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Bleeding and Shock
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Blood loss Body blood volume 9 lb newborn 12 oz coke can 60 lb child 2 liter bottle 125 lb adult liter bottles
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Circulatory System Responsible for distribution of blood to all parts of the body Heart Arteries Capillaries Veins Perfusion Hypoperfusion Functions of the blood
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Heart Muscular organ that pumps blood, which supply oxygen and nutrients to the cells of the body Arteries Carry oxygen-rich blood away from the heart Capillaries Oxygen-rich blood is emptied from arteries into microscopically small capillaries, which supply every cell of the body
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Veins Carry blood that has been depleted of oxygen and loaded with CO2 and wastes from capillaries Perfusion Adequate blood throughout, which fills the capillaries and supplies the cells and tissues with oxygen and nutrients
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Hypoperfusion aka shock
Inadequate perfusion of the body’s tissues with oxygen and nutrients Functions of the blood Transportation of gases Nutrition Excretion Protection Regulation
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Bleeding Hemorrhage Severe bleeding is a major cause of shock
During S A M P L E ask if on blood thinners i.e. coumadin, Plavix
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External Bleeding Use standard precautions Classifications Arterial bleeding Venous bleeding Capillary
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Severity of external bleeding
Physical size of the patient Natural response constriction of vessels and clotting restrictive clothing
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Care ABCs Standard precautions Assess circulation radial pulse skin color temperature and condition
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Control ; methods Direct pressure Elevation Pressure points Splinting *sharp ends of broken bones may cause tissue and vascular injury *Stabilizing may prevent further injury
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Cold packs PASG Tourniquet Blood pressure cuff Provide O2
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STAGES OF HEMORRHAGE CONTROLLED VS UNCONTROLLED Stage 1 – controlled Up to 15% intravascular loss Compensated by constriction of the vascular bed ( blood vessels of…..) Blood pressure maintained
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Normal pulse pressure change in blood pressure seen during contraction of the heart Normal respiratory rate Normal renal output Pallor of the skin Central venous pressure normal to low
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Central Venous Pressure:
reflects the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system. measured by connecting the patient's central venous catheter to a special infusion set which is connected to a small diameter water column. If the water column is calibrated properly the height of the column indicates the CVP.
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STAGE 2 15 – 25% intravascular loss Intravascular loss: loss of blood volume; volume of blood plasma Cardiac output cannot be maintained by arteriolar constriction
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Reflex tachycardia: heart beats faster in order to raise b/p.
Increased respiratory rate Blood pressure maintained Catecholamines (epinephrine) increase peripheral resistance
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Peripheral Resistance:
Vascular resistance is a term used to define the resistance to flow that must be overcome to push blood through the circulatory system.
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Increased diastolic pressure
Narrow pulse pressure Diaphoresis from sympathetic stimulation Renal output almost normal
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STAGE 3 – uncontrolled 25 – 35% intravascular loss Classic signs of hypovelemic shock Marked tachycardia Marked tachypnea Decreased systolic pressure 5 – 15 ml/hr urine output AMS Diaphoresis with cool, pale skin
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STAGE 4 Loss >35% Extreme tachycardia Pronounced tachypnea Significantly decreased systolic b/p Confusion and letargy Skin is diaphoretic, cool, and extremely pale
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ASSESSMENT Bright red blood from wound, mouth, rectum, or other orifice Coffee ground emesis Melena; black tarry stool Hematochzia; Maroon colored stool Dizziness
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Dizziness or syncope on sitting or standing
Orthostatic hypotension Orthostatic hypotension: a form of hypotension in which a person's blood pressure suddenly falls when the person stands up. The decrease is typically greater than 20/10 mmHg
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Signs and symptoms of hypovelemic shock
MANAGEMENT ABCs Bleeding from nose or ears after head trauma: Refrain from applying pressure Apply loose sterile dressing to protect against infection
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Bleeding from other areas
