Shock

In military training we are taught that one of the leading causes of death on the battlefield is shock; not shock because their battle buddy jumps out and yells “boo!” at a stressful moment, but because of traumatic injury. When I first started learning about shock I thought it was a side effect of a wound leading to a mentally debilitating state; which is completely wrong.

What is shock?

I pulled this very simple definition from medicinenet.com.

“Shock is a life-threatening medical condition as a result of insufficient blood flow throughout the body. Shock often accompanies severe injury or illness. Medical shock is a medical emergency and can lead to other conditions such as lack of oxygen in the body’s tissues (hypoxia), heart attack (cardiac arrest) or organ damage. It requires immediate treatment as symptoms can worsen rapidly.”

“Medical shock is different than emotional or psychological shock that can occur following a traumatic or frightening emotional event.”

 

Shock is an extremely vague term as there are many medical conditions that fall under this loose genera:

Hemorrhagic shock–reduced blood volume caused by either external or internal bleeding.

Plasma loss shock–reduced blood volume results from loss of plasma into the interstitial spaces and greatly increased blood viscosity.

Intestinal obstruction–results in the movement of large amount of plasma from the blood into the intestine.

Severe burns–loss of large amounts of plasma from the burned surface.

Dehydration–results from severe and prolonged shortage of water intake.

Severe diarrhea or vomiting–loss of plasma through the intestinal wall.

Neurogenic shock–rapid loss of vasomotor tone that leads to vasodilation to the extent that a severe decrease in blood pressure results.

Anesthesia–deep general anesthesia or spinal anesthesia that decreases the activity of the medullary vasomotor center or the sympathetic nerve fibers.

Brain damage–leads to an ineffective medullary vasomotor function.

Emotional shock (vasovagal syncope)–results from emotions that cause strong parasympathetic stimulation of the heart and results in vasodilation in skeletal muscles and in the viscera.

Anaphylactic shock–results from an allergic response that causes the release of inflammatory substances that increase vasodilation and capillary permeability.

Septic shock or “blood poisoning”–results from peritoneal, systemic, and gangrenous infections that cause the release of toxic substances into the circulatory system, depressing the activity of the heart, leading to vasodilation, and increasing capillary permeability.

Cardiogenic shock–occurs when the heart stops pumping in response to conditions such as heart attack or electrocution.

 

Speaking to a friend who is also in the military, but spent years working as a paramedic in the Twin Falls area of Idaho; and has witnessed many deaths and examples of shock, he told me that shock can be summarized as the body’s process of dying.  Your body is attempting to compensate for trauma and disruption to its homeostasis.  Taking this into account, then yes, shock really is the number one killer on the battlefield.

As you start spiraling down a person will go through different phases of shock, each increasing in severity:

In compensated phase- Pulse rate may be normal or high, arterial blood pressure is normal or high, respiratory rate may be normal or high, EKG will be normal.  Your body will be going through its normal response to trauma, including shunting blood away from the skin and limbs to the brain, kidneys, and heart.  This is the reason skin will feel cool and clammy; a misconception that in heat exhaustion the body is over compensating for heat, when in reality the constricted veins indicate a physical control over where the blood is be delivered.  Some of the symptoms like nausea are caused by the depletion of fluids to the stomach and rise in acidity.

In decompensated phase -A patient in the decompensated phase of shock is typically tachycardic (fast pulse rate.), blood pressure is low, respiratory rate is high, EKG may show ST depression with sinus tachycardia.  Failing muscles lead to a flow of blood back into the limbs; the rapid movement of blood away from the brain and other key organs generally leads to unconsciousness.  In the case of heat casualties, the symptoms are the same as heat stroke, because heat stroke is simply decompensated phase.  This phase can last about 5-20 minutes depending on an unlimited number of variables.

In irreversible phase- Pulse rate is high, blood pressure is low, respiratory rate is high or there is laboured breathing, EKG shows sinus tachycardia and ST depression.  If a person is brought back from the brink in the phase of shock he can expect organ damage and potential loss of life over the next few days; it is irreversible because there will be permanent damage.

 

Below is the army standard for evaluation and treatment; which I pulled from the online army study guide.  The terms are simplified in the way a child understands red means stop when driving; we don’t divulge the laws and possible repercussions, we simply state that when it is red you stop.  The army focuses on the treatment, not exactly why your body is reacting the way it is.

 

Causes and Effects

a. Shock may be caused by severe or minor trauma to the body. It usually is the result of–

Significant loss of blood.

Heart failure.

Dehydration.

Severe and painful blows to the body.

Severe burns of the body.

Severe wound infections.

Severe allergic reactions to drugs, foods, insect stings, and snakebites.

b. Shock stuns and weakens the body. When the normal blood flow in the body is upset, death can result. Early identification and proper treatment may save the casualty’s life.

c. See FM 8-230 for further information and details on specific types of shock and treatment.

 

Signs/Symptoms

Examine the casualty to see if he has any of the following signs/symptoms:

Sweaty but cool skin (clammy skin).

Paleness of skin.

Restlessness, nervousness.

Thirst.

Loss of blood (bleeding).

Confusion (or loss of awareness).

Faster-than-normal breathing rate.

Blotchy or bluish skin (especially around the mouth and lips).

Nausea and/or vomiting.

 

Treatment/Prevention

In the field, the procedures to treat shock are identical to procedures that would be performed to prevent shock. When treating a casualty, assume that shock is present or will occur shortly. By waiting until actual signs/symptoms of shock are noticeable, the rescuer may jeopardize the casualty’s life.

a. Position the Casualty. (DO NOT move the casualty or his limbs if suspected fractures have not been splinted.)

(1) Move the casualty to cover, if cover is available and the situation permits.

(2) Lay the casualty on his back.

NOTE: A casualty in shock after suffering a heart attack, chest wound, or breathing difficulty, may breathe easier in a sitting position. If this is the case, allow him to sit upright, but monitor carefully in case his condition worsens.

(3) Elevate the casualty’s feet higher than the level of his heart. Use a stable object (a box, field pack, or rolled up clothing) so that his feet will not slip off (Figure 2-44).

WARNING: DO NOT elevate legs if the casualty has an unsplinted broken leg, head injury, or abdominal injury.

WARNING: Check casualty for leg fracture(s) and splint, if necessary, before elevating his feet. For a casualty with an abdominal wound, place knees in an upright (flexed) position.

(4) Loosen clothing at the neck, waist, or wherever it may be binding.

CAUTION: DO NOT LOOSEN OR REMOVE protective clothing in a chemical environment.

(5) Prevent chilling or overheating. The key is to maintain body temperature. In cold weather, place a blanket or other like item over him to keep him warm and under him to prevent chilling (Figure 2-45). However, if a tourniquet has been applied, leave it exposed (if possible). In hot weather, place the casualty in the shade and avoid excessive covering.

(6) Calm the casualty. Throughout the entire procedure of treating and caring for a casualty, the rescuer should reassure the casualty and keep him calm. This can be done by being authoritative (taking charge) and by showing self-confidence. Assure the casualty that you are there to help him.

(7) Seek medical aid.

b. Food and/or Drink. During the treatment/prevention of shock, DO NOT give the casualty any food or drink. If you must leave the casualty or if he is unconscious, turn his head to the side to prevent him from choking should he vomit (Figure 2-46).

c. Evaluate Casualty. If necessary, continue with the casualty’s evaluation.

 

If you remember anything from this it is to seek medical aid as soon as possible.

Jon