CARDIOGENIC SHOCK
Cardiogenic shock is caused by inadequate functioning of the heart, not by loss of circulating blood volume. If the heart muscle is weakened by disease or damaged by trauma or lack of oxygen (as in cases of pulmonary disease, suffocation, or myocardial infarction), the heart will no longer be able to maintain adequate circulatory pressure, even though the volume of fluid is unchanged. Shock will develop as the pressure falls. Heart attack is an extreme medical emergency all Hospital Corpsmen must be ready to handle. It will be discussed in greater detail in the "Common Medical Emergencies" section of this chapter.

SEPTIC SHOCK
Septic shock usually does not develop for 2 to 5 days after an injury and the patient is not often seen by the Corpsman in a first aid situation. Septic shock may appear during the course of peritonitis caused by penetrating abdominal wounds or perforation of the appendix. Gross wound contamination, rupture of an ulcer, or complications from certain types of pneumonia may also cause septic shock. Septic shock is the result of vasodilation of small blood vessels in the wound area, or general vasodilation if the infection enters the bloodstream. In addition to increasing circulatory system volume, the walls of the blood vessels become more permeable, which allows fluids to escape into the tissues. This type of shock carries a poor prognosis and should be treated under the direct supervision of a medical officer.

ANAPHYLACTIC SHOCK
Anaphylactic shock occurs when an individual is exposed to a substance to which his body is particularly sensitive. In the most severe form of anaphylactic shock, the body goes into an almost instantaneous violent reaction. A burning sensation, itching, and hives spread across the skin. Severe edema affects body parts and the respiratory system. Blood pressure drops alarmingly, and fainting or coma may occur.

The causative agent may be introduced into the body in a number of ways. The injection of medicines (especially penicillin and horse-or egg-cultured serums) is one route. Another method is the injection of venoms by stinging insects and animals. The inhalation of dusts, pollens, or other materials to which a person is sensitive is a third route. Finally, a slightly slower but no less severe reaction may develop from the ingestion of certain foods and medications. Specific treatment of venoms and poisons will be discussed in chapter 5, "Poisoning, Drug Abuse, and Hazardous Material Exposure."

GENERAL TREATMENT PROCEDURES
Intravenous fluid administration is the most important factor in the treatment of all types of shock except cardiogenic shock. Ringer's lactate is the best solution to use, although normal saline is adequate until properly cross-matched whole blood can be administered. The electrolyte solutions replace not only the lost blood volume, but also lost extracellular fluid that has been depleted. If the shock is severe enough to warrant immediate administration of intravenous fluids, or if transportation to a medical facility will be delayed and a medical officer is not available to write an administrative order, be conservative: Start the intravenous fluids and let them run at a slow rate of 50 to 60 drops per minute. If intravenous solutions are unavailable or transportation to a medical treatment facility will be delayed, and there are no contraindications (such as gastrointestinal bleeding or unconsciousness), you may give the patient an electrolyte solution by mouth. An electrolyte solution may be prepared by adding a teaspoon of salt and half a teaspoon of baking soda to a quart or liter of water. Allow the patient to sip the solution.

Other treatment procedures for shock are as follows:

· Maintain an open airway. Oxygen may also be administered if proper equipment is available.

· Control hemorrhages.
· Check for other injuries that may have been sustained. Remove the victim from the presence of identifiable causative agents.
· Place the victim in a supine position, with the feet slightly higher than the head (shock position). Certain problems, such as breathing difficulties or head injuries, may require other positioning.

· Reduce pain by splinting fractures, providing emotional support, and attending to the victim's comfort. Unless contraindicated, aspirin may be dispensed.

· Conserve the patient's body heat.

· Avoid rough handling of the victim, and transport to a medical treatment facility.
· If transportation to a definitive care facility will be lengthy or delayed, seek the radio or phone advice of a medical officer on whether to give fluids by mouth or to start an intravenous line. If this consultation is impossible, use your own judgment. In the case of cardiogenic shock, DO NOTstart intravenous fluids since blood volume is sufficient and only function is impaired.

· Constantly monitor the patient and record vital signs every 15 minutes so that you are able to keep track of the patient's progress.
PNEUMATIC COUNTER-PRESSURE DEVICES (MAST)

Commonly known as Medical Anti-Shock Trousers or Military Anti-Shock Trousers (MAST), pneumatic counter-pressure devices are designed to correct or counteract certain internal bleeding conditions and hypovolemia. The garment does this by developing an encircling pressure up to 120 mm Hg around both lower extremities, the pelvis, and the abdomen. The pressure created

· slows or stops venous and arterial bleeding in areas of the body enclosed by the pressurized garment;
· forces available blood from the lower body to the heart, brain, and other vital organs;

· prevents pooling of blood in the lower extremities; and
· stabilizes fractures of the pelvis and lower extremities. Some indications for use of the pneumatic counter-pressure devices are when

· systolic blood pressure is less than 80 mm Hg,
· systolic blood pressure is less than 100 mm Hg and the patient exhibits the classic signs of shock, or
· fracture of the pelvis or lower extremities is present.

Although the only absolute contraindication in the use of these devices is in the case of pulmonary edema, other conditional contraindications include congestive heart failure, heart attack, stroke, pregnancy, abdominal evisceration, massive bleeding into the thoracic cavity, and penetrating wounds where the object is still impaled in the victim.

Application of the anti-shock garment is a simple procedure, but it requires some important preliminary steps. When the garment is laid out flat, ensure that there are no wrinkles. If the patient is to remain clothed, remove all sharp and bulky objects from the patient's pockets. Take vital signs before applying the MAST garment. When applying the garment, inflate sufficiently so the patient's systolic blood pressure is brought to and maintained at 100 mm Hg. Once the garment is inflated, take the patient's vital signs every 5 minutes. The garment should be removed only under the direct supervision of a physician.

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