1. Bleeding and Shock
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2. Blood and it’s function
Transports gases-brings oxygen to the cells and takes carbon dioxide back to the lungs
Transports nutrients and waste products
Protection-carries antibodies and WBC’s
Regulation-transports regulatory hormones, chemicals, etc

3. Blood Vessels Arteries Capillaries Veins Thick muscular walls
Maintains high pressures
Carries oxygen from lungs
Capillaries
Thin walls
Location of oxygen exchange between blood and cells
Veins
Lower pressure than arteries
Bring carbon dioxide back to the lungs
Have one way valves

4. Blood Volumes Blood volumes Serious blood loss Average of 4.5-5 Liters
Average adult male-7% total body weight
Average adult female-6.5% total body weight
Serious blood loss
Adult-rapid loss of 1 Liter can be serious
Child-500 cc
Infant-150 cc

5. Types of Shock
Hypovolemic-decreased circulating volume caused by bleeding, dehydration, burns, etc
Cardiogenic-inadequate pumping due to mechanical problems (MI, valve disease, contusion), electrical problems (irregular heartbeat, dysrhythmia) or congestive heart failure
Anaphylactic-massive histamine response from exposure to antigen causing arterioles and capillaries to dilate and intravascular fluid to leak out

6. Types of Shock (cont..)
Septic-toxins from severe bacterial infection alters permeability of the vessels causing third spacing
Neurogenic-uncontrolled dilation of the vessels caused by a spinal cord injury
Remember: Shock can be related to a leaky tank (hypovolemic), a bad pump (cardiogenic), a change in the piping (neurogenic), or additives that can affect many things (septic or anaphylaxis).

7. The Stages of Shock Compensated Uncompensated Irreversible
The body is able to “compensate” for the decrease in perfusion
Uncompensated
Compensation mechanisms are starting to fail
Irreversible
Cell, tissue, and organ death begin due to lack of perfusion

8. Compensated Shock
Cardiac output and systolic blood pressure are maintained
Signs and Symptoms
Mental Status-anxiety, restlessness, combativeness
Vital Signs- slightly increased respirations and pulse, slightly delayed cap refill, cool skin

9. Uncompensated Shock
Blood pressure begins to decrease and patient condition worsens
Signs and Symptoms
Mental Status-lethargy, confusion, unconsciousness
Vital Signs-decreased blood pressure, increased heart rate and respirations, delayed cap refill, pale, cold and clammy skin, narrowing pulse pressures, cyanosis, weak and thready pulse

10. Irreversible Shock
Cell ischemia and death occur leading to organ death
May begin from one day up to three weeks after the initial event
If patient reaches this stage, they will most likely die
Signs and Symptoms
Mental Status-unconscious, coma
Vital Signs-bradycardia, profound and severe hypotension, dysrhythmias

11. Internal Bleeding Internal Bleeding
Gastrointestinal-could have many causes
coffee ground or bright red emesis
dark, tarry or bright red stool
Trauma-blunt or penetrating
bruising over the abdomen or chest
swollen and painful extremities
2 units of blood can be contained in the lower leg
4 units of blood can be contained in the femur area
closed head injuries won’t cause hypovolemia

12. External Bleeding
Arterial-profuse amounts of bright red blood often spurting with the pulse
can cause hypovolemia if not treated immediately
Venous-steady flow of dark red or maroon colored blood, can be profuse
can cause hypovolemia if left untreated
Capillary-slow, small amount of reddish blood that oozes from the wound
usually stops on own with minimal blood loss

13. Controlling Bleeding to the Extremity
1. Direct pressure.
2. Elevation.
3. Pressure bandage.

14. If that doesn’t work...
4. Pressure point.
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15. Special Considerations
Nosebleed
Have patient sit upright and leaning forward slightly
Pinch as much of the nose as possible and hold for 5-10 minutes
Vaginal bleeding
Do not hold direct pressure or pack
Use OB pad or towel externally
Mouth injuries
Do not hold pressure
Suction as needed
Head injuries
Head wounds tend to bleed profusely
Do not press hard if crepitus is present or area is mushy
If bleeding from nose or ears related to HI, loosely place gauze externally to absorb blood

16. Treating Hypovolemic Shock
Apply high flow oxygen
Red blood cells account for 45% of the the blood and carry 99% of the oxygen
Control external bleeding
Apply MAST if indicated
TEMS protocol-MAST can be inflated in the presence of a pelvic fracture and/or bilateral femur fractures with signs of shock (including a systolic BP less than 80 mmHg) at all levels

17. Treating Hypovolemic Shock (cont..)
Elevate the lower extremities 8-12 inches
Do not elevate in presence of head, spine, chest, abdominal or lower extremity injuries
Maintain body temperature
Provide rapid transport
And of course, IV therapy

18. IV Therapy and Shock Two large bore
16-18 gauge
Lactated Ringers and/or Normal Saline
Bleeding is controlled-external bleeding
250 cc bolus and reassess (BP and lung sounds)
Maintain BP>90 mmHg and/or pulse <120
Suspected uncontrolled bleeding-internal
IV fluids to maintain systolic BP at mmHg
Head injury
Maintain Systolic BP of 110 if GCS <8
Burns
Carefully monitor and document IV fluids

19. Minimum Systolic Blood Pressures
<10 kg (22 lbs) = 50 mmHg
10-20 kg (25-44 lbs) = 70 mmHg
20+ kg (44+ lbs) = 90 mmHg

20. In Closing...
Patients with signs and symptoms of shock must be rapidly transported to the hospital for definitive care.
Do not delay transport for IV access!

21. References Mosby’s Paramedic Textbook by M. J. Sanders, 1994
Mosby-Year Book Inc., St Louis
Brady Emergency Care 8th edition by M. F. O’ Keefe et al, 1998
Brady/Prentice Hall, New Jersey
Tidewater EMS Council Inc, Regional Medical Protocols, 2001