Is there any reliable sign of shock at the pre-hospital?

[oferzern]

hello to all,

my name is Ofer and I'm a medic from Israel, and this is my first thread here, so I hope that this is the right place.

I'm searching for some reliable sign of shock at his early stages, while he might be still compensated shock.

After reading the PHTLS I've noticed that I can only know for sure that my patient is in the shock condition after his hypotesive or/and tachycardi about 140 HR - when he is at the uncompensated shock (class 3 as the PHTLS define) but I'm looking for earlier signs.

I'm looking for some sign that will help me to notice the shock as soon as possible, while at start the BP will will be normal or increased and HR at start will be little tachy about 100-120, but this also occurs due to sympathetic activity that happens after a road accident for example.

so, is there any reliable sign of shock at the prehospital? that also rely of some researches or even your experience?

It not must be for all types together - if there is any good sign to look for in any type is also good.

thank you all!

ofer.

 

[OregonEMT]

With compensated shock you will see restlessness, anxiety and sometimes a look of impending doom. The "shift" from compensated to decompensated is usually a major LOC change. Remember that patients will present with different signs and symptoms, although these are pretty common signs I have personally seen in my hemorrhagic shock patients.

 

[teedubbyaw]

With compensated shock you will see lethargy, restlessness and sometimes a look of impending doom. The "shift" from compensated to decompensated is usually a major LOC change. Remember that patients will present with different signs and symptoms, although these are pretty common signs I have personally seen in my hemorrhagic shock patients.

Decompensation is where BP drops. LOC is not a reliable indicator.

 

[OregonEMT]

Decompensation is where BP drops. LOC is not a reliable indicator.

What generally happens when someones blood pressure tanks? A sudden loss of consciousness in hemorrhagic shock is a good indicator that the patient is entering compensated shock. These are signs/symptoms I have personally seen in the field.

 

[mycrofft]

Before the compensated shock stage sets in, think about the severity of the insult, the nature of the insult, and the systems affected. Some insults (I take it we are largely talking about wounds here) are just going to cause shock. Depth and location and mechanism (burn versus shrapnel versus bullet versus closed fracture etc etc) and a knowledge of anatomy will help you think and target assessments for potential oncoming trouble.

Some individuals are more prone to shock. Basic physical condition (nutrition, other illness or injury, lactating or pregnant, age, etc) can make you more prone to enter shock.

Individuals who are afraid and upset at the concept of being wounded (versus just experiencing pain and physical damage) are more likely. (In my unscientific experience, though, if the pt can scream and shout and beg in an organized manner, they tend not to be as severely damaged, albeit still deserving of prompt care and attention).Those who are not exhibiting the usual responses may actually be entering shock already.

Dr Ziv Ayel (spelling?) of Hadassah Medical Center taught us about "triage of time", wherein the time elapsed since injury tends to wean out the most injured through death during transport. It also will show who is going into shock as well, and not in a good way. Keep re-assessing and have measures planned in case things don't go well.

 

[mycrofft]

What generally happens when someones blood pressure tanks? A sudden loss of consciousness in hemorrhagic shock is a good indicator that the patient is entering compensated shock. These are signs/symptoms I have personally seen in the field.

I've seen both, and certainly LOC before shock sets in. I've seen LOC tank just as they clinically died, no really perceptible (well, no clinically useful presentation of) "compensated shock" due to the nature of the insult.
And consciousness can be tricky to assess with an anxious, excruciating, maybe medicated pt. We had a woman answering questions about her self with "yes/no" minutes before expiring from a lacerated descending aorta, but her LEVEL of consciousness was not sufficient to get more than that.

 

[OregonEMT]

I've seen both, and certainly LOC before shock sets in. I've seen LOC tank just as they clinically died, no really perceptible (well, no clinically useful presentation of) "compensated shock" due to the nature of the insult.
And consciousness can be tricky to assess with an anxious, excruciating, maybe medicated pt. We had a woman answering questions about her self with "yes/no" minutes before expiring from a lacerated descending aorta, but her LEVEL of consciousness was not sufficient to get more than that.

I agree, it can be difficult to differentiate which stage of shock your patient is in based on presenting signs and symptoms. Especially on scene!

 

[STXmedic]

POC Lactate monitoring is gaining favorability prehospitally as a shock indicator.

 

[mycrofft]

Physiology is probably the only certain indicator.

