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Division 3 Trauma Emergencies

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1 Division 3 Trauma Emergencies
Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

2 Chapter 19 Hemorrhage and Shock
Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

3 Topics Introduction to Hemorrhage and Shock Hemorrhage Shock
Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

4 Introduction to Hemorrhage and Shock
Abnormal internal or external loss of blood Homeostasis Tendency of the body to maintain a steady and normal internal environment Shock INADEQUATE TISSUE PERFUSION Transition between homeostasis and death Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

5 Hemorrhage Circulatory System Hemorrhage Classification Clotting
Factors Affecting Clotting Hemorrhage Control Stages of Hemorrhage Hemorrhage Assessment Hemorrhage Management Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

6 Cardiac Anatomy Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

7 Heart Cardiac Cycle Cardiac Output
The repetitive pumping action that produces pressure changes that circulate blood throughout the body Cardiac Output The total amount of blood separately pumped by each ventricle per minute, usually expressed in liters per minute Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

8 Cardiac Output Normal cardiac output = 5 to 6 liters per minute (LPM)
Can increase up to 30 LPM in times of stress or exercise Determined by multiplying the heart rate by the volume of blood ejected by each ventricle during each beat (stroke volume) CO is influenced by: Strength of contraction Rate of contraction Amount of venous return available to the ventricle (preload) Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

9 Circulatory System (1 of 4)
Heart Autonomic nervous system Parasympathetic nervous system Slows rate Mediated by vagus nerve Sympathetic nervous system Increases rate Cardiac plexus Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

10 Circulatory System (2 of 4) Key Terms
Stroke Volume Preload Ventricular Filling Starling’s Law of the Heart Afterload (End Diastolic Pressure or EDP) Cardiac Output SV x HR 5 liters/minute Fick Principle Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

11 Circulatory System (3 of 4)
Arteries Tunica Adventitia Tunica Media Tunica Intima Arteriole Capillary: 7% of total blood volume Venule Vein Constriction returns 20% (1 liter) of blood to active circulation } 13% of blood volume } 64% of blood volume Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

12 Circulatory System (4 of 4)
Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

13 Cardiac Physiology LUNGS Vena Cava and Systemic Veins Right Atrium
Pulmonary Arteries LUNGS Vena Cava and Systemic Veins Right Atrium Right Ventricle Left Ventricle Left Atrium Pulmonary Veins Systemic Capillaries Aorta and Systemic Arteries Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

14 Circulation (1 of 2) Systolic Pressure Diastolic Pressure
Strength and volume of cardiac output Diastolic Pressure More indicative of the state of constriction of the arterioles Mean Arterial Pressure 1/3 pulse pressure added to the diastolic pressure Tissue perfusion pressure Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

15 Circulation (2 of 2) Vascular Control Microcirculation
Increased sympathetic tone results in increased vasoconstriction Microcirculation Blood flow in the arterioles, capillaries, and venules Sphincter functioning Most organ tissue requires blood flow 5 to 20% of the time. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

16 Cardiac Physiology (1 of 2)
Oxygen Supply The myocardium receives its blood/oxygen supply during the diastole phase of contraction. The blood flows from the aorta through the two coronaries into the relaxed myocardium. Oxygen Demand 90% of the O2 demand, or work, of the heart is performed during the isovolumetric phase of contraction. In this phase, NO blood flows from the heart into the aorta, until the pressure in the heart is greater than the end diastolic pressure (EDP). Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

17 Cardiac Physiology (2 of 2)
Releases a polypeptide called atrial natriuretic peptide (ANP) Works antagonistically to renin-angiotensin Four Effects Promotes Na+ and water loss at the kidneys Inhibits renin release and ADH, aldosterone secretion Suppresses thirst Blocks action of angiotensin II and norepinephrine Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

18 Negative Feedback Important negative feedback mechanisms in maintaining tissue perfusion are the: Baroreceptor reflexes Central nervous system ischemia responses Hormonal mechanisms Reabsorption of tissue fluids Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

19 Cardiovascular System Regulation (1 of 3)
PNS and SNS always act in balance Baroreceptors: monitor BP Chemoreceptors Hormone regulation Reabsorption of tissue fluids Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

