The document presents a lecture on shock in trauma, covering its clinical characteristics, types of traumatic shock (hypovolemic, cardiogenic, distributive, and obstructive), and management strategies during emergencies. It details the diagnosis and treatment of various injuries, including thermal burns and inhalation injuries, emphasizing the importance of recognizing shock signs and initiating rapid intervention to prevent deterioration. The lecture highlights guidelines for managing hemorrhagic shock, burn injuries, and the effects of low temperatures in a tactical field care setting.

1. Ivano-Frankivsk National Medical University
Department of disaster and military medicine
Premedical care in emergency situation
LECTURE
“Shock in trauma, their clinical characteristics.
Combat thermal injury. Diagnosis of burns.
Inhalation injuries. Emergency medical care in the
tactical field care, at the stages of evacuation.
Effect of low temperatures”
Ivano-Frankivsk - 2025
lecturer
Anna Ovchar

2. Plan of lecture
• Shock in trauma.
• Combat thermal injury.
• Inhalation injuries.
• Effect of low temperatures.

3. Purpose of lecture
The management of shock has been the subject of intensive research for
decades. As a result, changes continue to be made in the recommendations
for prehospital treatment of the patient with shock and burns.

4. Shock
The first step in the initial management of shock is to recognize its presence.
Shock — abnormality of the circulatory system that
results in inadequate organ perfusion and tissue
oxygenation.

5. Normal Perfusion
• Blood Pressure = Cardiac Output х Peripheral Vascular
Resistance
• Cardiac Output = Heart Rate х Stroke Volume

6. Types of Traumatic Shock
Hypovolemic shock
The term hypovolemic means
low fluid volume. Hypovolemic
shock includes all types of shock
caused by fluid loss, such as
bleeding, burns, vomiting,
diarrhea, and severe
dehydration. There must be an
adequate amount of fluid within
the body and circulatory system
at all times. If there is loss of
fluid volume, blood pressure will
drop and shock will result.

7. Types of Traumatic Shock
Cardiogenic shock
The heart (pump) is at the center of the
circulatory system and must be
functioning properly to maintain a
proper blood pressure to circulate blood
adequately. If the heart fails to pump an
adequate volume of blood, the result can
be an abnormally low blood pressure
(hypotension). This category of shock is
sometimes referred to as pump failure.

8. Types of Traumatic Shock
Distributive shock
Blood circulates throughout the body
by way of a closed system of vessels.
The vessels are made up of smooth
muscle and can dilate and constrict,
depending on the needs of the body.
Certain conditions can cause the
vessels to dilate excessively, resulting
in a much larger space than the
available blood supply can fill. When
there is more space within the
system than blood to fill it, blood
pressure drops and shock results.

9. Types of Traumatic Shock
Obstructive shock
The adequate flow of blood can be disrupted due to a variety of
obstructions to the heart, lungs, and great vessels. Damage to the
heart from trauma and blockages in the vessels that connect the
heart and lungs are causes of obstructive shock. The obstruction of
blood flow reduces perfusion, which can lead to shock

10. The Body’s Response During Shock
Compensated shock the condition in
which the body is using specific
mechanisms, such as increased pulse
rate and increased breathing rate, to
compensate for a lack of adequate
perfusion.
Decompensated
shock the
condition in which
the body is no
longer able to
compensate for a
lack of adequate
If the root cause of
the shock is not cared
for soon enough, the
patient will eventually
enter a condition
called irreversible
shock and will die.

11. HEMORRAGIC SHOCK

12. SIGNS of shock:
• Mental confusion or altered
mental status in the absence of a
head injury
• Weak or absent radial pulses
• Tachycardia
• Tachypnea
• Excessive thirst
• Cyanosis with pale, grey, or
blotchy blue skin
• Nausea and/or vomiting
• Diaphoresis with sweaty, cool,
clammy skin
One of the key signs for shock is Altered Mental
Status in the absence of head injury. Check
casualty every 15 minutes for AVPU.
Alertness: Knows who, where they are.
Verbal: Orally responds to verbal commands.
Pain: Level of pain felt when the sternum is briskly
rubbed with the knuckle (if needed)
Unconscious: Unresponsive
Decreasing: AVPU could indicate condition

