1. Lesson 6 Circulation, Hemorrhage, and Shock
Instructor Notes
Lesson 6 will provide participants with an overview on how to manage circulation, hemorrhage, and shock in a trauma patient.

2. Circulatory System A functioning circulatory system requires:
A heart that pumps adequately
Intact blood vessels to contain the fluids (blood) being pumped
Adequate amount of blood (fluid) to fill the vascular container
Instructor Notes
Expand on the following points:
A functioning circulatory system requires:
A heart that pumps adequately
Intact blood vessels to contain the fluids (blood) being pumped
An adequate amount of blood (fluid) to fill the vascular container

3. Metabolism All cells require energy to function
Energy is stored within the cell in the form of adenosine triphosphate (ATP) molecules
Aerobic metabolism
Oxygen is required for efficient production of ATP (energy)
Anaerobic metabolism
Inadequate oxygen results in decreased energy (ATP) production and accumulation of lactic acid
Instructor Notes
Expand on the following points:
All cells require energy to function.
Energy is stored within the cell in the form of adenosine triphosphate (ATP) molecules.
Aerobic metabolism describes the use of oxygen by cells.
This form of metabolism is the body’s principal combustion process.
It produces energy (ATP) using oxygen in the complicated processes of glycolysis and the Krebs cycle.
In turn, ATP is required for maintaining cellular energy and an efficient metabolism.
Cells cannot function without an adequate supply of ATP.
Anaerobic metabolism is a short-term solution to inadequate oxygenation that will not keep a patient alive for very long.
Oxygen is required for the production of adequate amounts of ATP.
The production of ATP without oxygen is extremely inefficient.
Without ATP, cells cannot convert lactic acid to carbon dioxide and water.

4. Shock Results from inadequate energy production to sustain life
Any condition that causes generalized cellular hypoperfusion
Leads to inadequate cellular oxygenation that does not meet metabolic needs
Instructor Notes
Expand on the following points:
Shock results from inadequate energy production to sustain life.
It is any condition that causes generalized cellular hypoperfusion.
Shock leads to inadequate cellular oxygenation that does not meet the cells’ metabolic needs.
Shock means that:
Blood flow to the cells and body organs is inadequate.
The cells are not receiving enough oxygen.
The cells cannot produce an adequate amount of energy for them to continue to function.

5. Hypoperfusion (1 of 2) Results from:
Loss of blood (either externally or internally)
Most common cause of shock in trauma
Impaired pumping of blood
Dilation of the blood vessels (increased vascular space)
Instructor Notes
Expand on the following points:
Hypoperfusion is decreased blood flow to cells and organs.
It results from:
Hemorrhage
Which may be visible (external bleeding) or not visible (internal bleeding)
Injury to the heart
Which damages its ability to pump effectively
Dilated blood vessels
Which increases the space for the available blood volume and decreases blood pressure

6. Hypoperfusion (2 of 2)
The end result is a decrease in circulating volume and red blood cells (RBCs) moving through the capillary beds to deliver oxygen to the cells
Lack of oxygen impairs metabolism
Impaired metabolism decreases energy production
Instructor Notes
Expand on the following points:
The end result is a decrease in the circulating volume and red blood cells (RBCs) moving through the capillary beds to deliver oxygen to the cells.
Inadequate cellular oxygenation impairs metabolism.
An impaired metabolism decreases energy production.

7. Shock in Trauma Classifications Hypovolemic Distributive Cardiogenic
Instructor Notes
Expand on the following points:
Trauma patients may suffer from any of three different types of shock:
Hypovolemic
Distributive
Cardiogenic
Other causes of shock, such as septic shock, will not be discussed during this program.

8. Hypovolemic Shock (1 of 2)
The most common cause of shock in the trauma patient
Due to hemorrhage
Loss of RBCs impairs oxygen transportation
In any trauma patient with shock, assume hemorrhage is the cause until proven otherwise
Instructor Notes
Expand on the following points:
Of the three causes of traumatic shock, hypovolemic is the most common.
The most common cause of hypovolemia in trauma is hemorrhage (external or internal).
The loss of RBCs impairs the transportation of oxygen.
Prehospital care providers should assume shock is from hemorrhage until proven otherwise.

