William W. Forgey, MD
ASSESSMENT AND STABILIZATION part 2 of 3 Shock /Difficult Respirations / Airway Obstruction / CPR
Updated: Nov 12, 2020
Excerpt from The Prepper's Medical Handbook. Page reference numbers point to more in-depth treatment and self-reliant care available within the book.
Shock is a deficiency in oxygen supply reaching the brain and other tissues as a result of decreased circulation. An important aspect in the correction of shock is to identify and treat the underlying cause.
Shock can be caused by burns, electrocution, hypothermia, bites, stings, bleeding, fractures, pain, hyperthermia, high altitude cerebral edema, illness, rough handling, allergic reaction (anaphylaxis), damage or excitement to the central nervous system, dehydration from sweating, vomiting, or diarrhea, or loss of adequate heart strength. Each of these underlying causes is discussed separately in this text.
Shock can progress through several stages before death results. The first phase is called the compensatory stage, during which the body attempts to counter the damage by increasing its activity level. Arteries constrict and the pulse rate increases, thus maintaining the blood pressure. The next phase is called the progressive stage (or decompensatory stage), when suddenly the blood pressure drops and the patient worsens, often swiftly. When he has reached the irreversible stage, vital organs have suffered from loss of oxygen so profoundly that death occurs even with aggressive treatment.
Consider the possibility of shock in any victim of an accident or when significant illness develops. Ensure that an adequate airway is established (see further discussion under Adult One-Rescuer CPR, page 17). Assess the cardiovascular status. Place your hand over the carotid artery (figure 2-1) to obtain the pulse. In compensatory shock the patient will have a weak, rapid pulse. In adults the rate will be over 140; in children, 180 beats per minute. If there is doubt about a pulse being present, listen to the bare chest. If cardiac standstill is present, begin one-person or two-person CPR (see pages 17–20). Elevate the legs 45 degrees to obtain a better return of venous blood to the heart and head. However, if there has been a severe head injury, keep the person flat. If he has trouble breathing, elevate the chest and head to a comfortable position. Protect the patient from the environment with insulation underneath and shelter above. Strive to make him comfortable. Watch your spoken and body language. Reassure without patronizing, and let nothing that you say or do cause him increased distress.
Attempt to treat the underlying cause of the shock. The primary or secondary assessment and history may well elicit the cause of shock, and appropriate treatment can be devised from the fieldexpedient methods listed in this book.
Shock due to severe allergic reactions is called anaphylactic shock and is discussed on page 193.
Vasovagal syncope is a common form of shock. Sometimes called fainting, the clue is a very slow heartbeat in the patient. Generally something has happened to the patient that precipitates this reaction, such as witnessing blood loss in herself or another person, receiving an injection (or even witnessing someone else receiving one), or perhaps attending one of my medical lectures. (See slow heart rate, page 25.)
It has been stated that you can live three minutes without air, three days without water, three weeks without food, and three months without love. While some feel that they may stretch any of these time limits to four, others feel they could survive only the shorter periods. Without any question, adequate respirations are the most significant demand of the living creature. When respiratory difficulties start, it’s urgent to find the reason and alleviate it. When breathing stops, reestablishing airflow is critical.
FOREIGN BODY AIRWAY OBSTRUCTION
If a conscious adult seems to be experiencing distressed breathing, ask, “Are you choking?” A choking victim cannot talk but may be making a high-pitched sound during
attempts to breathe. He or she will rapidly become a bluish color and unconscious if the blockage is total. If the victim is apparently choking, perform an abdominal thrust to relieve foreign body airway obstruction. If the victim is standing or sitting, stand behind and wrap your arms around the patient, proceeding as follows: Make a fist with one hand. Place the thumb side of the fist against the victim’s abdomen, in the mid- line slightly above the navel and well below the breastbone. Grasp your fist with the other hand. Lift your elbows away from the victim’s body and press your fist into the victim’s abdomen with a quick upward thrust. Each new thrust should be a separate and distinct movement. It may be necessary to repeat the thrust multiple times to clear the airway.
If the person is obese or pregnant, use chest thrusts in the same manner as described, but place your arms around the lower chest and your fists on the center of the victim’s sternum.
If the victim becomes unconscious and is on the ground, she should be placed on her back, face up. In civilization and on the grid, you would activate the emergency medical services (EMS) system by calling 911. Perform a tongue-jaw lift, open the mouth, and remove any visible objects. With the airway open, try to ventilate. If still obstructed, reposition the head and try to ventilate again. If still obstructed, give 30 chest thrusts, followed by 2 attempts to ventilate as described above. Each time you open the mouth to ventilate the victim, check for a visible obstruction and remove it if you see one. Repeat these steps until effective.