13. SIGNS and SYMPTHOMS of
hemorrhagic shock

14. ATLS classification of hemorrhagic shock
CLASS I CLASS II CLASS III CLASS IV
BloodLoss (ml)
%
<750
15%
750-1500
15%-30%
1500-2000
30-40%
>2000
>40%
HR <100 >100 >120 >140
BP normal normal decrease decrease
PP normal decrease decrease decrease
RR 14-20 20-30 30-40 >35
UOP >30 20-30 5-15 negligible
CNS slightly
anxious
mildly
anxious
anxious
confused
confused
lethargic

15. Progression of symptoms
• Usually, up to 500 ml of blood loss is well-tolerated, often with no effects
except perhaps a slight tachycardia.
• 1,000 ml of blood loss will usually produce tachycardia greater than 100,
but otherwise, the casualty may appear normal.
• 1,500 ml of blood loss may be associated with changes in mental status, a
weak radial pulse, persistent tachycardia, and tachypnea.
• 2,000 ml of blood loss is accompanied by confusion and lethargy, a weak
radial pulse often greater than 120, and tachypnea greater than 35. This
amount of blood loss is possibly fatal if not managed quickly.
• And 2,500 ml of blood loss will usually present with the casualty
unconscious, no radial pulse, a carotid pulse greater than 140, and
tachypnea greater than 35. This amount of blood loss will be fatal without
immediate and rapid intervention.

16. PROGRESIVE CHANGES IN
SHOCK

17. Lethal triad of hemorrhagic shock

18. Lethal triad of hemorrhagic shock
Acidosis is most commonly
the result of lactic acid
buildup as cells revert to
anaerobic processes in the
absence of adequate
cellular oxygenation (or
shock). Sometimes there is
a respiratory contribution if
the respiratory drive is
blunted and there is a
buildup of carbon dioxide,
but the metabolic acidosis
from lactic acid buildup in
trauma tends to be the
predominant issue.
Coagulopathy can result from
direct losses of clotting factors
and platelets due to massive
hemorrhage but can be
accentuated by hemodilution
if fluids are replaced by
crystalloid or colloid fluids that
do not replace clotting factors
and platelets like you would
get from using whole blood
transfusions as fluid
replacement therapy.
Additionally, the function of
clotting factors is
temperature-dependent and
hypothermia leads to clotting
factor dysfunction, even if
there is an adequate quantity.
Hypothermia results from a
combination of
environmental factors
(exposure, even in warmer
climates) and physiologic
responses to blood loss. As
mentioned previously, the
functions of the clotting
cascade are impaired in
hypothermia, and further
blood loss from coagulopathy
leads to increasing
hypothermia. This vicious
cycle of acidosis,
hypothermia, and
coagulation (or the lethal
triad) requires prevention

19. Steps in the management of shock are as
follows: Management:
– Control bleeding
–Shock position
– High-flow oxygen
– Rapid safe transport
– Large-bore IV access
– Fluid bolus (500–1,00
mL for adult and repeat
if necessary
– Cardiac monitor,
SpO2, ETCO2
–Ongoing exam

20. The initial fluid bolus elicits three
possible responses:
• Rapid response. The vital signs return to and remain normal. This
typically indicates that the patient has lost less than 20% of blood
volume and that the hemorrhage has stopped.
• Transient response. The vital signs initially improve (pulse slows and
blood pressure increases); however, during reassessment, these
patients show deterioration with recurrent signs of shock. These
patients have typically lost between 20% and 40% of their blood
volume.
• Minimal or no response. These patients show virtually no change in
the profound signs of shock after a 1- to 2-liter bolus.

