Shock and Acute Stress Response (ASR)
It looks like the patient got through this without any long bone or pelvic fractures, but we still need to worry about an internal injury, especially with an initial vital sign pattern suggesting shock.
A patient in shock classically has a rapid pulse rate that may feel weak and irregular. 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. The “adrenaline rush” increases heart rate and respiratory rate, causing the skin to pale and sweat, and the nausea and restlessness. These changes pump the blood faster, reduce the size of the blood vessels, and route the blood to essential organs, hopefully helping the body to compensate for the shock.
If the circulatory system is unable to compensate to the injury, a spiral of deterioration may begin in which first tissues, then organs, and finally entire systems fail from poor perfusion. These patients need to be transported quickly to the hospital; our wilderness shock management tools--leg elevation, oral fluids, stabilizing injuries, and keeping the patient warm and comfortable--may not be enough.
Most people, when frightened, injured, or ill, have a "fight or flight" or acute stress response that mimics shock. This is the familiar fast heart rate, sweaty pale skin, nervous shakes, and queasy gut from the adrenaline rush. 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.
Positional (orthostatic) vital signs refer to our ability to compensate for changes in position and the effect gravity has on our cardiovascular system. Healthy people can stand from a supine position with little or no problems. People in shock may not react well to the position change. We teach a positional (orthostatic) vital sign test to help find patients with low volume status who don’t have obvious signs and symptoms of shock. Have the patient stand, then wait one minute and measure vital signs. An HR increase of 30 beats/min or more in adults, or the presence of dizziness or fainting suggests shock. Evaluating the patient’s symptoms is as critical as measuring numbers. Regardless of their heart rate, if the patient becomes pale, woozy and nauseated with a position change, lie them down and treat for shock.
Spine Protection
It’s tempting to rule out a spine injury because the patient was seen walking, but people can do amazing things when reacting to stress. The fact that the head-to-toe assessment does not reveal any spine pain or tenderness and the normal CSMs in all four extremities suggest the spine is injury-free. The focused spine assessment can be done on this reliable, sober and alert patient to gather the information needed to make a decision on the spine. Until this decision is made the spine is protected by gently assisting the patient onto their back and using soft head blocks to limit neck motion. A cervical collar is unnecessary, but if used as a precaution, a soft rolled collar is fine.