1. The definition of shock—No longer is shock defined by your typical clinical signs of high pulse, high respiratory rate, and low blood pressure. Instead PHTLS taught me that shock begins at the cellular level. Shock is now defined as the inability for our bodies to make or sustain energy (ATP). Glucose and oxygen are the two main components that produce ATP, the body’s currency for energy. When deprived, our lactic acid level increases, which decreases our body’s pH levels, leading to hypothermia and ultimately cells being deprived of O2, which begins the process for shutting down vital organs.
2. It’s OK to use more than one airway adjunct on a patient—Initially I was taught to open the airway, if the patient has no gag reflex, insert an OPA (with a gag reflex, then an NPA), and move on to breathing. However, PHTLS stressed that airway is the greatest priority, and while using both NPA and OPA simultaneously could put pressure on the head, maintaining the airway is more important.
3. No longer should patients in shock be put into the Trendelenburg position—When the body goes into shock, the blood vessels are shunted and deliver a proportionally greater amount of blood to the trunk or core of the body. I learned in my initial EMT training that patients suffering symptoms and signs of shock should be placed in the Trendelenburg position, with their feet elevated to allow gravity to force blood to the core. However, research now shows elevating the patient’s feet can put pressure on the diaphragm, reducing the surface area of the lungs, allowing for less gas exchange. Therefore, all shock patients should be placed in a position of comfort, with their torso elevated 15–30 degrees above the ground (see No. 5 for the logic behind elevation).
4. The primary assessment now consists of five letters (ABCDE), not three—Airway, breathing, and circulation are still our primary framework, but now providers are also urged to check for disability and exposure. Say you have a 45-year-old female who presents unconscious in the street. In this scenario providers would check her ABCs and then check for disability, or what caused the unconsciousness, whether it’s drugs or extreme hypoperfusion. Following that would be exposure. This expanded outlook helps combat the common EMS pitfall of getting sidetracked by distracting injuries. Providers are now encouraged to expose the patient’s body and scan for further injuries before treating the obvious ones.
5. Unconscious patients should not be put into a direct supine position, but with their heads elevated 15–30 degrees—In EMT school I probably ran through more than 50 scenarios, and the patients in every one were supine. But PHTLS outlined the physiological changes that occur to the patient in severe shock. One of those is the sphincter relaxing, which causes the cardiac sphincter to relax, which could result in gastric materials leaking from the stomach, leading to aspiration and potentially blocking the airway. Therefore, PHTLS instructors now suggest either elevating the patient's upper body on the stretcher 15–30 degrees or even putting your jump bag under their back for a source of elevation.
6. The “golden hour” of care begins the moment the patient gets injured—Many EMTs believe the so-called “golden hour” begins upon arrival. In fact it actually begins at the onset of injury. This emphasizes the importance of getting the patient off scene quickly and efficiently.
7. While many believe PEEP is the supreme intervention in respiratory-failure patients, it has its fair share of contraindications—Through increasing the level of pressure at the end of each expiration, alveolar sacs can store air for a longer time. As a result patients retain more oxygen per squeeze of the BVM, increasing their level of oxygenation and gas exchange. However, PEEP valves notoriously lower blood pressure. In a shock patient this can be the difference between life and death. As the blood pressure decreases, perfusion also decreases; the heart must now work harder to deliver oxygenated red blood cells to the rest of the body. In addition to lowering the patient’s BP, PEEP can also increase intracranial pressure (the last thing a head trauma patient needs) as a result of the increase in thoracic pressure from the extra storage of air in the alveolar sacs.
8. If only one provider is available to deliver breaths to a respiratory-failure patient, the preferred method should be the pocket mask, not the bag-valve mask—The reasoning behind this centers around the difficulty of maintaining a good seal with a BVM. It is almost impossible to hold an adequate seal with one hand on the mask and one hand on the bag. Therefore, it is recommended that providers use a pocket mask, hooked up to oxygen, which can deliver a steady 55% O2. In addition, patients will be less likely to suffer from gastric insufflation, as hyperventilating a patient with just your mouth would be nearly impossible.
Special thanks to my course coordinator, Steven P. Velasquez, and Robert Wood Johnson Somerville for hosting my PHTLS course.
Ross Bell, EMT-B, serves with the Millburn-Short Hills Volunteer First Aid Squad in Millburn, N.J.