1. Introduction to Emergency Medical Care 1
Advance Preparation
Prepare anatomical models for demonstration.
Research related multimedia links for illustration purposes.
Prepare bandaging supplies for demonstration.
Invite assistant instructors and programmed patients to assist with psychomotor sessions.

2. OBJECTIVES
27.1 Define key terms introduced in this chapter. Slides 17, 21, 28–30, 47, 49, 52– Describe the structure and function of the circulatory system, including the functions of the blood. Slides 12– Explain the concept of perfusion. Slide 17
continued

3. OBJECTIVES
27.4 Compare and contrast arterial, venous, and capillary bleeding. Slide Discuss causes and effects of severe external bleeding. Slides 20–21, 34– Discuss assessment and management of external bleeding, including methods of controlling external bleeding. Slides 23–31, 33–35
continued

4. OBJECTIVES
27.7 Identify patients at risk for internal bleeding. Slides 38– Recognize signs of internal bleeding and discuss patient care for internal bleeding. Slides 40– Discuss the causes of shock and its effects on the body. Slides 47–50
continued

5. OBJECTIVES
27.10 Explain the concepts of compensated, decompensated, and irreversible shock. Slide Discuss the types of shock. Slides 51– Relate the signs and symptoms of shock to the body’s attempts to compensate for blood loss. Slide 55
continued

6. OBJECTIVES
27.13 Discuss the management of patients in shock. Slides 56–59

7. MULTIMEDIA
Slide 45 Bleeding Control/Shock Management Video Slide 60 Shock Video
These videos appear later in the presentation; you may want to preview them prior to class to ensure they load and play properly. Click on the links above in slideshow view to go directly to the slides.

8. How to recognize arterial, venous, and capillary bleeding
How to evaluate the severity of external bleeding
How to control external bleeding
continued

9. Signs, symptoms, and care of a patient with internal bleeding
Signs, symptoms, and care of a patient with shock

10. Topics The Circulatory System Bleeding Shock
Planning Your Time: Plan 105 minutes for this chapter.
The Circulatory System (20 minutes)
Bleeding (40 minutes)
Shock (Hypoperfusion) (45 minutes)
Note: The total teaching time recommended is only a guideline.

11. The Circulatory System
Teaching Time: 20 minutes
Teaching Tips: Relate this lesson to the metabolism discussion in Chapter 6. Consider the basic requirements of cells when reviewing the function of the circulatory system. Use anatomical models and multimedia graphics to illustrate the circulatory system. Spend time clarifying the need for perfusion. Other lessons depend on a fundamental understanding of this concept.

12. Circulatory System
Talking Points: The circulatory system is responsible for distributing blood to the body. It is comprised of the heart, the blood vessels, and the blood.
Discussion Topics: Describe the role of the circulatory system. What functions does it provide to the body? Describe the components of the circulatory system. What role does each component play within the system?
Knowledge Applications: Have students label the components of the circulatory system on a blank illustration. List the components of the circulatory system. Ask students to describe the basic function of each component.

13. Arteries Carry oxygen-rich blood away from the heart
Comprised of thick, muscular walls that enable dilation and constriction
Point to Emphasize: Arteries, veins, and capillaries are the three main types of blood vessels.

14. Veins
Carry oxygen-depleted blood rich in carbon dioxide back to the heart
Contain one-way valves to prevent back flow of blood

15. Capillaries Microscopic blood vessels
Vital exchange site: oxygen, nutrients passed through capillary walls in exchange for carbon dioxide from cells

16. Functions of Blood Transportation of gases Nutrition Excretion
Protection
Regulation
Talking Points: Blood transports oxygen to cells, distributes nutrients from intestines and storage tissues, and carries waste products for excretion. It is comprised of white blood cells and antibodies to fight infection. It regulates hormones and electrolytes in cells.

17. Perfusion Hypoperfusion (Shock)
Adequate circulation of blood throughout
body
Inadequate circulation of blood to tissues and organs
Talking Points: Perfusion is the adequate filling of the body’s capillaries, supplying cells and tissues with oxygen and nutrients. Hypoperfusion results in some cells and organs not receiving adequate oxygen and causes a dangerous build up of waste in the cells.
Discussion Topic: Define hypoperfusion. What are the implications of inadequate perfusion?
Class Activity: Role-play the circulatory system. Assign specific roles and have students act out the normal function of a circulatory system.
Critical Thinking: What role does the pulmonary system play with regard to the normal function of the circulatory system? Describe how the two are linked.