21. Volume Resuscitation
There are two general categories of fluid resuscitation products that have been
for the management of trauma patients-blood and IV solutions.
Isotonic Crystalloid Solutions
Isotonic crystalloids are balanced salt solutions
comprised of electrolytes (substances that
separate into charged ions when dissolved in
solutions). They act as effective volume expanders
for a short time, but they possess no oxygen-
carrying capacity.
Immediately after infusion, crystalloids fill the
vascular space that was depleted by blood loss,
improving preload and cardiac output.
Lactated Ringer's
Lactated Ringer's solution remains the isotonic
crystalloid solution of choice for the management
of shock because its composition is most similar to
the electrolyte composition of blood plasma. It
contains specific amounts of sodium, potassium,
calcium, chloride, and lactate ions.
The order of preference for blood
products is:
- Cold-stored low-titer O whole
blood
- Pre-screened low-titer O fresh
whole blood
- Plasma, red blood cells (RBCs) and
platelets in a 1:1:1 ratio
- Plasma and RBCs in a 1:1 ratio
- Plasma or RBCs alone
If possible, IV fluids should be warmed to about
39°C before infusion. Infusion of large amounts of
room temperature or cold IV fluid contributes to
hypothermia and increased hemorrhage.

23. Distributive (Vasogenic) Shock
Distributive shock, or vasogenic shock, occurs when the vascular
container enlarges without a proportional increase in fluid volume.
After trauma, this is typically found in patients who have sustained
a spinal cord injury.
Spinal shock is a neurologic phenomenon
that occurs for an unpredictable and variable
amount of time after spinal cord injury,
resulting in temporary loss of all sensory and
motor function, muscle flaccidity and
paralysis, and loss of reflexes below the level
of the spinal cord injury.
Cord contusion is usually caused by a
penetrating type of injury or movement of
bony fragments. The severity of injury
resulting from the contusion is related to the
amount of bleeding into the spinal cord
tissue.
Damage to or disruption of the spinal blood
Neurogenic "shock" secondary to spinal cord injury
represents a significant additional finding. When the
spinal cord is disrupted, the body's sympathetic control
mechanism is interrupted and can no longer maintain
constriction of the muscles in the walls of the blood
vessels below the point of disruption. These arteries and
arterioles dilate, enlarging the size of the vascular
container, which leads to a partial loss of systemic
vascular resistance.
Signs and symptoms:
– Hypotension
– Heart rate normal or slow
– Skin warm, dry, pink
– Paralysis or deficit (No chest movement, simple

24. Cardiogenic Shock
Pumping strength is reduced, cardiac output falls, and blood pressure goes
down. Such a condition is called cardiogenic shock.
Myocardial contusion
Direct trauma to the heart can injure it,
damaging the muscle and reducing
pumping strength, a condition called
myocardial contusion.
Myocardial contusion can result in
diminished cardiac output because of
this heart muscle damage, as well as
possibly causing cardiac dysrhythmia.
Myocardial contusion often cannot be
differentiated from cardiac tamponade
in the field.
Myocardial infarction (MI)
Though this is a medical cause of loss
of heart muscle
strength, the emergency care provider
must remember that cardiogenic
shock must be considered in the
hypotensive and usually tachycardic
patient who presents with chest pain.
Especially in older patients, an MI may
be the precipitating cause of the
traumatic event.
In the trauma patient, the significant causes of cardiogenic shock are the
following:
Myocardial contusion may cause ventricular
ectopy

25. Mechanical (or Obstructive)
Shock
Traumatic conditions that can cause mechanical shock are tension
pneumothorax and cardiac tamponade:
Physical findings of tension pneumothorax Pathophysiology and physical findings of cardiac
tamponade

26. Algorithm MARCH-PAWS
• MARCH PAWS

27. Burns
Categories of burns based on source include:
• Heat (thermal) burns, which may be caused
by fire, steam, or hot objects.
•Chemical burns, which may be caused by
caustics, such as acids and alkalis.
•Electrical burns, which originate from
outlets, frayed wires, and faulty circuits.
•Lightning burns, which occur during
electrical storms.
•Light burns, which occur with intense light.
Light from the arc welder or industrial laser will
damage unprotected eyes. Also, ultraviolet light
(including sunlight) can burn the eyes and skin.
•Radiation burns, which usually result from
nuclear sources.

