1. Chapter 25
Bleeding and Shock

2. Case History
You are summoned to the scene of a shooting. You find a 58-year-old deli owner bleeding profusely from gunshot wounds to his arms and chest. The man is cool and pale with a rapid pulse and no discernible blood pressure. As you apply oxygen, he tells you that he is thirsty and would like to have a drink of water.

3. Control Bleeding External bleeding Direct pressure Pressure point
Tourniquets

4. Shock Internal bleeding can result in shock.
A state of profound depression of vital processes of body caused by inadequate perfusion of vital organs with blood

5. Anatomy and Physiology Review
Three major components of circulatory system:
The blood
The heart
The blood vessels

6. Heart and Great Vessels

7. Anatomy and Physiology Review
Blood
Liquid (plasma) and cellular components
Cellular components
Red blood cells
Transport oxygen
White blood cells
Combat infection
Platelets
Help control bleeding

8. Anatomy and Physiology Review
Heart
Four chambers
Atria (receiving chambers)
Ventricles (pumping chambers)
Left ventricle pumps blood to aorta with each beat; circulates to body
Right ventricle pumps blood throughout pulmonary arteries to lungs; unloads carbon dioxide, picks up fresh oxygen

9. Chambers of the Heart

10. Anatomy and Physiology Review
Blood vessels distribute blood to all parts of body and lungs.
Arteries carry blood away from heart.
Veins carry blood back to heart.
Arteries branch into smaller vessels, ending as capillaries.
Capillaries - one cell thick; exchange gas, nutrients, waste products with alveoli

11. Systemic and Pulmonary Circulation

12. Arteries, Capillaries, and Veins

13. Major Systemic Arteries

14. Capillaries

15. Major Systemic Veins

16. Stroke Volume and Cardiac Output
Circulation changes according to the body’s needs.
Changes occur through
Increase in heart rate
Increase in force of contraction
Adequate blood volume is needed.

17. Stroke Volume Amount of blood ejected from ventricle with each beat
Approximately 70 ml
Related to:
Adequate contraction
Venous return

18. Cardiac Output Stroke volume  heart rate = cardiac output
SV HR = CO
Example
70 ml (SV) 60 (HR) = 4200 ml or 4.2 L (CO)
Cardiac output changes if stroke volume or heart rate change.

19. Blood Pressure and Perfusion
Blood pressure – force exerted on walls of vessels
Determinants of blood pressure:
Cardiac output
Size of vascular space
Measurements
Systolic and diastolic

20. Pressures in the Circulatory System

21. Hypotension
Cardiac output decreases and vascular space remains the same.
Decrease in blood pressure
Size of the vascular space increases and cardiac output remains the same.

22. Effects of Epinephrine
Epinephrine release accounts for many of the signs of shock.
Increased cardiac output
Increased blood flow to brain
Increased respiratory rate
Dilated pupils
Redistributed blood flow
Shunted away from less vital organs and skin
Pale skin

23. Skin Signs Associated with Epinephrine Release

24. Personal Precautions Eye protection Gloves Gown Mask
Hand washing after each patient contact

25. Severity of Blood Loss Based on: Major blood loss = sudden loss of
Signs and symptoms
General impression of the amount of blood loss
Major blood loss = sudden loss of
Adult: 1 L
Child: 500 ml
Infant: 100 to 200 ml

26. Natural Response to Bleeding
Vessel contraction
Clotting
Serious injury may prevent effective clotting.
Uncontrolled bleeding or significant blood loss leads to shock (hypoperfusion) and possibly death.

27. Types of Bleeding Arterial Spurts from wound Bright red
Most difficult to control

28. Types of Bleeding Venous Flows as steady stream Dark red
Can be profuse
Easy to control, in most cases

29. Types of Bleeding Capillary Oozes from capillary Dark red
Often clots spontaneously

30. Care of External Bleeding
Body substance isolation
Maintain airway/artificial ventilation.
Bleeding control
Direct pressure
Elevation
Pressure point
Tourniquet

31. Tourniquet – Precautions
Use a wide bandage.
Never use wire, rope, or a belt
Apply as close to the injury as possible.
Do not apply over any joint.
Secure it tightly.
Leave the tourniquet in open view.
Do not remove or loosen tourniquet unless instructed by medical direction.

32. Causes of Bleeding from Ear, Mouth, and Nose
Injured skull
Facial trauma
Digital trauma (e.g., nose picking)
Sinusitis
Upper respiratory tract infections
Hypertension (high blood pressure)
Coagulation disorders

33. Bleeding from Ears and Nose Owing to Skull Fracture
Do not attempt to stop the blood flow.
Apply a loose dressing.
Limit exposure to sources of infection.

