Shock and Bleeding

Shock and Bleeding By Kevin O’Loughlin, MICP This Course Has Been Approved for 2.5 Hour of Continuing Education for: First Responders EMT-I Paramedics

Continuing Education To receive continuing education for this course you must complete the post test and evaluation available on the EMS Agency website San Joaquin County EMS- Training / Continuing Education. Submit the completed test and evaluation to the EMS Agency and a CE certificate will be mailed to you. There is no charge for this course.

LEARNING OBJECTIVES Upon completion of this course, you will be able to: Define shock and identify the different types of shock. Discuss the signs, symptoms and treatment for shock. Describe the three types of external bleeding. Discuss the four ways to control bleeding. Properly control bleeding and dress a wound utilizing the Emergency Bandage. Stop bleeding with the SOF Tactical Tourniquet.

Instructor Contact Information If you have questions regarding this course, please contact Kevin O’Loughlin, MICP, EMS Specialist. Phone (209) 468-6818. Email: koloughlin@sjgov.org. A response will be provided within 48 hours.

Routine Medical Care Routine Medical Care is provided to all patients regardless of presenting complaint. Standard precautions: Application of body substance isolation precautions including the use of appropriate personal protective equipment (PPE) shall apply to all patients receiving care, regardless of their diagnosis or presumed infectious status

Routine Medical Care Body substance isolation precautions apply to: Blood; All bodily fluids, secretions, and excretions except sweat, regardless of whether or not they contain visible blood; Non intact skin; and Mucous membranes. Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in the prehospital setting.

Routine Medical Care Patient Assessment: Primary Survey – which includes scene survey and ABC’s Secondary Survey – which includes, history, medications, allergies and a head-to-toe survey. Initiation of appropriate basic life support (BLS) treatment including, when appropriate: Monitoring of vital signs: Initial set. Repeated every 5 – 10 minutes.

Routine Medical Care Hemorrhage control. Initiation of spinal precautions. Administration of oxygen. Hemorrhage control. Ensuring ALS transport response. Initiation of specific treatments in accordance with San Joaquin County EMS Agency Policies and Procedures.

Shock Defined as inadequate perfusion (blood flow) leading to inadequate oxygen delivery to tissues.

Physiology Basic unit of life = cell Cells get energy needed to stay alive by reacting oxygen with fuel (usually glucose) No oxygen, no energy No energy, no life

Cardiovascular System Transports oxygen, fuel to cells Removes carbon dioxide, waste products for elimination from body Cardiovascular system must be able to maintain sufficient flow through capillary beds to meet cell’s oxygen and fuel needs

What is needed to maintain perfusion? Pump = Heart Pipes = Blood Vessels Fluid = Blood

How can Perfusion Fail? Loss of Volume Pump Failure Pipe Failure

Types of Shock and Causes

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

Cardiogenic Shock Causes Acute myocardial infarction Very low heart rates (bradycardias) Very high heart rates (tachycardias)

Neurogenic Shock Spinal cord injured Loss of peripheral resistance Vessels below injury dilate

Hypovolemic Shock Loss of volume Causes Blood loss: trauma Plasma loss: burns Water loss: Vomiting, diarrhea, sweating, increased urine, increased respiratory loss

Psychogenic Shock Simple fainting (syncope) Caused by stress, pain, fright Heart rate slows, vessels dilate Brain becomes hypoperfused Loss of consciousness occurs

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

Anaphylactic Shock Results from severe allergic reaction Body responds to allergen by releasing histamine Histamine causes vessels to dilate and become “leaky”

Shock: Signs and Symptoms Nausea, vomiting Thirst Diminished urine output Dull eyes Restlessness, anxiety Increased pulse rate Decreasing level of consciousness Rapid, shallow respirations

Shock: Signs and Symptoms Hypovolemia will cause Weak, rapid pulse Pale, cool, clammy skin Cardiogenic shock may cause: Weak, rapid pulse or weak, slow pulse Neurogenic shock will cause: Weak, slow pulse Dry, flushed skin Sepsis and anaphylaxis will cause: Weak, rapid pulse

Shock: Signs and Symptoms Patients with anaphylaxis will usually: Develop hives (urticaria) Itch Develop wheezing and difficulty breathing (bronchospasm)

Shock: Signs and Symptoms Shock is NOT the same thing as a low blood pressure! A falling blood pressure is a LATE sign of shock!

Shock: Signs and Symptoms Obscure/less viewed symptoms of shock Drop in end tidal carbon dioxide (ETCO2) level Indicative of respiratory failure resulting in poor oxygenation, therefore, poor perfusion or Shock

Treatment Secure, maintain airway (ABC’s) High concentration oxygen Assist ventilations Control obvious bleeding Stabilize fractures Replace Fluids (paramedics only) Prevent loss of body heat Transport rapidly to appropriate facility

Treatment Elevate lower extremities 8 to 12 inches Treatment in Hypovolemic shock Do NOT elevate the lower extremities in Cardiogenic shock Administer nothing by mouth, even if the patient complains of thirst

Bleeding Severe bleeding or hemorrhage is a major cause of shock (hypoperfusion), which can be life threatening if the body loses an excessive amount of blood. If the body loses enough blood, the cells of the body will not receive enough oxygen and begin to die. Once cells begin to die, bigger cells such as organs will also fail and eventually the entire body will fail and death will occur.

Control of External Bleeding Direct Pressure gloved hand dressing/bandage Elevation Arterial pressure points Tourniquet (last resort)

Three Types Of External Bleeding: Arterial Venous Capillary bleeding

Arterial bleeding Usually bright red in color because it is rich in oxygen. Bleeding from an artery is often profuse and spurting due to the high pressure from the heart as it contracts, forcing blood out to the rest of the body. This is the reason why it is so hard to control and direct pressure will be required all the way to the hospital.