9. Hypovolemic Shock (2 of 2)
Instructor Notes
Expand on the following points:
Shock has traditionally been categorized into “classes” of shock based upon the amount of blood loss and the clinical presentation of the patient.
The table on this slide discusses the classes of shock and the indications of each class of shock in greater detail.
The values and descriptions for the criteria listed for these classes of shock should not be interpreted as absolute determinants of the class of shock, as significant overlap exists.

10. Distributive Shock Neurogenic “shock”
Decreased systemic vascular resistance due to vasodilation
Most common cause is spinal cord injury
Instructor Notes
Expand on the following points:
Neurogenic “shock” results from the interruption of the sympathetic nervous system on the blood vessels as a result of damage to the spinal cord.
The sympathetic nervous system causes vasoconstriction.
When it is interrupted, the blood vessels dilate and blood pressure decreases.

11. Cardiogenic Shock Intrinsic Extrinsic
Blunt cardiac trauma leading to muscle damage and/or dysrhythmia
Valvular disruption
Extrinsic
Pericardial tamponade
Tension pneumothorax
Instructor Notes
Expand on the following points:
Cardiogenic shock in trauma patients results from:
Intrinsic or direct injury to the heart
The heart muscle itself is damaged.
Damage causes rhythm irregularities.
Damage to a heart valve causes a murmur and abnormal flow of blood.
Extrinsic factors or a problem around the heart that interferes with the ability of the heart to pump normally
Blood in the pericardial sac compressing the heart
Pericardial tamponade
Decreased blood return to the heart from tension pneumothorax and shift of the mediastinum and great blood vessels

12. Assessment (1 of 7) Evaluate: Hemorrhage Level of consciousness Skin
Pulse
Respiration
Blood pressure
Confounding factors
Instructor Notes
Expand on the following points:
The components in the assessment of circulation include:
Evaluating for signs of an external or internal hemorrhage
Evaluating the patient’s level of consciousness
Evaluating the condition of the patient’s skin
Evaluating the patient’s pulse
Evaluating the patient’s respirations
Evaluating the patient’s blood pressure
Evaluating confounding factors

13. Assessment (2 of 7) Hemorrhage If present must be controlled ASAP
External
Address in the prehospital setting
Internal
Transport to appropriate destination
Instructor Notes
Expand on the following points:
If present, hemorrhage must be controlled as soon as possible.
Other efforts to treat the patient will be futile if hemorrhage is allowed to continue.
Significant external hemorrhage is an indication of shock.
Address external hemorrhage in the prehospital setting.
Internal hemorrhage can be treated only in the trauma center operating room.
Rapid assessment and transport to the appropriate destination are crucial.

14. Assessment (3 of 7) Level of consciousness (LOC)
Decreased cerebral perfusion results in altered LOC
Assume altered LOC is due to shock, and treat accordingly
Other causes of altered LOC will not kill as rapidly as shock
Instructor Notes
Expand on the following points:
Keep these items in mind when evaluating the patient’s level of consciousness.
Altered levels of consciousness, confusion, or combativeness may all be an indication of decreased brain perfusion and cerebral ischemia.
There may be other causes of altered level of consciousness (LOC), but ischemia should be suspected and treated.
Assume that altered LOC is due to shock and treat the patient accordingly.
Other causes of altered LOC will not kill as rapidly as shock will.

15. Assessment (4 of 7) Skin Pulse Color Temperature Moisture
Capillary refill
Pulse
Rate
Quality
Location
Instructor Notes
Expand on the following points:
Keep these items in mind when evaluating the patient’s skin and pulse.
Skin color and temperature
The skin may be cool, pale, and moist due to vasoconstriction (compensatory), loss of RBCs, or localized vascular causes.
Mottling or cyanosis indicates poor perfusion and deoxygenated hemoglobin.
Warm and dry skin with hypotension is suggestive of neurogenic shock.
Capillary refill is an indicator of peripheral perfusion:
Other environmental and physiological conditions may also contribute to delayed capillary refill and must be taken into consideration.
Pulse
A heart rate between 100 and 120 beats per minute (beats/min) indicates early shock.
A heart rate above 120 beats/min indicates shock, but fear and pain may be contributory.
A heart rate of 140 beats/min or more is critical, and the patient should be assumed to be near death.
A bradycardic rate is indicative of terminal hypovolemia.
A weak, thready pulse indicates shock.
Loss of peripheral pulses indicates severe hypovolemia and/or vascular damage to the extremity.