Control bleeding Direct pressure Elevation if appropriate Pressure points Tourniquet Splinting Apply sterile dressing and pressure dressing
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Transport considerations
Psychological support/communication
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PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT OF SHOCK
Epidemiology: cause, factors morbidity / mortality Prevention strategies Pathophysiology: any disturbances of body functions
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Perfusion Depends on cardiac output, systemic vascular resistance and transport of oxygen Cardiac output = HR x SV Stroke Volume: amount of blood ejected in one cardiac contraction
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BP = CO x SVR SVR:
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Hypoperfusion can result from:
inadequate CO Excessive systemic vascular resistance Inability of RBCs to deliver O2 to cells
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Compensation for decreased perfusion
Baroreceptors sense decreased flow and activate vasomotor center Baroreceptors: sensors located in the blood vessels detects the pressure of blood flowing through them, and can send messages to the central nervous system to increase or decrease total peripheral resistance and cardiac output
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Vasomotor center: a portion of the medulla oblongata that regulates blood pressure Normally stimulated between mmHg systolic (lower in children) Located in carotid sinuses and aortic arch
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Decrease in systolic pressure less that 80 mmHg stimulates vasomotor center to increase arterial pressure Chemoreceptors are stimulated by decrease in PaO2 and increase in PaCO2
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Chemoreceptors: Chemoreceptors in the medulla oblongata, carotid arteries and aortic arch, detect the levels of carbon dioxide in the blood, in the same way as applicable in the Breathing Rate section. In response to this high concentration, a nervous impulse is sent to the cardiovascular centre in the medulla, which will then feedback to the sympathetic ganglia, increasing nervous impulses here, and prompting the sinoatrial node to stimulate more contractions of the myogenic cardiac muscle, increasing heart rate by causing the secretion of nor-adrenaline directly on to the sinoatrial node.
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Failure of compensation to preserve perfusion
Preload (pressure within the ventricles during diastole ; influences the force of the next contraction) decreases Cardiac output decreases Myocardial blood supply and oxygenation decrease
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Myocardial perfusion decreases
Cardiac output decreases further Coronary artery perfusion decreases Myocardial ischemia
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Capillary and cellular changes – ischemia – minimal blood flow to capillaries
STAGES OF SHOCK Compensated or nonprogressive Characterized by signs and symptoms of early shock Arterial b/p normal or high Treatment will typically result in recovery
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DECOMPENSATED OR PROGRESSIVE
Characterized by signs and symptoms of late shock Arterial blood pressure is abnormally low Treatment sometimes result in recovery
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IRREVERSIBLE Characterized by signs and symptoms of late shock Arterial blood pressure is abnormally low Even aggressive treatment does not always result in recovery
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Hypovelemic Hemorrhage Plasma loss Fluid and electrolyte loss Shock may be the result of hidden volume loss chest injury abdominal injury other violent injury
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Treatment Focus primarily on volume replacement ASSESSMENT Early or compensated Tachycardia Pale, cool skin diaphoresis
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LOC Normal Anxious or apprehensive B/P maintained Narrow pulse pressure systolic – diastolic reflects tone of the arterial system
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Positive orthostatic tilt test
lie, sit, stand Dry mucosa Complaints of thirst Weakness Possible delay of capillary refill
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LATE OR PROGRESSIVE DECOMPENSATED / UNCOMPENSATED Extreme tachycardia Extreme pale, cool skin Diaphoresis Significant decrease in LOC Hypotension Dry mucosa Nausea
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Cyanosis with white waxy-looking skin
IRREVERSIBLE Becomes bradycardic Profound hypotension B/P continues to fall in spite of interventions
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Management ABCs Hemorrhage control Intravenous volume expanders Types isotonic hypertonic synthetic Rate of administration
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External hemorrhage that can be controlled
External hemorrhage that cannot be controlled Internal hemorrhage blunt trauma penetrating trauma Volume needed for replacement
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Transport considerations
