Even more Bleeding stuff ....

ER doctors view

Now it’s time to have our little chat about shock. Shock is what kills people. Shock, dear friends, is
what will eventually kill you, personally. The only question will be how you got into shock to start
with.

Shock is the simple word, hypoperfusion is the fancy word. That is hypo (low), perfusion (delivery of
oxygen and nutrients to the cells throughout the body).

Some of those body cells are more sensitive to low perfusion than others. Brain cells, now, can go
without oxygen for between four and six minutes. That’s why we’re checking Airway, Breathing,
and Circulation every five minutes. Big chunks of emergency medicine, and all of CPR, is about
getting oxygenated blood to the brain. Skin cells can go hours without oxygenated blood. Maybe
days. Other tissues have other thresholds.

There are four main classes of shock:

 Hypovolemic (from hypo, low, and volemic, of or pertaining to volume). Bleeding is the most
obvious way to get there, but dehydration from whatever cause (burns, diarrhea, etc.) will
get you to the same place.

 Obstructive (something is stopping the blood from picking up oxygen) (examples: pulmonary
embolism, tension pneumothorax, cardiac tamponade),

 Distributive (something is preventing the oxygenated blood/nutrients from reaching the

cells), with its subcategories

o neurogenic,

o psychogenic,

o anaphylactic,

o toxic

 Cardiogenic (the heart isn’t beating well enough to push the blood around).

But now for the good stuff: Hypovolemic shock.

Usually in trauma the kind of shock you see is Hypovolemic shock—there just isn’t enough blood to
move oxygen around to everywhere, because that blood is now in a puddle on the ground. As the
body loses blood, it compensates by shutting down peripheral circulation. Skin and muscle can go
for a long time without nutrients and oxygen. Then the various internal organs get their blood
supply shunted to the heart/lungs/brain area. And here is where the Golden Hour—the hour from
when the trauma occurs to the moment the OR doors close behind the patient—comes from. Just as
the brain lasts four to six minutes without oxygen, the kidneys last forty-five minutes to an hour
and a quarter without oxygen. And if your kidneys die, you’re dead, and not in any kind of quick and
pleasant way, either.

Your patient will complain of being thirsty. Don’t give him water. He’ll just vomit it up, because
when he started going into shock one of the first systems to shut down was the digestive system.
That gives you the added problems of ruining his blood pH by dumping stomach acid, and
compromising his airway from aspirating the vomitus. Besides, who wants to get puked on?

The adult human body contains between four and six liters of blood. That isn’t a heck of a lot. Kids
and babies have less.
A sign is something that you can see for yourself. A symptom is something that your patient tells
you. The first symptom of going into shock is a feeling of anxiety. The patient is restless and
apprehensive. As time goes on and shock progresses, the skin gets cool and pale as blood is shunted
away from the skin and into the deeper organs. The heart rate goes up, to move what blood is still
in the body around, the respiration rate increases to get more oxygen on the red cells that are left.
The body releases adrenaline, which causes sweating. The body temperature goes down. The
patient becomes listless, speech becomes confused, blood pressure plummets, the pupils get
sluggish and dilate, breathing becomes slow and irregular. Then the patient dies.

This is all no fun for you, and less fun for the patient. The abbreviation for this is CTD, for Circling
The Drain.

Even if you can’t see a pool of blood, the patient can be bleeding out internally. One of the tiny little
costal arteries (the ones that run along the bottom edge of each rib) can bleed 50 mL per minute.
The femoral arteries are as big around as your thumb: you can lose a lot of blood out of one of those
puppies, very fast.

Less than 15% blood loss is referred to as Class I shock. The only thing you’ll see in Class I shock is
that anxiety. The patient remains alert, the blood pressure, heart rate, and respiration rates stay
within normal limits, and the skin’s temperature, color, and condition are unchanged.

For an adult with the average 5 liters of blood, that’s up to 750 mL. 750 mL is the amount in a wine
bottle. For an adult bleeding internally with a torn costal artery, that’s fifteen minutes.