16. Assessment (5 of 7) Respiration
Hypoxia, hypercarbia, and acidosis stimulate the respiratory center
Increasing ventilatory rate may be the earliest sign of shock
Intolerance of oxygen face mask suggests hypoxia
Instructor Notes
Expand on the following points:
Keep these items in mind when evaluating the patient’s respirations.
Hypoxia, hypercarbia, and acidosis stimulate the respiratory center.
An increasing ventilatory rate may be the earliest sign of shock.
Patients with hypoxia may become intolerant of the oxygen face mask and try to pull it off.

17. Assessment (6 of 7) Blood pressure (BP) Not the determinant of shock
30% blood loss before BP drops
Not part of the primary assessment
Trends are crucial
Adequate blood pressure does not equate to adequate tissue perfusion
Treatment is not aimed at returning BP to normal
Instructor Notes
Expand on the following points:
Generally, blood loss must reach 30% of the patient’s volume (Class III hemorrhage) before blood pressure (BP) drops.
While the patient is compensating, the pulse pressure narrows.
Obtaining a blood pressure is not part of the primary assessment.
Blood pressure trends are crucial in assessing a patient.
Is the blood pressure improving or decreasing over time?
Adequate blood pressure does not always equal adequate tissue perfusion.
Treatment is aimed at maintaining adequate organ perfusion, not at returning the patient’s blood pressure to normal.
Systolic blood pressure of approximately 90 mm Hg
Higher blood pressures may worsen bleeding.

18. Assessment (7 of 7) Complicating factors Patient age Medications
Pregnancy
Pre-existing conditions
Instructor Notes
Expand on the following points:
A number of factors may cause patients in shock to present atypically:
Age
Neonates and the elderly do not compensate well.
Children compensate well.
Decompensation represents a dire emergency.
Medications that interfere with compensatory mechanisms
Beta-blockers and calcium channel blockers may prevent tachycardia and vasoconstriction.
Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) may interfere with blood clotting.
Pregnancy
Blood volume increases by approximately 50% during pregnancy.
Later in pregnancy, a woman may lose 30% to 35% of blood volume before signs of shock are clinically apparent.
The weight of the uterus may compress the vena cava, thus impeding blood return to the heart if the patient is supine.
Placental blood vessels are sensitive to catecholamines (epinephrine), which results in vasoconstriction and decreased blood flow to the placenta.
This results in fetal hypoxia.
Pre-existing conditions
Well-conditioned athletes may not show the expected increase in heart rate, despite being in shock.
Patients with cardiovascular and pulmonary disease cannot compensate well.
Patients with pacemakers cannot show an increase in heart rate.

19. Shock Without Obvious Cause (1 of 4)
Assume the patient is bleeding somewhere, even if you can’t see it
Internal hemorrhage
Fracture
Instructor Notes
Expand on the following points:
If a patient who has sustained trauma has shock, assume the cause is blood loss.
The blood loss could be external, easily visible, and controllable.
Or the blood loss could be internal and not visible.
Fractures of the pelvis or femurs can also result in enough blood loss to produce shock.

20. Shock Without Obvious Cause (2 of 4)
Internal hemorrhage
The chest and abdomen can hold large volumes of blood
The chest is usually associated with visible external signs of trauma; the abdomen often is not
Instructor Notes
Expand on the following points:
If your patient is in shock with an obvious cause, suspect an internal hemorrhage.
The chest and abdomen can hold large volumes of blood.
The chest is usually associated with visible external signs of trauma; the abdomen often is not.

21. Shock Without Obvious Cause (3 of 4)
Internal hemorrhage (cont’d)
Abdominal trauma is a cause of significant hidden hemorrhage
Assume abdominal trauma if hypovolemic shock is not otherwise explainable
Instructor Notes
Expand on the following points:
If your patient is in shock with an obvious cause, suspect an internal hemorrhage (continued).
Abdominal tenderness, rigidity, and distension are all very late signs of abdominal hemorrhage.
These signs are not always present in the case of significant abdominal injury.
Assume abdominal trauma if hypovolemic shock is not otherwise explainable.
Courtesy of Peter T. Pons, MD, FACEP

22. Shock Without Obvious Cause (4 of 4)
Fractures
Multiple fractures
Blood loss into the surrounding soft tissues from a long-bone fracture, such as the femur, can be significant
Blood loss into the pelvic and abdominal spaces from a pelvis fracture can be massive
Instructor Notes
Expand on the following points:
If your patient is in shock with an obvious cause and has a fracture, suspect an internal hemorrhage.
Multiple fractures may add up to a large amount of blood loss.
Blood loss into the surrounding soft tissues from a long-bone fracture, such as the femur, can be significant.
Blood loss into the pelvic and abdominal spaces from a pelvis fracture can be massive.
The soft tissues around a femur as well as the pelvic space can accommodate a large amount of blood without being obvious visually.

