By Mike McEvoy, PhD, REMT-P, RN, CCRN
If you watch seasoned medical providers, you’ll notice that the first thing they do is touch their patient. Surgeons touch a patient’s leg or foot as they approach the hospital bed; paramedics often grasp a patient’s hand initially. What seems a greeting is actually a finely tuned assessment process. You see, we die in an incredibly predictable manner. The feel of a patient’s extremity provides three clues directly related to the “Look Test” you were taught with patient assessment.
Regardless of the cause, every death results from shock (lack of perfusion) to important organs in the body. The progression from an initial injury through to death follows an inevitable three-step sequence. Along the way, your patient will fail the “Look Test.” Let’s review how a patient dies and correlate this progression of events with symptoms that will help you improve your “Look Test” assessment ability.
There are three phases of shock (decreased perfusion) leading to death: stimulation, decreased cardiac output, and organ failure. Each phase has a unique series of characteristic signs and symptoms.
Stimulation of the nervous and endocrine systems occurs immediately in response to any significant illness, injury, or threat to the body’s well being. The first and immediate reaction is an increased heart rate that serves to improve blood flow to all organs of the body. Next, the respiratory rate increases to meet the greater requirements for oxygen from faster heart rates. The observable changes so far, namely a faster pulse and increased respirations, are subtle. It’s unlikely that you would notice them at first glance.
To sustain a higher heart rate, the body produces certain chemicals called catecholamines. The appearance of these chemicals in the bloodstream not only sustains faster heart rates but also increases the force of the heart muscle contractions, ejecting more blood with each beat. Side effects from catecholamines produce characteristic symptoms that lead us to suspect trouble brewing inside our patient. Sweat glands activated by catecholamines cause the patient to suddenly break out in a cold sweat. Arteries and veins constrict, resulting in pale, cool skin that is more pronounced in peripheral areas such as hands and feet. Hence the three clues a seasoned provider gleans from touching a patient’s hand or foot. A pale, clammy, and cool extremity signals that some significant stimulation of the nervous and endocrine systems is in progress!
Decreased cardiac output is the second phase of shock. This is caused in some ways by reduced blood flow through constriction of arteries and vessels produced in the stimulation phase. In this second phase of shock, the kidneys attempt to increase total fluids in the body by retaining water. This seems helpful, but the end result overloads the heart with fluid, leading to progressively higher heart rates, greater oxygen needs, and finally a reduction in the amount of blood the heart is able to pump forward to the body. In this phase of shock, patients will often complain of thirst. The same process that triggers the kidneys to retain water causes thirst. Unfortunately the reduced blood supply to internal organs seen in this phase of shock stops digestion of food in the gut. Nausea and vomiting often follow. Urine output decreases (if you were able to measure it). While the symptoms associated with this phase of shock may seem random, they rarely vary in their order of appearance. Thirst nearly always presents initially, followed by nausea and vomiting. This explains why you would not want to provide fluids to a thirsty shock patient.
Organ failure is the third and final phase of shock. This occurs in patients rounding the corner on their way to dying. Organs without adequate perfusion begin to fail at this stage. The kidneys cease to make any urine. The liver is unable to keep the body warm or make clotting factors for the blood. The heart is increasingly unable to pump adequately, with blood sometimes backing up and congesting the lungs. Level of consciousness declines as oxygen supply to the brain drops; confusion or agitation may occur before loss of consciousness. Blood pressure falls precipitously and may be difficult to measure at all. Death finally occurs due to serious lack of oxygen and circulation in the body. Signs of this final stage of shock include loss of alertness and the inability to detect radial or pedal pulses.
You can use your knowledge of the progressive nature of shock to rapidly identify the seriousness of one or many patients. A quick look and touch can provide all the clues needed to either pass or fail the age old “Look Test.”
Mike McEvoy, PhD, RN, CCRN, REMT-P is the EMS coordinator for Saratoga County, New York. A former forensic psychologist, he now works in the Cardiac Surgical ICU at Albany Medical Center and teaches at Albany Medical College in NY. He is a paramedic for Clifton Park-Halfmoon Ambulance Corps and medical advisor for West Crescent Fire Department. He presently serves as a member of the New York State EMS Council and the State Emergency Medical Advisory Council and chairs the EMS Section of the New York State Association of Fire Chiefs.
