Page 46 - 2021 Advanced Ranger First Responder Handbook

Shock Management
Hypotensive Resuscitation
The employment of Hypotensive Resuscitation is meant to avoid over-resuscitation of shock. Basing the titration of
fluids upon a monitored physiologic response may avoid the problem of excessive blood pressure elevation and fatal
re-bleeding from previously clotted injury sites.

Shock Assessment
Important information can be rapidly obtained regarding perfusion and oxygenation from the level of consciousness,
pulse, skin color, and capillary refill time. Mental status is the most important indicator of shock. Decreased brain perfu-
sion may result in an altered mental status. The patient may progress from anxious to confused to unresponsive. Beware
of the patient with an impending sense of doom. The patient’s pulse is easily accessible, and if palpable, the systolic
blood pressure in millimeters of mercury (mmHg) can be roughly estimated as follows:
RADIAL PULSE: PRESSURE 80mmHg
FEMORAL PULSE: PRESSURE 70mmHg
CAROTID PULSE: PRESSURE 60mmHg
It is important to state, that the above pressure ranges are merely quick estimates of systolic blood pressures
and are generally OVERESTIMATED and inaccurate. They are to be used during the rapid initial assessment of
a trauma patient. Actual blood pressure measurement and a complete patient assessment should direct your
trauma and shock management decisions.
Skin color and capillary refill will provide a rapid initial assessment of peripheral perfusion. Pink skin is a good sign versus
the ominous sign of white or ashen, gray skin depicting hypovolemia. Pressure to the thumb nail or hypothenar eminence
will cause the underlying tissue to blanch. In a normovolemic patient, the color returns to normal within 2 seconds. In the
hypovolemic, poorly oxygenated patient and/or hypothermic patient, this time period is extended or absent.
The classic classes of shock are inaccurate and misleading but are often referred to in trauma literature. Ranger medics
and ARFRs should consider mechanism of injury, mental status, pulse, and other signs when making decisions on triage,
treatments, and evacuation priority.
The following table is provided for educational purposes only and should not be relied upon.

Estimate of Fluid and Blood Requirements in Shock*
Class I Class II Class III Class IV
C Blood Loss (mL) Up to 750 750–1500 1500–2000 > 2000
Blood Loss (% BV) Up to 15% 15–30% 30–40% > 40%
Pulse Rate < 100 > 100 > 120 > 140
Blood Pressure WNL WNL Decreased Decreased
Pulse Pressure (mmHg) WNL/increased Decreased Decreased Decreased
Capillary Blanch Test Normal Positive Positive Positive
Respiratory Rate (RR) 14–20 20–30 30–40 > 35
Urine Output (mL/hr) > 30 20–30 5–15 Negligible
CNS – Mental Status Slightly anxious Mildly anxious Anxious/confused Confused/lethargic
*Modified from Advanced Trauma Life Support (ATLS)

36 SECTION 5 CIRCULATION