Emergency War Surgery NATO Handbook: Part II: Response of the Body to Wounding: Chapter IX: Shock and Resuscitation
United States Department of Defense
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The approach to the casualty in the shock state should be directed to the adequacy of the airway, control of bleeding, and the restoration blood volume. Simultaneously, with the institution of initial fluid administration, the surgeon ascertains the mechanism of injury, the wounding agent, the time elapsed since wounding, and, if possible, the position of the casualty when wounded, the estimated initial and enroute blood loss, the drugs administered prior to hospital arrival and the presence or absence of known allergies. Since most combat casualties are young and were previously healthy, history of past or preexisting diseases or chronic medication requirements is usually of little value. This may not be the case in older casualties, especially civilian casualties.
On arrival, a rapid but thorough physical examination is performed to determine vital signs and to identify the number, location, and extent of wounds. The casualty should be completely undressed to allow head-to-toe front and back examination. Blood pressure, respiratory rate, mental status, skin color, capillary refill, and temperature are recorded in the abbreviated clinical record. The capillary refill test is performed by depressing the fingernail or tip of the finger. A normal response is refill of the capillary bed as manifested by the return of color within two seconds. Hidden blood loss into the chest, abdomen, fracture sites (pelvis and thigh) or crush injury sites may be present. These fractures can account for 1.5-2 liters of acute blood volume loss. In the presence of shock, with a chest wound or probable chest wound, a closed-tube thoracostomy should be performed without delay.
As the large-bore intravenous infusion lines are placed, blood is aspirated for type and crossmatch. If additional laboratory tests are indicated, blood is drawn at this time. Usually this amounts to a hematocrit determination for future comparison as therapy progresses. It should be emphasized that the hematocrit has no place in the estimation of the volume of acute blood loss.
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