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INTRODUCTION

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The evaluation and treatment of shock in the prehospital environment presents unique challenges to the EMS physician. Decisions regarding the balance between sophisticated field treatment and minimizing transport time to definitive care must continually be evaluated. The benefit of advanced care in the field has been questioned.13 Some studies have demonstrated that the addition of the physician on the scene may increase scene time in certain scenarios, while other studies have not observed this effect.3 This is likely related to the prehospital training and experience of the physician. Balancing physician intervention with scene time is an important part of the care of the patient in shock and must be explored during the EMS education of residents and fellows.

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OBJECTIVES

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  • Describe the identification of shock in the field.

  • Describe the initial management of shock in the field.

  • Analyze the causes of shock.

  • Examine how to treat specific causes of shock while in the prehospital setting.

  • Present the use of advanced vascular access and pressors in the field.

  • Discuss the use of tourniquets and hemostatic agents for severe hemorrhage.

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CARE OF SHOCK IN THE FIELD

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Physician participation in the field is routine in the Franco-German model of prehospital care and is becoming more common in the United States. Participation in the field also allows the physician to gain a first-hand perspective on how the system works. The physician is often in a position to have an effect on protocols, provider education, and operational matters that affect patient care. For those in training, participation in the field provides them with critical insight into the challenges and limitations of caring for patients in the out-of-hospital setting. Without an understanding of the differences inherent in the provision of prehospital emergency care, it is often less than productive to apply in-hospital evaluation and treatment techniques in the field environment. To treat a patient in shock effectively in the field environment requires a knowledge base specific to EMS.

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Shock is a state of decreased perfusion resulting in inadequate delivery of oxygen to the tissue. Typically, the body has exhausted its ability to compensate for the stressors it is experiencing. The principles for management of shock include the maintenance of perfusion while supporting ventilation and oxygenation. The precise degree of resuscitation of the patient depends on a number of factors and has been the topic of significant discussion in the literature.4 The prehospital environment presents unique challenges when treating a patient in shock. Equipment and supplies are typically limited in the field environment. Austere conditions such as temperature extremes, darkness, and precipitation may hamper care of the patient in shock. Temperature control is a significant factor. Initial studies indicated that therapeutic hypothermia may have beneficial effects on patients after return of spontaneous circulation (ROSC), although further evaluation of this is required.5 Alternatively, trauma patients requiring massive transfusion ...

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