Pipes, pump, and fluid…really, it’s that simple! 1

2 The Second Rule of EMS…. …eventually the bleeding will stop!

Amount and composition of body fluids Approximately 60% of a typical adult’s weight consists of fluid (water and electrolytes). Factors that influence the amount of body fluid are:

Age., in general, younger people have a higher percentage of body fluid than older people Gender., men have proportionately more body fluid than women And body fat composition. obese people have less fluid than thin people because fat cells contain little water.

Intracellular space (fluid in the cells) Extracellular space (fluid outside the cells). Body fluid is located in two fluid compartments:

The intravascular space (the fluid within the blood vessels) contains plasma. Approximately 3 L of the average 6 L of blood volume is made up of plasma.. The interstitial space contains the fluid that surrounds the cell The transcellular space is the smallest division of the ECF and contains approximately 1 L of fluid at any given time. Examples of transcellular fluid are cerebrospinal fluids

7 Heart Arteries Veins Capillaries Blood

8  Transports O2 and fuel to the cells, tissues, and organs.  Removes CO2 and wastes from the cells for elimination from the body.  Must be able to maintain sufficient flow through the capillary beds to meet the cell’s O2 and fuel needs

9 Internal External

10 Trauma Clotting disorders Rupture of blood vessels Fractures (injury to nearby vessels) Can result in rapid progression to hypovolemic shock & death!

11 Signs and Symptoms Anxiety, restlessness, irritability Pale, diaphoretic skin Sustained tachycardia Hypotension Unstable vitals signs (postural changes)

12 Signs and Symptoms Vomiting bright red blood Bleeding form any body orifice Dark, tarry stools (melena) Tender, rigid, or distended abdomen Pain, discoloration, swelling tenderness at injury site

13 Managing Internal Bleeding ABC’s High concentration oxygen Assist ventilations Control external bleeding Stabilize fractures RICE Transport rapidly to appropriate facility

15  Arterial Bleed  Bright red, spurting  Venous Bleed  Dark red, steady flow  Capillary Bleed  Dark red, oozing

16 Control of External Bleeding Direct Pressure: Gloved hand Or Dressing and bandage

17 Control of External Bleeding Elevation: Raise extremity above the level of the heart

18 Control of External Bleeding Pressure Dressing: Use bandage to secure dressing in place

19 Arterial Pressure Points Upper extremity : –Brachial –Radial Lower extremity : –Femoral –Popliteal

20 Tourniquets Final resort when all else fails Used for amputations 3-4” wide (blood pressure cuffs) Write “TK” and time of application on forehead of patient Notify other personnel Once applied, DO NOT REMOVE

21 Stage of bleeding

22 Management of bleeding 1.IV Access : This step should not be delayed. 2.Observations : Blood pressure, Heart rate, Capillary refill time, ECG 3.Fluids & Blood Transfusion : need significant volumes of fluid & blood to be given FAST 4.Monitor Urine Output : If the kidneys are not getting sufficient perfusion, urine output falls

23 Causes :- –Fractured skull ( Trauma ) –Sinusitis –High BP –Clotting disorders –Digital insertion (nose picking)

24 Causes Cracked mucous membranes Anything that reduces the blood’s ability to clot, such as hemophilia or leukemia, regular aspirin use, anticoagulant therapy, or chemotherapy, can also predispose a patient to nosebleeds. Cocaine use can also cause epistaxis.

25 Signs and Symptoms The patient may complain of a chronically stuffy nose or discomfort from blocked sinus drainage. Some patients experience headaches and nosebleeds.

26 Management of Epistaxis Sit up, lean forward Pinch nostrils together Keep in sitting position/ semi-Fowler’s position Apply ice over nose (15 min) to reduce swelling Aspirin and related medications are avoided because they increase the risk of bleeding. Can result in life-threatening blood loss!

