INTRODUCTION:

1. LESSON PURPOSE:

The major problem associated with battlefield trauma is blood loss and associated shock. The prompt recognition and treatment of shock is crucial to saving lives.

2. LEARNING OBJECTIVES:

a. TERMINAL LEARNING OBJECTIVE:

While functioning as a Combat Lifesaver in a simulated combat situation, without the aid of reference materials, recognize and treat a simulated patient for shock.

b. ENABLING LEARNING OBJECTIVES:

(1) Without the aid of the reference, name the three elements of the vascular system that keep the vascular container full.

(2) Without the aid of the reference, describe how a failure of any of these three elements can produce shock.          

(3) Without the aid of the reference, list five types of shock; describe what causes each type.

(4) Without the aid of the reference, state an example of an injury of condition associated with each kind of shock.

                        (5) Without the aid of the reference, describe the signs and symptoms of shock.  

                        (6) Without the aid of the reference, explain the treatment for shock utilizing the A, B, C’s.

3. METHOD/MEDIA:

This material will be covered by lecture, and demonstration, with the use of computer-generated graphics, and practical application.

4. EVALUATION:

You will be evaluated on the material in this by a written and practical application exam on T-63.

The last step in the four life saving steps is the treatment of shock. This is the first thing we discuss.

SHOCK

a. Shock, also known as hypoperfusion is the inability of the body to supply (perfuse) cells with oxygen and nutrients. (Hypo means “less than”; hypoperfusion means “less than adequate perfusion”). Shock, if not treated, results in death.

I. CAUSES OF SHOCK:

1. Three elements of the vascular system—the heart, the blood, and the blood vessels—can be related to the failure to keep the vascular container full and the consequent development of shock.

a. The Heart—If the heart fails to pump blood efficiently enough to keep the vascular container filled, shock with develop.

b. The Blood—There must be enough blood to fill the vascular container. A serious loss of blood will lead to shock.

c. The Blood Vessels—

1) The vascular container must not be too large for the volume of blood.

a) Dilation (expansion) of some blood vessels without sufficient constriction (shrinking or contracting) of other blood vessels to compensate can cause shock.

2) Blood vessels can change their diameter.

a) If an area of the body requires more blood because it is doing more work, the vessels in that area dilate as needed to allow greater flow.

b) At the same time, another area of the body that does not require the extra blood flow may constrict its vessels to reduce the blood flow in that area and help keep the overall system filled with blood.

c) If all the vessels in the body dilated at once, there would not be enough blood to fill the entire system causing circulation to fail.

d) Whenever too many vessels dilate to allow for adequate perfusion, shock develops.

3) If there is a failure of any of these three factors—the pumping of the heart, the supply of blood, or the dilation and compensatory constriction of the blood vessels—perfusion of the brain, lungs, and other body organs will not be adequate.

4) Regardless of the mechanism, shock is the failure of the cardiovascular system to provide sufficient blood and oxygen to all the vital tissues of the body.

TYPES OF SHOCK

1. There are different types of shock and they are usually named by their cause.

            a. Hypovlomeic Shock—“low fluid volume”

                        1. Cause by the loss of blood or other body fluids.

a. When shock develops due to blood loss, we call this kind of shock “hemorrhagic” shock.

b. Dehydration due to diarrhea, vomiting, or heavy perspiration can also lead to the development of hypovlomeic shock.

                        2. It’s the most common kind of shock encountered on the battlefield.

3. In addition to the loss of whole blood, enough plasma may also be lost to result in a severe drop in blood volume.

                                    a. This may be the case with burns and crushing injuries.

b. Cardiogenic Shock—Caused by the heart failing to pump blood adequately to all parts of the body.

                        1. Heart failure, heart valve disease, or heart attack

c. Neurogenic Shock—Caused by the failure of the nervous system to control the diameter of blood vessels. Once the blood vessels are dilated, there is not enough blood in circulation to fill this new volume, causing shock.

