Managing Injuries – Shock by Dennis Hawkins, RN ("Data")
So what exactly is "shock"? The term "shock" has multiple meanings and definitions depending on who you talk to. Touching a downed power line can cause one type of shock. Another type is an unpleasant or disappointing surprise. It can also refer to the thing on your bike that softens bumps in the road. A pile of grain stacked on end in a field is also called a shock. But the kind I'm going to talk about here is called physiological or medical shock.
There are three basic kinds of physiological shock. Cardiogenic (which is caused by heart disease), Septic (which is the result of a massive blood infection) and hypovolemic (which is caused by excessive blood loss). In an accident, hypovolemic shock is pretty much the only kind of shock we need to be worried about.
Sometimes when an accident victim is hurt bad enough, they can die from shock instead of their actual injuries. We have already discussed circulation in which we need to stop any bleeding that we see. That comes first. But what happens after you have stopped the bleeding and the accident victim is acting funny - like something is wrong, but you can't quite figure it out? And what does it mean when you hear someone say that a person is going into shock?
Hypovolemic shock is the body's attempt to compensate for blood loss. There are three stages of shock.
In stage 1, the body reduces blood flow to the skin, arms and legs and diverts it to more essential organs like the brain and heart. The pulse will become faster and the victim may complain of being cold even though its a warm day. His skin may be cold, clammy or discolored. The victim may have a strong carotid (neck) pulse, but a weak or non-existent pulse at the wrist. Just looking at the patient you might not be able to tell that anything is wrong.
In stage 2, the blood loss becomes so bad that the body can no longer compensate. At this point the victim's organs, including the brain and heart, start to fail for lack of blood. The victim may exhibit signs of disorientation, confusion, or even chest pain. This stage can only last a few minutes, but the patient may still recover if he receives proper medical treatment in time.
Stage 3 is where the organs have been permanently damaged due to lack of blood flow. Once the person hits this stage, its just a downward spiral as their kidneys, heart and then brain completely shut down one by one. Medical treatment cannot save them. The accident victim will now die.
So what can we do about it? Not much unfortunately. But first we need to recognize it if its there.
1. We need to stop any bleeding that we can. Bleeding, externally or internally, is the chief cause of hypovolemic shock in accidents.
2. Check the pulse at the wrist every few minutes. At the same time, note whether or not their skin is cold and clammy. Cold and clammy skin can also indicate shock. If there used to be a pulse, but now there isn't, and the victim still has a good carotid (neck) pulse, then stage 1 has begun. You should ask someone else to verify that the person has no wrist pulse just to make sure.
3. You can also check for capillary refill. To do this, squeeze their fingernail briefly between your thumb and forefinger. This will temporarily squeeze all of the blood out of the capillaries under the fingernail. When you let go, the skin under the nail will be white. On a normal person, the normal pink color will return within a second or two. If it doesn't, then the victim no longer has capillary perfusion. Combined with other symptoms, this can be a sign of shock, but other things can cause this too.
4. Shock can happen to both conscious and unconscious victims. Talk to the accident victim if they are conscious. If they start talking strange or act disoriented, then stage 2 has begun. Talking strange may include things like making weird sounds that resemble a foreign language or ill forming sentences such as "cloud beat go octopus."
If you suspect a person is in shock, then its a good idea to tell 911 about it so they can alert the paramedics who can start getting things ready for treatment prior to their arrival. Loosen any jackets or shirts around the neck to help with breathing. A blanket can help the victim feel better. If you can do so without causing pain or aggravating a spinal injury, raise their feet 6 inches above their heart. Sometimes shock can cause people to start vomiting. If that happens, they have to be turned on their sides to prevent them from inhaling the barf. If you have to do this, try to keep the head, neck and back as straight as possible to protect them from spinal injury as best as you can.
Shock is common with fractures to the femur (the thigh bone) and femur fractures are common in motorcycle accidents. Big arteries run alongside the femur and these can rupture causing internal bleeding. Every case is different, but if you suspect internal bleeding which is causing shock, you might consider a tourniquet above the fracture. Broken bones are a common source of internal bleeding that can cause shock. Remember that.
Ultimately, shock is a symptom of bleeding. Although there isn't much we can do to treat the shock itself, we can use it as a warning sign that we missed something. In my article about circulation, I said that internal bleeding sometimes manifests itself as a large lump resembling a tennis ball under the skin. The important thing to remember is that this is not always true in every case and sometimes the victim can look totally normal and be bleeding profusely on the inside. As always, you just have to use good common sense to figure it all out.
Ride safe and ride smart. Dennis "Data" Hawkins.
Managing Accidents by Dennis Hawkins, RN ("Data")
On September 12, 2011, another video went viral on Youtube. This one was of a motorcyclist, Brandon Wright, who was pinned under a burning SUV and rescued when bystanders lifted the car off him. Brandon was lucky and is recovering well.
However, about a week before that, on September 2nd, another motorcyclist, Karam Rampersaud, in New York city was also pinned under a car. Karam was not so lucky. Although there were plenty of people around, nobody tried to help him. Karam died under the car from suffocation.
Many people have been told that you shouldn't move an accident victim unless they are in danger of fire. This is not entirely true. The presumption is that if you move someone, you could injure their spine. So, in a way, it was fortunate for Brandon that there was a fire and people felt that it was OK to move him.