23. Mechanism of Injury and Shock (1 of 3)
Penetrating injuries
Object traverses the chest, abdomen, or extremity
May injure organs, tissues, and blood vessels along its pathway
Instructor Notes
Expand on the following points:
Penetrating injury occurs along the pathway of the penetrating object.
Therefore, the potentially injured organs can be predicted.
After penetrating injury occurs in the chest, a pneumothorax may develop from the lung collapse and prevent effective ventilation.
The respiratory center will stimulate more rapid breathing.
The continued entry of air will cause more pressure to build, further impeding the ability to ventilate, and lead to a tension pneumothorax and compromised perfusion.
Penetrating wounds of the chest or abdomen can damage the major vessels and result in catastrophic bleeding.
The pleural space can accommodate approximately 3000 cc of fluid.
Large volumes of blood in the pleural space also impedes the ability to breathe.
The abdomen can hold 2–3 liters of blood without any obvious external clues.
Courtesy of Lance Stuke, MD, MPH

24. Mechanism of Injury and Shock (2 of 3)
Blunt injuries
Path of injury is less visible
Force (energy) is applied to the trunk and extremities
Energy is transmitted to the thoracic and abdominal organs and bones causing damage
Instructor Notes
Expand on the following points:
Blunt trauma often leaves little in the way of external clues to the severity of the internal injury.
The path of injury is less visible.
Force (energy) is applied to the trunk and extremities.
Energy is transmitted to the thoracic and abdominal organs and bones, causing damage.

25. Mechanism of Injury and Shock (3 of 3)
Blunt injuries (cont’d)
Compression, cavitation, and deceleration can tear and shear organs and blood vessels and fracture bones
Damaged organs, tissues, and blood vessels bleed into the surrounding cavities and tissue
As the amount of blood lost increases, signs of shock develop
Instructor Notes
Expand on the following points:
Blunt trauma often leaves little in the way of external clues to the severity of the internal injury (continued).
Compression, cavitation, and deceleration can tear and shear organs and blood vessels and fracture bones.
Damaged organs, tissues, and blood vessels bleed into the surrounding cavities and tissue.
As the amount of blood lost increases, signs of shock develop in the patient.

26. Injuries Commonly Associated With Hemorrhagic Shock
Instructor Notes
This section will focus on injuries that are commonly associated with hemorrhagic shock.

27. Traumatic Aortic Rupture (Tear)
Usually occurs at the junction of the mobile and fixed portions of the aorta just beyond the left subclavian artery
80% to 85% die prehospital from intrathoracic hemorrhage
Of those who survive, 50% die within 48 hours if not treated.
McSwain NE Jr, Paturas JL: The Basic EMT: Comprehensive Prehospital Patient Care, ed 2, St. Louis, 2001, Mosby
Instructor Notes
Expand on the following points:
Traumatic aortic rupture (tear) usually occurs at the junction of the mobile and fixed portions of the aorta just beyond the left subclavian artery.
80% to 85% of patients with a traumatic aortic rupture die in the prehospital setting from intrathoracic hemorrhage.
Of those who survive, 50% die within 48 hours if not treated.

28. Hemothorax Bleeding into the pleural cavity
Blunt or penetrating mechanism
Each hemithorax can hold up to 30% to 40% of a patient’s total blood volume
Instructor Notes
Expand on the following points:
Hemothorax is bleeding into the pleural cavity.
It is caused by either a blunt or penetrating mechanism.
Each hemithorax can hold up to 30% to 40% of a patient’s total blood volume.