28. Most often burns are categorized according
to the depth of the burn

29. Most often burns are categorized according
to the depth of the burn

30. Burn Depth Characteristics

31. Total burns surface area

32. Total burns surface area

33. Total burns surface area

34. Total burns surface area
• The Lund-Browder chart is a
diagram that takes into account
age-related changes in children.
Using these charts, a prehospital
care provider maps the bum and
then determines bum size based
on an accompanying reference
table.
• This method requires drawing a
map of the bums and then
converting the map to a calculated
burned surface area. The
complexity of this method makes it
difficult to use in a prehospital
situation.

35. Burns greater than 15% surface area (adult), greater than 10% (child)
or any burn occurring in the extremes of age are considered serious
Serious burns requiring hospitalization include the following:
•Adult: greater than 15% burn
•Pediatric: greater than 10% burn
•Any burn in the very young, elderly or the infirm
•Any full thickness burn
•Specific regions: face, ears, eyes, hands, feet, perineum
•Circumferential burns
•High-voltage electrical burns
•Inhalational injury
•Associated trauma or significant pre-burn illness, e.g. diabetes

36. Burns management
1. Stop the burning process immediately.
2. Flush superficial burns with water (or saline) for several min.
3. Remove smoldering clothing and jewelry. Do not remove
any clothing that is melted onto the skin.
4. Continually monitor the airway. Any burns to the face or exposure to smoke
may cause airway problems.
5. Cover partial- and full-thickness burns with dry, clean dressings.
6. If the eyes or eyelids have been burned, place clean dressings or pads over
them. Moisten these pads with sterile water if possible.
7. If a serious burn involves the hands or feet, always place a clean pad
between toes or fingers before completing the dressing.
8. Provide oxygen and care for shock.
9. Painkillers. Narcotic analgesics such as fentanyl (1 mcg per kg body weight) or
morphine (0.1 mg per kg body weight) in adequate dosages will be required to
control pain.
11. Maintain body temperature. Prevent hypothermia, by remove wet clothing

37. Burns management
11. Fluids should be given to all patients over one year
with burns covering 15% or more of TBSA and to all
infants under one year with burns covering 10% or
more of TBSA.
Parkland formula to calculate the patient’s fluid
requirement over the first 24 hours. The formula tells
what volume of Ringer’s lactate to give, in milliliters.
Parkland formula
Volume (ml) = 4 x body weight (kg) x % TBSA
burned

38. Circumferential Burns
Circumferential burns of the trunk or limbs are
capable of producing a life- or limb-threatening
condition as a result of the thick, inelastic eschar that is
formed.
Circumferential bums of the chest can constrict the
chest wall (inability to inhale)
Circumferential burns of the extremities create a
tourniquet-like effect that can render an arm or leg
pulseless.
Management:
• Monitor respiration and chest expansion
• Monitor distal PMS
• Escharotomies (surgical incisions made through the
burn eschar to allow expansion of the deeper tissues
and decompression of previously compressed and
often occluded vascular structures)

39. Classic lines for escharotomy incisions
Escharotomy Technique
Escharotomies should be performed
in as clean an environment as
possible. Required equipment
includes a scalpel, hemostats, ties,
and electrocautery if available.
It is helpful to mark lines on the
patient beforehand, especially over
the arm, to avoid inadvertent
involvement of a joint.
Avoid exposing major neurovascular
structures.
Never place escharotomy incisions
on the palmar surfaces of the hands
or the soles of the feet.
Escharotomies to address increased
chest wall resistance and pulmonary
problems should include abdominal
wall escharotomies if the abdomen
is affected.

40. Chemical burns
Chemical injury can result from exposure to acids, alkalizes, and
petroleum products.
Acidic burns cause a coagulation necrosis of the surrounding tissue, which
impedes the penetration of the acid to some extent (pH between 7
(neutral) and 0 (strong acid)).
Alkali burns are generally more serious than acid burns, as the alkali
penetrates more deeply by liquefaction necrosis of the tissue (pH between
7 and 14 (strong base)).
The severity of chemical injury is
determined by four factors:
• nature of the chemical,
• concentration of the chemical,
• duration of contact,
• mechanism of action of the
chemical.

