From the Guidelines
The latest sign of shock to occur in a patient with RTA, pelvic fracture, thigh wound with profuse bleeding, and hypovolemic shock parameters is increased cortisone level (option B). In hypovolemic shock, the body progresses through a series of compensatory mechanisms to maintain perfusion to vital organs. Tachycardia (increased heart rate) is one of the earliest signs as the body attempts to maintain cardiac output despite decreased blood volume. Increased arteriolar resistance occurs early as peripheral vasoconstriction helps maintain blood pressure. Decreased venous return (not increased) happens early due to blood loss. The adrenal stress response with cortisol (cortisone) elevation is a later physiological response to shock, occurring after the initial cardiovascular compensatory mechanisms have been activated. This hormonal response represents the body's attempt to mobilize energy reserves and maintain glucose levels during the stress of shock, but it takes time for the hypothalamic-pituitary-adrenal axis to fully activate and produce significant cortisol elevation, making it one of the later detectable signs in the progression of hypovolemic shock, as supported by the management guidelines for bleeding following major trauma 1.
Some key points to consider in the management of such patients include:
- The importance of early identification and control of bleeding sources, as emphasized in the European guidelines for management of bleeding following major trauma 1.
- The classification of hemorrhage severity, which helps in assessing the extent of blood loss and guiding management decisions, as outlined in the American College of Surgeons Advanced Trauma Life Support classification 1.
- The need for a multidisciplinary approach in the management of patients with multiple injuries, including pelvic fractures, which are associated with a high risk of hemorrhage and other complications 1.
Given the complexity and severity of injuries in patients with RTA, pelvic fracture, and thigh wound with profuse bleeding, prompt recognition and management of shock, including the latest sign of increased cortisone level, are crucial for improving outcomes and reducing morbidity and mortality.
From the Research
Latest Sign of Shock to Occur
The latest sign of shock to occur in a patient with RTA, pelvic fracture, and thigh wound with profuse bleeding, and hypovolemic shock parameters is:
- Increased arteriolar resistance and decrease COP [(2,3)] This is because the body tries to compensate for the loss of blood volume by increasing arteriolar resistance to maintain blood pressure, and decreasing cardiac output (COP) as a result of decreased preload.
Other Options
The other options are not the latest sign of shock to occur:
- Increase venous return: This is an early compensatory mechanism to increase cardiac output 4
- Increased cortisone level: This is a stress response to injury, but not a direct sign of shock 5
- Tachycardia: This is an early sign of shock, as the body tries to compensate for decreased blood volume by increasing heart rate 6