34. Internal Bleeding – Severity
Injured or damaged internal organs commonly lead to extensive bleeding.
Bleeding is often concealed.
Fractures may also lead to serious internal blood loss.
Suspicion and severity based on
Mechanism of injury
Clinical signs and symptoms

35. Relationship of Internal Bleeding to Mechanism of Injury
Blunt trauma
Falls
Motorcycle crashes
Pedestrian impacts
Automobile collisions
Blast injuries
Contusions, abrasions, deformity, impact marks, and swelling
Penetrating trauma

36. Signs and Symptoms — Internal Bleeding
Pain, tenderness, swelling, or discoloration
Bleeding from the mouth, rectum, vagina, or other orifice
Vomiting bright red or dark “coffee ground”-colored blood
Dark, tarry stools or stools with bright red blood
Tender, rigid, and/or distended abdomen

37. Sites of Hidden Blood Loss
Site Amount of Blood Loss % of blood volume
Thorax 2 Liters 40%
Abdomen >1 Liter 50%
Femur >1 Liter 20%
Pelvis 0.5 Liters/Fracture 10%/Fracture
Skull Not significant unless infant

38. Shock
Failure of circulatory system to adequately perfuse and oxygenate the tissues of the body

39. Causes of Shock Pump failure Low blood volume
Vasodilation or obstruction

40. Shock — Severity Inadequate perfusion of cells
Cell and organ malfunction and death
Prompt recognition is critical

41. Shock — Severity Peripheral perfusion is drastically reduced
Due to the reduction in circulating blood volume
Trauma patients develop shock (hypoperfusion) from loss of blood from both internal and external sites.
Hypovolemic or hemorrhagic shock

42. Peripheral Perfusion Weak, thready, or absent peripheral pulses
Pale, cool, clammy skin
Delayed capillary refill >2 seconds
Infants and children only
Normal ambient air temperature

43. Signs and Symptoms — Shock
Mental states
Restlessness
Anxiety
Altered mental status

44. Vital Signs Increased pulse rate (early sign), weak, and thready
Increased breathing rate
Shallow
Labored
Irregular
Decreased blood pressure (late sign)

45. Other Signs and Symptoms
Dilated pupils
Marked thirst
Nausea and vomiting
Pallor with cyanosis to the lips

46. Infants and Children Infant or child in shock has less reserve
Can maintain blood pressure until 50% loss of blood volume
When blood pressure drops, they are close to death

47. Emergency Medical Care
Take personal protection measures.
Maintain airway.
Administer oxygen.
Control bleeding.
Elevate legs, if condition permits.
Splint fractures, if time permits.
Maintain body temperature.
Immediate transport is critical.

48. Hypovolemic Shock Fluid or blood loss Several causes of fluid loss
Vomiting
Diarrhea
Metabolic problems

49. Signs of Dehydration Thirst Lack of tearing or sweating Dry tongue
Tenting of the skin

50. Signs and Symptoms — Hypovolemic Shock
Anxiety, restlessness, combativeness, or altered mental status
Weakness, faintness, or dizziness
Thirst
Shallow, rapid breathing
Rapid, weak pulse

51. Signs and Symptoms — Hypovolemic Shock
Pale, cool, clammy skin
Capillary refill >2 seconds
Decreasing blood pressure (late sign)
Dilated pupils that are sluggish to respond
Nausea and vomiting

52. Stages of Hypovolemic Shock
10% to 15% blood loss
Venous constriction
No signs of shock
Rely on mechanism of injury to suspect criticality
<30% blood loss
Increased pulse rate
Pale skin
Delayed capillary refill (children)

53. Stages of Hypovolemic Shock
30% to 45% blood loss
Blood pressure drops
Altered mental status
>45% blood loss
Circulatory collapse
Cardiac arrest

54. Emergency Medical Care
Take personal protection measures.
Maintain airway.
Administer oxygen.
Control bleeding.
Elevate legs, if condition permits.
Manage fractures with splints, if time permits.
Maintain body temperature.
Immediate transport is critical.

55. Shock Caused by Dilated Vessels
Anaphylactic
Psychogenic
Spinal

56. Septic Shock Shock is caused by massive infection.
Infection causes vasodilation.
Fluid leaks through blood vessel walls causing hypovolemia.

57. Summary
Evidence of bleeding in shock is elicited during patient assessment.
Control of external bleeding includes
Direct pressure
Elevation
Pressure points
Tourniquet (as a last resort)
Early recognition of internal bleeding and shock is critical to patient survival.