41. Prehospital Management
•Wear appropriate protective gloves, eyewear, and respiratory
protection if needed. In some situations you will need to wear a
chemical protective suit.
•Remove all the patient’s clothing. Place in plastic bags to limit
further contact.
•If dry powder is still present on the skin, brush it away before
irrigating with water.
•Immediately lush away the chemical with large amounts of
water, for at least 20 to 30 minutes, using a shower or hose (alkali
burns require longer irrigation).
•Neutralizing agents offer no advantage over water lavage
(reaction with the neutralizing agent can itself produce heat and
cause further tissue damage).
•Alkali burns to the eye require continuous irrigation during
the first 8 hours after the burn, If possible, ocular
decontamination with continuous irrigation using a Morgan lens

42. Electrical burns
The factors that determine severity of
electrical injury:
• Type and amount of current (alternating
versus direct current and also the voltage)
• Path of the current through the body
• Duration of contact with the current
source
Electrical injuries cause skin burns at the entrance and exit sites because of high
temperatures generated by the electric arc 2,500°C at the skin surface.
Fractures and dislocations may be present due to the violent muscle contractions
that electrical injuries cause.
The most serious and immediate injury that results from electrical contact is
cardiac arrhythmia (premature ventricular contractions, ventricular tachycardia,
and ventricular fibrillation).
In cases of electrical burns, damage is caused by electricity entering the body and traveling
through the tissues.
Lightning injury:
injury by the
multiple effects of
very short duration,
very high voltage
direct current on the
body. The most
serious effect is
cardiac and
respiratory arrest.

43. Prehospital Management
• At the scene of an electrical injury, your first priority is scene safety.
• Determine if the patient is still in contact with the electrical current.
• If so, you must remove the patient from contact without becoming a victim yourself
(connect with power company personnel are turning off the electricity).
• Due to the potential for arrhythmia development, routine IV access should be
initiated in the ambulance, along with continuous cardiac monitoring (be ready for CPR).
Follow standard guidelines for CPR and advanced cardiac life support (ACLS).
• Electrical burn patients are at risk for developing rhabdomyolysis. In those cases,
adequate fluid resuscitation is indicated by maintaining a urine output of 0.5 to 1 cc/kg
body weight per hour.
• Also with breakdown of muscle cells, potassium is released into the circulation and
can lead to hyperkalemia, which can result in cardiac arrhythmias and death. Tall peaked
T-waves on the ECG may be a sign of hyperkalemia. Intravenous calcium (gluconate or
chloride) along with intravenous sodium bicarbonate, 50% dextrose, and insulin can
temporarily reduce the effects of hyperkalemia on the heart.

44. Inhalation Injuries
There are three elements of smoke inhalation:
• thermal injury (injury to the skin caused by heat from
flame, hot liquids, hot gases, or hot solids)
• asphyxiation (two gaseous products that are clinically
important as asphyxiants are carbon monoxide and
cyanide gas)
• delayed toxin-induced lung injury (injury to the lungs or
other body organs from inhalation of toxic gases found
in smoke). Danger signs of upper
airway burns:
• Burns of the face
• Singed eyebrows or nasal
hair
• Burns in the mouth
• Carbonaceous (sooty)
sputum
• History of being confined in
a
Heat inhalation can cause complete
airway
obstruction by swelling of the
hypopharynx: left side-normal

45. Frostbite
• Damage from frostbite can be due to freezing of tissue,
ice crystal formation causing cell membrane injury,
microvascular occlusion, and subsequent tissue anoxia.
Some of the tissue damage also can result from
reperfusion injury that occurs on rewarming.
Frostbite is classified into (according to depth):
• first-degree,
• second-degree,
• third-degree,
• fourth-degree.

46. Classification of frostbites
• 1. First-degree frostbite: Hyperemia and edema are present
without skin necrosis.
• 2. Second-degree frostbite: Large, clear vesicle formation
accompanies the hyperemia and edema with partial-thickness
skin necrosis.
• 3. Third-degree frostbite: Full-thickness and subcutaneous tissue
necrosis occurs, commonly with hemorrhagic vesicle formation.
• 4. Fourth-degree frostbite: Full-thickness skin necrosis occurs,
including muscle and bone with later necrosis.