Next comes Class II shock. 15-30% blood volume loss. The patient is more anxious and restless. The
skin gets pale, cool, and dry as blood is shunted to the vital organs. Blood pressure remains within
normal limits, The heart rate increases to over 100 beats per minute, the respiration rate rises
above 20 per minute. Capillary refill slows. (To check capillary refill, pinch the fingernail. It’ll
blanch. Release pressure. The color returns. Normal is less than two seconds. (Not a reliable sign in
adults.)) The pulse becomes thready (that is, hard to feel).

Class III shock is 30% to 40% blood volume loss. Up to two liters (a large plastic Coke bottle) in that
average adult. The body’s compensatory mechanisms start to fail. The blood pressure plummets;
you lose the radial pulse (in the wrist), then the femoral pulse (in the groin), then the carotid pulse
(in the neck). Only now do you get the classic “signs of shock”: pale, cold, clammy skin; confused
verbal responses, rapid heartrate, rapid respirations; cold extremities.

By the time you see the classic signs of shock you are on the edge of Too Friggin’ Late.

Next stage is Class IV shock. 40%+ blood loss. Forty minutes for that guy with the tiny little costal
artery bleed The vasoconstriction from earlier, compensated, shock starts to be a complication
itself. The heartrate continues to rise, then falls. Blood pressure continues to fall. Respiration rates
rise further still, then fall sharply. The patient becomes incoherent, then unconscious. The pupils
dilate. On a scale from good to bad, the needle is now pegged out on Bad.

What to do about this: Establish an IV (or two) and put in crystaloid (normal saline or Lactated
Ringer’s) to a max of about two liters. You don’t want to raise the blood pressure too high, because
that can blow off any newly-formed clots that are limiting bleeding. Take it up to about a systolic
pressure of 90mm Hg (the point where you can first detect a radial pulse). Likewise it does you no
good just to run water around in the patient’s veins. Without red cells (which are likewise lying in
that pool on the ground) oxygen won’t be transported. This patient needs a nice blood transfusion,
which you probably don’t have in the trunk of your car.

Another way we categorize shock progression is as:

 Compensated shock,
  Decompensated shock,

 Irreversible shock.

Friends, you don’t want to get to Irreversible shock.

Little kids are very good at compensating. They maintain their blood pressure, and they maintain
their blood pressure, and they maintain their blood pressure … then they crash and there’s no
coming back. Don’t look at blood pressure in kids. Look at heart rate.

Here’s something else you can do: take your Sharpie marker. Feel the kid’s arm. You’ll notice a place
where the arm starts getting cold. Draw a line on his arm at that level. Do the same again a while
later. If what you’re doing is working, the line between warm and cold will have moved down the
arm. Keep doing it. If the line is moving up the arm, what you’re doing isn’t working. Find
something else to do (or continue what you’re doing only more, and better).

The signs and symptoms for all varieties of shock are very similar, and the treatment for all of them
is nearly identical in the field.

Some brief notes on some kinds of shock you might see on a trauma scene.

You can see Neurogenic shock and Obstructive shock in trauma cases. Distributive and Cardiogenic
less often.

In Obstructive Shock the blood is prevented from picking up oxygen. Some examples of this include
cardiac tamponade (the pericardial sac is filling with blood, preventing the heart from expanding
and moving blood), tension pneumothorax (the chest is filling with air and is squeezing the lungs
and heart), and pulmonary embolism (there’s a blockage in the pulmonary artery (blood clot, fat,
marrow, air) that keeps blood from moving through the lungs to pick up oxygen.

Some of what I’m going to talk about is Black Belt EMS-fu. Don’t try this at home, kids. You need
training, equipment you probably don’t have with you, and a license, to do it.

That being said: Cardiac tamponade. You’ll suspect cardiac tamponade when the patient’s pulse
pressure is narrowing (the top and bottom numbers on the blood pressure are getting closer
together), the heart sounds are muffled, the mechanism of injury suggests trauma to the mid-chest,
and the guy is developing signs and symptoms of shock and you’ve already fixed everything else but
it didn’t help. What’s going on: The heart is inside of a tough fibrous sac called the pericardium. If
the heart is lacerated and is bleeding into that sac, eventually the pericardium will fill up with blood
and the heart won’t have room to expand. No expansion, no blood being pumped, no oxygenated
blood reaches the cells, the organs die, no fun for anyone.

