Operational Medicine 2001
Field Medical Service School
Student Handbook

SHOCK CASUALTIES

FMST 0401

17 Dec 99

TERMINAL LEARNING OBJECTIVES:

1.      Given a shock casualty in a combat environment (day and night) and standard Field Medical Service Technician supplies and equipment, manage shock casualties per the references. (FMST.04.01)

ENABLING LEARNING OBJECTIVES:

1.      Without the aid of reference materials and given a list of four (4) types of shock, select the cause of each type of shock, per the student handbook.  (FMST .04.01a)

2.      Without the aid of reference materials and given a list of four (4) classifications of hemorrhagic shock, identify the classifications, per the student handbook.  (FMST .04.01b)

3.      Without the aid of reference materials and given a list of four (4) types of shock, select the treatment for each type of shock, per the student handbook.  (FMST .04.01c)

4.      Without the aid of reference materials and given a FMST MOLLE Medic bag and provided a simulated shock casualty, identify, treat, and monitor the casualty, per the student handbook.  (FMST .04.01d)  

OUTLINE:

A.     SHOCK (general)

1. DEFINITION – A state of inadequate tissue perfusion, which causes cellular metabolic oxygen demands to exceed the supply.

2. CAUSES:

a.       Life threatening injuries – e.g. head injuries, C-spine injuries, amputations

b.      Disease states

3. SIGNS / SYMPTOMS OF SHOCK:

a.       Weakness – occurs when musculoskeletal tissues are deprived of an adequate oxygen supply.   The muscles are not able to complete aerobic metabolic cycles and cannot produce normal energy levels.

b.      Altered Level of Consciousness – occurs when the brain is deprived of an adequate oxygen supply.  Changes in the level of consciousness are usually progressive in nature if not treated immediately.

1.       Restlessness – initial stage of oxygen deprivation

2.      Anxiety – secondary stage of oxygen deprivation

3.      Hostility – secondary stage of oxygen deprivation

4.      Lethargy – moderate to severe oxygen deprivation

5.      Unconsciousness – severe oxygen deprivation

c.       Feeling of Impending Doom

d.      Tachycardia – pulse will be fast and thready

e.       Pallor / Cyanosis

f.        Cool extremities – due to decreased blood circulation to the peripheral portions of the body

g.       Tachypnea – the body’s response to decreased oxygen levels.  The body attempts to compensate by increasing the respiratory rate to deliver more oxygen into the system.

h.       Diaphoresis (sweatiness)

4. TREATMENT OF SHOCK

a.       Keep the patient warm

b.      Trendelenberg positioning (elevate extremities if unable to place in Trendelenburg position)

c.       Oxygen therapy (if available)

d.      Identify the causative factor for the shock and treat appropriately.

B.     CLASSIFICATIONS OF SHOCK (4)

1. HYPOVOLEMIC SHOCK

a.       DEFINITION – A type of shock characterized by an inadequate perfusion of the body due to volume loss within the circulatory system.  This is the most common form of shock seen in the combat / field / tactical environment.

b.      CAUSES:

1.      External loss of whole blood – i.e. hemorrhage

2.      Loss of plasma – i.e. severe burns

3.      Loss of extracellular fluids – i.e. gastrointestinal fluids lost through vomiting or diarrhea

4.      Internal hemorrhage

5.      Third Space losses – fluid moves from vascular system into the tissues, i.e. edema

  c.       SIGNS / SYMPTOMS:

1.      Signs and symptoms seen with hypovolemic shock are usually linked with the amount of fluid lost.  However, these parameters are only guidelines and should not be taken as absolute amounts.

a)      Class I –  Initial Stage

1)      The circulatory blood volume is decreased but not enough to cause serious effects.