47. Prehospital Management
Patients with superficial frostbite should be placed with the affected area against a warm body
surface (covering the patient's ears with warm hands or placing affected fingers into armpits, axillae,
or groin regions).
Management of deep frostbite in the prehospital setting includes:
• Assessing and treating the patient for hypothermia, if present. Get the patient out of the cold. Take
the patient indoors (depending on circumstances). Remove wet clothing.
• Do not rub or massage the frostbitten area (massage will cause further damage to injured tissues).
• Transport the patient to the hospital with the injured area elevated.
• Administer analgesia as needed.
• Cover blisters with a dry, sterile dressing.
• Consider rewarming only if the potential to refreeze does not exist.
IV opiate analgesics are usually required for pain relief and should be initiated before the tissues have
thawed. Initiate IV NaCl with a 250-ml bolus to treat dehydration and reduce blood viscosity and capillary
sludging.
Attempts to begin rewarming of deep frostbite patients in the field can be hazardous to the patient's eventual
recovery and are not recommended unless prolonged transport times (over 2 hours) are involved. If prolonged
transport is involved, thaw the affected part in a warm water bath at a temperature no greater than 37°C to 38.9°C on
the affected area until the area becomes soft and pliable to the touch (-30 min).
Administer ibuprofen (12 mg/kg up to 800 mg) if available. NSAIDs such as ibuprofen help decrease

48. Hypothermia
• Hypothermia is defined as a decrease in BT generally
35°C, owing to inadequate thermogenesis and/or
excess environmental cold stress. Extreme cold
weather does not need to be present for a person to
become hypothermic.
• Hypothermia is sometimes also called accidental
hypothermia to distinguish it from therapeutic or
induced hypothermia, which is a key step in the last
link in the chain of survival for comatose patients
with return of spontaneous circulation.

49. Mechanism of heat loss of the body

50. Signs and symptoms of hypothermia
Decreasing mental status:
Amnesia, memory lapses, and incoherence
Mood changes
Impaired judgment
Reduced ability to communicate
Dizziness
Vague, slow, slurred, or thick speech
Drowsiness progressing even to
unresponsiveness
Decreasing motor and sensory
function:
Stiffness, rigidity
Lack of coordination
Exhaustion
Shivering at first,
little or no shivering later
Loss of sensation
Changing vital signs:
Breathing rapid at first; shallow,
slow later; absent near end
Pulse rapid at first; slow and barely
palpable later; irregular or absent
near end
Skin red in early stages, changing
to pale, to cyanotic, to gray, waxen,
and hard; cold to the touch
Slowly responding pupils
Low to absent blood pressure
Stage Clinical Findings
Estimated Core
Temperature ( °C)
Hypothermia I (mild) Conscious, shivering * 35–32 °C
Hypothermia II
(moderate)
Impaired consciousness
*; may or may not be
shivering
<32–28 °C
Hypothermia III
(severe)
Unconscious *; vital
signs present
<28 °C
Hypothermia IV
(severe)
Apparent death; vital
signs absent
Classically < 24 °C **
Classical staging of
accidental hypothermia
based on clinical signs
Copyright 2021 European
Resuscitation Council.

51. Principles of pre-hospital management of hypothermia

52. Treatment of hypothermia
Mild hypothermia
Passive rewarming:
 removing the patient
from the cold
environment,
 optimizing insulation,
 offering food and warm
drinks,
 and promoting active
movements,

53. Moderate and Severe Hypothermia
 Patients with moderate or severe hypothermia require active rewarming. The whole body
should be insulated to reduce the risk of further cooling. Protection should be provided
against cold, wind, and moisture. A hypothermic patient should be packaged with several
layers.
Attempts to rewarm should not delay transport. They should receive adequate oxygenation and
be placed on a cardiac monitor. When IV or IO fluids are required, they should be warmed to
38–42 °C and should be given in boluses guided by vital signs . Use of heated fluids helps to
limit secondary cooling and may protect lines from freezing but has little direct effect on
rewarming.