28 Inadequate perfusion(blood flow) leading to inadequate oxygen delivery to tissues

29 Physiology Cell is the basic unit of life Cells get energy needed to stay alive by reacting oxygen with fuel (usually glucose) No oxygen, no energy No energy, no life

30 Perfusion Failure Pump Failure (heart) Pipe Failure (vessels) Loss of Volume (blood)

31 Stages of Shock Compensated Shock Decompensated Shock Irreversible Shock

32 Compensated Shock Body still compensates for blood loss Pulse rate increases Pulse strength decreases Pale, diaphoretic skin Anxiety, restlessness, combativeness Thirst, weakness, eventual air hunger

33 Decompensated Shock Body compensatory mechanisms fail Unpalpable pulse Precipitous drop in blood pressure Patient becomes unconscious Respirations slow or cease

34 Irreversible Shock Lack of circulation causes: –Cellular death –Tissue dysfunction –Organ dysfunction –Patient death

35 Shock: Etiology

36 Psychogenic Hypovolemic Distributive Obstructive Cardiogenic Respiratory Neurogenic

37 Psychogenic Shock Simple fainting (syncope) Caused by stress, fright, pain Heart rate slows, vessels dilate Brain becomes hypo-perfused Loss of consciousness occurs Patient usually recovers by self

38 Psychogenic Shock S/S Anxiety, restlessness, irritability Rapid pulse Normal or low blood pressure Hyperventilation

39 Hypovolemic Shock Loss of volume Causes:- –Blood loss from trauma –Plasma loss from burns –Fluid/electrolyte loss from vomiting, diarrhea, sweating, increased urine output, increase respiratory loss –“Third space” fluid shifts

40 Hypovolemic Shock S/S Anxiety, restlessness, irritability Rapid, weak pulse Change in mental status Signs of inadequate perfussion (diaphoresis, cyanosis, pale/clammy skin) Increased respiratory rate

41 Distributive Shock: Septic Results from body’s response to bacteria in bloodstream Vessels dilate, become “leaky”

42 Distributive Shock: Septic S/S Anxiety, restlessness, irritability Febrile, warm skin Hypotension Tachycardia Increased respiratory rate Change in mental status

43 Distributive Shock: Anaphylactic Results from severe allergic reactions Body responds to allergen by releasing histamine Histamine release causes vessels to dilates and become “leaky

44 Distributive Shock: Anaphylactic S/S Sudden onset Mild itching, rash, uticaria, hives Burning sensation (skin) Hypotension Generalized edema Angiodema, airway compromise Respiratory distress Coma, rapid death

45 Obstructive Shock Interference with blood flow through the cardiovascular system Tension pneumothorax Cardiac tamponade Pulmonary embolism

46 Obstructive Shock S/S Anxiety, irritability, restlessness Weak, irregular pulse Chest pain, shortness of breath Hypotension Pale, cool, clammy skin JVD, discoloration above nipple line

47 Cardiogenic Shock Pump failure Heart’s output depends on –How often it beats (heart rate) –How hard it beats (contractility) Rate or contractility problems cause pump failure

48 Cardiogenic Shock Causes –Acute myocardial infarction –Very low heart rates (bradycardias) –Very high heart rates (tachycardias) Why would a high heart rate caused decreased output? Hint: Think about when the heart fills.

49 Cardiogenic Shock S/S Chest pain Weak, irregular pulse Hypotension (HTN with CHF) Cyanosis, signs of inadequate perfusion Cool, clammy skin Anxiety

50 Respiratory Shock Failure of respiratory system to supply oxygen to or remove CO2 from the alveoli Airway obstruction Flail chest, SCW Pneumothorax Respiratory muscle paralysis

51 Respiratory Shock S/S Anxiety, restlessness, irritability Rapid, weak pulse Hypotension Change in mental status Signs of inadequate perfussion Increased respiratory rate Bronchoconstrcition (wheezes)

52 Neurogenic Shock Spinal cord injuries that result in the interruption of communication pathways between CNS and rest of body Vessels below the injury site dilate leading to decreased vascular resistance

53 Neurogenic Shock S/S Anxiety, restlessness, irritability Bradycardia Hypotension Skin above injury site: pale, cool, clammy Skin below injury site: warm, pink, dry Signs of spinal injury

54 Treatment ABC’s Apply O2, assist ventilations as needed Keep patient in position of comfort Control bleeding, stabilize fractures Prevent loss of body heat Assist with medications Nothing by mouth Calm and reassure

55 Treatment Elevate lower extremities 8 to 12 inches in hypovolemic shock Do NOT elevate the lower extremities in cardiogenic shock Why the difference in management?

56 Shock is NOT the same as low pressure A falling blood pressure is a LATE sign of shock!