            1. Spinal cord injury.

d. Anaphylactic Shock—A life-threatening reaction of the body to a substance to which the person is extremely allergic.

1. In this type of shock, the victim may get a skin rash, have swollen hands, eyes, or a swollen tongue (which interferes with breathing), suffer from respiratory difficulty and subsequent respiratory arrest.

                        a. Insect bite or sting                       

                        b. Severe food allergy (shellfish or nuts, for example)

                        c. Medication allergy

e. Septic Shock—Caused by severe infection.

1. Toxins are released into the bloodstream and cause vessels to dilate, increasing the volume of the circulatory system beyond functional limits.

2. This type of shock is most often seen in the hospital after a patient has been admitted for an illness.

SYMPTOMS OF SHOCK

(1) Altered Mental Status.

(2) Pale, cool, clammy skin.

(3) Thirst.

(4) Vital sign changes.

(5) Blotchy or bluish skin (especially around the mouth and lips).

(6) Nausea and/or vomiting.

TREATMENT FOR SHOCK

(1) The primary care for a shock victim includes airway maintenance, oxygen administration, attempting to stop whatever is causing the shock, and measures to attempt to maintain perfusion.

(2) Although major treatments for shock cannot be performed for a casualty on the battlefield (administration of a high concentration of oxygen and Intravenous fluid therapy) there are measures that can help. Always begin by remembering the A, B, C’s.

(A) Maintain an Open Airway: Keep an unconscious casualty’s airway open with the Head/Tilt-Chin/Lift or the Modified Jaw Thrust if necessary.

(B) Assure the adequacy of respirations: Assist with rescue breathing if it becomes necessary.

(C) Restore Circulation: Control external bleeding using measures taught in the previous lesson.

(3) Elevate the victim’s feet higher than the level of the heart using a stable objects such as a box, field pack, or rolled up clothing.

(4) Loosen clothing or equipment wherever it may be binding. But, DO NOT remove chemical protective equipment.

(5) Prevent the casualty from chilling or overheating. The key is to maintain normal body temperature. In cold weather, place a blanket or other like item over the casualty to keep him warm and under him to prevent chilling. In hot weather, place the victim in the shade and avoid excessive covering.

(6) Calm the victim. Throughout the entire procedure of treating and caring for a victim, the rescuer should reassure the casualty and keep him calm.

DRESSING AND BANDAGING WOUNDS

1. LESSON PURPOSE:

Soft tissue injuries on the battlefield can be caused by many things but primarily, you will see: missile wounds that come from bullet or wounds that come from fragments of explosive devices or fragments of buildings that have exploded, blast injuries from explosions, or thermal (burn) injuries from explosions, to name a few. Many of these soft tissue injuries are life threatening and require prompt dressing and bandaging treatment.

2. LEARNING OBJECTIVE:

While functioning as a Combat Lifesaver in a simulated combat situation, without the aid of reference materials, apply dressings and bandages to soft tissue injuries on a simulated patient.

3. ENABLING LEARNING OBJECTIVES:

Without the aid of reference materials the student will be able to:

            1. Describe the major functions of the skin.           

            2. Identify and describe the characteristics of each layer of skin.

            3. Describe the six types of open soft tissue injuries.

            4. Describe the signs, complications, and treatment of Head Injuries.

            5. Describe the signs, complications, and treatment of Open Neck Wounds.

            6. Describe the signs, complications, and treatment of Sucking Chest Wounds.

            7. Describe the signs, complications, and treatment of Open Abdominal Evisceration.

I. SOFT TISSUES

The soft tissues of the body include the skin, fatty tissues, muscles, blood vessels, fibrous tissues, membranes (tissues that line or cover organs) and nerves. The teeth, bones, and cartilage are considered hard tissues. The most obvious soft tissue injuries involve the skin. Most people do not think of the skin as a body organ, but it is. In fact, it is the largest organ in the human body.

