How do I recognize shock in a trauma patient?
We learn that shock in a trauma patient is usually hemorrhagic shock.
Vitals are vital!
Here's a chart from LITFL that goes through the different stages of hemorrhagic shock:
The take away is that the patient can be in stage 1 hemorrhagic shock with normal vitals. Early signs are:
Widened pulse pressure (difference between systolic and diastolic)
Cool extremities/pale skin
Mild anxiety (but which patient isn't anxious coming into the trauma bay?)
Patients don't read textbooks
The stages are useful to conceptualize, but there are several reasons a patient's response may vary from the chart above:
Elderly patients have a blunted response
Pediatric patients are able to compensate well
Medications (e.g. beta blockers and other antihypertensives) or intoxication
Extreme pain or anxiety
Comorbidities
Blunt vs penetrating trauma can have different physiologic responses
Bradycardia is possible with hemorrhagic shock
Several theories exist as to why this happens (vagal stimulation, sympathetic response, post catecholamine surge...)
Seen more with acute, severe blood loss
Up to 1/3 of patients with hemorrhagic shock may be bradycardic