The term compensated shock I find odd in the clinical sense. If you are not exhibiting signs and symptoms of shock then you are not in shock. Physiologically I can see that, although I am not precisely sure what that picture might be (maybe cortisol and epinephrine levels etc?).

We try to slice things up and categorize them, but if the boundaries are too blurred in real life, perhaps they need to be looked at again. Maybe rejected.

 

[oferzern]

First thank you all for your answers!

While reading the answers I returned to the PHTLS book to read if there is additional information the can Strengthens the individual experience, and I've found some things:

As OregonEMT wrote – about the LOC at patients with hemorrhagic shock – the PHTLS describe the same and says that at start the patients will be slightly anxious (class I) and as the shock state continues the patients will become more anxious and confused (class II + III), and at the class IV – he will become lethargic. So is it a good sign to rely on when there is a situation and injury that leads me as the EMT on scene to suspect of hemorrhagic shock? Regarding that my patient has isolated injury – I can assume it fast sometimes, but – while my patient injury involves also head injury, or maybe at his normal condition he is having some CNS disease that makes his LOC altered – I can't rely on that sign. (I can say that at situation with isolated injury it will be more clearly to assume the patients in shock at early stage)

But eventually, as mycrofft said – at the comprehensive shock there will be no signs of shock, and the shock signs will be at the decomprehensive shock – BP drops for sure.

Continues with physiology understanding and the scene analyzing with the right and fast conclusions, and with the look over your patient, you can assume what kind of shock he could be by knowing the injury mechanism and physiology, the EMT at scene can assume what type of shock the patients will might be, if he is developing some shock. For example, patients having Tension Pneumothorax and his BP drops I know he is now might be at the cardiogenic shock because I know what will happen if not well treated, but even when treated well for this injury – he could also bleeding inside his body.

So and after that I will know that my patient is in shock (BP drops), all I left to understand is how he got into the shock state by understanding the injury mechanism.

At the end, thinking while writing it all- the EMT experience might be his only tool to assume patients in his early stages of shock?

I'm not looking for 100% knowing what kind of shock my patient is, but just knowing that the patient is in shock and sooner than the decomprehensive shock state, and not only for the hemorrhagic shock, but also for the distributive and cardiogenic shock as well.

 

[Handsome Robb]

Persistent tachycardia is a good indicator or early shock. Like you said it's normal to see a response like this after a traumatic injury but with calming and time it should resolve. When it doesn't you need to consider that there's something else to it. Hypertension can also be indicative of the early stages of shock secondary to the body's natural compensatory mechanisms. Catecholamines are dumped into the system, heart rate increase, vessels vasoconstrict and you can see these hypovolemic patients present as hypertensive and tachycardic.

Even with a patient with an altered LOC from a chronic neurological pathology you can use their men ration, provided you have someone on scene who can relay what is normal for them but it definitely is more difficult. With a multi system trauma where you suspect a traumatic brain injury mentation isn't reliable for reasons already stated.

Skin signs are a very good indicator of a patient's perfusion status although you won't generally see them until they start to decompensate and shunt their remaining volume towards their core.

Recent research is showing that we're too aggressive with fluid resuscitation in trauma cases and it had a negative affect on outcomes. Rather than BP look at the MAP and have a goal of 60-65, the BP numbers might looks scary but massive saline infusions don't help the clotting cascade and can "blow out" clots that have already formed and worsen the situation.

 

[UnkiEMT]

First, let me say that I have little to add to the discussion, I think the responses so far have been both accurate and cogent.

Then:

Dr Ziv Ayel (spelling?) of Hadassah Medical Center taught us about "triage of time"

Aa an aside: I love that phrase, it's now competing in my brain for the title of "Favorite EMS phrase" with 'Injuries incompatible with life'.

The term compensated shock I find odd in the clinical sense.

I'd always just accepted the phrase at it's face value, never really subjected it to critical thinking, but you're right, if we accept the definition of shock of "inadequate perfusion", then logically, if the body is compensating, the perfusion is maintained, and shock doesn't exist. I would argue, however, that this is a lexical failure rather than a conceptual one.