The major functions of the skin include:

            1. Protection

            2. Water Balance           

            3. Temperature Regulation

            4. Excretion

            5. Shock (Impact) Absorption

The skin has three major layers;

1. The Epidermis is the outermost layer and is composed of dead skin cells, which are rubbed or sloughed off and are replaced. Except for certain types of burns and some cold injuries, injuries to the epidermis can be considered slight.

2. The Dermis is the layer below the epidermis. This layer is rich with blood vessels, nerves, and specialized structures such as sweat glands, sebaceous (oil) glands, and hair follicles. Once the dermis is opened to the outside world, contamination and infection become major problems. Wounds to this layer can be serious, accompanied by profuse bleeding and intense pain.

3. The layers of fat and soft tissue below the dermis are called the subcutaneous layers. Shock absorption and insulation are the major functions of this layer. Again, there are problems of tissue and bloodstream contamination, bleeding and pain when these layers are injured.

II. SOFT TISSUE INJURIES

Soft tissue injuries are classified as open or closed.

            1) Closed injuries are often the result of the impact of blunt objects.

2) Open injuries are the result of many things from the outside such as a bullet wounds, or from the inside such as a fractured bone end tearing out of the skin. Open injuries are classified as:

a) Abrasions: simple scrapes and scratches commonly called “road rash,” “rug burns,” or “brush burns.” These are not severe and rarely need more than a minor bandage.

b) Lacerations: cuts to the skin from the outside or the inside. Laceration edges can be smooth or jagged depending upon what has made the laceration. Bleeding from a laceration can be minor, or severe depending on the depth and location of the cut.

c) Punctures: when a sharp, pointed object passes through the skin or other tissue, a puncture wound has occurred. A penetrating puncture wound can be shallow or deep. A perforating puncture wound has both an entrance and an exit wound. In many cases, the exit wound is more serious than the entrance wound. Bullets that travel through the body and out the other side cause a perforating puncture wound.

d) Avulsions: flaps of skin and tissues that are torn loose or pulled off completely.

e) Amputations: fingers, toes, hands, feet, or limbs that have been torn, cut, or blown (by explosion) off. There may or may not be massive bleeding.

f) Crush Injury: the same kind of crush injury that can cause an internal injury without breaking the skin can also cause the skin to be broken and result in an open injury.

III. GENERAL WOUNDS

1. Head Wounds

There is a high mortality rate associated with head trauma. All head trauma casualties are assumed to have a cervical spine injury until proven otherwise. Head wounds should be treated with care since there is always the possibility of brain damage.

CLASSIFICATION

A practical classification of head injuries divides them into two groups.

CLOSED INJURIES (without obvious external damage)

• In closed head injuries, there may or may not be lacerations of the scalp, but the skull is intact, and there is no opening to the brain.

• Injury to the brain itself may be far more extensive in a closed head injury because more of the injuring force is transmitted deeper into the brain due to pressure build-up.

• Rising intracranial pressure produces complications because the brain is enclosed in a rigid box (the skull). Some signs of intracranial pressure are:

a. Headache

b. Altered level of consciousness

c. Restlessness

d. Decreased respirations

OPEN INJURIES (with obvious external damage)

• Open head injuries usually combine lacerations of the scalp, fragmentation of the skull from fractures, and lacerations of the membranes that cover the brain.

• The brain may be relatively untouched, or it may be extensively bruised or lacerated.

• Will bleed profusely no matter how minor the injury.

• May be through and through wound. Need to check for exit wounds.

SIGNS OF HEAD INJURY

a. Deformity of the skull

b. Blood or clear fluid leaking from the nose or ears

c. Discoloration (bruising) of the soft tissue under the eyes may be present. Black eyes (raccoon eyes) indicates skull fracture.

d. Discoloration (bruising) of the soft tissue behind the ear (called Battle Signs) indicates skull fracture.

e. Loss of consciousness (Altered level of consciousness)—most important of all symptoms.