The reality is that you shouldn't move accident victims unnecessarily. When there is a fire, necessity is obvious. But when someone is trapped under a car that isn't on fire, it might not be so obvious. People who are trapped under a car are not able to breathe because of the crushing weight of the car. Thus, getting the pressure off the victim is an absolute emergency and trumps any risk of spinal damage.
In Brandon's case, this meant a bunch of bystanders actually lifted the vehicle. But if there aren't enough cooperative people around, a car jack is a good choice. If you use a jack, make sure the car is in park and the parking brakes engaged. Use books or whatever you can find to chock under the car so that if the jack fails, it won't make things worse.
If you pull the victim out, try to keep his neck and back as straight as possible. Don't pull him by the helmet as tempting as that is. The shoulders of a motorcycle jacket makes a good grabbing point. Just try to keep his head sandwiched between your arms as you pull. Pulling by the feet is also OK.
So if you come across an accident where someone is trapped under a car, explain to everyone that the person cannot breathe under there and that its imperative to get the victim out immediately. If you don't explain this, then its likely that people with fight you when you try to get him out.
When helping any accident victim, always remember your ABC's. That is,
A = AIRWAY B = BREATHING C = CIRCULATION
In that order, do whatever is necessary to make sure these body functions are working normally. All of these trump spinal injuries. So if its absolutely necessary to move someone to clear their airway (i.e. drowning), then do it. The same is true if you need to move them to stop bleeding (circulation) by applying pressure to a wound.
Hopefully, you won't ever need these tips, but if you do, it might save someone's life.
Ride safe.
Dennis "Data" Hawkins
Managing Injuries - Airway and Breathing by Dennis Hawkins, RN ("Data")
Last month we learned our ABC's of accident management - Airway, Breathing and Circulation - and how these are all more important than most everything else. This month I will be elaborating on airway and breathing. Some of my descriptions are a bit gory, so if you are squeamish, consider yourself forewarned.
On October 23, 2011, we lost one our motorcycle racing legends. Italian rider Marco Simoncelli #58 was killed when he lost control of his motorcycle at the Malaysian MotoGP in Sepang. Millions of fans watched helplessly as #58's unconscious body lay on the racetrack asphalt. The point to remember here is that no matter how much riding skill and experience you have, accidents can still happen and its important to be prepared for them.
If you do come upon an accident scene, the first rule to remember is to use good common sense. In Simoncelli's case, you didn't see everyone rush out to check on him right away. He was in the middle of a race track and another motorcycle could easily come along and run over and kill anybody trying to help him.
Before you start your ABC's, you need to stabilize the accident scene in such a way that will allow you access to the victim without putting yourself at risk. In many cases, this can be as simple as blocking traffic with your vehicle. But it may still be necessary to physically move the victim to a non-threatening location such as pulling him out of a ditch or away from a fire or potential fire. Unfortunately sometimes, as in the case of downed electric lines on wet asphalt, you might not be able to do anything except wait.
Once the accident scene is stable, the first thing to check is the person's airway. The easiest way to check is to figure out if he is actually breathing. If he can talk or is screaming in pain, his airway is probably fine. Don't confuse muscle spasms with breathing. You want to know for a fact if air is getting in and getting out. Is there anything blocking his airway? Is he making gurgling sounds? If so, its possible that there is fluid pooling in his throat. If you see that, then it will be necessary to carefully turn him on his side, while trying to keep his neck and spine as straight as possible, to let the fluid run out so he can breathe. Pooling fluids could be things like blood or vomit, either way, it can't stay there. Its also possible that if the person had something in his mouth prior to the accident, such as chewing gum or dentures, it could be blocking his airway and must be removed if it is.
Then there is breathing. In most cases, you will check the person's airway and breathing at the same time. However, there are multiple reasons that can cause a person to not breathe properly and a blocked airway is just one of them. If a person's airway is clear, but they aren't breathing anyway, you'll need to start mouth to mouth resuscitation and breathe for them until the paramedics arrive. One of the reasons why a person in an accident might not be able to breathe is a neck injury, so keep that in mind when you're breathing for them.
Other things that can affect a person's ability to breathe include brain injuries, chest wounds or punctures, and heart failure. When an injury affects a person's breathing, it sometimes manifests itself as labored, difficult sounding breaths. Don't confuse this with gurgling. Labored breathing is still breathing so you wouldn't start mouth to mouth or turn them on their side for that. But again, don't confuse labored breathing with muscle spasms which can happen when a person is trying to breathe, but can't.
If a person has a puncture wound to the chest area, and its bubbling or hissing, there is a good chance that he has a punctured lung. Since the lungs work by a vacuum, a hole in the chest area that lets in air will make the lung stop working and the victim will have a harder and harder time breathing. To prevent this, the best thing to do is to use the palm of your hand to seal the air flow at the wound. This wont make him better, but will help prevent him from getting worse.
Doing mouth to mouth resuscitation is part of a CPR training course. Taking a formal class is important because if you don't do these things correctly, you could actually do more harm than good. Its not something that can be learned properly by watching your favorite medical TV show.
As I said before, the only thing more important than your ABC's is good common sense. You'll want to make a point to tell the victim and bystanders what you're doing and why you're doing it. You'll also want to avoid putting yourself in harm's way. That last thing you want to do is add yourself to the list of victims that the paramedics have to deal with when they arrive.
Next month, I'll be covering Circulation management at an accident scene.
Ride safe. Dennis "Data" Hawkins
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