A Clinical Diagnosis to watch out for..
Cannot Miss Diagnosis No.4
- Section Editor: Prof. T.K.

A 25 year old obese truck driver who has had a couple of drinks of beer before starting to drive lost control of the vehicle and went off the road

No other abnormality was noticed. Bowel sounds were heard normal.
A 40 year old male sales executive after a long day of touring felt tired and wanted to rest for a while. An hour later when he tried to get out of the bed he felt weak light headed and dizzy and fainted. A few minutes later he was able to get up and get back to bed. He was unable to take any food because he had no appetite. Except for history of hyperacidity for which he was taking antacids on and off there was no significant past medical problems and is not a known diabetic. As his weakness persisted his friend took him to a nearby nursing home for a check up. On arrival his heart rate was assessed as 124 p/m and respiratory rate was 30 p/m. His BP on recumbent position was 108/78 and on standing dropped to 90/62. Blood test and other investigations were requested.A 40 year old male slipped on the road and fell down. He felt normal enough to get up and go home. Late evening he started to feel tired and weak, and so he went to see his family physician. The family physician who knew him well examined him and found his BP was 100/80 mmHg. He was on medication for hypertension for about 3 years. His cardio respiratory status was normal except for Tachycardia (pulse rate 106) and abdomen was minimally distended. He always had an enlarged spleen which was almost felt up to the umbilicus. Except for some areas of tenderness in the abdomen there was no guarding or rigidity. There was a small contusion over the left costochondral area due to the fall that he had that morning. He was somewhat confused and felt unusually tired and weak.
All the above four patients have one disease in common and the physician cannot afford to miss the diagnosis. Immediate effort should be made to actively pursue this diagnosis and manage this vigorously to prevent a disastrous outcome. All of them have either established or impending “ hemorrhagic shock” .
In the first patient because of his presentation it may be difficult to find out the location of bleeding. It is entirely possible that when his truck went off the road and hit the tree forcibly he could have sustained internal injuries to liver or spleen leading to internal bleeding.
The second patient most probably has a ruptured ectopic pregnancy. She is in the reproductive age group and gave a history of irregularity and scanty menstrual periods in the last 2 cycles and the course of events would indicate the possibility of a ruptured tubal pregnancy.
The Sales Executive with a history of hyperacidity probably has peptic ulcer disease from which he is bleeding now internally. Very soon he will vomit a large amount of blood and likely to end up in a full-fledged shock.
The fourth patient who is known to have splenomegaly is likely to have sustained a minor injury to the spleen and during the period of the day he must have slowly bled inside and now presents with symptoms of “shock syndrome”.
In a busy private practice when people present with subtle symptoms it is entirely possible to miss the underlying diagnosis and provide inadequate treatment resulting in disasters. So it is very vital that “hemorrhagic shock” as a dangerous disease is kept in mind and that where circumstances could indicate a possibility, the family practitioner should spend a few extra minutes to take the history and look for specific signs and symptoms that may indicate an impending and/or an ongoing hemorrhagic shock. If shock syndrome is suspected and appropriate line of management is provided, one can count on significant success. Let us examine the common finding in the above individuals. They all presented relatively acutely.
For the patient with bleeding peptic ulcer and the one who had possible injury to the spleen, because of the basic body strength as well as the type of bleeding it probably took a few hours before definitive symptoms started to appear. They all have tachycardia with a pulse rate in excess of 100/mt and tachypnoea. The status of confusion is usually due to inadequate oxygenation to the brain as a result of loss of blood. Although there are other causes of shock, including neurogenic shock, hemorrhagic shock has to be considered under all circumstances and has to be ruled out. When shock is full blown with evidence of inadequate perfusion to the skin, kidneys and central nervous system (CNS) the diagnosis is fairly straightforward. The family practitioner has to watch out for 2 important signals.
1. A near normal systolic pressure does not ensure that the patient is not in shock. It can take up to a loss of 30% of blood volume before systolic BP comes down significantly. However, PR, RR, skin circulation and pulse pressure have to be carefully checked. Pulse pressure is the difference between systolic and diastolic pressures. The earliest signs of shock are tachycardia and chillness of the skin due to vasoconstriction. In an adult a pulse rate of more than 100 is considered to be tachycardia, particularly when lying down (160 in infants and 120 in children up to age of puberty). Some patients may not show tachycardia either because they are on certain medications (beta blockers) or their cardiac response is not adequate. A useful information is a narrowed pulse pressure (difference between systolic and diastolic). This indicates that there is significant blood loss and the body is trying to do its best to maintain the peripheral resistance by compensatory mechanisms.
2. It is useless to depend on Hematocrit, PCV or hemoglobin in dealing with patients of hemorrhagic shock. One should know the baseline Hb or Hct of a patient to see how much it has dropped. Unless the volume is restored the status of Hb and Hct cannot be relied upon.
Irrespective of the etiology of hemorrhagic shock, certain procedures are absolutely essential for the family practitioner to follow for all the patients while awaiting specialist’s help in the management e.g. the lady with a ruptured ectopic pregnancy would require prompt services of the OBGYN or surgical specialists who can quickly explore the abdomen and take care of the problem. Patient with bleeding peptic ulcer or the one with the internal injury may also require definitive surgical consultations and management. But in the meantime, several important vital steps have to be taken so that patient is better prepared and stabilised and possibility of irreversible shock prevented.
For purposes of understanding, hemorrhagic shock is divided into four classes:
Class I hemorrhage - where the loss is up to 15% of total blood volume. Except for minimal tachycardia no other sign may be apparent
Class II hemorrhage -15% to 30% of blood volume has already been lost. Definite evidence of tachycardia and tachypnea and a decrease in pulse pressure will be obvious. This decrease in pulse pressure is due to elevation of the diastolic pressure which is a natural response as a result of increase in peripheral resistance brought out by catecholamine circulation. In Class II hemorrhage early central nervous system changes take place leading to anxiety and at times minimal confusion. The urinary output becomes significantly less.
Class III hemorrhage - where there is 30 to 40% loss of blood volume (almost 3 liters in an adult). All the typical signs and symptoms of shock are obvious.
Class IV hemorrhage -When a patient looses more than 40% of blood volume we call it Class IV hemorrhage. Patient is cold and pale with significant loss of blood pressure, narrowed pulse pressure, negligible urine output and depressed mental status.
Although a family practitioner may not have time to evaluate either the volume loss or the class of hemorrhage an idea of this would help him to understand the seriousness of the situation. The important thing to realize is that even up to 15% loss of blood sometimes may not be adequate to alert a physician. When they start loosing between 15 to 30% signs and symptoms are apparent, but it is possible for a doctor to miss if he is not keen about looking for them. If medical and surgical inventions are available at this stage disastrous end results of Class III and Class IV hemorrhages could be avoided. family practitioner can readily appreciate that hemorrhagic shock is one disaster where by circumstantially clinical history and a few subtle findings he gets the clue and use other diagnostics only to assess the grade and establish further lines of management. He does not wait for his suspicion to be confirmed for starting the treatment.
Any person presenting with shock will have to be immediately assessed within seconds for the following:
a. Whether his airway and breathing (A & B) are within normal.
b. To see if there are any obvious external bleeding source requiring immediate attention.
c. If there are gross evidence of skeletal injury with displacement.