29. Abdominal Organ Injury (1 of 2)
Results from a blunt or penetrating mechanism
Injury to:
Solid organs (liver, spleen, kidney, pancreas)
Results in hemorrhage that varies from mild to life-threatening
May also be associated with leak of enzymes, bile, or urine into abdomen
Instructor Notes
Expand on the following points:
Abdominal organ injury results from a blunt or penetrating mechanism.
Injury to the solid organs (liver, spleen, kidney, pancreas):
Results in hemorrhage that varies from mild to life-threatening
May also be associated with leak of enzymes, bile, or urine into abdomen

30. Abdominal Organ Injury (2 of 2)
Injury to (cont’d):
Hollow organs (small and large bowel)
Usually not a cause of major blood loss
Leak contents and cause peritonitis
Instructor Notes
Expand on the following points:
Abdominal organ injury results from a blunt or penetrating mechanism (continued).
Injury to the hollow organs (small and large bowel)
Usually not a cause of major blood loss
Leak contents and cause peritonitis

31. Fractures (1 of 2)
Major or multiple fractures can lead to significant blood loss
Femur or pelvic fractures are the most common cause
Do not underestimate blood loss due to multiple fractures
Instructor Notes
Expand on the following points:
Major or multiple fractures can lead to significant blood loss.
Femur or pelvic fractures are the most common cause.
Do not underestimate blood loss due to multiple fractures.

32. Fractures (2 of 2) Fracture (Isolated) Blood Loss (ml) Single rib 125
Radius or ulna
250–500
Humerus
750
Tibia or fibula
500–1000
Femur
1000–2000
Pelvis
Massive
Instructor Notes
Expand on the following points:
This table illustrates the potential amount of blood loss for each type of fracture.
Do not underestimate blood loss due to multiple fractures.
Courtesy Norman McSwain, MD, FACS, NREMT-P

33. Rib Fractures Most common thoracic injury
Usually in ribs 4–8, laterally
May be associated with injuries to intercostal blood vessels, liver, spleen, or lung
Instructor Notes
Expand on the following points:
Fractures of the ribs may produce a pneumothorax, a hemothorax, or both.
Rib fractures are the most common thoracic injury.
Fractures usually occur laterally in ribs 4–8.
Fractures of the lower ribs may damage:
The spleen (most commonly)
Liver
Lungs
Blood vessels
Courtesy of Peter T. Pons, MD, FACEP.

34. Injuries Commonly Associated With Distributive Shock
Instructor Notes
This section will focus on injuries that are commonly associated with distributive shock.

35. Neurogenic “Shock”
Secondary to spinal cord injury, usually cervical spine (down to T6)
Loss of sympathetic system vascular tone
Blood vessels dilate
Blood return to the heart decreases and cardiac output drops
Perfusion and tissue oxygenation are usually maintained
Skin remains warm and dry
Instructor Notes
Expand on the following points:
Neurogenic “shock” occurs secondary to spinal cord injury, usually to the cervical spine (down to T6).
There is a loss of sympathetic system vascular tone.
Blood vessels dilate.
Blood return to the heart decreases and cardiac output drops.
Perfusion and tissue oxygenation are usually maintained with neurogenic “shock.”
The skin remains warm and dry.
The action of the sympathetic nervous system is to cause vasoconstriction, which helps maintain the patient’s blood pressure.
Injury to the spinal cord interrupts the normal sympathetic effects.
Unlike hemorrhagic shock, the patient usually does not have an increased heart rate or diaphoresis.

36. Injuries Commonly Associated With Cardiogenic Shock
Instructor Notes
This section will focus on injuries that are commonly associated with cardiogenic shock.

37. Pneumothorax Tension Simple Blunt or penetrating
Breath sounds decreased or absent
Marked ventilatory distress
Hemodynamic compromise
Simple
Blunt or penetrating
Breath sounds decreased or absent
Mild to moderate ventilatory distress
No hemodynamic compromise
Instructor Notes
Expand on the following points:
Tension and simple pneumothorax are associated with cardiogenic shock.
In tension pneumothorax:
Air leaks into the pleural space and begins to build up pressure, which pushes the heart and great vessels over to the other side of the chest.
This leads to “kinking” of the vena cava and decreased blood return to the heart, which, in addition to significant respiratory distress, causes the signs of shock.
It is caused by blunt or penetrating injury.
Breath sounds are decreased or absent.
There is marked ventilatory distress.
There is hemodynamic compromise.
In simple pneumothorax:
Air leaks into the pleural space, which causes partial or total collapse of the lung.
This leads to respiratory distress and pain.
There is mild to moderate ventilatory distress.
There is no hemodynamic compromise.

