WMI Case Study:
Shock vs. Stress

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Assessment

· Due to the mechanism of injury, this is a possible spine injury.

· Possible head injury.

· Possible shock.

· Possible internal injury.

· Abrasions on left upper back.

Plan

· Perform focused spine assessment.

· Patient has been log rolled onto a sleeping pad. She is in a sleeping bag with legs elevated 8”. We will try to calm her down, get her to drink some water, and monitor vital signs.

· Reassess for s/s of internal and head injury.

· Clean and dress the abrasions.

· Develop a plan for evacuating the patient.

Anticipated problems

· Internal Bleeding

· Developing shock.

· Developing spinal cord injury.

Comments

With this mechanism of injury we have to consider shock, an internal injury, and possible spine injury. It’s tempting to rule out a spine injury because the patient was seen running a short distance, but people can do amazing things when reacting to stress, and it’s not beyond the realm of possibility that she could have hurt her spine and still be up moving around.

It looks like she got through this without any long bone or pelvic fractures, but we still need to worry about an internal injury, especially with s/s indicating shock that is not explained by any other obvious injury. There is also an MOI for a head injury, but no indication of this; no loss of responsiveness, altered mental status or head wounds. We’ll keep our eye on this nonetheless.

A patient in shock has a rapid pulse rate that may feel weak, irregular, and "thready." The skin is pale, cool, and clammy. These signs and symptoms are a product of our "fight or flight" response; our body's response to danger. One product of this response is the release of adrenaline from glands located just above the kidneys. This hormone has the effect of increasing heart rate and respiratory rate, causing the skin to pale and sweat, and causing nausea and restlessness. Blood is routed away from the digestive tract and concentrates around the muscles and essential organs. These changes pump the blood faster, reduce the size of the blood vessels, and route the blood to essential organs, possibly enabling the body to compensate for the shock.

Most people, when frightened, injured, or ill, have a "fight or flight" response. Sometimes this is called an acute stress response. Your heart beats strong and fast; you sweat, become pale, and feel nervous. If you're not seriously ill or injured and your circulatory system is healthy, this response should abate in short order. The heart rate slows, you relax, and the skin returns to its normal color. When you measure a series of vital signs over time, you may see this initial acute stress diminish as you recover from the initial fright. If the circulatory system is unable to adjust, a downward spiral of deterioration may begin in which first tissues, then organs, and finally entire systems fail from lack of oxygen.

Orthostatic vital signs refer to our ability to compensate from changes in position and the effect gravity has on our cardiovascular system between lying flat and standing. Healthy people make these position changes with little or no problems. People in shock may not react well to the position change. We use orthostatic vital signs to help find patients with low volume status who don’t have obvious s/s of shock. To measure orthostatic vital signs test the patient by waiting 2 minutes with the patient supine, then stand the patient and wait 1 minute before measuring vital signs. An intermediate sitting position is not helpful. A positive test is an HR increase of 30 beats/min or more in adults, or the presence of neurological symptoms (e.g. dizziness, syncope).

Treatment

Over the next 45 minutes, you and your friend talk over the evacuation possibilities and sketch out a plan in the event the patient can’t walk. You’re a long way in and even if your cell phone call works, it looks like it may be dark, or tomorrow morning, before help will arrive.

Under your calming influence the patient becomes less anxious. You gather another set of vital signs and don’t find anything new to report. You decide to perform a focused spine assessment. The patient is A+Ox4, is sober, is not distracted, has good CSM in all four extremities, and denies any spine pain or tenderness upon you second palpation. You confer with your friend and you both agree your can release control of the spine.

Realizing you can now try an orthostatic vital sign test you help the patient stand. She is a bit dizzy, but this quickly resolves. Her HR does not change and she says she feels ok. This negative Orthostatic Vital Sign change is welcome news. In fact, her only complaint is a sore and abraded shoulder. This is another indication she dodged a bullet and doesn’t have any major injuries.

The End of the Tale

She wants to look for her horse. You want to clean the abrasions and monitor her condition – after all, it was a spectacular horse wreck. The compromise presents itself when the horse wanders back into the meadow, and you can take care if it while your friend cleans the abrasions. Although very sore, the rider is able to walk, and she is seems to be physically well. You take her to your camp where she makes a cell phone call home telling her folks not to worry, she will be out tomorrow. Not wanting to wait, her parents load the contents of her surprise graduation party onto the pack animals. That night you and twenty new friends dine surf and turf style under the stars. Lobster anyone?

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