1. Shock and Bleeding in the Trauma Patient
April Morgenroth RN, MN

2. Shock: Hypoperfusion
Hypoperfusion: A state where the body’s organs are not sufficiently perfused with oxygenated blood.

3. Nursing Priorities
Establish “Rapid Dominance “ over states of hypoperfusion by:
Early recognition
Aggressive treatment
Prevention of progressive and decompensated stages of shock

4. Recognizing Shock Types of Shock: Distributive: Neurogenic Septic
Anaphylactic
Cardiogenic:
MI, Cardiomyopathy, tamponade
Hypovolemic:
Relative vs. Absolute

5. Key Points
Remember: Hypoperfusion= oxygenated blood not getting where it needs to go
Blood is driven by pressures
Pressure = amount of stuff in a given space

6. Distributive Shock Insult Vasodilation Same Stuff/ More Space
Hypotension

7. Causes of Distributive Shock
Neurogenic:
Head injuries
Spinal Cord injuries
Pain and drugs
Septic:
UTI
SIRS
Bacteremia
Anaphylactic
Bee stings
Drugs
Foods

8. The Autonomic Nervous System
The autonomic nervous system controls the body’s involuntary functions: digestion, heartbeat, respirations…
Sympathetic Nervous System
Parasympathetic Nervous System
Fight or Flight
Regulate the body’s response to danger or threat:
Vasoconstriction
Rapid Heartbeat
Deep Respirations
Dilated Pupils
Rest and Digest
The body’s resting state allowing metabolism and energy conservation:
Vasodilation
Increased blood flow to the gut
Slower Heartbeat
Lower Blood Pressure
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9. Neurogenic Shock Damage to the brain and spinal cord
Loss of Sympathetic Tone:
Parasympathetic Nervous System is Unopposed
Uncontrolled Vasodilation
Low Blood Pressure
Hypoperfusion: Shock

10. Cytokines released in response to infection
Septic Shock
Cytokines released in response to infection
Vasodilation and increase capillary permeability
Decreased SVR
Decreased Pressure
Decreased Perfusion

11. Anaphylactic Shock Allergen Massive Release of Mast Cells
Systemic Vasodilation
Increased Capillary Permeability
Edema
Hypotension

12. Hypovolemic Shock Relative: Internal fluid shift
Hypovolemic Shock= Decreased amount of fluid in the vascular space
Absolute: external fluid loss
Hemorrhage
Burns
Dieresis
Relative: Internal fluid shift
Internal bleeding
Blood pooling

13. Hypovolemic Shock Decreased fluid in circulation
Decreased preload in the heart
Decreased stroke volume
Decreased cardiac output

14. Hypovolemia: The Body’s Response
Mechanism
Response
Clinical Picture
Decreased fluid in circulation
Vasoconstriction
Shunting of blood from the periphery, gut, kidneys, and liver to the vital organs
The body will release hormones to hold water
Cool, clammy, pale extremities, nausea, vomiting, decreased urine output.
Prolonged hypoperfusion: Increase in BUN Creatinine
Possible kidney failure .
Decreased preload in the heart
Increased heart rate
Tachycardia
Arrhythmias
Decreased Stoke Volume
Cardiac output= stroke volume x heart rate
Narrowed pulse pressure: systolic and diastolic pressures begin to equalize
Decreased Cardiac Output
Delayed capillary refill, hypoperfusion
The Body will always strive to work toward a state of homeostasis, as steady state of balance.

15. Respiratory Response Bleeding = Less red blood cells =
Less oxygen carrying capacity
CO2
Patient becomes short of breath and tachypnic
Patient hyperventilates and blows off excessive carbon dioxide causing respiratory alkalosis

16. Compensated Shock In compensated:
Body’s compensatory mechanisms temporarily maintain a steady state.
Vital organs perfused.
Blood pressure stable.
Blood is shunted from the periphery.
Sympathetic nervous system is activated.
You may start to see the following early signs.
Anxious
Tachypnea
Blood pressure may be normal or somewhat low
Tachycardia/rapid pulse
Extremities may be cool and pale under the nail beds.

17. Clinical Manifestations of Progressive Shock
Confusion, listlessness, apathy
decreased response to painful stimuli
Tachycardia
Beta blockers may blunt
Weak or absent peripheral pulses
Hypotension (SBP < 90) & falling
> 25% decrease in hypertensive pt
May need to use doppler or Arterial line
Resp rapid & shallow
Low urine output
Thirst
Skin cool & clammy, dusky, slow capillary refill

18. Decompensated Shock Slow deep respirations
Altered level of consciousness
Decompensated Shock:
Body exhausts reserves
Damage is not reversible
Patient will eventually die.
Pulse pressure narrows
Blood pressure continues to fall
arrhythmias
Cold extremities
Cyanosis

19. Metabolic Response
As the body continues to fight against the altered state it begins to go into anaerobic metabolism
This causes a build of lactic acid eventually leading to a metabolic acidosis O2
Metabolic acidosis and respiratory alkalosis can exist concurrently to some degree compensating for one another resulting in a relatively normal pH.

