SHOCK RECOGNITION & MANAGEMENT
Source: ATP 4-02.11, Chapter 7 — Circulation Control, 23 March 2026
Key Points
- Shock = inadequate blood flow to body tissues
- Circulation is the "C" in MARCH-PAWS
- On the battlefield, assume shock is hemorrhagic (blood loss)
- Mental confusion + weak/absent radial pulse = significant blood loss
- Normal adult blood volume: ~5,000 cc (5 liters)
- Loss of 2,500 cc (half blood volume) = fatal without immediate intervention
- It is more effective to prevent shock through hemorrhage control than treat it after onset
- Internal bleeding to abdomen/chest cannot be controlled in field — rapid MEDEVAC required
Shock Signs — Alert Medical Personnel
- Mental confusion / altered mental status
- Weak or absent radial pulse
- Rapid breathing
- Nausea
- Sweaty, cool, or clammy skin
- Excessive thirst
- Pale or gray skin
- Previous severe bleeding
Anti-Shock Position
Lay casualty flat on back. Elevate legs 15–30 cm (6–12 inches) unless: spinal injury suspected, head injury, abdominal wounds, breathing difficulty, or fractures of legs/pelvis. Keep casualty warm — prevent hypothermia.
Alert medical personnel if the casualty is presenting signs of shock. If the casualty has both mental confusion and a weak or absent radial pulse, the casualty has lost a significant amount of blood. Shock will lead to the casualty's death if not quickly recognized and treated. (ATP 4-02.11, para 7-7)
General Indicators of Shock — Blood Volume Loss Table
Table 7-1 from ATP 4-02.11 shows why it is critical to quickly apply a tourniquet during CUF, reassess, and evaluate for additional bleeding sources during TFC. An average adult has approximately 5,000 cc of blood.
| Blood Volume Remaining | Blood Volume Lost | Signs and Symptoms | Effects and Outcomes |
|---|---|---|---|
| 4,500 cc | 500 cc | Possible increased heart rate | Usually no effects |
| 4,000 cc | 1,000 cc | Radial pulse >100. Breathing probably normal. | Unlikely to die from this amount of loss |
| 3,500 cc | 1,500 cc | Change in mental status. Weak radial pulse >100. Increased respirations. | If no further blood loss, still unlikely to die |
| 3,000 cc | 2,000 cc | Confusion and lethargy. Very weak radial pulse >120. High respiratory rate >35. | Very possibly fatal if not managed |
| 2,500 cc | 2,500 cc | Unconscious. No radial pulse, carotid pulse. HR >140. Respirations >35. | Fatal without immediate and rapid interventions |
Source: ATP 4-02.11, Table 7-1 — General Indicators of Shock. cc = cubic centimeter, HR = heart rate.
Causes of Shock
Shock is caused by a decrease in blood volume circulating in the body's circulatory system. On the battlefield, assume the cause is hemorrhagic unless proven otherwise. Causes include: (ATP 4-02.11, para 7-5)
- Hypovolemia — low blood volume from dehydration or blood loss (most common in combat)
- Low blood pressure
- Heart failure — pump failure
- Neurologic damage — infection, allergic reaction
- Obstructive causes — tension pneumothorax or pericardial tamponade
Note: Hypovolemic shock can also result from internal bleeding into the abdominal or chest cavity. The first responder or CLS cannot control internal bleeding — this requires rapid evacuation.
Prevention and Treatment of Shock
It is more effective to prevent shock through hemorrhage control than to treat it once it has developed. Even in cases where shock is already present, the most critical first action is to control any bleeding. (ATP 4-02.11, para 7-8)
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1
Control all external bleeding — reassess all tourniquets and pressure dressings; tighten as needed. This is the single most important intervention.
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2
Position the casualty — Lay flat on back. Elevate legs 15–30 cm unless contraindicated (spinal injury, head injury, abdominal wound, breathing difficulty, leg/pelvic fracture).
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3
Prevent hypothermia — Remove wet clothing, apply heat-reflective blanket or Hypothermia Prevention and Management Kit (HPMK). Cold reduces clotting ability and worsens shock.
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4
Do NOT give fluids by mouth — A casualty in shock should not be given anything to drink. This can cause aspiration and complicate surgical intervention.
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5
Request MEDEVAC and continuously monitor — Check for shock every 5 minutes if evacuation is delayed. Alert medical personnel immediately.
ATP 4-02.11 Source
Chapter 7: Circulation Control — Army Techniques Publication 4-02.11, Casualty Response, Tactical Combat Casualty Care, and First Aid. Headquarters, Department of the Army, 23 March 2026.
See It in Practice — ESB Tasks
These ESB Medical Lane tasks apply this doctrine directly: