Hamburg High School EMT Program 4/22/2017 Shock and Bleeding Hamburg High School EMT Program Temple College EMSP

Circulatory System Anatomy Heart Arteries Capillary Veins Muscular organ, size of your fist, located in the center of the thoracic cavity Arteries Carry blood rich in oxygen – all arteries carry blood away from the heart Capillary Place where exchange of oxygen and carbon dioxide take place Veins Carry blood high in carbon dioxide – all veins carry blood back to the heart

Function of the Blood Transportation of Gases Nutrition Excretion Carries oxygen from lungs to body cells, carries carbon dioxide back to lungs to be exhaled Nutrition Circulates nutrients from tissue to other body cells Excretion Carries waste products from cells to organs, such as the kidneys

Function of the Blood Protection Regulation Carries antibodies and WBC’s, which help fight disease and infection Regulation Blood carries substances that control the functions of the body, such as hormones, water, salt, enzymes, and chemicals Blood also helps regulate body temperature by carrying body heat to the lungs and skin

The average amount of blood found in a: Male: 5 – 6 Liters Female: 4 – 5 Liters

Composition of Blood Plasma Red Blood Cells Water, salty fluid that makes up over half the volume of the blood. (56% of the bloods volume) Red & white blood cells and platelets are carried in plasma Red Blood Cells RBC’s, erythrocytes, or red corpuscles. Carry oxygen to tissues and carbon dioxide away. Gives blood its red color

Composition of Blood White Blood Cells Platelets WBC’s or leukocytes Involved in destroying micro-organisms (germs) and produce antibodies that help the body resist infection Platelets Helps the blood to clot; when fragments are activated they release chemical factors Solid part of blood

Perfusion Circulation of blood through an organ Perfusion supplies oxygen and other nutrients to the cells of all organ systems and the removal of waste products

Hypoperfusion (SHOCK) Inadequate circulation of blood through an organ

Types of Bleeding Arterial Bleed Venous Bleed Capillary Bleed Bright red Spurting Venous Bleed Dark red/maroon Steady flow Easier to control Capillary Bleed Dark red Oozing Often clots spontaneously

Severity of Bleeding Considered severe when loss equals: One liter (1000 cc) in an adult ½ liter (500 cc) in a child 100-200 cc in an infant Uncontrolled bleeding or significant blood loss leads to shock (hypoperfusion) and possibly death

Severity of Blood Loss Determined by: General impression of the amount of blood loss Signs or symptoms of hypoperfusion If the patient exhibits signs and symptoms of shock (hypoperfusion), the bleeding is to be considered serious

Control of External Bleeding PPE for BSI Maintain Airway Administer Oxygen 1. Direct Pressure gloved hand dressing/bandage 2. Elevation 3. Tourniquet CONSIDER: Arterial pressure points Upper extremity: Brachial Lower extremity: Femoral

Other Methods to Control Bleeding Splints Air splints

Tourniquet Application can cause permanent damage to nerves, muscle, and blood vessels resulting in loss of the extremity Used for amputations 3-4” wide & 6-8 layers deep Wrap around extremity twice at a point above bleeding as close to the wound as possible Tie one knot in the bandage and place a stick or rod on top of the knot and tie it Twist the stick until the bleeding stops Once the bleeding has stopped secure in place

Tourniquet Blood pressure cuff may be used as a tourniquet until bleeding stops Write “TK” and time of application on forehead of patient Notify other personnel Do not loosen or remove until definitive care is available Do not use wire, rope, or any material that may cut into the skin Do not cover with sheets, blankets, etc. Do not apply over a joint, but as close to the injury as possible

Bleeding from the Nose, Ears, and Mouth Possible causes Skull fracture Simple nose bleed – epistaxis Facial trauma

Skull Fracture May cause loss of blood or clear fluid (cerebrospinal fluid) from the nose and ears. Check for Halo Effect Do not stop the flow of fluid – collect in a loose dressing

Epistaxis Causes Fractured skull Facial injuries Sinusitis, other URIs High BP Clotting disorders Digital trauma (nose picking)

Epistaxis Nosebleed Management Sit up, lean forward Pinch the fleshy portion of the nostrils together Keep in sitting position Keep patient calm and quiet Apply ice over nose 15 min adequate

Epistaxis can result in life-threatening blood loss

Internal Bleeding 1. Can result in severe blood loss which can lead to shock and subsequent death 2. Injured or damaged internal organs are a common cause of extensive bleeding that is concealed 3. Painful, swollen, deformed extremities (fractures) may lead to serious internal blood loss 4. Suspicion and severity of internal bleeding should be based on mechanism of injury and clinical signs and symptoms

Internal Bleeding Mechanism of Injury Blunt trauma Falls 4/22/2017 Internal Bleeding Mechanism of Injury Blunt trauma Falls Motorcycle Crashes Pedestrian Impacts Automobile Collision Blast Injuries Look for evidence of contusions, abrasions, deformities, impact marks and swelling Temple College EMSP

Internal Bleeding Mechanism of Injury Penetrating Trauma Pain, tenderness, swelling or discoloration at site of injury Bleeding from mouth, rectum, vagina or other orifice Vomiting of bright red blood or dark coffee-ground-colored emesis Dark, tarry stools or stools with bright red blood Tender, rigid abdomen S/S of shock