38. Pericardial Tamponade
Penetrating mechanism most common
Blood in pericardial sac:
Compresses the heart
Prevents adequate filling
Thus, cardiac output decreases
Instructor Notes
Expand on the following points:
A penetrating mechanism is the most common cause of pericardial tamponade.
Blood in pericardial sac:
Compresses the heart
Prevents adequate filling
Thus, cardiac output decreases
Rarely, blunt injury can also cause pericardial tamponade by rupturing the right atrium or ventricle.

39. Blunt Cardiac Injury Direct injury to heart muscle May cause:
Dysrhythmia
Sinus tachycardia most common
Right atrial or right ventricular rupture
Valve rupture — rare
New murmur
Sudden death
Instructor Notes
Expand on the following points:
A blunt cardiac injury is a direct injury to the heart muscle.
It may cause:
Dysrhythmia
Sinus tachycardia is the most common.
Right atrial or right ventricular rupture
Valve rupture
Rare
This will manifest as a new murmur.
Sudden death

40. Shock Management (1 of 14)
Four questions guide prehospital management:
What is the cause of shock in this particular patient?
Hemorrhage is the most common
What is the care for this type of shock?
What can and should be done between now and the time the patient reaches definitive care?
Where is the best place for the patient to get definitive care?
Instructor Notes
Expand on the following points:
Four questions guide the prehospital care provider in the management of shock in the prehospital setting:
What is the cause of shock in this particular patient?
Hemorrhage is the most common cause.
What is the care for this type of shock?
Where is the best place for the patient to get definitive care?
What can and should be done between now and the time the patient reaches definitive care?
The assessment of the patient’s circulation should simultaneously provide:
Evidence that the patient is in shock
Clues about what type of shock the patient is suffering from
Hemorrhagic shock is most common in trauma.

41. Shock Management (2 of 14) Proper shock management Airway Ventilation
Improves the oxygenation of RBCs
Improves the delivery of RBCs to the tissues
Airway
What are the needs?
Ventilation
Does it require assistance?
Instructor Notes
Expand on the following points:
Anaerobic metabolism is occurring before signs and symptoms of shock are evident.
Managing shock requires definitive treatment of the cause, as well as restoration of tissue perfusion.
Proper shock management improves the oxygenation of RBCs and improves the delivery of RBCs to the tissues.
Evaluate the patient for airway patency and need for airway intervention.
Evaluate whether the patient’s ventilation is adequate or whether assistance is necessary.

42. Shock Management (3 of 14) Oxygenation Circulation Is it adequate?
Hemorrhage controllable?
Instructor Notes
Expand on the following points:
Provide supplemental oxygen to ensure the maximum available oxygen saturation in the blood.
Evaluate for blood loss.
Stop any external hemorrhage.
Recognize the possibility of internal hemorrhage and the need for rapid transport to a trauma center.

43. Shock Management (4 of 14) Patient positioning Supine
Trendelenburg position no longer recommended
Allows the abdominal organs to push up on the diaphragm and impede its movement
No benefit in elevating lower extremities
Instructor Notes
Expand on the following points:
The best position for the patient in shock is the supine position.
The Trendelenburg position
Allows the abdominal organs to push up on the diaphragm and impede its movement
This further compromises the patient’s ventilation and oxygenation.
Patients in hemorrhagic shock are maximally vasoconstricted.
No blood is available in the lower extremity vasculature to provide an autotransfusion.

44. Shock Management (5 of 14) Hemorrhagic shock
Critical to stop ongoing blood loss and to maintain perfusion
Hemorrhage control
External hemorrhage
Internal hemorrhage
Every RBC counts!
Instructor Notes
Expand on the following points:
It is critical to stop ongoing blood loss and to maintain perfusion.
Every red blood cell counts!
Hemorrhage control is dependent on the type of hemorrhage.
External hemorrhage
Internal hemorrhage

45. Shock Management (6 of 14) Hemorrhagic shock (cont’d)
External hemorrhage control
Direct pressure will control most external hemorrhage
Tourniquet
Immobilization of fractures
Topical hemostatic agents (use to pack bleeding wounds)
Internal hemorrhage
Controlled in the operating room
Instructor Notes
Expand on the following points:
Most external hemorrhage can be controlled with direct pressure.
Tourniquet use is acceptable if direct pressure fails to control the hemorrhage.
Immobilizing fractures is important in controlling hemorrhage due to fractures.
Depending on the patient’s condition, immobilization to a long backboard may be the best way of accomplishing this.
Topical hemostatic agents are being used in military applications and may be useful in the civilian setting.
The preferred agent involves an impregnated gauze that is used to pack an open wound to control external bleeding.
Most importantly, internal hemorrhage can only be treated in the operating room, so rapid transport must be initiated.