20 Cardiovascular System Regulation (2 of 3)
Parasympathetic Nervous System Decrease Heart rate Strength of contractions Blood pressure Increase Digestive system Kidneys Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

21 Cardiovascular System Regulation (3 of 3)
Sympathetic Nervous System Increase Body activity Heart rate Strength of contractions Vascular constriction Bowel and digestive viscera Decreased urine production Respirations Bronchodilation Increases skeletal muscle perfusion Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

22 Baroreceptor Reflexes (1 of 5)
High in the neck, each carotid artery divides into external and internal carotid arteries. At the bifurcation, the wall of the artery is thin and contains many vine-like nerve endings. The small portion of the artery is the carotid sinus. Nerve endings in this area are sensitive to stretch or distortion. Serve as pressure receptors or baroreceptors. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

23 Baroreceptor Reflexes (2 of 5)
Similar area found in the arch of the aorta. Serves as a second important baroreceptor Large arteries, large veins, and the wall of the myocardium also contain less important baroreceptors. Baroreceptor reflexes help maintain blood pressure by two negative feedback mechanisms: By lowering blood pressure in response to increased arterial pressure By increasing blood pressure in response to decreased arterial pressure Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

24 Baroreceptor Reflexes (3 of 5)
Normal blood pressure partially stretches the arterial walls so that baroreceptors produce a constant, low-frequency stimulation. Impulses from the baroreceptors inhibit the vasoconstrictor center of the medulla and excite the vagal center when blood pressure increases. Results in vasodilation in the peripheral circulatory system and a decrease in the heart rate and force of contraction. Combined effect is a decrease in arterial pressure. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

25 Baroreceptor Reflexes (4 of 5)
Baroreceptors adapt in 1 to 3 days to whatever pressure level they are exposed. Therefore, they do not change the average blood pressure on a long-term basis. This adaptation is common in people who have chronic hypertension. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

26 Baroreceptor Reflexes (5 of 5)
When baroreceptor stimulation ceases due to a fall in arterial pressure, several cardiovascular responses are evoked: Vagal stimulation is reduced and sympathetic response is increased. The increase in sympathetic impulses results in increased peripheral resistance and an increase in heart rate and stroke volume. Sympathetic discharges also produce generalized arteriolar vasoconstriction, which decreases the container size. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

27 The vasoconstriction in peripheral vascular beds results in the characteristic pale, cold skin of patients suffering from hypovolemic shock. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

28 Chemoreceptor Reflexes
Chemoreceptors Monitor level of CO2 in CSF Monitor level of O2 in blood Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

29 Chemoreceptor Physiology
Low arterial pressure leads to hypoxemia and/or acidosis. Hypoxemia/acidosis stimulate peripheral chemoreceptor cells within the carotid and aortic bodies. These bodies have an abundant blood supply. When oxygen or pH decreases, these cells stimulate the vasomotor center of the medulla. The rate and depth of ventilation are also increased to help eliminate excess carbon dioxide and maintain acid-base balance. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

30 CV System and Hormone Regulation (1 of 7)
Catecholamines Epinephrine Norepinephrine Actions Alpha 1 Alpha 2 Beta 1 Beta 2 Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

31 CV System and Hormone Regulation (2 of 7)
Alpha 1 Vasoconstriction Increased peripheral vascular resistance Increased preload Alpha 2 Regulates release of NE Beta 1 Positive inotropy Positive chronotropy Positive dromotropy Beta 2 Bronchodilation Smooth muscle dilation in bowel Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

32 CV System and Hormone Regulation (3 of 7)
Antidiuretic Hormone (ADH) AKA: Arginine Vasopressin (AVP) Release Posterior pituitary Drop in BP or increase in serum osmolarity Action Increase in peripheral vascular resistance Increase water retention by kidneys Decrease urine output Splenic vasoconstriction 200 mL of free blood to circulation Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