Internal Bleeding Management BSI Open airway High concentration oxygen 4/22/2017 Internal Bleeding Management BSI Open airway High concentration oxygen Assist ventilations Control external bleeding with direct pressure Stabilize fractures Transport rapidly to appropriate facility Temple College EMSP

Abdominal Evisceration Penetrating Trauma

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

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

How can perfusion fail, thus causing shock? Heart fails as a pump Blood vessels dilate Loss of Volume

3 Types of Shock and Their Causes Hypovolemic Shock Cardiogenic Shock Distributive Shock

1. Hypovolemic Shock A type of shock that is the result of low blood volume

A. Hemorrhagic Shock Shock most often seen by EMT’s The natural response to bleeding is blood vessel constriction and clotting. Uncontrolled or significant bleeding can lead to shock and possibly death Loss of volume

A. Hemorrhagic Shock Signs and Symptoms AMS, restlessness, anxiety Increased respiratory rate Weak, rapid pulse Pale, moist/clammy, cool skin Nausea, vomiting Thirst Falling blood pressure (LATE SIGN) Infants and children maintain their blood pressure until their blood volume is more than half gone, so by the time their blood pressure drops they are close to death

B. Metabolic Shock Form of Hypovolemic shock that is the result of electrolyte or plasma loss and does not involve the loss of whole blood. It can occur due to dehydration or from burns

B. Metabolic Shock Signs and Symptoms Sunken eyes Poor skin turgor or tenting of the skin Recent episodes of vomiting and diarrhea Presence of burns

2. Cardiogenic Shock Result of a massive myocardial infarction Heart is unable to pump effectively and as a result blood begins to back up in the system Heart’s output depends on How often it beats (heart rate) How hard it beats (contractibility)

2. Cardiogenic Shock Signs and Symptoms Emergency care Those symptoms commonly seen during a heart attack Emergency care CPR with AED

3. Distributive Shock Blood vessels suddenly dilate causing the blood pressure to fall

A. Anaphylactic Shock Form of shock caused by a violent systemic reaction to an allergen/toxin Signs and Symptoms Those seen with a severe allergic reaction

B. Neurogenic Shock Spinal cord severed Uncontrolled dilation of the blood vessels and drop in blood pressure Compensatory mechanisms are not activated because nerve impulses cannot be conducted through the spinal cord

C. Septic Shock Caused by a severe bacterial infection Toxins (poisons) released into the bloodstream Vessels dilate and there is a drop in blood pressure Increase in fluid seeping into the tissues from the capillaries Urinary tract infection is a common cause Seldom seen in the field

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

Shock: Signs and Symptoms Anxiety, restlessness, combativeness, or altered mental status Weakness, faintness or dizziness Thirst Shallow rapid breathing Rapid, weak pulse Pale, cool, clammy skin

Shock: Signs and Symptoms Capillary refill >2 seconds (infants and children ONLY) Dropping blood pressure (late sign) Dilated pupils that are sluggish to respond Nausea & vomiting

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!

Severity of Shock Compensated shock (Early) Decompensated shock (Late) Body senses a decrease in perfusion and attempts to compensate Increased heart rate & respirations to increase flow of blood and oxygen Decompensated shock (Late) Body can no longer compensate for low blood volume (late sign is falling B/P)

Severity of Shock Irreversible shock Body has lost the battle to maintain perfusion Cell damage occurs in liver & kidneys. Even if vital signs can be restored patient may die

Emergency Care for Shock Golden Hour From the time the injury occurs, until the patient is in the operating room Platinum Ten Minutes Goal for on-scene time when caring for a trauma patient

Treatment Secure, maintain airway Apply high concentration oxygen Control bleeding (MAST if needed) Splint fractures Prevent loss of body heat

Treatment Elevate lower extremities 8 to 12 inches in hypovolemic shock if no fractures Do NOT elevate the lower extremities in cardiogenic shock Administer nothing by mouth, even if the patient complains of thirst

Anti-Shock Garment MAST – military anti-shock trousers PASG – pneumatic anti-shock garment Purpose: to create artificial vasoconstriction in the lower extremities and the lower abdomen

Indications Systolic B/P of 50 mmhg with signs of shock Systolic B/P of 90 mmhg with a pelvic injury

S/S of Shock Restlessness Cool clammy skin Tachycardia Delayed capillary refill (children & infants)

Absolute Contra-Indications Pulmonary Edema Penetrating Chest Wound

Partial Contra-Indications Pregnancy (legs only) Abdominal injury (evisceration) or impaled object (legs only) Impaled object in leg (abdominal and one leg only)

MAST Use You must remove all undergarments before putting MAST in place Inflate all 3 compartments at one time to 100 to 106 mmhg MAST can only be deflated under Medical Control IVs established Surgical team ready Abdomen then one leg at a time SLOWLY

Never deflate entire suit at once

Adequate Flow = Adequate Perfusion Flow = Perfusion Adequate Flow = Adequate Perfusion Inadequate Flow = Inadequate Perfusion (Hypoperfusion) Hypoperfusion = Shock