There are conditions which we know will lead to shock, to pick the easy one, massive hemorrhage. We know that the pathophysiology of that process which, if it is not halted, inevitably leads to shock, no ifs, ands or buts, there is, however, a period during which the body has the ability to compensate for the progress of the process to that point, which lexically we call "compensated shock", even though were we to parse the phrase individually, it is patently incorrect. When we treat the phrase as a cohesive unit of the lexicon that we learn in basic school, it is accurate.

I know that at best, I'm discussing tangents to the main discussion, and at worst I'm tromping through the daisy fields all on my own, but, well, it's my birthday (or it was), I'm not working (for once), I'm drunk (off my ***), and I think this is an interesting point (probably only because I'm drunk.).

 

[mycrofft]

Persistent tachycardia is a good indicator or early shock. Like you said it's normal to see a response like this after a traumatic injury but with calming and time it should resolve. When it doesn't you need to consider that there's something else to it. Hypertension can also be indicative of the early stages of shock secondary to the body's natural compensatory mechanisms. Catecholamines are dumped into the system, heart rate increase, vessels vasoconstrict and you can see these hypovolemic patients present as hypertensive and tachycardic.

Even with a patient with an altered LOC from a chronic neurological pathology you can use their men ration, provided you have someone on scene who can relay what is normal for them but it definitely is more difficult. With a multi system trauma where you suspect a traumatic brain injury mentation isn't reliable for reasons already stated.

Skin signs are a very good indicator of a patient's perfusion status although you won't generally see them until they start to decompensate and shunt their remaining volume towards their core.

Recent research is showing that we're too aggressive with fluid resuscitation in trauma cases and it had a negative affect on outcomes. Rather than BP look at the MAP and have a goal of 60-65, the BP numbers might looks scary but massive saline infusions don't help the clotting cascade and can "blow out" clots that have already formed and worsen the situation.

Like he says.

Quality of pulse is apparently not taught anymore either. If a rapid pulse is palpable, is it fast, regular and strong (normal response) or fast and weak (starting to decompensate)? This does not replace a blood pressure and apical pulse(or taken with an EKG machine; don't use a pulse oximeter), but especially if you are swamped with casualties a five or ten second look over while taking pulse and listening/watching respirations may key you in to who is doing well (not that they won't go bad) and who is going down.
Cool and quiet=deep trouble.

 

[mycrofft]

First, let me say that I have little to add to the discussion, I think the responses so far have been both accurate and cogent.
Then:
Aa an aside: I love that phrase, it's now competing in my brain for the title of "Favorite EMS phrase" with 'Injuries incompatible with life'.

I'd always just accepted the phrase at it's face value, never really subjected it to critical thinking, but you're right, if we accept the definition of shock of "inadequate perfusion", then logically, if the body is compensating, the perfusion is maintained, and shock doesn't exist. I would argue, however, that this is a lexical failure rather than a conceptual one.

Dr Ayel was speaking to a bunch of us at Scott AFB's airevac reception hospital in 1985, bringing his perspective from experience in the Six Day War (1967), the Yom Kippur War (1974) and sundry attacks since. He also said "Make sure you minimize hard walls in your emergency departments" to allow for fluid movement of patients.

Conceptual versus lexical: we think what we speak. Man is a categorizing/naming animal and we must subdivide big issues to understand and teach them; these divisions are not set in stone and sometimes just wrong. (E.G., anatomic divisions between infant, child and adult CPR).

 

[Handsome Robb]

Like he says.

Quality of pulse is apparently not taught anymore either. If a rapid pulse is palpable, is it fast, regular and strong (normal response) or fast and weak (starting to decompensate)? This does not replace a blood pressure and apical pulse(or taken with an EKG machine; don't use a pulse oximeter), but especially if you are swamped with casualties a five or ten second look over while taking pulse and listening/watching respirations may key you in to who is doing well (not that they won't go bad) and who is going down.
Cool and quiet=deep trouble.

They still teach it but I'm not sure how much I trust it but n=1. The reason being is I've had plenty of patients with normal or even high BPs that I could not find or could only faintly feel a radial pulse. After two and a half years I'm pretty confident in my ability to locate the correct anatomic location to palp for it too but I have been wrong in the past

 

[oferzern]

They still teach it but I'm not sure how much I trust it but n=1. The reason being is I've had plenty of patients with normal or even high BPs that I could not find or could only faintly feel a radial pulse. After two and a half years I'm pretty confident in my ability to locate the correct anatomic location to palp for it too but I have been wrong in the past

Here in Israel, when I first learned about shock (2006), I have learned that by monitoring the pulse I can understand that if my patient shock state is getting worse - just by measuring pulse constantly and if he goes faster with several measures I know my patient getting worse.