33 CV System and Hormone Regulation (4 of 7)
Angiotensin II Release Primary chemical from kidneys Lowered BP and decreased perfusion Action Converted from renin into angiotensin I Modified in lungs to angiotensin II 20-minute process Potent systemic vasoconstrictor 1-hour duration Causes release of ADH, aldosterone, and epinephrine Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

34 CV System and Hormone Regulation (5 of 7)
Aldosterone Release Adrenal cortex Stimulated by angiotensin II Action Maintain kidney ion balance Retention of sodium and water Reduce insensible fluid loss Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

35 CV System and Hormone Regulation (6 of 7)
Glucagon Release Alpha cells of pancreas Triggered by epinephrine Action Causes liver and skeletal muscles to convert glycogen into glucose Gluconeogenesis Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

36 CV System and Hormone Regulation (7 of 7)
Insulin Release Beta cells of pancreas Action Facilitates transport of glucose across cell membrane Erythropoietin Release Kidneys Hypoperfusion or hypoxia Action Increases production and maturation of RBCs in the bone marrow Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

37 Reabsorption of Tissue Fluids (1 of 2)
Arterial hypotension, arteriolar constriction, and reduced venous pressure during hypovolemia lower the blood pressure in the capillaries (hydrostatic pressure). The decrease promotes reabsorption of interstitial fluid into the vascular compartment. Considerable quantities of fluid may be drawn into the circulation during hemorrhage. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

38 Reabsorption of Tissue Fluids (2 of 2)
Approximately 0.25 mL/min/kg of body weight (1 L/hr in the adult male) can be autotransfused from the interstitial spaces after acute blood loss. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

39 Vasculature Lined with smooth muscle.
All vessels larger than capillaries have layers of tissues (tunicae). Maintains blood flow by changes in pressure and peripheral vascular resistance. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

40 Vascular Pressure Gradients
Fluid flows through a tube in response to pressure gradients between the two ends of the tube. It is not the absolute pressure in the tube that determines flow, but the difference in pressure between the two ends. In humans, the two ends are the aorta and the vena cava. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

41 Vasculature Measurements of pressure in the vascular system:
Systemic pressure (Left‑sided pressure) Pulmonic pressure (Right‑sided pressure) Systemic pressure, like pulmonic pressure, has two phases: systolic and diastolic. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

42 Diastolic Blood Pressure
Diastolic blood pressure is a reflection of peripheral vascular resistance. Pulse pressure is the difference between these two pressures. Pressure is greatest at its origin (the heart) and least at its terminating point (the vena cavae). This pressure gradient changes significantly at the arteriole because of peripheral vascular resistance. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

43 Peripheral Vascular Resistance (Afterload)
The total resistance against which blood must be pumped. It is essentially a measure of friction between the vessel walls and fluid, and between the molecules within the fluid itself (viscosity). Both oppose flow. When resistance to flow increases, blood pressure must increase for the flow to remain constant. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

44 Starling’s Law of the Heart
When the rate at which blood flows into the heart from the veins (venous return) changes, the heart automatically adjusts its output to match inflow. The more blood the heart receives the more it pumps… Increased end diastolic volume increases contractility. Increases stroke volume. Increases cardiac output. Starling curves at any end-diastolic volume. Increased sympathetic input increases stroke volume. Decreased sympathetic input decreases stroke volume. Think of the cardiac muscle fibers as rubber bands… The rubber band stretches and recoils back depending upon how much stretch has been applied to it. If you put a large amount of volume in the ventricle, the ventricle will stretch like the rubber band. Once stretched, the ventricle will “snap” back into position. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

45 Resistance to Blood Flow Increases with…
Increased fluid viscosity Increased vessel length Decreased vessel diameter Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

46 Viscosity The physical property of a liquid characterized by the friction between its component molecules (e.g., between the blood cells and between the plasma proteins) Normally plays a minor role in blood flow regulation as it remains constant in healthy people Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

47 Blood Flow Resistance (1 of 2)
Arteries are large and offer little resistance to flow unless they have an abnormal narrowing (stenosis). Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

48 Blood Flow Resistance (2 of 2)
Arterioles have a much smaller diameter and offer the major resistance to blood flow. Smooth muscles in the arteriole walls can relax or contract. Can change the diameter of the vessel as much as fivefold. Arterial blood pressure is regulated primarily by the vasoconstriction or vasodilation of these vessels. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

49 Microcirculation (1 of 3)
Can be divided into pulmonary microcirculation and peripheral microcirculation. Pressure in each division is produced by the right and left heart, respectively. Approximately 5% of the total circulating blood flow is always flowing through capillaries. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

50 Microcirculation (2 of 3)
Venules and veins serve as collecting channels and storage vessels (capacitance). Normally contain 70% of the blood volume. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

51 Microcirculation (3 of 3)
Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

52 Mechanisms That Control Blood Flow
Local control of blood flow by the tissues Nervous control of blood flow Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

53 Local Control Blood usually flows through capillaries intermittently due to: The pulsatile manner of blood flow resulting from cardiac pumping action and vasomotion The intermittent constriction and dilation of arterioles and precapillary sphincters Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

54 Vasomotion (1 of 3) Regulated primarily by the concentration of oxygen in the tissues. When oxygen concentration is low, the cells lining and adjacent to the closed capillaries secrete histamine, which is thought to be responsible for arteriolar smooth muscle vasodilation, causing the capillary to open. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

55 Vasomotion (2 of 3) Histamine is quickly destroyed in the blood and does not enter the general circulation. As cells become reoxygenated they stop the histamine secretion, and the capillary closes. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

56 Vasomotion (3 of 3) A decrease in oxygen concentration leads to a local release of vasodilating substances, which allows blood flow to increase. This in turn increases the delivery of oxygen and restores aerobic metabolism. The heart, skeletal muscle, and other muscular organs have an increased blood flow when metabolism increases. This increase in blood flow is termed “reactive hyperemia” and is the direct result of arteriolar dilation within the more active organs. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

57 Nervous control of circulation is accomplished by negative feedback mechanisms.
Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

58 CNS Ischemia Response CNS ischemia response is activated when blood flow to the vasomotor center of the medulla is decreased. In the presence of ischemia, the neurons within the medulla stimulate the sympathetic nervous system. Sympathetic vasoconstriction can elevate arterial pressure for as long as 10 minutes. The cerebral ischemia response functions only in emergency situations. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

59 Blood and Blood Components
Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

60 Blood Blood Volume Average adult male has a blood volume of 7% of total body weight. Average adult female has a blood volume of 6.5% of body weight. Normal adult blood volume is 4.5–5 L. Remains fairly constant in the healthy body. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

61 Blood Components (1 of 2) Erythrocyte: 45%
Hemoglobin Hematocrit Miscellaneous blood products: <1% Platelets Leukocytes Monocytes, basophils, esonophils, neutrophils Plasma: 54% Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

62 Blood Components (2 of 2) Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

63 Plasma (1 of 2) Approximately 92% water
The liquid portion of blood Circulates salts, minerals, sugars, fats, and proteins throughout the body Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

64 Plasma (2 of 2) Contains 3 major proteins: Albumin
Most plentiful plasma protein Similar in consistency to egg whites Gives blood its gummy texture Helps keep water concentration of blood low enough to allow water to diffuse readily from tissues into blood Globulins serve 2 main functions: Alpha and beta globulins transport other proteins Gamma globulins give people immunity to disease Fibrinogen Aids in blood clotting by forming a web of protein fibers that binds blood cells together Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

65 Other Functions of Plasma
Proteins function as an acid or base to correct changes in blood acidity. Can temporarily meet nutritional need of the body should the body run short of food. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

66 Proteins Account for 50% of the body’s organic material
Components of most body structures Roles in the chemical reactions in the body Specialized proteins are responsible for: Immune responses Coagulation Digestion of foodstuffs Metabolism of nutrients Many other functions Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

67 Erythrocytes (RBCs) Transport 99% of blood oxygen.
Remaining 1% carried in plasma Make up approximately 45% of the blood and are the most abundant cells in the body. Provide oxygen to tissues and remove carbon dioxide. Each RBC contains approximately 270 million hemoglobin molecules. Allow RBCs to pick up oxygen in the lungs and release it to body tissues Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

