Shock — Managing Position and Monitoring Until Help Arrives

Once a person in shock has been identified and emergency services have been called, the role of a first aider is to maintain the person's condition as stable as possible while waiting for professional medical care. This involves managing the person's position, preventing heat loss, monitoring for deterioration, and being ready to perform CPR if the situation escalates.

Position and monitoring are not passive activities — they are active management decisions that influence how the person arrives at hospital, whether deterioration is caught in time, and whether the handover to emergency services is accurate and helpful.

The Primary Assessment and Priority Actions

Before focusing on position and monitoring, confirm:

1. Is the airway open? — If unconscious, head tilt and chin lift to open the airway.
2. Is the person breathing? — Look, listen, and feel for at least 10 seconds.
3. Is there significant bleeding? — Stop or reduce it before managing position.
4. Have you called 999? — If not, call now.

These are always the first actions. Positioning and monitoring follow.

Positioning for Shock — Types and Rationale

There is no single universal shock position because the correct position depends on the cause and presentation of the shock:

Legs-Elevated Position (Shock Position)

When to use: Conscious person in hypovolaemic (blood loss) or distributive (anaphylactic, septic) shock who can lie flat and has no contraindications.

How:

1. Lie the person on their back on a flat surface.
2. Elevate the legs approximately 30cm (12 inches) — use folded clothing, bags, or any available prop.
3. Maintain elevation; do not allow legs to fall.

Why: Gravity assists venous return — blood from the legs flows back toward the core, temporarily increasing central circulating volume. This is a short-term measure; it does not replace lost blood volume but helps maintain cerebral circulation.

When NOT to use:

• Suspected fractures in the legs
• Breathing difficulty — lying flat worsens respiratory compromise; these patients should sit up
• Suspected spinal injury — do not elevate legs if spinal movement is required
• Pregnancy (beyond 20 weeks) — use left lateral tilt instead

Recovery Position

When to use: Unconscious person who is breathing adequately.

How:

1. Kneel beside the person.
2. Place the arm nearest to you at a right angle to their body, elbow bent, palm facing upward.
3. Bring their far arm across their chest; hold the back of their hand against their near cheek.
4. Pull up the far knee so the foot is flat on the floor.
5. Roll the person toward you by pulling on the bent knee until they are on their side.
6. Position the upper leg so the hip and knee are at right angles.
7. Tilt the head back to keep the airway open.
8. Check breathing regularly.

Why: An unconscious person can vomit; the recovery position prevents aspiration (stomach contents entering the lungs). The open airway is maintained by the head position.

Semi-Recumbent (Sitting Up)

When to use: Person in shock with significant breathing difficulty; suspected anaphylaxis with respiratory component; pulmonary oedema.

Why: Lung capacity is better when sitting upright; diaphragm can move freely; pooled fluid in lungs gravitates away from air exchange areas.

Left Lateral Tilt for Pregnant Women

When to use: Pregnant women (beyond approximately 20 weeks) who need to lie down.

Why: In late pregnancy, the uterus compresses the inferior vena cava when lying flat, reducing venous return and worsening shock. A 15–30 degree left lateral tilt moves the uterus off the vessel.

How: Place folded clothing or a bag under the right hip to create a tilt; or roll slightly to the left.

Monitoring — What to Check and How Often

While waiting for emergency services, monitor the following every 2–3 minutes:

What to Monitor	How	Concern
Consciousness	Ask their name; ask them to squeeze your hand	Any deterioration; less responsive than before
Breathing	Watch chest rise; listen; feel for breath	Slowing, stopping, or becoming very rapid or shallow
Skin colour	Look at lips, fingertips, face	Increasing pallor; blue colouration (cyanosis)
Skin temperature	Touch the skin	Becoming colder; increasingly clammy
Pulse	Two fingers on the wrist (radial) or neck (carotid)	Becoming weaker; very fast (>120) or slowing
Responsiveness to pain	Gently squeeze the nail bed	Only if unresponsive to voice — not done routinely

Record the time of any significant changes — emergency services will need this.

What to Tell Emergency Services on Arrival

Prepare a clear handover:

• What happened (cause of shock if known)
• When you found them and their condition at that time
• What you have done (tourniquet applied at X time; epinephrine given at X time)
• Current vital signs (rate of breathing, pulse rate, consciousness level)
• Any changes since you started monitoring
• Any relevant medical history you know

A clear, structured handover of 30–60 seconds is more useful than a long unclear account.

Recognising Deterioration — When to Start CPR

If at any point the person becomes unresponsive and is not breathing normally:

1. Begin CPR immediately.
2. Send someone to get a defibrillator (AED) if available.
3. Continue until paramedics take over.

Signs of imminent deterioration:

• Decreasing response to your voice
• Breathing becoming very slow, gasping, or agonal (infrequent irregular gasps)
• Pulse disappearing at the wrist (still present at the neck in deeper stages)
• Extreme pallor or blue colouration

If in doubt, check breathing for 10 seconds. If not breathing normally, start CPR.

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Quick Reference

Situation	Position
Conscious, no contraindications	Lie flat; elevate legs ~30cm
Breathing difficulty	Semi-recumbent (sitting up)
Unconscious, breathing	Recovery position
Pregnant (>20 weeks)	Left lateral tilt
Suspected spinal injury	Minimal movement; call for guidance
Monitor frequency	Every 2–3 minutes
Key monitoring	Consciousness; breathing; skin colour and temperature; pulse
CPR trigger	Unresponsive + not breathing normally