                        f. Headache, nausea, vomiting

                        g. Vision problems, unequal pupils

                        h. Staggering or dizziness

                        i. Mental confusion

                        j. Slurred speech

                        k. Convulsions or twitching

                        l. Difficulty breathing

                        m. Paralysis

COMPLICATIONS OF HEAD INJURIES

                        a. Blood from torn vessels may cause pressure on brain tissue.

                        b. Gag reflex may be absent.

                        c. Cough reflex may be absent.

                        d. Cessation of respiration with C-spine injury.

                        e. Tongue may obstruct throat of unconscious patient.

                        f. If base of skull fractured, blood may flow from ears and nose into back of the throat into lungs and stomach, causing vomiting and further airway obstruction.

TREATMENT

a. CHECK THE CASUALTY’S LEVEL OF CONSCIOUSNESS—Ask the casualty to tell you his name, where he is, the month and year, or other information which cannot be answered by a simple yes or no. Incorrect responses, inability to answer, or changes in responses may indicate a serious head injury.

b. POSITION THE CASUALTY—A casualty with a serious head injury may also have a fractured neck. Avoid moving the casualty when possible.

Position the casualty on his side with the wound away from the ground if the casualty is choking, nauseous, vomiting, or bleeding from his mouth.

Have the casualty sit up and lean against a support such as a tree if only minor wounds are present. After the wounds are dressed, he can be positioned on his back with his head elevated slightly.

If the casualty is having convulsions, ease him to the ground and gently support his head and neck. Do not try to forcefully hold his arms and legs.

c. EXPOSE THE WOUND—Remove the casualty’s helmet if he is still wearing it.

Do not expose or dress the wound in a chemical environment. If the mask or hood has been breached, repair the breach with tape or wet cloth stuffing if possible.

Do not attempt to clean the wound or attempt to push any brain matter back into the head.

d. APPLY A DRESSING

            1. To the forehead or back of head:

                        a. Remove a field dressing from its wrappers.

b. Grasp a tail in each hand, hold the dressing directly over the wound with the white pad toward the wound, pull the dressing open, and place the pad directly over the wound with the tails horizontal.

                        c. Place one hand on the dressing or have the casualty hold it in place.

d. Wrap one tail horizontally around the casualty’s head and bring it back across and past the dressing. Angle the bandage so it will cover the top or bottom edge of the dressing.

                        e. Do not cover the casualty’s eyes or ears with the bandages.

                        f. Wrap the second tail around the head in the opposite direction.

g. Bring the tail across the dressing angled so it will cover the other edge (top or bottom) of the dressing.

h. Continue to wrap the bandage around the head again until it meets the first tail.

                        i. Tie the tails in a non-slip knot on the side of the head.

j. The bandages should keep the dressing from slipping, but do not place undue pressure on the wound.

                        k. Tuck any excess bandaging material (tails) under the bandage.

            2. To the top of the head:

                        a. Remove a field dressing from its wrappers.

b. Place the dressing oever the wound allowing the tails to fully unfold and hang along the side of the casualty’s cheeks.

c. Grasp one tail, wrap it under the chin, up over the head covering the dressing, and down the opposite side of the head to the level of the casualty’s eyes.

d. Grasp the other tail, wrap it under the chin in the opposite direction and bring it up the side of the head, meeting the first tail at the level of the casualty’s eyes.

e. Cross the tails, wrap one tail around the back of the head to the opposite ear. Wrap the other tail around the forehead until it meets the first tail.

                        f. Tie the tails over the crossings of the two directional wrappings.

3. To a head wound with a protruding object or a head wound with a suspected underlying fracture:

                        a. Create an “O” ring out of a cravat.

b. Place the “O” ring over the protruding object or place “O” ring around the area of a fracture. Ensure the ring is bigger than the fracture area.

c. Apply a small battle dressing over the “O” ring or apply bulky dressing materials to support an impaled object.

                        d. Continue to bandage the area as described above.

                        e. MONITOR

                                    1. Evacuate as soon as possible.

                                    2. Check the casualty’s level of consciousness every 15 minutes.

                                    3. Do not give the casualty anything to eat or drink.

                        f. TREAT FOR SHOCK

2. Neck Wounds

Due to the fact that large arteries and veins lie close to the surface of the neck, the potential for serious bleeding from an open wound is great. In addition to severe bleeding, the possibility of an air embolus (air bubble) being sucked in through a vein is also great.

Large, open neck wounds can be life-threatening. If you note during the “B” (assessment of breathing) portion of your Primary Assessment that the casualty has difficulty breathing and a large, open neck wound, treat it now!

COMPLICATIONS

                        a. Severe, uncontrollable bleeding

                        b. Shock

                        c. Air Embolism to the brain or heart (deadly).

                        d. Involvement of the voice box (larynx) or esophagus.

TREATMENT

                        a. APPLY AN OCCLUSIVE DRESSING

1. Seal the wound immediately with one hand while you gather a dressing with the other.

2. Remove your hand and quickly apply an occlusive dressing that is at least 2 inches larger than the wound.

                                                a. Use the inner plastic wrapper of a field dressing.

                                                b. If it is too small, it may get sucked into the wound.

                        b. APPLY A DRESSING

                                    1. Apply a dressing over the occlusive dressing and apply pressure.

                                                a. Do not occlude both carotid areteries at one time.

b. Wrap the tails around the neck, and then form a figure-of-eight under the armpit on the opposite side. (This prevents a circumferential dressing around the neck which would interfere with circulation and/or breathing.)

                        c. POSITION THE CASUALTY

1. Place the casualty on his left side with legs elevated and head down if possible. (This aids in trapping possible air emboli in the right atrium of the heart where it causes less damage.)

                        d. TREAT FOR SHOCK

                        e. TRANSPORT AS SOON AS POSSIBLE

3. Chest Wounds

Your body has two lungs. Each lung is enclosed in an airtight area within the chest. If an object punctures the chest wall and allows air to enter the chest, the lung begins to collapse. This collapse is fairly gradual and does not happen all at once. Any degree of collapse, however, interferes with the body’s ability to inhale and absorb oxygen.

If you note during the “B” (assessment of breathing) portion of your Primary Assessment that the casualty has difficulty breathing (he may be gasping for breath) and there is an open chest wound, treat it now!

COMPLICATIONS

                        a. Severe internal or external bleeding.

                        b. Severe damage to the lung.

                        c. Damage to the heart.

                       d. Pressure build up in the cavity from a punctured lung may compress the heart and interfere with its ability to pump blood.

                        e. Shock.

TREATMENT

                        a. LOCATE THE WOUND

                                    1. Expose open chest wound.

                        b. APPLY AN OCCLUSIVE DRESSING

1. Seal the wound immediately with one hand while you gather a dressing with the other.

2. Remove your hand, and then instruct the casualty to exhale and hold his breath.

3. Quickly apply an occlusive dressing that is at least 2 inches longer than the wound.

                                                a. Use the inner plastic wrapper of a field dressing.

                                                b. If it is too small, it may get sucked into the wound.

c. If the casualty is unconscious, apply the occlusive dressing after his chest falls but before it rises again.

                                    4. Tape the occlusive dressing down to the chest leaving all sides closed.

                                                a. A flutter type valve allows trapped air to escape through.

                        c. APPLY ANOTHER DRESSING

                                    1. Apply a dressing over the occlusive dressing and secure it.

                                                a. Wrap the tails around and under the casualty.

b. Just before you tighten the tails, tell the casualty to exhale one more time.

                                                c. Secure the tails in a non-slip knot.

