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

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

3 Cardiovascular System Heart Arteries Veins Capillaries Blood

4 Cardiovascular System 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

5 Bleeding Internal External

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

7 Internal Bleeding S/S Think about MOI or NOI! Anxiety, restlessness, irritability Pale, diaphoretic skin Sustained tachycardia Hypotension Unstable vitals signs (postural changes)

8 Internal Bleeding S/S Vomiting bright red blood or coffee ground material Bleeding form any body orifice Dark, tarry stools (melena) Tender, rigid, or distended abdomen Pain, discoloration, swelling, tenderness at injury site

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

10 External Bleeding Arterial Bleed –Bright red, spurting Venous Bleed –Dark red, steady flow Capillary Bleed –Dark red, oozing

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

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

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

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

15 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

16 Epistaxis (Nosebleed) Causes –Fractured skull –Facial injuries –Sinusitis, other URIs –High BP –Clotting disorders –Digital insertion (nose picking)

17 Management of Epistaxis Sit up, lean forward Pinch nostrils together Keep in sitting position Keep quiet Apply ice over nose (15 min) Can result in life-threatening blood loss!

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

19 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

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

21 Stages of Shock Compensated Shock Decompensated Shock Irreversible Shock

22 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

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

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

25 Shock: Etiology

26 Psychogenic Hypovolemic Distributive Obstructive Cardiogenic Respiratory Neurogenic

27 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

28 Psychogenic Shock S/S Anxiety, restlessness, irritability Rapid pulse Normal or low blood pressure Hyperventialtion

29 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

30 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

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

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

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

34 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

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

36 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

37 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

38 Cardiogenic Shock S/S 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.

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

40 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

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

42 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

43 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

44 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

45 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?

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