• As the airway and breathing are assessed, which should take only a very brief period,all these patients should be started on oxygen either by a valve mask reservoir system or at least high delivery nasal prongs.

• The patient should be maintained in recumbent position with the lower extremities raised above the level of the chest.

• Immediate establishment of 2 intravenous lines with catheter placements to deliver I.V. fluids rapidly.

• Draw adequate blood for testing complete blood count, blood sugar and other necessary parameters as also to type and cross match blood.

• Place a naso gastric tube to look for any GI bleeding and a catheter to monitor urine output.

• Cardiac and pulse oximeter monitoring will add to our diagnostic and management strategies.

• The time honoured method of treating an established or impending hemorrhagic shock is to start oxygen and establish I.V lines rapidly. Infuse Ringer Lactate or normal saline solution as much as 1000 to 2000 ccs being delivered in less than half to one hour time.

• The first several hundred ccs flow in minutes for an adult. This so called bolus therapy is likely to provide the key that will determine further treatment to this patient. As a rule of thumb and in particular trauma situations the American College of Surgeons recommend that fluid replacement should be as per 3:1 rule. This means for every 100 ml of estimated blood loss about 300 ccs of fluid will have to be replaced. In dealing with Class III and Class IV situations, in addition to fluid, early blood transfusion in the management becomes absolutely necessary. When we give bolus infusion of a crystalloid fluid during the first half hour we can await the arrival of at least a type specific blood for administration when necessary. In rare cases where there is no time, replacement has to be made with O negative blood ( a universal donor) even if it is not cross matched to save lives.
  On the basis of the bolus I.V. administration if we are able to stabilise the patient (hemodynamically stable) one may have time to study the patient further with minimal investigations and plan for surgical management. Some patients may return back to normal status after the bolus treatment and may only require further observation. Most disasters take place when patients are kept waiting in emergency departments or x-ray departments or lab test. Consulting physician and nursing attendance is constant till patient is stable. The American College of Surgeons gives the following recommendation which is worth remembering and following in dealing with hemorrhage shock.