46. External Hemorrhage Control
Instructor Notes
Expand on the following points:
This flowchart illustrates the measures to take when managing an external hemorrhage.

47. Shock Management (7 of 14) Fluid therapy in hemorrhagic shock
Balanced resuscitation
Balance between how much fluid is given and how high the BP is raised
Excessive resuscitation leads to increased bleeding
Instructor Notes
Expand on the following points:
If administrating fluid therapy during the management of hemorrhagic shock, practice balanced resuscitation.
Balance between how much fluid is given and how high the blood pressure is raised.
Excessive fluid resuscitation leads to increased bleeding.
Avoid returning the patient’s blood pressure to normal as that may disrupt clotting that has formed and increase bleeding.

48. Shock Management (8 of 14) Patients with signs of hemorrhagic shock
Maintain systolic BP at approximately 80–90 mm Hg
If signs of traumatic brain injury are present, maintain systolic BP at approximately –100 mm Hg
Adult patients may require 1000–2000 ml of warmed lactated Ringer’s solution or normal saline
Pediatric patients: 20 ml/kg bolus
Instructor Notes
Expand on the following points:
In patients with signs of hemorrhagic shock:
Maintain blood pressure at approximately 80–90 mm Hg.
If signs of traumatic brain injury are present, maintain systolic blood pressure at approximately 90–100 mm Hg.
Adult patients with controlled hemorrhage may require 1000–2000 ml of warmed lactated Ringer’s solution or normal saline.
Pediatric patients with a controlled hemorrhage should receive a bolus of 20 ml/kg of warmed crystalloid solution.
Keep in mind that there is no evidence that fluid therapy in the prehospital setting improves survival.
Moderate hypotension is beneficial in reducing bleeding.
However, in patients with traumatic brain injury (TBI), blood pressure should be kept greater than 90 mm Hg.
Hemodilution and increased blood pressure may impair clotting.
Blood is the fluid of choice but is impractical in prehospital care.
The alternatives are:
Isotonic crystalloids
Short-term volume expanders
Lactated Ringers is preferred.
Traditionally, a 3:1 ratio of crystalloid solution to the amount of blood loss has guided resuscitation, but the end-points of prehospital resuscitation are not known.
Hypertonic crystalloids
Offer no improvement in the patient survival rate over isotonic crystalloids
Advantageous in military settings where large volumes of fluid cannot be carried
Synthetic colloids
Large protein molecules help maintain vascular volume
Drawbacks include cost, allergic reactions, interference with blood typing, and transmission of infectious diseases
Blood substitutes
Clinical trials showed promise but have not been demonstrated to improve outcome, and there are drawbacks

49. Shock Management (9 of 14) Reassessment following fluid therapy
Three responses:
Rapid response
Suggests that hemorrhage has stopped, may still require surgery
Transient response
Significant blood loss and probably ongoing hemorrhage, requires urgent surgery
Minimal or no response
Massive ongoing hemorrhage, requires immediate surgery
Instructor Notes
Expand on the following points:
Remember these points while reassessing a patient following fluid therapy.
A rapid return to normal vital signs and the stabilization of the patient’s condition usually indicates that the patient has lost up to 20% of blood volume but that hemorrhage has stopped.
Surgery may still be necessary.
An initial improvement followed by deterioration indicates a 20% to 40% volume loss and ongoing hemorrhage in the patient.
The patient requires rapid surgical intervention.
No change in condition after a rapid infusion of 1000–2000 ml of fluid indicates massive exsanguinating hemorrhage and the need for immediate surgical intervention to prevent death.

50. Shock Management (10 of 14) Distributive (neurogenic) shock
Must rule out hemorrhage as the primary cause of shock
Spine movement restriction (immobilization)
Fluid administration
Instructor Notes
Expand on the following points:
When managing distributive (neurogenic) shock:
Because it is difficult to completely rule out hemorrhage as a cause of shock, most patients will be treated as if they were in hypovolemic shock.
Immobilize the patient to restrict spinal movement.
Begin fluid administration.