What to do about it: Hook the guy up to an EKG. Get a big-ass needle attached to a syringe. Go in
below the rib cage, angled slightly up. When you touch the heart you’ll seek EKG changes. Put the
needle through the pericardial sac. Pull out the blood. It’ll be dark and very liquid. When you’ve
done this, the guy should improve.

Another cause of obstructive shock is tension pneumothorax. The chest is filling up with air, leaving
no room for the lungs to expand and the heart to beat. You can get this from a ruptured lung or
from a sucking chest wound.

Ruptured lungs. Gotta love ‘em. You see this with “paper bag syndrome.” The guy sees the tree
approaching the nose of his car. He reflexively takes a deep breath and holds it—then his chest hits
the steering wheel. Should have been wearing his seatbelt.

Tension pneumothorax is bad — you can tell you’ve got that because you have an injury to the
chest, absent lung sounds on one side, diminishing lung sounds on the other, and the trachea
moving (tracheal deviation — it isn’t just for breakfast any more!) away from the injured side
toward the uninjured side. That’s happening because the contents of the chest are all moving over
toward the uninjured side, smushing them, and the trachea is attached to the stuff that’s moving.
Plus, the patient is CTD and you’ve already fixed everything else that you’ve found. Oh — and it’s
getting increasingly difficult to ventilate the patient with a BVM. (BVM is not only the Blessed Virgin
Mary. It’s also a Bag Valve Mask, used for artificial ventillation. Sometimes called an Ambu Bag
because they’re made by the Ambu company.)

Tracheal deviation is a late sign. How to look for it: Put your thumb and forefinger on either side of
the patient’s windpipe and trace it down. The trachea should be vertical. Shifting to right or left is
bad. If the trachea shifts toward the injured side, it’s simple pneumothorax, which is merely bad. If
the trachea is shifting away it’s tension pneumothorax, which is Bad.

One thing to do (and again, this is high-level EMS-fu, don’t try it at home): Needle decompression:
Put a big-ass needle through the chest wall just above the third rib on the mid-clavicular line. Wait
for a nice gush of air and the patient’s condition to improve. This is what we call “an invasive
procedure.” If the guy didn’t have an open pneumothorax before he does now.

In practical terms, get a large-bore IV catheter. Snip the tip off one of your spare latex gloves. Shove
the needle through the tip of that cut-off finger (this will form a one-way valve). Find the space
between the second and third ribs. (Here’s how: Find the suprasternal notch (the little dished out
bit at the top of the breastbone at the neck, centerline). Trace down to the Angle of Louis, which is
the bump you feel as you run your finger down the sternum. That marks the gap between the 2nd
and 3rd ribs. (You can’t count ribs directly because the clavicle overlies the first rib.) Now trace the
space between the ribs at that level over toward the injured side to the mid-clavicular line (the
vertical line that bisects the collarbone), and stick the needle with its little glove-tip through into
the the chest. If everything is working right, you get a rush of air, and the patient improves. You
want to go on the top of the rib rather than the bottom of the rib, because there’s a little costal
artery and a nerve that run along the bottom edge and hitting them would be bad.

If you don’t have the needle, and the training (or better still, a chest tube), the quick hold-what-
you’ve-got fix is to roll the guy onto his injured side and let gravity help keep the uninjured side
open.

Another cause of Obstructive Shock is Pulmonary Embolism (PE).

For Pulmonary embolism check the ABCs: Adios, Buy Flowers, Call the Coroner.