18. Bleeding Teaching Time: 40 minutes
Teaching Tips: Use multimedia graphics to illustrate the different types of bleeding. Have personal protective equipment (PPE) on hand. Demand appropriate protective equipment, even when practicing. Have bleeding control equipment on hand for practice. Unless it is exsanguinating, bleeding likely will be a lower priority than airway and breathing. However, bleeding is often distracting. Emphasize an appropriate progression through the primary assessment. Instill a fear of internal bleeding. Make sure students know that it is impossible to estimate and is potentially deadly.

19. Types of Bleeding External Internal
Talking Points: Hemorrhage or severe bleeding is a major cause of shock in trauma. The cells and tissues of the brain, spinal cord, and kidneys are the most sensitive to inadequate perfusion.

20. External Bleeding Spurting Steady
Talking Points: Whenever bleeding is suspected, standard precautions are essential to avoid exposure of the skin and mucous membranes. While this will decrease the possibility of exposure, you should always wash your hands immediately after patient contact.

21. External Bleeding
Point to Emphasize: The three types of external hemorrhage are directly related to the amount of pressure within the ruptured vessel.
Talking Points: Arterial circulation is a high-pressure system inside thick, muscular walls making it most difficult to control. Venous circulation is a low-pressure system that is often lower than atmospheric pressure, which may suck in debris or air bubbles through an open wound.
Discussion Topic: Compare and contrast the three types of bleeding. Include assessment findings.

22. Think About It
How severe is the bleeding? Is it exsanguinating hemorrhage? If so, how does that affect the priorities of treatment?
Talking Points: Exsanguinating hemorrhage is rapidly life threatening, so it must be the first priority.

23. Skin: Color, Temp, Condition,
Patient Assessment
Standard
Precautions
Monitor
Respirations
Ventilate
if Necessary
Open
Airway
Control Bleeding
Skin: Color, Temp, Condition,
Check Pulses
Talking Points: Bleeding control comes after airway and breathing assessment in the patient assessment as shown here. Standard precautions are still the first and most important step in every assessment.

24. Methods to Control External Bleeding
Point to Emphasize: Treatment of external hemorrhage includes a progression through the following steps: direct pressure, elevation, tourniquet application, and the use of hemostatic agents.
Talking Points: In addition to controlling bleeding, an essential treatment for all trauma patients is the application of supplemental oxygen. As blood loss decreases perfusion, less oxygen is delivered to the cells and tissues. Supplemental oxygen will increase the saturation of each of the circulating red blood cells.

25. Direct Pressure
Apply firm pressure to wound with gloved hand and gauze bandage
Hold pressure until bleeding is controlled
If necessary, add dressings when lower ones are saturated
Talking Points: If bleeding is minor, apply a sterile gauze bandage with direct pressure. If bleeding is severe or spurting, use a gloved hand quickly. Do not waste time looking for a sterile bandage.
continued

26. Direct Pressure Never remove bandages—even when bleeding is controlled
When controlled, check for pulse distal to wound

27. Elevate
Elevate injured extremity above level of the heart while applying direct pressure
Do not elevate if musculoskeletal injury is suspected
Talking Points: Elevating an extremity allows gravity to assist control of bleeding.

28. Pressure Dressing Place several gauze pads on wound
Hold dressings in place with self-adhering roller bandage wrapped tightly over dressings and above and below wound site
Create enough pressure to control bleeding

29. Hemostatic Agents
Commonly, dressing containing substance that absorbs and traps red blood cells
Can be wadded up and inserted into wound
May be a powder poured directly into the wound
Manual pressure is always necessary
Talking Points: When placed directly into wounds, hemostatic agents are believed to speed or assist clotting to stop bleeding. Always follow manufacturer’s directions for the product you are using.

30. Tourniquet Use if bleeding is uncontrollable via direct pressure
Use only on extremity injuries
Talking Points: Battlefield testing has shown that tourniquets are useful in bleeding not otherwise controllable and that the average transport time of less than one hour does not pose a severe risk to the long-term outcome. Removing a tourniquet can dislodge clots that have formed, resulting in further blood loss.
continued

31. Tourniquet Once applied, do not remove or loosen
Attach notation to patient alerting other providers tourniquet has been applied

32. Think About It
Is the current method of bleeding control working? Do you need to move on to a more aggressive step? How would you evaluate this?
Talking Points: EMTs must evaluate the efficacy of the current treatment before escalating.