indications for rapid transport indications for transport to a trauma center considerations for air medical transportation
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Special situations involving bleeding
Head injury Do not apply pressure to ears and nose but allow drainage to flow freely Nosebleed Have pt. sit and lean forward Direct pressure Keep calm and quiet Do not let pt. lean back If pt. is uncomfortable; recovery position, prepare to suction and manage airway
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Internal Bleeding Perform a through history and exam Mechanism of blunt trauma that may cause internal bleeding Falls MVA or motorcycle crashes Auto-pedestrian collisions Blast injuries
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Penetrating injuries Gunshot wounds Stab wounds Impaled objects Signs Injuries to the surface of the body indicative of underlying injuries Bruising, swelling, or pain over vital organs
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Painful, swollen, or deformed extremities
Bleeding from mouth, rectum, vagina or other orifice Vomiting; coffee-ground, bright red Dark, tarry stools or bright red blood in stools Signs and symptoms of shock
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Care ABCs O2 Control external bleeding Rapid transport
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Shock Inadequate tissue perfusion Failure of Pumping of the heart
Supply of blood Integrity of blood vessels ability to dilate or constrict
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Types of shock C A N S H R I M P Severity of shock Compensated Decompensated Irreversible
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Stages Stage 1: Initial Stage of Shock The first of the stages of shock is reversible, but there aren't any signs to indicate shock at this stage. Cells begin to change due to issues with perfusion and oxygenation. Perfusion is the method used by veins to deliver blood to capillary beds in body tissues. Without this nutritive blood and an adequate oxygen supply, the cells switch to anaerobic metabolism, producing pyruvic and lactic acid.
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Stage 2: Compensatory Stage of Shock
During the compensatory stage of shock, the body tries to reverse the results of the initial stage. Physiological, neural, hormonal, and biochemical reactions are employed to correct the imbalances. Hyperventilation is one such mechanism. This causes an increased rate of breathing which, in turn, may help to get more oxygen flowing to the cells and neutralize the newly acidic conditions. Another mechanism is the catecholamine response. Hypotension, or low blood pressure, due to the reduced volume of blood flow triggers this response. Catecholamines are hormones released by the adrenal glands. These hormones increase heart rate and attempt to increase blood pressure.
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Compensated Shock Increased pulse rate Decreased pulse strength Cool, clammy skin Progressing anxiety, restlessness, combativeness Thirst, weakness, eventual air hunger
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Stage 3: Progressive Stage of Shock
Decompensated If the stages of shock progress to the third stage before the initial cause is corrected, damages become more severe and can be irreversible. Cellular function continues to deteriorate, anaerobic metabolism leads to increased metabolic acidosis, and the compensatory mechanisms can no longer maintain the balance required to protect the organs.
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Decompensated shock Pulse becomes unpalpable B/P drops precipitously Patient becomes unconscious Respirations slow or cease
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Stage 4: Refractory Stage of Shock
Irreversible The stages of shock will eventually lead to the refractory stage if the cause of shock cannot be fixed. At this stage, the organs completely fail and lead to death. It is important to understand the stages of shock in order to recognize and prevent the progression to this final stage.
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Irreversible shock Irreversible cell damage Cell death Tissue dysfunction Organ dysfunction Patient dies
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Signs and Symptoms of shock
AMS Pale, cool, clammy skin Nausea and vomiting VS changes Pulse; Increased Respirations; Rapid, labored, shallow B/P; Drops {late sign}
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Thirst Dilated pupils Sometimes cyanosis Pediatric compensation
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Care Airway and O2 Transportation Clock starts at time of injury Limit on-scene time On Scene ABCs with spinal precautions Rapid trauma exam Immobilization Moving the Pt. to ambulance
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VS Trending q 5 minutes Control any external bleeding Splint any suspected bone or joint injuries Maintain body heat Rapid transport Detailed PE
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Notify hospital ASAP Notify medical direction if necessary Request ALS If conscious speak calmly, reassuringly
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