68 Leukocytes (WBCs) Defend the body against various pathogens (bacteria, viruses, fungi, and parasites) Produced in bone marrow and lymph glands Release reserves when pathogens invade the body Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

69 Platelets Part of the body’s defense mechanism
Formed in red bone marrow Work by swelling and adhering together to form sticky plugs (initiating the clotting phenomenon) Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

70 Clotting (1 of 2) Three-Step Process Vascular phase Platelet phase
Vasoconstriction Platelet phase Tunica intima damaged Turbulent blood flow Frictional damage to platelets Agglutination and aggregation Coagulation Release of enzymes Extrinsic – nearby tissue Intrinsic – damaged platelets Fibrin release Normal coagulation in 7–10 minutes Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

71 Clotting (2 of 2) Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

72 Factors Affecting Clotting (1 of 2)
Movement of the wound site Aggressive fluid therapy Increased BP and displaced clots Dilution of clotting factors Low body temperature Ineffective clot formation Medications ASA, heparin, Ticlid, warfarin (Coumadin) Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

73 Factors Affecting Clotting (2 of 2)
Nature of the wound Transverse (clean tear) Vessels constrict and draw inward Reduction of the lumen Reduction of blood loss Longitudinal (crush injury) Constriction of the smooth muscle Enlarges the wound Increases blood loss Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

74 Stages of Shock Cellular Level
Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

75 Four Stages Stage 1: Vasoconstriction
Stage 2: Capillary and venule opening Stage 3: Disseminated intravascular coagulation Stage 4: Multiple organ failure Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

76 Stage 1: Vasoconstriction (1 of 4)
Vasoconstriction begins as minimal perfusion to capillaries continues. Oxygen and substrate delivery to the cells supplied by these capillaries decreases. Anaerobic metabolism replaces aerobic metabolism. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

77 Stage 1: Vasoconstriction (2 of 4)
Production of lactate and hydrogen ions increases. The lining of the capillaries may begin to lose the ability to retain large molecular structures within its walls. Protein-containing fluid leaks into the interstitial spaces (leaky capillary syndrome). Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

78 Stage 1: Vasoconstriction (3 of 4)
Sympathetic stimulation produces: Pale, sweaty skin Rapid, thready pulse Elevated blood glucose levels The release of epinephrine dilates coronary, cerebral, and skeletal muscle arterioles and constricts other arterioles. Blood is shunted to the heart, brain, skeletal muscle, and capillary flow to the kidneys and abdominal viscera decreases. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

79 Stage 1: Vasoconstriction (4 of 4)
If this stage of shock is not treated by prompt restoration of circulatory volume, shock progresses to the next stage. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

80 Stage 2: Capillary and Venule Opening (1 of 5)
Stage 2 occurs with a 15% to 25% decrease in intravascular blood volume. Heart rate, respiratory rate, and capillary refill are increased, and pulse pressure is decreased at this stage. Blood pressure may still be normal. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

81 Stage 2: Capillary and Venule Opening (2 of 5)
As the syndrome continues, the precapillary sphincters relax with some expansion of the vascular space. Postcapillary sphincters resist local effects and remain closed, causing blood to pool or stagnate in the capillary system, producing capillary engorgement. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

82 Stage 2: Capillary and Venule Opening (3 of 5)
As increasing hypoxemia and acidosis lead to opening of additional venules and capillaries, the vascular space expands greatly. Even normal blood volume may be inadequate to fill the container. The capillary and venule capacity may become great enough to reduce the volume of available blood for the great veins and vena cava. Resulting in decreased venous return and a fall in cardiac output. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

83 Stage 2: Capillary and Venule Opening (4 of 5)
Low arterial blood pressure and many open capillaries result in stagnant capillary flow. Sluggish blood flow and the reduced delivery of oxygen result in increased anaerobic metabolism and the production of lactic acid. The respiratory system attempts to compensate for the acidosis by increasing ventilation to blow off carbon dioxide. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