33. Other Ways to Stop Bleeding
Splinting
Cold application
Pneumatic anti-shock garment (PASG)
Talking Points: Bleeding associated with musculoskeletal injury will commonly be controlled by properly splinting the injury. In addition, the splint may provide direct pressure on the wound. Cold application will reduce swelling and constrict vessel walls, thereby stopping bleeding.
Discussion Topic: Describe the steps used to control external hemorrhage.

34. Special Bleeding Situations
Head injury
From increased intracranial pressure, not direct trauma
Stopping bleeding only increases intracranial pressure
Talking Points: Bleeding from the ears and nose associated with a head injury isn’t from direct trauma but from increased intracranial pressure. Stopping this bleeding will only further increase pressure. Nosebleeds can be from direct trauma or from the rupture of tiny vessels in the nares from another medical condition such as hypertension.

35. Special Bleeding Situations
Nosebleed (Epistaxis)
Have patient sit and lean forward
Apply direct pressure to fleshy portion of nostrils
Keep patient calm and quiet
Talking Points: If the patient leans back, the patient can swallow blood causing stomach irritation and eventually nausea and vomiting.
Discussion Topic: Describe the procedure for treating a nosebleed.
continued

36. Special Bleeding Situations
Nosebleed (Epistaxis)
Do not let patient lean back
If patient becomes unconscious, place patient in recovery position and be prepared to suction
Knowledge Applications: Have students work in small groups. Assign each group a method of bleeding control. Have the group research and present the correct procedure for using its particular method. Include benefits and costs. Use programmed patients to practice bleeding control. Use all the methods discussed.
Critical Thinking: How might blood-thinning medications change your strategy for bleeding control?

37. Internal Bleeding
Damage to internal organs and large blood vessels can result in loss of a large quantity of blood in short time
Blood loss commonly cannot be seen
Severe blood loss can even result from injuries to extremities
Point to Emphasize: Internal bleeding is bleeding that occurs inside the body. This type of bleeding is difficult to assess and can be massive.
Talking Points: Sharp bone ends from a fractured extremity can tear surrounding vessels and tissue, resulting in severe bleeding.
Discussion Topic: Describe the signs that indicate internal bleeding.

38. Blunt Trauma Leading cause of internal bleeding Falls
Motor vehicle crashes
Automobile–pedestrian collisions
Blast injuries
Class Activity: Describe signs and symptoms of a trauma patient. Ask the class if there are signs of internal hemorrhage. Discuss decision making.

39. Penetrating Trauma Common penetrating injuries Gunshot wounds
Stab wounds
Impaled objects
Talking Points: Penetrating trauma is also a leading cause of internal bleeding. The amount of internal injury and bleeding is often difficult to judge.

40. Signs of Internal Bleeding
Injuries to surface of body
Bruising, swelling, or pain over vital organs
Painful, swollen, or deformed extremities
Bleeding from mouth, rectum, or vagina
Talking Points: Red blood is usually “new” and dark blood is usually “old.” Signs and symptoms may appear late in the stages of bleeding, as significant blood loss must have occurred to initiate shock. The best clue to internal bleeding is the presence of a mechanism of injury.
continued

41. Signs of Internal Bleeding
Tender, rigid, or distended abdomen
Vomiting coffee-ground or bright-red material

42. Pediatric Considerations
Infants and children—efficient compensating mechanisms maintain blood pressure until half of volume is depleted
Potential for shock must be recognized and treated before tell-tale signs appear
Talking Points: Because of the efficiency of their compensating mechanisms, by the time their blood pressure drops, infants and children are already near death.

43. Cultural Considerations
Places on body to look to assess circulation via skin color
Fingernails and lips
Conjunctiva in eyes
Palms of hands; soles of feet
Talking Points: In all patients, skin color is best evaluated where the epidermis is thinnest.

44. Treatment of Internal Bleeding
Maintain
ABC’s
Administer
Oxygen
Control
External Bleeding
Rapid Transport to
Appropriate Medical Facility
Point to Emphasize: Care for internal bleeding must include rapid transport to an appropriate facility.
Talking Points: Most internal bleeding can be controlled only in the operating room.