And I've just go with it, as I were at age 15. but now, after seeing some patients and having a better knowledge about all the physiologic and pathologic of shock, and while I got the option to teach people without medical background, and let them have their wish to become medics, I started digging even dipper than I did till now (and I'm also a medic so I still have a lot to learn) by searching about shock researches online, and talk to paramedics here in Israel, and even this forum.

And after I read and analyzed each opinion and field experience of all together, and also looked back again each time to the PHTLS and Mosby, I've found that there is no reliable sign of shock at early stages, which I'm looking for weeks, and at the end the shock state will show itself only when the BP is dropping, and tachycardia over 140, tachypnea over 30 and my patient at his de-comprehensive shock.

The pulse, as roob also said:

Persistent tachycardia is a good indicator or early shock. Like you said it's normal to see a response like this after a traumatic injury but with calming and time it should resolve. When it doesn't you need to consider that there's something else to it.

As I learned (and please correct me if I'm wrong) that elevated BP and tachycardia from sympathetic state will pass 10 to 15 min, from the moment someone has started to relax and treat the patient.

And here, when I called to some road car accident, and I at the scene evaluating the kinematics and see that nothing can go good from now, (E.G from real life - man who while crossing the road got hit by truck driving 40-50 km per hour), I won't wait with him too long at the field, and rush as fast as I can to nearest hospital - which I have trauma A level hospital at each direction I would choose - five to ten minutes driving. So I don't have much time to monitor that patient pulse and to see if he is persist itself after calming the patient, or not.

I can see little bit of change if the hemorrhage is significant enough to show me the signs with 5-10 minutes driving.

But, it will show me the pulse if my patient is healthy man - let's say that the patient is taking beta-blockers - I won't see any faster pulse. Or if he just has cardiac shock and suffering from Bradycardiac arrhythmia?

There are so many things that as EMS I have to ask my patient, and make the whole puzzle parts together individually for each one of my patients. because at start I won't watch the shock patient, I will watch a patient who might be soon at the de-comprehensive shock, what I need to understand after asking myself all the right questions and have the physiologic and pathologic knowledge to get all those little pieces together for a solid conclusion that I'm might watching patient who is at my assessment about to develop, or even now develops the shock.

And won't we forget the other types of shock, not only the hemorrhagic who is the most common one at the field, how about the distributive and cardiogenic shock? So I have to consider them too, and add them to my puzzle.

So as I critical thinking - the variety of people and knowing each one of us will react differently to the same injury, at the end there isn't any good sign to shock while the body continues to compensate – even when I tried to look for separately at each type of shock – I haven't found any.

 

[mycrofft]

They still teach it but I'm not sure how much I trust it but n=1. The reason being is I've had plenty of patients with normal or even high BPs that I could not find or could only faintly feel a radial pulse. After two and a half years I'm pretty confident in my ability to locate the correct anatomic location to palp for it too but I have been wrong in the past

I see your point. The pulse thing is certainly not scientifically justified, more on the "art" end, but if it's crazy noisy, you don't have your stethoscope, wild bleeders or quiet people with holes in their heads coming in, it can give you SOME means of starting to sort things out. The key is to keep rechecking.

The pulse ox thing I'm adamant about, though. You will be short of them in a push, they're all beeping and running down, and their software does not encompass pulse affects of pathology or trauma.

 

[mycrofft]

So as I critical thinking - the variety of people and knowing each one of us will react differently to the same injury, at the end there isn't any good sign to shock while the body continues to compensate – even when I tried to look for separately at each type of shock – I haven't found any.

No magic sign. Know the anatomy, do good assessments, and KEEP RECHECKING AND RECORDING. You'll spot shock.

 

[Handsome Robb]

I see your point. The pulse thing is certainly not scientifically justified, more on the "art" end, but if it's crazy noisy, you don't have your stethoscope, wild bleeders or quiet people with holes in their heads coming in, it can give you SOME means of starting to sort things out. The key is to keep rechecking.



The pulse ox thing I'm adamant about, though. You will be short of them in a push, they're all beeping and running down, and their software does not encompass pulse affects of pathology or trauma.

I will agree with that.