84 Stage 2: Capillary and Venule Opening (5 of 5)
As acidosis increases and pH falls, the RBCs may cluster together (rouleaux formation). Halts perfusion Affects nutritional flow and prevents removal of cellular metabolites Clotting mechanisms are also affected, leading to hypercoagulability. This stage of shock often progresses to the third stage if fluid resuscitation is inadequate or delayed, or if the shock state is complicated by trauma or sepsis. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

85 Stage 3: Disseminated Intravascular Coagulation (DIC) (1 of 4)
Time of onset will depend on degree of shock, patient age, and pre-existing medical conditions. Stage 3 occurs with 25% to 35% decrease in intravascular blood volume. At this stage, hypotension occurs. This stage of shock usually requires blood replacement. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

86 Stage 3: Disseminated Intravascular Coagulation (DIC) (2 of 4)
Stage 3 is resistant to treatment (refractory shock), but is still reversible. Blood begins to coagulate in the microcirculation, clogging capillaries. Capillaries become occluded by clumps of RBCs. Decreases capillary perfusion and prevents removal of metabolites Distal tissue cells use anaerobic metabolism, and lactic acid production increases. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

87 Stage 3: Disseminated Intravascular Coagulation (DIC) (3 of 4)
Lactic acid accumulates around the cell. Cell membranes no longer have the energy needed to maintain homeostasis. Water and sodium leak in, potassium leaks out, and the cells swell and die. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

88 Stage 3: Disseminated Intravascular Coagulation (DIC) (4 of 4)
Pulmonary capillaries become permeable, leading to pulmonary edema. Decreases the absorption of oxygen and results in possible alterations in carbon dioxide elimination May lead to acute respiratory failure or adult respiratory distress syndrome (ARDS) If shock and disseminated intravascular coagulation (DIC) continue, the patient progresses to multiple organ failure. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

89 Stage 4: Multiple Organ Failure (1 of 2)
The amount of cellular necrosis required to produce organ failure varies with each organ and the underlying condition of the organ. Usually hepatic failure occurs, followed by renal failure, and then heart failure. If capillary occlusion persists for more than 1 to 2 hours, the cells nourished by that capillary undergo changes that rapidly become irreversible. In this stage, blood pressure falls dramatically (to levels of 60 mmHg or less). Cells can no longer use oxygen, and metabolism stops. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

90 Stage 4: Multiple Organ Failure (2 of 2)
If a critical amount of the vital organ is damaged by cellular necrosis, the organ soon fails. Failure of the liver is common and often presents early. Capillary blockage may cause heart failure. GI bleeding and sepsis may result from GI mucosal necrosis. Pancreatic necrosis may lead to further clotting disorders and severe pancreatitis. Pulmonary thrombosis may produce hemorrhage and fluid loss into the alveoli. Leading to death from respiratory failure. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

91 Shock and Hemorrhage Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

92 “The rude unhinging of the machinery of Life”
Defining Shock (1 of 2) Shock is best defined as inadequate tissue perfusion. Can result from a variety of disease states and injuries. Can affect the entire organism, or it can occur at a tissue or cellular level. “The rude unhinging of the machinery of Life” Gross, 1877 Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

93 Defining Shock (2 of 2) Shock is not adequately defined by: Pulse rate
Blood pressure Cardiac function Hypovolemia Loss of systemic vascular resistance Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

94 Hemorrhage Classification
Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

95 External Hemorrhage Results from soft tissue injury.
Accounts for nearly 10 million emergency department visits in the United States each year. Most soft tissue trauma is accompanied by mild hemorrhage and is not life threatening. Can carry significant risks of patient morbidity and disfigurement The seriousness of the injury is dependent on: Anatomical source of the hemorrhage (arterial, venous, capillary) Degree of vascular disruption Amount of blood loss that can be tolerated by the patient Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

96 Internal Hemorrhage (1 of 2)
Can result from: Blunt or penetrating trauma Acute or chronic medical illnesses Internal bleeding that can cause hemodynamic instability usually occurs in one of four body cavities: Chest Abdomen Pelvis Retroperitoneum Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