45. Bleeding Control/ Shock Management Video
Video Clip
Some Ways to Control Bleeding
What happens when the body loses too much blood?
What are the signs and symptoms of shock?
List and describe the three types of external bleeding.
What materials can an EMT use to control bleeding?
Explain how to control external bleeding.
Click here to view a video on the subject of controlling bleeding and shock management.
Back to Directory

46. Shock Teaching Time: 45 minutes
Teaching Tips: Review A&P of the cardiovascular system. Shock becomes much clearer when it is framed against normal perfusion. Teach compensation. If students understand how the body compensates, they can relate signs and symptoms. This also works the other way: If students see signs and symptoms, they can predict the level of compensation. Shock is about supply and demand. Cells need oxygen. In shock, there is more demand than supply. Use specific examples to discuss how the cardiovascular system fails and how hypoperfusion begins. Relating signs to real life is often helpful in explaining these points. Early recognition is essential. Teach students to beware blood pressure as an indicator of shock.

47. Shock Inadequate removal Inability to supply cells with oxygen
and
nutrients
Inadequate removal
of waste
products from
cells
Point to Emphasize: Shock is defined as inadequate tissue perfusion.
Talking Points: The result of the joining of these two conditions is death.

48. Causes of Shock Failure of any component of circulatory system
Heart: loses ability to pump
Blood vessels: dilate, making too large a “container” to fill
Blood: loses volume from bleeding
Talking Points: Blood vessels will constrict and dilate to compensate for a decrease in circulating volume. The heart will increase it’s rate to pump more blood to compensate, although this will often cause more bleeding.
Discussion Topic: Discuss the main causes of shock. How are they different? How are they similar?

49. Severity of Shock
Talking Points: Compensated shock occurs when the body detects a decrease in perfusion and attempts to compensate for it. Decompensated shock begins when the body can no longer handle its efforts to maintain perfusion. In irreversible shock, too much cell damage has occurred and the body cannot function.
Discussion Topic: Explain how the body compensates for hypoperfusion. What steps does it take, and how will these steps be noticeable in your patient?
Knowledge Application: Ask small groups to discuss the long-term effects of compensation. Why does it eventually lead to decompensation? Are there lasting effects?

50. Knowledge Application: Assign small groups a component of the cardiovascular system. Ask them to discuss how that component is affected by shock and subsequent compensation. What changes occur?

51. Types of Shock Hypovolemic Cardiogenic Neurogenic
Knowledge Application: Assign small groups examples of anaphylactic and obstructive shock. Have groups research the pathophysiology, signs and symptoms, and appropriate treatments. Discuss.

52. Hypovolemic Shock
Results from a decreased volume of circulating blood and plasma
Called hemorrhagic shock if caused by uncontrolled bleeding (internal or external)
Can be caused by burns or crush injuries
Talking Points: Hypovolemic shock is the type most frequently seen by EMTs. It may also be caused by burns or crush injuries, where plasma is lost or by severe dehydration.

53. Cardiogenic Shock Seen in patients suffering myocardial infarction
Results from inadequate perfusion to heart, decreasing strength of contractions
Heart’s electrical system may malfunction, causing heartbeat that is too slow, too fast, or irregular
Talking Points: Other cardiac problems, such as congestive heart failure, may also cause shock.

54. Neurogenic Shock
Results from inability to control dilation of blood vessels because of nerve paralysis
No blood loss, but vessels dilated so much that blood volume can’t fill them
Rarely seen in the field

55. Signs and Symptoms of Shock
Altered mental status
Pale, cool, clammy skin
Nausea and vomiting
Vital sign changes
Talking Points: Mental status changes are the result of a decrease in oxygen supply to the brain. When the body senses a decrease in volume, it shunts blood from non-essential areas. This results in a loss of skin color and temperature. Nausea develops for the same reason as blood is shunted from the digestive tract. Vital signs change differently as the severity of shock increases. The first to change is the respiratory and pulse rates (both increasing). Blood pressure drops as the body can no longer keep up with the decrease in perfusion.
Discussion Topics: Define shock. What effect does shock have on the body? Describe the signs and symptoms of shock.
Class Activities: Describe the signs and symptoms of a shock patient. Have students tell you what stage of shock the patient is experiencing. Discuss cell hypoperfusion. Ask the class what steps the body might take to compensate for this problem. How will the body save itself?