20. Assessment for Shock Recent history of event putting pt at risk
Recent history of event putting pt at risk
Assess for clinical manifestations
General appearance & skin
LOC & orientation
Vitals
Urine output
Foley if at risk, or evidence of shock
Bleeding (external or internal) or fluid loss
Signs of cardiac dysfunction
Hemodynamic parameters
ABGs & oxygen saturation

21. Aggressive Treatment
Always begin with ABCs: airway, breathing, circulation
Airway: establish and maintain the airway
Breathing: be prepared to support breathing with supplemental O2, manual ventilation may be needed
Circulation: be prepared for massive fluid resuscitation and make plans for circulatory support

22. Basic Treatment Intervention Rational Raise the feet
Dumps blood to vital organs of the body by gravity
Supplemental
Oxygen
Maximizes oxygenation of red blood cells
Indentify and remove cause (if possible)
Stop the bleeding, treat the infection etc…
Removing the mechanism prevents worsening of symptoms and is vital in recovering the patient.
Two large bore IVs
Provide access for medication administration and fluid replacement therapy
Check Electrolytes and Hematocrit
Loss of body fluids plus the body’s altered state can cause dangerous electrolyte imbalances. A patients hematocrit can drop quickly in the presence of heavy bleeding.
Protect from hypothermia
In an altered state, thermoregulation is affected

23. Fluid Resuscitation More Stuff in the SpaceB L
OOD O S T =
Three liters of normal saline replaces 1 liter of blood lost for intravascular volume to come out even.
Fluid shifts and much of it is displaced into the surrounding tissues

24. Hypertonic Solutions: higher salt concentrations
Fluid
Effect
Drawbacks
Hypertonic Solutions: higher salt concentrations
Remain in the intravascular space
Rapid fluid volume expansion
(salt sucks)
Watch for hypernutremia (seizures and confusion)
Blood Products
Replace fluid volume
Increase oxygen carrying capacity
severe bleeding may require blood
Availability, possibility for transfusion reaction
Colloids
Albumin
Large molecules remain in inctravascular space
Increase osmotic pressure
(protein sucks)
Availability and expense
Lactated Ringers
Replacement of fluid volume and some electrolytes
Compromised liver can’t metabolize lactic acid into bicarbonate and lactic acid may build up
Normal Saline
Replaces fluid volume
Generally more available
Caution in patients who have high sodium

25. Fluid Resuscitation Obtain I.V. access
Two Large Bore I.V.s
18 gauge or larger
Choose a large vein LR
Choose the most appropriate I.V. fluid for the situation

26. Fluid Resuscitation Infusion Rates
In severe cases of hypovolemic shock, fluids may initially need to be run wide open as fast as possible.
Assess the patient frequently and document their response to interventions
Heart rate
Blood Pressure
Normalize
Respiratory Rate
Skin Temperature
Once the patient becomes more stable the infusion rate may be slowed.

27. Fluid Volume Overload
Fluid volume overload can result from rapid aggressive fluid resuscitation.
Keep Track of :
Vital signs
Intake and Output
Weight gain or loss
Look for:
Pitting edema
Increased respiratory rate
Orthopnea
Wet sounding lungs
Pink frothy sputum
Massive weight gain
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If you see signs and symptoms of fluid overload you may need to slow infusion rate and/or stop fluids if the patient is stable enough. The patient may need careful dieresis once stable.

28. Circulatory Support Space/Vasoconstriction
Medications:
Vasopressors:
Dopamine
Norepinepherine/ Levophed
Vasopressin
Considerations:
Use of these meds requires intense monitoring and titration.
Monitor: EKG, BP, HR, RR, O2, hemodynamics, peripheral pulses.
Prolonged use at higher doses can cause peripheral tissue damage related to ischemia.

29. Aggressive Care Constant Assessment: Indentify the cause!
Notice signs and symptoms early
Aggressive Treatment:
Treat the cause effectively
Support the body systems

30. Hemorrhage Control

31. Direct Pressure
Application of direct pressure to a open wound helps to control bleeding and can help to speed the body’s natural process of clot formation.
Use sterile or clean dressing to apply direct pressure over the bleeding wound.
Be careful with wounds to the chest and neck, too much pressure can impair breathing.

32. Pressure Dressings Place sterile dressing directly over the wound.
Stack bulky dressings on top.
Wrap a gauze dressing snuggly around the wound.
Tie the rolled gauze with the knot directly over padding previously placed over the wound.
If gauze becomes soaked add more on top.
Reassess:
Sensory, motor, circulatory function distal to the wound

33. Use of the Tourniquet
Tournquets should only be used with other method of hemorrhage control have failed.
Attempt to control bleeding with direct pressure, and pressure dressing before using a tourniquet.
Wrap the wound snuggly
Pile dressings over the wrap
Wrap the ends around a stick
Use the stick to twist the tourniquet tighter until bleeding is controlled
Wrap wound again leaving two long ends.

34. Inappropriate use of a tourniquet can be very dangerous!
Use of the Tourniquet
Inappropriate use of a tourniquet can be very dangerous! .
Tie a knot to secure the stick in place
Be sure to label with date and time of application
Reassess the patient frequently and document your findings

35. Emergency: Pt may need surgery, call doctor immediately
Internal Bleeding
Internal bleeding: bleeding out of vessels into tissue.
Early Recognition + Early Intervention = Better Outcome
Mechanism of injury: crushing injury, impact, blows to the head, chest, abdomen, car vs. pedestrian accident
Signs:
Hematoma
Edema
Area under the skin may be firm
Pain
Signs of shock
Vomiting or coughing up blood
Pain directly over an organ
Emergency: Pt may need surgery, call doctor immediately
Patients with internal bleeding can die very quickly if they are not treated immediately!