Actually, seriously, a PE is a blockage in the pulmonary artery that is bringing blood through the
lungs to pick up oxygen. Lots of things can block that blood vessel: a blood clot that’s broken loose
(which is why DVT (Deep Vein Thrombosis) is so dangerous; that’s what kills people who’ve been
sitting in one position for a long time (for example on a long air flight in a cramped position, or
when attached to a cell wall with handcuffs at Abu Ghraib)—a clot forms due to sluggish
circulation, then breaks free, travels through the Vena Cava (a big vein), through the right side of
the heart (still large-bore) then into the pulmonary artery, where the diameter of the blood vessels
get smaller and smaller until at some point it’s too small to pass the clot. Other things that might
form emboli include fat, marrow from broken bones, air, and little bits of plastic from very bad
technique when you’re starting your IVs.

With blood blocked from dumping carbon dioxide and picking up oxygen, bingo, there you are in
hypoperfusion. Shock.

What to do about it? Provide oxygen so that if any part of the lungs is getting blood flow around the
aveoli that it’s oxygen rich there, and get your patient to the hospital.
Now that we’ve lightly touched on Obstructive shock, time to move on to Distributive shock. Oxygen
is getting to the blood, the heart is beating, but the oxygen isn’t getting distributed to the organs.

First up is Neurogenic shock.

As you know, Bob, the veins and arteries have layers of muscle that are under control of the
autonomic nervous system, to change their diameters and thus control exactly where the blood
goes. If the body loses that ability to constrict the blood vessels and they fully relax, there just isn’t
enough blood to fill all those miles and miles of veins and arteries and venules and arterioles and
capillaries and so on. You might as well have that pool of blood on the ground, because there isn’t
enough fluid to move oxygen and nutrients to the vital organs. You get this if the spinal cord is
disrupted, or in certain disease conditions.

You can tell you have neurogenic shock because the patient has the classic signs of shock (pale,
sweaty, cold) above a horizontal line on his body, but below that line he’s all warm, pink, and dry.
You’re also looking for mechanism of injury: did he get hit in the spine? Also, in males, he has a
raging erection. This is the ever-popular priapism (named for King Priapus, who apparently had it),
a Bad Sign. (The blood vessels below the injury have fully relaxed, and that’s blood pooling in those
open veins and arteries.) This may be part of why the Marquis de Sade thought that hanging was
the most sensual way to die. The trauma to the spine puts the person into neurogenic shock.

Very similar in most respects is Psychogenic shock. That’s when the Publisher’s Clearing House
Prize Patrol arrives at your door, gives you a check for ten million dollars, and you faint. What’s
happened there is again your nervous system not controlling the blood vessels, the vessels dilating,
and oxygen no longer reaching your organs. The brain being most sensitive to lack of oxygen you
pass out and down you go.

Psychogenic shock is self-limiting. Once you’re unconscious your autonomic nervous system checks
back in and gets oxygen back to your brain.

At an accident scene you can’t tell if your patient is in psychogenic shock because his new Beemer is
now junk, or he’s in hypovolemic shock because he’s bleeding out into his pelvis, so you treat ‘em
the same.

You don’t generally see toxic shock (aka septic shock) or anaphylactic shock on trauma scenes,
except maybe Granny fell down the stairs because that urinary tract infection got to her, or maybe
the reason Fred crashed was because he was stung by a bee and he’s allergic. In both toxic and
anaphylactic shock the root cause is the blood vessels getting porous and allowing fluid to dump
into the intercellular space, not leaving sufficient to move the red cells around to perfuse the
organs.

Similarly for cardiogenic shock — having a heart attack can make someone fall in the shower.

I haven’t touched on asphyxia (a kind of obstructive shock) or diabetic shock (distributive) or many
other things. I did talk about diabetes in general elsewhere.

What to do about this?

First, assume that your patient is going to go into shock if he isn’t there already. Once the patient
starts to slide it’s awfully hard to get back up the slope, so start treating for shock early, before any
signs or symptoms develop.

To treat for shock, get the patient lying down. A person in shock can’t control body
temperature well, so wrap the patient in a blanket (under them as well as over them). Raise
the patient’s feet twelve to eighteen inches. Provide oxygen if you have it. Establish two large-
bore IVs in the best, most proximal veins you can find. Stay with the patient, hold their hand, talk
to them.
Do all of these things for any variety of shock and you will be doing well.