                        d. LOOK FOR AN EXIT WOUND

                                    1. Treat the same way.

                        e. IN CASE OF A FOREIGN OBJECT

                                    1. If an object is protruding from the open chest wound, do not remove it.

                                                a. Place airtight material around the object.

                                                b. Stabilize the object with bulky dressing materials.

                                                c. Do not wrap bandages around the object.

                                                d. Secure the dressing knot beside the object, not over it.

                        f. POSITION THE CASUALTY

                                    1. Have the casualty lie on his side with the injured side next to the ground.

                                    2. If he can breathe easier sitting up, allow him to do so.

                        g. TREAT FOR SHOCK

                        h. TRANSPORT AS SOON AS POSSIBLE

                        i. MONITOR THE CASUALTY

a. If the casualty has increased difficulty breathing, shortness of breath, or a bluish tint to the skin, find the flutter valve corner and lift to allow trapped air to escape the chest. Rest the wound.

4. Abdominal Wounds

The body’s abdominal cavity contains organs such as the stomach, small intestine, large intestine, liver, kidneys, and spleen. Several large arteries and veins are also located in the abdominal cavity. An object that punctures the muscular abdominal wall can injure one or more organs, cause severe bleeding, and result in infections, which could spread to the organs within the cavity.

An open abdominal wound can be cause by the muscular abdominal wall being penetrated by a bullet, by a stab from a knife, by an object blown from an explosion, or by falling on a sharp object.

A projectile entering the body can be deflected, or it can explode and send out tiny fragments in many directions. Keep in mind that the pathway of a bullet between an entrance wound and an exit wound is rarely a straight line.

SIGNS OF AN OPEN ABDOMINAL WOUND

a. Obvious bleeding from a laceration to the abdomen.

b. If the laceration is large enough and deep enough, the intestines will protrude (this is called an evisceration).

c. Pain and/or cramps in the abdomen.

d. Nausea, vomiting.

e. Thirst.

COMPLICATIONS

                        a. Severe internal or external bleeding.

                        b. Infection (this is a late complication).

                        c. Shock.

TREATMENT

                        a. POSITION THE CASUALTY

                                    1. Place the casualty on his back with his knees flexed.

2. This position helps to prevent exposure of the abdominal organs, lessens pain, controls shock, and relieves pressure on the abdominal area.

                                    3. Tie the knees together with a cravat to assist in maintaining the position.

                        b. LOCATE WOUND

                                    1. Check for entry and exit wounds.

                                    2. Expose the wound by removing, tearing, or cutting clothing.

                                                a. Do not try to remove stuck clothing; cut or tear around stuck clothing.

                                                b. Do not try to probe, clean, or remove foreign objects from the wound.

                        c. POSITION DISLODGED ORGANS

                                    1. If an organ (intestines or other) is outside the body, do not try to replace it.

                                    2. Do not touch exposed organs with your hands.

                                    3. If organs are on the ground, pick them up using a clean dressing, or T-shirt.

                                    4. Place the organs on the abdomen near the wound. Not on or in the wound.

                        d. APPLY A DRESSING

1. Open a large battle dressing and moisten the side that will be toward the abdomen with water from a canteen.

                                    2. Cup any exposed organs with the dressing like a TACO shell.

                                    3. Bring the tails around the small of the back, and back over the opposite side.

                                    4. Tie the tails off to the side of the abdominal wound.

                        e. TREAT FOR SHOCK

                        f. MONITOR THE CASUALTY

                                    1. Keep knees in an up position.

2. Never give anything by mouth (if the casualty is extremely thirsty, moisten his lips with a damp cloth).

                        g. TRANSPORT AS SOON AS POSSIBLE

5. Other Dressings

                        a. Extremity injuries

                        b. Sling and Swathe

REFERENCES

1. First Aid For Soldiers                                                                        FM 21-11

2. First Aid                                                                                            MCRP 3-02G