ADULT ONE-RESCUER CARDIOPULMONARY RESUSCITATION (CPR)
Note: This brief presentation of the basics of CPR reflects research indicating the importance of immediately reestablishing circulation via chest compressions. If you are without training in rescue breathing, you may choose to perform hands-only CPR.
To establish unresponsiveness, first try talking—clearly and loudly—to the victim, asking questions such as “Are you OK? Can you hear me?” If there is no response to your verbal contact, make gentle physical contact by touching the victim’s shoulder and repeating your questions. If gentle contact fails, apply a painful stimulus, such as a pinch to the back of the arm. If the patient remains unresponsive, in civilization, activate the EMS system (call 911) prior to attempting CPR. Off the grid immediately proceed with the following steps.
Check for signs of circulation that include coughing, breathing, or movement. If you have been trained, you may also check for a carotid pulse. This is found by placing your hand on the voice box (larynx). Slip the tips of your fingers into the groove beside the voice box and feel for the pulse (see figure 2-1). Check for circulation for a maximum of 10 seconds.
If the victim is unresponsive with no signs of circulation, start chest compressions.
Chest compressions are performed by the rescuer kneeling at the victim’s side, near his chest. Place the heel of one hand on the center of the sternum. Place the other hand on top of the one that is in position on the sternum (see figure 2-3).
Be sure to keep your fingers off the ribs. The easiest way to prevent this is to interlock your fingers, thus keeping them confined to the sternum. With your shoulders directly over the victim’s sternum, compress downward, keeping your arms straight. Depress the sternum at least 2 inches. Relax the pressure completely, keeping your hands in contact with the sternum at all times, but allowing the sternum to return to its normal position between compressions. Both compression and relaxation should be of equal duration.
Perform 30 external chest compressions at a rate of at least 100 per minute. Push down hard, and push down fast.
Open the airway using the head-tilt/chin-lift or jaw-thrust technique (see figure 2-4).
Place one hand on the victim’s forehead and apply firm backward pressure with the palm to tilt the head back. Place the fingers of the other hand under the bony part of the lower
jaw near the chin and lift to bring the chin forward and the teeth almost shut, thus supporting the jaw and helping to tilt the head back, as indicated in figure 2-4. In case of a suspected neck injury, use the chin-lift without the head-tilt technique. The nose is pinched shut by using the thumb and index finger of the hand on the forehead.
The chin-lift method will place tension on the tongue and throat structures to ensure that the air passage will open.
If breathing is absent, give 2 slow breaths (about 1 second per breath), watching the chest rise, then allow for exhalation between breaths. The breathing rate should be once about every 6 seconds. Using slow breaths reduces the amount of air that tends to enter the stomach and cause gastric distention.
After 5 cycles of 30:2 compressions and ventilations (lasting about 2 minutes), reevaluate the patient. Check for the return of circulation. If it is absent, resume CPR with 30 compressions followed by 2 breaths, as indicated above. If it is present, continue to the next step. Check breathing. If present, monitor breathing and pulse closely. If absent, perform rescue breathing at 1 breath about every 6 seconds and monitor pulse closely.
If CPR is continued, do not interrupt CPR for more than 5 seconds except in special circumstances. Once CPR is started, it should be maintained until professional assistance can take over the responsibility, or until a physician declares the patient dead.
If CPR has been continued for 30 minutes without regaining cardiac function, and the eyes are fixed and nonreactive to light, the patient can be presumed dead. The exceptions would be hypothermia (see page 247) and lightning injuries (page 261). In these circumstances, if professional help does not intervene, CPR should be continued until the rescuers are exhausted.
Some authorities in remote-area rescues feel that the survival rate is very low without defibrillation within 4 minutes by paramedics, and that CPR should not be started when cardiac standstill is due to a heart attack. It certainly should not be started or maintained under these conditions when its performance might endanger the lives of members of the rescue party. Regardless, CPR is an important skill that every person should master. The only way to learn this technique is to take a CPR course—it cannot be properly self-taught.
ADULT TWO-RESCUER CPR
The two-rescuer technique differs in that Rescuer One will take a position by the head and Rescuer Two assumes the position as described under one-rescuer CPR (page 17).
After establishing unresponsiveness (and activating the EMS system if in civilization) and finding no signs of circulation, Rescuer Two begins chest compressions with his hands on the center of the patient’s sternum, at a rate of at least 100 compressions per minute, and compressing the chest at least 2 inches with each compression.
After 30 compressions, Rescuer One opens the airway (head- tilt/chin-lift or jaw-thrust), takes a quick look for obstructions and removes any that are visible, and then gives 2 breaths of about 1 second each. After 5 cycles of 30:2, the two rescuers may switch places if one rescuer is experiencing fatigue.
Two-person CPR is not generally taught to the public in basic courses to avoid confusion. However, off the grid where prolonged CPR might be necessary, being familiar with this technique can help alleviate the tremendous fatigue that CPR induces in rescuers.