2)      Blood volume reduction up to 10% or approximately 500 cc’s

3)      Clinical Findings

(a)    No clinical findings

b)      Class II –  Compensatory Stage

1)      Although the circulating blood volume is reduced, compensatory mechanisms are able to maintain blood pressure and tissue perfusion at a level sufficient to prevent cellular damage

2)      Blood volume reduction from 15 – 25% or approximately 750 – 1250 cc’s

3)      Clinical Findings:

(a)    Minimal tachycardia (heart rate up to 100 – 105)

(b)   Slight decrease in blood pressure

(c)    Mild evidence of peripheral vasoconstriction with cool hands and feet

c)      Class III – Progressive Stage or Decompensated Shock

1)      At this point, unfavorable signs begin to appear.  The body’s compensatory systems can no longer maintain adequate perfusion with the continued blood loss.

2)      Blood volume reduction from 25 – 35 % or approximately 1250 - 1750 cc’s

3)      Clinical Findings:

(a)    Tachycardia (heart rate 105 – 120 beats per minute)

(b)   Decrease in pulse pressure

(c)    Systolic pressure, 70 – 100 mm Hg

(d)   Restlessness

(e)    Increased Sweating

(f)     Pallor

(g)    Oliguria (decreased urine output)

d)      Class IV – Irreversible Stage

1)      Even though the blood volume may be restored and vital signs stabilized, death is imminent

2)      Blood volume reduction from 35 to 50% or approximately 1750 – 2500 cc’s

3)      Clinical Findings

(a)    Tachycardia over 120 beats per minute

(b)   Blood pressure below 60 mmHg systolic and frequently unobtainable by cuff

(c)    Mental stupor

(d)   Extreme pallor

(e)    Cold extremities

(f)     Anuria (no urine output)

d.      TREATMENT:

1.      Identify the source of the fluid loss and correct the problem

a)      Control gross bleeding – direct pressure, pressure bandaging, pressure points, tourniquets

b)      Anti-emetics to control vomiting

1)      Phenergan

2)      Tigan

c)      Anti-diarrhea medications to control diarrhea

1) Immodium

2.      Restore intravascular volume:

a)      Fluid and electrolyte replacement (3 cc’s of a crystalloid fluid for every 1 cc of blood lost) – available at the BAS

b)      Whole blood replacement – 1 cc of whole blood for every 1 cc of blood lost)

c)      Blood Substitute Product replacement – i.e. Hespan. Dosing is 250 - 500 cc’s at a time.  Maximum allowable in 24 hours is 1500 cc’s. Other products are currently being researched and developed.

3.      Elevate lower extremities

4.      Trendelenburg positioning

5.      Keep the patient warm.

2. CARDIOGENIC SHOCK

a.       DEFINITION – Failure of the heart to adequately pump blood throughout the body. 

b.      CAUSES:

1.      Myocardial Infarction (heart attack) – damage to the muscle tissue of the heart

2.      Dysrhythmias – abnormal heart beats cause ineffective / uncoordinated contractions of the heart, thus decreasing the cardiac output

3.      Mechanical defects of the heart – congenital defects which impair the normal functioning of the heart

4.      Cardiac Disease

a) Congestive Heart Failure (CHF)

5.      Injuries to the heart

a)      Myocardial contusion - i.e. blunt trauma to the chest wall

c.       SIGNS / SYMPTOMS:

1.      Chest pain

2.      Shortness of breath

3.      Cyanosis

4.      Dependent edema

5.      Distant heart tones (cardiac tamponade)

d.      TREATMENT:

1.      Keep patient warm

2.      Maintain ABC’s

3.      Evacuate immediately to nearest treatment facility

3. OBSTRUCTIVE SHOCK

a.       DEFINITION – A type of shock resulting from the mechanical obstruction of the flow of blood through the central circulation (great veins, heart, or lungs)

b.      CAUSES:

1.      Dissecting Aortic Aneurysm

2.      Cardiac tamponade

3.      Pneumothorax

4.      Evisceration of abdominal contents into the thoracic cavity

5.      Pulmonary Embolism – the most frequent cause of Obstructive shock

c.       SIGNS / SYMPTOMS:

1.      Chest Pain

2.      Shortness of Breath / Difficulty Breathing

3.      Tachycardia

4.      Cyanosis

5.      Distant heart tones (cardiac tamponade)

6.      Decreased / absent lung sounds (pneumothorax)

7.      Altered Level of Consciousness

d.      TREATMENT:

1.      Maintain ABC’s

2.      Keep patient warm

3.      Oxygen therapy (if available)

4.      Needle thoracentesis or Chest Tube insertion (for pneumothorax)

5.      Immediate evacuation to nearest Medical Treatment Facility

4. DISTRIBUTIVE SHOCK

a.       DEFINITION – A form of shock characterized by loss of blood vessel tone, enlargement of the vascular compartment, and displacement of the vascular volume away from the heart and central circulation.

b.      CAUSES:

1.      Trauma to the brain and cervical spine / neck region

2.      Emotional factors – i.e. nervousness and fear

c.       TYPES:

1.      NEUROGENIC SHOCK

a)      Definition – A form of shock caused by the decreased sympathetic control of blood vessel tone.

b)      Causes:

1)      Brain / Spinal Cord Injuries

2)      Drugs – i.e. anesthesia agents

3)      Hypoxia

c)      Signs / Symptoms:

1)      Heart rate is slower than normal

2)      Skin is dry and warm

3)      Hypotension

d)      Treatment:

1)      Maintain ABC’s

2)      Trendelenberg position

3)      Evacuate to nearest Medical Treatment Facility

2.      ANAPHYLACTIC SHOCK

a)      Definition – A form of shock characterized by massive vasodilation, pooling of blood in the peripheral blood vessels, and increased capillary permeability pooling of blood

b)      Causes:

1)      Severe Reaction to Insect bites or stings – i.e. bee stings

2)      Allergic reaction to foods – i.e. nuts (raw cashews) or shellfish (shrimp)

3)      Systemic Reaction to Medications – i.e. penicillin

4)      Severe Reaction to Plants

5)      Systemic Reaction to Animal sera – i.e. tetanus antitoxin

c)      Signs / Symptoms:

1)      Abdominal Cramps

2)      Apprehension

3)      Burning and warm sensation of the skin

4)      Itching

5)      Angioedema – well demarcated localized swellings of the skin and subcutaneous tissue

6)      Bronchospasm –spasmodic constriction of the bronchial tubes

7)      Respiratory Difficulty

(a)    Coughing

(b)   Sneezing

(c)    Rhinorrhea (runny nose)

(d)   Shortness of breath

(e)    Chest tightness

(f)     Choking

8)      Hypotension

9)      Tachycardia

d)      Treatment:

1)      Oxygen therapy

2)      Epinephrine

(a)    Causes vasoconstriction (countering the vasodilation caused by histamine) in the extremities, thus increasing blood pressure and forcing blood into the vital organs

(b)    Dose is 0.5 – 1.0 cc’s of 1:1000 concentration epinephrine administered subcutaneously (SQ)

3)      Antihistamines

(a)    Directly counters the effects of histamine

(b)   Dose is 25 – 50 mg Benedryl given IV or IM

4)      Fluid Replacement therapy – may be required

3.      SEPTIC SHOCK

a)      Definition – a shock characterized by a severe, overwhelming infection

b)      Causes: toxins produced by microorganism

1)      Gram negative bacteria

2)      Gram positive bacilli

c)      Signs / Symptoms:

1)      Fever

2)      Warm, flushed skin

3)      Mild hyperventilation

4)      Tachycardia

5)      Altered level of consciousness

d)      Treatment:

1)      Culture site of infection – to identify microorganism causing the infection and its sensitivity to antibiotics

2)      Antibiotics

(a)    Broad Spectrum Antibiotics – used initially until microorganism identified

(b)   Once microorganism is identified, switch to type specific antibiotic

3)      Fluid Replacement therapy

REFERENCE (S):

1.  EMERGENCY WAR SURGERY

2.  PREHOSPITAL EMERGENCY CARE AND CRISIS INTERVENTION

3.  PATHOPHYSIOLOGY: CONCEPTS OF ALTERED HEALTH STATES

Field Medical Service School
Camp Pendleton, California

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Operational Medicine 2001
Health Care in Military Settings

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