C — Circulation

C Circulation

Assess and treat shock — the body’s response to blood loss

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Shock Assessment

Mental Status:

• Alert and oriented → Adequate perfusion
• Confused, anxious → Early shock
• Unresponsive → Severe shock

Pulse:

• Normal, strong → Adequate
• Rapid, weak → Shock
• Absent radial → Severe shock / near death

Skin:

• Warm, dry, pink → Normal
• Cool, pale, clammy → Shock

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Shock Classification

Class	Blood Loss	Heart Rate	BP	Mental Status
I	Under 15%	Normal	Normal	Normal
II	15-30%	Over 100	Normal	Anxious
III	30-40%	Over 120	Decreased	Confused
IV	Over 40%	Over 140	Very low	Unresponsive

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Treatment Priorities

1. Ensure hemorrhage is controlled

   • Recheck all tourniquets
   • Reassess wound packing
   • This is the most important step

2. IV/IO Access (if trained and equipped)

   • Large bore IV (18ga or larger)
   • IO if IV not obtainable

3. TXA (Tranexamic Acid)

   • If available and within 3 hours of injury
   • Helps prevent coagulopathy
   • 1g IV over 10 minutes

4. Fluid Resuscitation

   • Follow your protocol
   • Blood products preferred if available
   • Crystalloids if blood not available

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Permissive Hypotension

Exception: Head Injury

• Maintain systolic BP ≥90 mmHg
• Brain needs adequate perfusion
• Use fluids to achieve this target

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Signs You’re Winning

• Mental status improving
• Pulse slowing and strengthening
• Skin warming
• Urine output (if able to assess)

Signs You’re Losing

• Worsening mental status
• Pulse weakening despite fluids
• Continued bleeding somewhere
• → Reassess M — find the bleeding

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Positioning

• Shock position: Legs elevated (if no contraindications)
• Do NOT elevate legs if:
  • Suspected spinal injury
  • Head injury
  • Chest injury with respiratory distress

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Document

• Vital signs (pulse, BP if available, mental status)
• Fluids given (type, amount, time)
• TXA given (time)
• Response to treatment

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Reassess

• Every 5 minutes in active shock
• After every fluid bolus
• Any change in mental status
• Before and after movement