51. Shock Management (11 of 14) Cardiogenic shock in trauma Extrinsic
Tension pneumothorax
Needle decompression
Pericardial tamponade
Rapid transport
Fluid administration
Intrinsic
Treat dysrhythmias as necessary
Prevent fluid overload
Instructor Notes
Expand on the following points:
The type of injury will dictate how to manage the patient in cardiogenic shock.
Extrinsic
Tension pneumothorax
Requires needle decompression
See the Specific Skills section at the end of the Thoracic Trauma chapter to review this skill.
Pericardial tamponade
Requires rapid transport
Begin fluid administration.
Intrinsic
Treat dysrhythmias as necessary.
Prevent fluid overload.

52. Shock Management (12 of 14) Transport considerations
Transport without delay to appropriate destination
Most procedures may be accomplished while en route
Maintain body temperature
Cover patient after completing assessment
Patient compartment temperature should be kept as warm as possible
Instructor Notes
Expand on the following points:
Patients must receive appropriate management without delay in transport.
Appropriate interventions need to be provided without undue delay.
The choice of destination will depend on your assessment.
With critical trauma patients, it is better to bypass the closest hospital, if it is not a trauma center.
Spend a little more time en route to transport the patient to a trauma center where all of the necessary personnel, equipment, and supplies are immediately available.
Maintain the patient’s body temperature.
The temperature of the patient compartment must meet the needs of the patient, not necessarily the needs of the crew.
If you, as a crew member are comfortable in the patient compartment, it is not warm enough for the patient; turn up the temperature.
Cover the patient after completing the assessment and reassessments.

53. Shock Management (13 of 14) Prolonged transport
Ensure airway and optimize ventilatory status
Maintain external hemorrhage control
Prevent body heat loss
Reassess, reassess, reassess
Instructor Notes
Expand on the following points:
During prolonged transport:
Ensure the patient’s airway and optimize the patient’s ventilatory status.
Maintain external hemorrhage control.
Prevent body heat loss.
Reassess, reassess, reassess.

54. Shock Management (14 of 14) Left untreated, shock progresses
Prehospital care can affect outcome by helping to restore perfusion and energy production
Managing shock in the prehospital setting can help prevent the cascade of cell death, organ death, and patient death
Instructor Notes
Expand on the following points:
Left untreated, shock progresses.
Prehospital care can affect the patient’s outcome by helping to restore perfusion and energy production.
Managing shock in the prehospital setting can help prevent the cascade of cell death, organ death, and patient death.

55. Minimizing Complications (1 of 2)
Assess for and recognize the signs of shock
Assume hemorrhagic shock until proven otherwise
Control external hemorrhage as rapidly as possible
Cardiac output and tissue oxygenation are impaired early
Instructor Notes
Expand on the following points:
In order to minimize complications in a trauma patient:
Assess for and recognize the signs of shock.
Assume hemorrhagic shock until proven otherwise.
Control any external hemorrhage as rapidly as possible.
Remember that cardiac output and tissue oxygenation are impaired early.

56. Minimizing Complications (2 of 2)
Restore and maintain airway, ventilation, oxygenation, and circulation
Hypothermia creates a cycle of worsening shock and hypothermia
Transport without undue delay
Instructor Notes
Expand on the following points:
In order to minimize complications:
Restore and maintain the patient’s airway, ventilation, oxygenation, and circulation.
Hypothermia creates a cycle of worsening shock and hypothermia.
Transport the patient without undue delay.

57. Summary
Shock is a state of cellular hypoperfusion, leading to inadequate energy production to meet metabolic needs
The most common cause of shock in the trauma patient is hemorrhage
Shock is hemorrhagic until proven otherwise
The management of shock is aimed at improving oxygenation of RBCs, improving delivery of oxygenated RBCs to the microcirculation, and controlling hemorrhage
Instructor Notes
Expand on the following points:
Shock is a state of cellular hypoperfusion, leading to inadequate energy production to meet metabolic needs.
The most common cause of shock in the trauma patient is hemorrhage.
Shock is hemorrhagic until proven otherwise.
The management of shock is aimed at improving oxygenation of RBCs, improving delivery of oxygenated RBCs to the microcirculation, and controlling hemorrhage.

58. Questions? Instructor Notes
Allow time for a question and answer session to answer any questions about the topics presented in the lesson.