Venous bleeding Usually dark red/maroon in color because it does not contain much oxygen. The red blood cells have already left its oxygen behind with the cells of the body, picked up carbon dioxide and wastes, and are on their way back to the lungs to get rid of them and pick up more oxygen. It is usually easy to control venous bleeding because the veins are under low pressure. The main difficulty with venous bleeding is in the neck because it can actually suck in air and cause further complications.

Capillary bleeding Usually slow and oozing due to their small size and low pressure. Although there may be a significant amount of bleeding, the majority of capillary bleeding is considered to be minor and is easy to control. Capillary bleeding is usually the result of an abrasion. The color of capillary bleeding can be bright red or darker red depending on the amount of oxygen it is carrying. The majority of problems that arise with capillary bleeding is infection due to due to contaminants becoming embedded in the skin.

Care For External Bleeding

Direct Pressure Direct pressure is applied to the injury with sterile gauze. If bleeding is profuse or seeps through the gauze, add more gauze, but do not remove the existing pieces. This will prevent the clotting process from being interrupted

Elevation If bleeding continues to be severe, the extremity or body part should be elevated above the level of the heart. This will decrease the amount of blood flowing to the injury site by using gravity to help decrease the amount of blood flow.

Bleeding Continues If bleeding continues, add more gauze to the existing dressing and tie a pressure bandage to the site of injury.

Pressure Points If direct pressure, elevation, and pressure bandage fail to control bleeding, apply pressure to a pressure point of the injury if it is to an extremity. This will aid in further decreasing the flow of blood to the injury site.

Pressure Points www.armystudyguide.com

Tourniquet A tourniquet should only be applied after all other means have failed to control life threatening blood loss . Tourniquets are to be used in rare circumstances and only by trained EMS personnel. Once applied a tourniquet may only be removed by direct physician order. Application of a tourniquet greatly increases loss of limb below the tourniquet since blood flow is stopped to the area.

OLD VS. NEW Simple one handed application Complicated and takes more than two hands to apply correctly

SOF Tactical Tourniquet Components Windlass Safety Screw Windlass Strap Buckle Tri-Rings Strap

Applying the SOF Tactical Tourniquet 1. Pull Strap until Tourniquet is tight around the injured extremity 2. Twist the aluminum windlass until the bleeding is controlled

Applying the SOF Tactical Tourniquet 3. Secure the windlass in the tri-ring 4. Tighten the safety screw

Applying the SOF Tactical Tourniquet It is not necessary to secure the windlass on both tri-rings. Once secured reassess the limb for bleeding. Document the time the tourniquet was applied on the PCR or START triage tag.

SOF Tactical Tourniquet Training Video To view video click on link below: Note: The first link is required for this course, the second video link provides additional instruction on the use and care of the tourniquet. SOF Tactical Tourniquet Application SOF Tactical Tourniquet Instruction Answers to some exam questions come from this video

Emergency Bandage

Emergency Bandage The Emergency Bandage consolidates numerous treatment equipment into a single unit and provide in one device: Non-adherent pad: Eliminating the risk of causing pain and having the wound re-opened upon removal of the bandage. Pressure Applicator: Creating the immediate direct pressure to the wound site. Secondary Sterile Dressing: Keeping the wound area clean and maintaining the pad and pressure on the wound firmly in place, including immobilization of the injured limb or body part.

Emergency Bandage Closure Bar: Enabling closure and fixation of the Emergency Bandage at any point, on all parts of the body: no pins and clips, no tape, no Velcro, no knots. Quick and easy application and Self-application. Designed with the end-user in mind; for the first-aid trained and the lay care-giver. Significant per treatment time and cost savings.

Emergency Bandage The Emergency Bandage has efficient blood staunching capability and offers ease of operation: The application of immediate direct pressure to the wound site is achieved by wrapping the elasticized woven leader over the topside of the bandage pad where the specially designed pressure bar is situated. The pressure bar is designed to readily accept and hold the wrapping leader.

Emergency Bandage After engagement of the pressure bar, wrapping the leader in any direction around the limb or body part and onto the pressure bar forces the pressure bar down onto the pad creating the direct pressure needed to bring about homeostasis. The sterile, non-adherent pad is placed on the wound.

Emergency Bandage In addition to its primary function, the pressure bar also facilitates bandaging. The elastic bandage uses the rigid shape of the pressure bar to change direction while bandaging, thus affording the caregiver more options for effective dressing of the wound. Subsequent wrappings of the leader secures and maintains the pad in place over the wound, and by covering all the edges of the pad acts as a sterile secondary dressing. The bandage leader is woven to remain at its full width and will not bunch up or twist itself into a rope.

Emergency Bandage The closure system of the bandage is multi-functional yet simple, quick, and familiar. Situated at the end of the leader is a closure bar (dowel with hooking clips) at each end to secure the wrapping leader the same way that a pen is secured in a shirt pocket. The closure bar holds the bandage securely in place over the wound site.

Emergency Bandage If additional pressure is required the closure bar is easily removed from its first closure position and inserted between previous layers of the leader directly above the protruding pressure bar and rotated. This rotation of the closure bar acts to further press down the pressure bar onto the wound to exert blood-staunching pressure. The closure bar is used as before to secure the dressing.

Emergency Bandage Training Video To view video click on link below: Emergency Bandage Application Answers to some exam questions come from this video.

Post Test and Course Evaluation To complete the post test and evaluation, please click on the following links: Examination for Shock and Bleeding Online Continuing Education Course Evaluation Once you have completed both, please mail to: San Joaquin County EMS Agency, PO Box 220, French Camp, CA 95231 or it can be faxed to 209-468-6725