Stages of Shock: What You Need to Know As An EMT

Shock is a common and life-threatening medical emergency that many EMTs encounter during their careers; estimates suggest more than 1.2 million ED visits a year are for patients in shock.

However, identification of shock can be challenging since there is no one specific vital sign that is indicative of shock. Understanding the types and stages of shock, along with possible related vital signs, can help a provider more quickly provide treatment and stabilization.

Medical shock is described as inadequate perfusion or blood flow, meaning a lack of oxygen reaching the body’s peripheral tissues, causing global tissue hypoperfusion and circulatory collapse. This is different from the mental or psychological type of shock experienced after a traumatic event. While medical shock can be reversible if detected and treated early, it can cause multi-organ failure and death.

Types of Shock

Medical shock is not a diagnosis in itself; instead, it is a symptom of a more serious cause that must be treated. The four major types of shock typically encountered by EMS agencies include:

• Cardiogenic shock, caused by disease or event impacting the heart’s functioning, including myocardial infarction, myocarditis, disturbances of the electrical rhythm of the heart, and any kind of mass fluid accumulation and/or blood clot
• Hypovolemic shock, caused by low volume of blood available for circulation (due to internal or external bleeding, dehydration, severe vomiting or diarrhea, diseases causing excess urination, extensive burns, intestinal blockage, or pancreatitis)
• Septic shock, caused by an overwhelming infection, typically from bacteria, which can impact the heart function and cause blood vessel dilation and lowering of blood pressure
• Anaphylactic shock, caused by an overwhelming, systemic allergic reaction from insect sting, food allergen or other allergen

While some of these causes are immediately recognizable, others may be more difficult to ascertain. However, the ability for prehospital care to identify and begin treatment for the cause of the shock increases the patient’s chances of survival.

Three Stages of Shock

Shock can be categorized into three stages, which can be helpful in understanding where your patient is in progression. Stage I is considered “compensated” or non-progressive, meaning the patient’s body is engaging and is working to counteract the low blood flow on its own through increasing its rate of breathing and heart rate, vasoconstriction, and other functions. The patient in this stage of shock may still be alert, although they may be in an altered mental state, primarily exhibiting vital sign changes. At this point, aggressive treatment may slow progression.

In Stage II, also called “decompensated” or “progressive,” the natural mechanisms are beginning to fail and the body is beginning to shut down. A lack of oxygen to the brain may result in the patient degrading on the “alert, verbal, pain, unresponsive” (AVPU) scale, while heart rate and breathing are still increased. Blood pressure, however, may still appear to be at normal levels.

Finally, if Stage III of shock is reached, it is termed “irreversible,” as the body can no longer keep up with its attempts to maintain blood flow to its most vital organs. Heart rate and breathing remain high until crashing, while blood pressure finally drops very low. Permanent tissue and organ damage have begun, dilating blood vessels further, and the endpoint to Stage III shock is patient death.

Symptoms of Shock

While a significant drop in blood pressure is a common symptom of shock, it is a late finding; don’t wait for that vital sign change to begin treatment for shock. Additionally, children can lose almost half of their blood volume before dropping pressure; at this point, he or she is close to death.

Instead, work with the wholistic view of the patient’s vitals while looking for indicators of an underlying cause of shock. Initial symptoms could include:

• Cold, clammy hands and feet
• Pale or blue-tinged skin tone (cyanosis)
• Weak, fast pulse rate (tachycardia)
• Fast breathing rate (tachypnea), labored or irregular breathing

Other symptoms may also be presenting but are dependent on the underlying cause of the shock. For example:

• Altered mental state (restlessness, anxiety)
• Peripheral perfusion
• Weak, thready, or absent peripheral pulses
• Dilated pupils
• Increased thirst
• Nausea and vomiting
• Hives, mottling, chest pains, and other signs of underlying causes

Next Steps: Treat and Transport

As an EMT or paramedic, if you suspect shock, it is your objective to treat the symptoms as well as the root causes to the best of your abilities and certification. You should, of course, address the most urgent symptoms to halt the underlying conditions. Control or stop sources of external bleeding, maintain open airways, and administer high concentration oxygen or CPR as needed. Consult with a physician if needed to administer epinephrine or the patient’s EpiPen, or to begin to treat a potential cardiac event with aspirin or nitro.

Next, do your best to determine the patient’s type and stage of shock; treat the effects of shock with oxygen, IV fluids, and medications to maintain critical body systems. Elevate the patient’s legs 8″ – 12″ if there are no lower body or spinal injuries. Keep the patient warm and prevent loss of body heat. Transport immediately and continue to monitor vital signs and continue treatments.

Finally, if you have not already done so, communicate with your receiving hospital via radio or alerting software that you are en routeso that appropriate preparations can be made. Details regarding the type and stage of shock can be helpful to ensure the ED and any specialty labs/teams are assembled and ready to act once your patient arrives. Today’s top alerting software allows EMS agencies to securely send video, photos, and messages to receiving hospitals, along with estimated arrival time and patient vitals – all in real time.

By halting and treating the underlying conditions causing the shock effects, while treating the symptoms of shock itself, a paramedic or EMT can increase the patient’s chances of survival and recovery.