97 Internal Hemorrhage (2 of 2)
Signs and symptoms that may suggest significant internal hemorrhage include: Bright red blood from mouth, rectum, or other orifice Coffee-ground appearance of vomitus Melena (black, tarry stools) Dizziness or syncope on sitting or standing Orthostatic hypotension Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

98 Internal hemorrhage is associated with higher morbidity and mortality than external hemorrhage.
Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

99 Physiological Response to Hemorrhage
The body’s initial response to hemorrhage is to stop bleeding by chemical means (hemostasis). This vascular reaction involves: Local vasoconstriction Formation of a platelet plug Coagulation Growth of tissue into the blood clot that permanently closes and seals the injured vessel Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

100 Fick Principle A method for measuring cardiac output.
The Fick principle assumes that the quantity of oxygen delivered to an organ is equal to the amount of oxygen consumed by that organ plus the amount of oxygen carried away from that organ. Used to estimate perfusion either to an organ or to the whole body when oxygen content of both the arterial and venous blood is known and oxygen consumption is assumed to remain fixed. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

101 Hemorrhage Control External Hemorrhage
Direct pressure and pressure dressing General management Direct pressure Elevation Ice Pressure points Constricting band Tourniquet May use a BP cuff by inflating the cuff 20–30 mmHg above the SBP Release may send toxins to heart Lactic acid and electrolytes Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

102 Tourniquets are ONLY used as a last resort!
Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

103 Internal Hemorrhage Control
Hematoma Pocket of blood between muscle and fascia UNEXPLAINED SHOCK is BEST attributed to abdominal trauma General Management Immobilization, stabilization, elevation Epistaxis: Nose Bleed Causes: trauma, hypertension Treatment: lean forward, pinch nostrils Hemoptysis Esophageal Varices Melena Diverticulosis Chronic Hemorrhage Anemia Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

104 Stages of Hemorrhage 60% of body weight is fluid.
7% circulating blood volume (CBV) in men 5 L (10 units) 6.5% CBV in women 4.6 L (9–10 units) Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

105 Stages of Hemorrhage Stage 1
15% loss of CBV 70 kg pt = 500–750 mL Compensation Vasoconstriction Normal BP, pulse pressure, respirations Slight elevation of pulse Release of catecholamines Epinephrine Norepinephrine Anxiety, slightly pale and clammy skin Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

106 Stages of Hemorrhage Stage 2 (1 of 2)
15–25% loss of CBV 750–1250 mL Early decompensation Unable to maintain BP Tachycardia and tachypnea Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

107 Stages of Hemorrhage Stage 2 (2 of 2)
Decreased pulse strength Narrowing pulse pressure Significant catecholamine release Increase PVR Cool, clammy skin and thirst Increased anxiety and agitation Normal renal output Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

108 Stages of Hemorrhage Stage 3 (1 of 2)
25–35% loss of CBV 1250–1750 mL Late decompensation (early irreversible) Compensatory mechanisms unable to cope with loss of blood volume Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

109 Stages of Hemorrhage Stage 3 (2 of 2)
Classic Shock Weak, thready, rapid pulse Narrowing pulse pressure Tachypnea Anxiety, restlessness Decreased LOC and AMS Pale, cool, and clammy skin Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

110 Stages of Hemorrhage Stage 4
>35% CBV loss >1750 mL Irreversible Pulse: Barely palpable Respiration: Rapid, shallow, and ineffective LOC: Lethargic, confused, unresponsive GU: Ceases Skin: Cool, clammy, and very pale Unlikely survival Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

111 Stages of Hemorrhage Concomitant Factors (1 of 2)
Pre-existing condition Rate of blood loss Patient Types Pregnant >50% greater blood volume than normal Fetal circulation impaired when mother compensating Athletes Greater fluid and cardiac capacity Obese CBV is based on IDEAL weight (less CBV) Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

112 Stages of Hemorrhage Concomitant Factors (2 of 2)
Children CBV 8–9% of body weight Poor compensatory mechanisms TREAT AGGRESSIVELY! Elderly Decreased CBV Medications BP Anticoagulants Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

