, neurogenic, anaphylactic, and septic, the final common pathway in all types of shock is impaired cellular metabolism.

V Back to our patient... As the team begins assessment, you note that he's becoming increasingly confused. His abdomen is very distended and tender to light palpation. Despite receiving 100% oxygen via a non-rebreather mask, he remains tachypneic. After placing him on a cardiac monitor, you see sinus tachycardia at 120 bpm. A urinary catheter is inserted with minimal initial output. His BP is now 90/70. You realize that your patient is now decompensating.

VI You recognize that an alteration in level of consciousness (LOC), tachypnea, tachycardia, peripheral vascular changes, and oliguria are signs of shock. The drop in BP is an important sign that shock is progressing.

VII As always, your nursing assessment starts with the ABCs (assess and support airway, breathing, and circulation) followed by determining the patient's medical history and the extent of traumatic injury. Also perform a complete head-to-toe assessment to determine locations of pain, ecchymoses, or distension that could point to occult bleeding.

VIII An adequate assessment includes evaluation of the chest, abdomen, and pelvis. Evaluation of the abdomen is initially done through an assessment sonography , which can identify pericardial fluid in the chest as well as intraperitoneal fluid in the abdomen. If the patient is hemodynamically stable, then a CT scan is indicated for more definitive evaluation of any injuries. Long-bone fractures such as femur fractures can also cause significant bleeding, so prepare to obtain films .

IX A central venous pressure reading of less than 4 mm Hg (lactate levels, and the presence of an arterial base deficit greater than -2 mmol/L.

X Certain patient groups may also have atypical signs and symptoms:

* Older adults may not exhibit classic signs due to an inability to initiate compensatory mechanisms.

* Patients on beta-blockers may not be able to initiate the expected tachycardia response.

XI Management of patients with hypovolemic shock has three primary goals:

* Maximize oxygen delivery by ensuring an adequate airway (which may have been affected as the LOC decreases) and by improving oxygenation through administration of high-flow oxygen via a non-rebreather mask or mechanical ventilation.

* Control hemorrhage through basic means, such as direct manual pressure or surgical intervention.

* Restore and maintain adequate cardiac output. To meet this goal, I.V. fluid replacement is a top priority. (In early shock from dehydration, oral fluid replacement may be adequate.) The I.V. fluid of choice is usually a 0.9% sodium chloride solution or Ringer's lactate

XII Patients with continuing blood loss may need blood products, so obtain specimens for type and cross match. Transfusion may be indicated if the patient is hemodynamically unstable and shows little response to treatment with fluids. The patient's hemoglobin level may be used as a transfusion indication: in general, 8 g/dL is a marker for initiating transfusion in patients experiencing blood loss. However, a higher value may be appropriate for older patients and those with significant comorbities, such as coronary artery disease.

XIII After fluid resuscitation, the priority becomes identifying the origin of shock. Many patients with traumatic hypovolemic shock require diagnostic imaging studies, such as ultrasound or computed tomography scanning. Severe internal injury and ongoing blood loss may require surgery to locate and stop bleeding.

XIV Frequent nursing assessments should determine if the response to treatments is adequate. Monitor for improving LOC, increasing urine output (greater than 0.5 mL/kg/hour or at least 30 mL/hour in an average-sized adult), and hemodynamic stability. Continuous monitoring after fluid resuscitation is critical.

XV As you continue to assess and support your patient, the ED team moves at an accelerated pace. As prescribed, you administer a bolus infusion of Ringer's lactate through the peripheral venous access established by the EMTs while a coworker establishes a second large-bore venous access. Specimens are taken for initial lab tests and a call is placed to the blood bank requesting type-specific units of RBCs. A stat portable chest X-ray reveals no pneumothoraces, traumatic hemomediastinum, or hemothorax.

XVI A bedside scan shows a significant amount of free intraperitoneal fluid. The on-call surgeon decides to operate immediately due to the ongoing internal bleeding and hemodynamic instability. After surgical repair of a lacerated mesenteric artery and normalization of his fluid status, the patient recovers uneventfully.

IFSI Levallois Homework for 26/02/ or 27/02/14

I Read the article on hypovolemic shock and put a T for true and a F for false for each statement. Underline your answers in the text.

1) The patient was conscious but disoriented before he arrived in the ED. ____

2) Hypovolemic shock can result in death if not treated early. ___

3) Although the patient’s condition is deteriorating rapidly, his kidneys are still functioning well. ____

4) In all types of shock, compensatory mechanisms always improve organ and cellular perfusion. ____

5) Patients on beta blockers will always have a high tachycardic rate when in shock. ____

6) Older patients may be given blood transfusions for a Hb level over 8 g. _____

7) Rapid fluid replacement is essential for assuring adequate cardiac functioning. _____

8) The patient recovered well from surgery but had several complications. ____

II Read the article again and then find all the vocabulary related to the following categories. Know the French for these words for your next class.

Sx ( symptoms)

Causes of Shock

Tx ( treatment)

Medical equipment

Tests

III Find the verbs for the following nouns taken from your article .NOUN VERB TRANSLATION ( noun,verb)

e.g. a call to call un appel, appeler

1) an injury to ___________ ____________, ________

2) a loss to _____________ _____________ ________

3) a complaint to ____________ _____________ ________

4) a recovery to ____________ ____________ _______

5) breathing to ___________ ______________ ________

6) an insertion to ___________ ________________ ______

7) impairment to ____________ ____________, ________

8) a cause to ______________ _________ ________

9) perfusion to ___________ _____________, __________

10) failure to ___________ _____________, __________

IV a) Be prepared to translate the article (orally) for your next class.

b) Know the translations for all the words in bold print.

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low blood pressure inadequate blood flow