by Jon Solberg, MD, FACEP, FAWM

As a practicing ER doctor, I approach every medical emergency in the same order: 1) Airway, 2) Breathing, and 3) Circulation (known as the ABCs of resuscitation).If you are called to assist during a medical emergency, you can use thisABCapproach to remain calm and useful until professional help arrives. Previous installments of Overland Medicine addressed the airway and breathing portions, but this one will address some important emergencies of the circulatory system, including: hemorrhagic shock, asystole, compartment syndrome, and arterial embolism.

Shock

Shock is the condition that develops when we can no longer supply our body’s vital organs with fresh blood. This condition affects our body’s metabolism on the cellular level, and makes people very sick very quickly. Many problems can lead to shock, including heart attacks, massive internal or external hemorrhage, overdose, and abnormal heart rhythms. In the hospital setting, we use fancy tests to identify shock; but in the field, we can watch for specific physical clues. The easiest way to identify shock is by checking the pulse at the wrist or on the neck, where you may find it’s faint and difficult to feel, or perhaps its abnormally fast or slow. Look at and feel the skin, noticing if it’s cool, clammy, or unusualy sweating. Another good indicator of shock is the patient’s alertness because when we stop supplying our brain with fresh blood, we get very sleepy or pass out. Shock is a medical emergency, and its cause must be identified and reversed before the patient dies.

 Extremity hemorrhage

Most bleeding wounds can be stopped by applying direct pressure. Put on the medical gloves from your first aid kit, grab some gauze, and press directly over the wound for 5 minutes. No peeking! If the wound continues to bleed after 5 minutes, another option is to apply a hemostatic (Latin for “to arrest bleeding”) dressing such as Celox, Quick Clot, or Hemcon. These gauzes and powders can be pressed onto a wound or stuffed into a penetrating knife or gun-shot wound where they assist the body in forming a blood clot. Wrap the wound with an elastic ACE wrap to further slow the bleeding. Sometimes, however, local pressure and hemostatic dressings are inadequate, and you must resort to applying a tourniquet. Don’t be intimidated, a tourniquet can literally be applied by anyone.

A tourniquet is a strip of cloth material wrapped circumferentially around an extremity and then tightened until all blood flow past it, and thus any life-threatening hemorrhage beyond it, is stopped. The key to an affective tourniquet is the windlass, an integrated plastic or metal stick which is twisted around and around, applying a great deal of tightening force circumferentially around the extremity. Beware of any tourniquet which does not incorporate a windlass, especially the kind fashioned from a belt cinched tightly around an extremity; all effective tourniquets include a windlass! If you must fashion one during an emergency, tie a cravat or neckerchief around the extremity, inserting a windlass like a stick or large screwdriver underneath it, and winding it like a windlass before securing it in place. Better yet, stock your med kit with a $27 Combat Application Tourniquet (CAT Tourniquet), the kind utilized by the US Military.

Asystole (absence of heart beat)

If you find an unconscious person lying on the ground, or you witness someone pass out and slump to the floor, immediately call 911 and fetch an automatic external defibrillator (AED), a life-saving device which is thankfully found in more and more places like park ranger stations, shopping malls, and even in police squad cars. Spend no more than 10 seconds checking the patient for a pulse, and if none is found, immediately start CPR. Roll the patient to his or her back, place both your hands on the patient’s mid-chest, and press hard and fast, allowing the chest to fully recoil in between each compression at approximately 100-120 beats per minute (to the tune of Staying Alive by the Bee Gees). Strive to have minimal interruptions in your chest compressions if possible; but if you’re alone, stop after 30 compressions to deliver 2 rescue breaths into the patient’s mouth while plugging his/her nose and blowing air into his/her mouth, ensuring the chest rises up and down with each breath, and then immediately resume chest compressions. Hands only CPR, without mouth to mouth breathing, has become more acceptable and is preferable to standing there and doing nothing. If an AED arrives, turn it on and follow the verbal prompts. Place the pads on the skin as shown on the device packaging. The machine will automatically determine if a shock is advised and verbally prompt you. If the machine advises a shock, stop CPR, ensure you’re not touching the patient, and yell “clear!” Press the machine’s one and only button to deliver the shock and then immediately resume chest compressions without any delay. Repeat the procedure after every 2 minutes of CPR. If no shock is advised, then continue CPR until help arrives or you can get to a hospital.

 Compartment Syndrome and Arterial Embolism

Another disorder that causes impaired delivery of blood to the body is a compartment syndrome. This is a focal problem of an extremity, sometimes occurring after a forearm or lower leg fracture, or after a stabbing or gun-shot wound to the extremity. As the fracture site bleeds into the surrounding muscle compartment, it can build up so much pressure that the arteries delivering fresh blood to the extremity become compressed and no longer function. Usually this is manifested as a very firm muscle compartment, extreme pain in the extremity, numbness in the affected side’s hand or foot, and absence of pulse at the wrist or foot. If the extremity may be fractured, apply a splint and evacuate for an immediate exam by a physician before extremity develops ischemia (death from lack of blood flow). 

An arterial embolismis a small blood clot inside an artery which flakes off, traveling down a blood vessel and getting wedged, occluding any forward flow of blood into that extremity. This problem can occur in those with a blood clotting disorder, or more usually, in an older person who is supposed to be taking blood thinners but who has missed a few doses. Sudden and random onset of extreme arm or leg pain, coupled with a cool, numb, discolored, weak, and pulseless extremity, is an arteria embolism until proven otherwise and the patient should be taken immediately to a hospital because the limb is in danger of dying. 

Having a well thought out plan in place is a good idea whether we’re discussing a mechanical problem, medical emergency, or a winching operation. I recommend storing a small wilderness medicine field guide inside your glove box, next to your vehicle’s owner’s manual, and stocking your med kit with a CAT Tourniquet, a hemostatic dressing, and a good pair of exam gloves to protect you from blood transmitted infections. Most importantly, keep calm and remember to follow the ABCs: Airway, Breathing, and Circulation. Doctor’s orders!

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