56. Care for Shock Aggressive airway maintenance
Administer high-concentration oxygen
Attempt to stop cause of shock
Apply and inflate PASG if approved
Talking Points: Remember that transportation is the most important intervention. The PASG is usually indicated for bleeding in areas covered by the garment. It is contraindicated in cardiogenic shock or if there are abnormal lung sounds.
continued

57. Care for Shock Splint any suspected bone or joint injuries
Prevent loss of body heat
Deliver patient to appropriate medical facility within “golden hour”
Speak calmly and reassure throughout assessment and care
Talking Points: If the patient is in shock, splint injuries after transport has begun. The “golden hour” starts at the time of injury, not at arrival to the patient. Some bleeding will only be able to be controlled in the operating room.
Knowledge Application: Use programmed patients to create shock scenarios. Have teams practice assessment and treatment.
Critical Thinking: What can be done to assist compensation and prevent decompensation in a shock patient?

58. PASG Application Step 1 Step 2 Step 3
Talking Points: Step 1. Log roll the patient so the upper edge of the PASG is aligned with the lower rib cage. Step 2. Enclose the legs separately and secure with the velcro. Step 3. Enclose the abdomen and pelvis and secure with the velcro.

59. PASG Application Step 4 Step 5 Step 6
Talking Points: Step 4. Check lines. Open stopcocks to legs; close stopcocks to abdomen. Step 5. Inflate lower compartments until velcro “crackles.” Secure the stopcocks. If approved, inflate abdomen following this in the same manner. Step 6. Continually check for distal pulses and record vital signs.

60. Click here to view a video on the subject of shock.
Shock Video
Video Clip
Shock
What are some of the most common causes of shock?
Discuss the role of the EMT in the assessment and management of a patient in shock.
What types of shock usually result from blood vessel dilation?
Click here to view a video on the subject of shock.
Back to Directory

61. Chapter Review

62. Chapter Review
Almost all external bleeding can be controlled by direct pressure and elevation. If these don’t work, apply tourniquet if bleeding is on an extremity.
Emergency care for internal bleeding is based on prevention and treatment of shock.
continued

63. Chapter Review
Early signs of shock: restlessness, anxiety, pale skin, rapid pulse and respirations.
If shock is uncontrolled, patient’s blood pressure falls (late sign of shock).
Signs and symptoms may not be evident early; treatment based on MOI may be life-saving.
continued

64. Chapter Review
Treat shock by airway maintenance; administration of high-concentration oxygen; controlling bleeding; and keeping the patient warm. One of most important treatments is early recognition of shock and immediate transport.

65. Remember
The circulatory system is designed to ensure adequate perfusion of body tissues.
The classification of hemorrhage is directly related to the type of vessel ruptured and the pressure within that vessel.
continued

66. Remember
Treatment of external hemorrhage includes progression through the following steps: direct pressure, elevation, tourniquet application, use of hemostatic agents.
Internal bleeding is impossible to evaluate. The most appropriate treatment must be rapid transport to an appropriate facility.
continued

67. Remember
Shock develops if the heart fails, blood volume is lost, or blood vessels dilate, resulting in inadequate perfusion.
Signs of shock reflect the body’s attempts at compensating for inadequate perfusion.
continued

68. Remember
The most significant treatment for the shock patient is early recognition and prompt transport to a hospital where the patient will receive definitive care.
continued

69. Questions to Consider
What can I use for a tourniquet that will control bleeding but not damage tissue?
When treating a patient with shock, what should I do at the scene and what should I do en route to the hospital?
Talking Points: When students are discussing these questions, make sure to insert real-life details that will help them understand that the situations they find themselves in as EMTs will not necessarily follow the clear-cut order the find in their textbooks.
continued

70. Questions to Consider
Is a patient with pale, cool skin, tachycardia, and rapid, shallow respirations in shock or just under stress? How will continuing assessment help in making that decision?

71. Critical Thinking
A patient has been involved in a motor-vehicle collision. There is considerable damage to the vehicle. The steering column and wheel are badly deformed. The patient complains of a “sore chest.” You note no external bleeding.
continued

72. Critical Thinking
The patient’s vital signs are pulse 116, respirations 20, blood pressure 106/70. How would you proceed to assess and care for this patient?
Talking Points: Have one student suggest a course of assessment and care. When that student has finished, ask other students to critique the process.

73. Please visit Resource Central on www. bradybooks
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