113 Hemorrhage Assessment (1 of 5)
Scene Size-up Is it safe? BSI Blood loss Law enforcement Mechanism of Injury/Nature of Illness Should only be used in conjunction with vital signs and other clinical signs of injury to determine the probability of injury Number of Patients Need for Additional Resources Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

114 Hemorrhage Assessment (2 of 5)
Initial Assessment General Impression Obvious bleeding Mental Status CABC Interventions Manage as you go O2 Bleeding control Shock BLS before ALS! Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

115 Hemorrhage Assessment (3 of 5)
Focused H&P Rapid Trauma Assessment Full head to toe Consider air medical if stage 2+ blood loss Focused Physical Exam Guided by c/c Vitals, SAMPLE, and OPQRST Additional Assessment Orthostatic hypotension Tilt test: 20 BP or P from supine to sitting Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

116 Hemorrhage Assessment (4 of 5) Fractures and Blood Loss
Pelvic fracture: Femur fracture: Tibia/fibula fracture: Hematomas and contusions: 2,000 mL 1,500 mL 500–750 mL 500 mL Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

117 Hemorrhage Assessment (5 of 5)
Ongoing Assessment Reassess vitals and mental status: Q 5 min: UNSTABLE patients Q 15 min: STABLE patients Reassess interventions: Oxygen ET IV Medication actions Trending: improvement vs. deterioration Pulse oximetry End-tidal CO2 levels Normal expiratory CO2 levels are between 35 and 40 mmHg and should not drop below 30 mmHg, especially in head trauma patients. An expiratory CO2 level above 40 mmHg suggests hypoventilation and the need for faster or deeper ventilations. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

118 SHOCK is… INADEQUATE TISSUE PERFUSION.
Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

119 Shock Management Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

120 Specific Wound Considerations (1 of 2)
Head Wounds Presentation Severe bleeding Skull fracture Management Gentle direct pressure Fluid drainage from ears and nose DO NOT pack Cover and bandage loosely Neck Wounds Presentation Large vessel can entrap air Management Consider direct digital pressure Occlusive dressing Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

121 Specific Wound Considerations (2 of 2)
Gaping Wounds Presentation Multiple sites Gaping prevents uniform pressure Management Bulky dressing Trauma dressing Sterile, non-adherent surface to wound Compression dressing Crush Injury Presentation Difficult to locate source of bleeding Normal hemorrhage control mechanism nonfunctional Management Consider an air-splint and pressure dressing Consider tourniquet Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

122 Transport Considerations
Consider rapid transport: Suspected serious blood loss Suspected serious internal bleeding Decompensating shock AMS, pulse, narrowing pulse pressure WHEN IN DOUBT, TRANSPORT. Other Considerations Sympathetic response Anxiety Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

123 Shock Management (1 of 2) Airway and Breathing NRB PPV (overdrive respiration) ET CPAP PEEP Hemorrhage Control Fluid Resuscitation Catheter size and length Large bore 20 mL/kg of NS or LR Polyhemoglobins STABILIZE VITALS to SBP of 80 mmHg or 90 mmHg in head injuries. Any injury to the head or torso is ALSO considered an injury to the spine. In positive pressure ventilation, make certain that the patient has an adequate tidal volume of between 7 and 10 cc/kg. The average tidal volume of an adult patient is 500 cc. Polyhemoglobins are typically plasma-based hemoglobin molecules that are capable of delivering oxygen to the tissues and organs. In-hospital studies have been proven successful and currently, prehospital studies are being conducted and are being proven beneficial. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

124 Shock Management (2 of 2) Temperature Control PASG
Conserve core temperature Warm IV fluids PASG Action Increase PVR Reduce vascular volume Increase central CBV Immobilize lower extremities Assess Pulmonary edema Pregnancy Vital signs Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

125 Summary Introduction to Hemorrhage and Shock Hemorrhage Shock
Abnormal internal or external loss of blood Homeostasis Tendency of the body to maintain a steady and normal internal environment Shock INADEQUATE TISSUE PERFUSION Transition between homeostasis and death Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ


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