1. Bleeding and Volume Replacement Therapy J. Málek

2. Casualty treatment call for medical help vital functions control of major external bleeding general examination prevention of secondary injuries detailed examination

3. Blood in adults 40-50 ml/kg, in children 50-60 ml/kg oxygen and CO2 transport water and mineral balance transport of metabolites transport of hormones immunity

4. Blood red cells white cells thrombocytes plasma

5. Bleeding arterial, venous, capillary, mixed minor, major localisation normal, abnormal

6. Bleeding external internal from body orifices mixed

7. Minor bleeding clean with water apply antiseptic around the wound apply sterile dressing mind signs of infection –purulent –tetanus

11. Major external bleeding lay the victim down to supine position compress and elevate the bleeding site (if possible) –pressure dressing –manual compression –pressure points –tourniquet do not try to clean a large wound (remove only obvious debris) never remove a foreign body

16. Internal bleeding pain signs of injury signs of shock

17. Internal bleeding positioning call for emergency nothing to eat or drink, no oral medication

19. Bleeding from body orifices mouth nose ear haemoptoea vomiting of blood rectal bleeding/melaena vaginal bleeding

21. Volume replacement therapy crystalloid solutions colloids solutions –volume substituents –volume expanders blood

22. Crystalloid solutions advantages no allergic reactions easily available low effect on blood coagulation easily mobilised disadvantages move quickly from blood vessels no transport capacity for oxygen

23. Colloid solutions dextrans gelatine starch

24. Colloid solutions advantages stay longer in blood vessels rapid volume replacement (molecular weight dependent) easily available disadvantages allergic reaction possible various effect on blood coagulation difficulty in mobilisation no transport capacity for oxygen

25. Blood and blood products packed red cells fresh frozen plasma thrombocytes various factors

26. Risks of blood transfusion incompatibility infection allergy fever overloading bleeding problems immunity

27. Blood transfusion indication patient´s consent taking blood sample to transfusion dept. cross match in TD check documentation and transfusion bag security test biological test

28. Blood groups

29. Population O+ A+ B+ AB+ O− A− B− AB− Argentina [11] [11] 53.8%34.7%8.8%2.7%8.4%0.44%0.21%0.06% Australia [12] [12] 40%31%8%2%9%7%2%1% Belgium [13] [13] 38.1%34%8.5%4.1%7%6%1.5%0.8% Canada [14] [14] 39%36%7.6%2.5%7% 1.4%0.5% Denmark [15] [15] 35%37%8%4%6%7%2%1% Finland [16] [16] 27%38%15%7%4%6%2%1% France [17] [17] 36%37%9%3%6%7%1% Hong Kong, China [18] [18] 40%26%27%7%<0.3% Korea, South [19] [19] 27.4%34.4%26.8%11.2%0.1% 0.05% Netherlands [20] [20] 39.5%35%6.7%2.5%7.5%7%1.3%0.5% Poland [21] [21] 31%32%15%7%6% 2%1% Sweden [22] [22] 32%37%10%5%6%7%2%1% UK [23] [23] 37%35%8%3%7%6%2%1% USA [24] [24] 38%34%9%3%7%6%2%1%

30. Human red blood cells before (left) and after (right) adding serum containing anti-A antibodies. The agglutination reaction reveals the presence of the A antigen on the surface of the cells.

32. Transfusion Colecting blood sample from the patient Transfusion station –Blood group –Crossmatching –Delivery Ward –Check delivery list –Safety test –Biological test –Monitoring –Save blood pack for 24 hours

33. Indications for blood transfusions acute hemorrhage anemia bleeding disorders hematological diseases

34. Acute bleeding Blood lossReplacement <750 mlcrystalloid solutions 750 – 1500 mlcrystalloid solutions (colloid solutions or blood) >1500 mlcrystalloid solutions (colloid solutions) + blood

35. Shock

36. Definition Acute state in which tissue perfusion is inadequate to maintain the supply of oxygen and nutritients necessary for normal cell function, which results in widespread hypoxia.

37. Reasons for inadequate tissue perfusion A decreased circulating blood volume – hypovolaemic shock A failure of the heart to pump effectively – cardiogenic shock and obstructive shock A massive increase in peripheral vasodilatation – neurogenic shock Combination – septic shock, anaphylactic shock

38. Stages of shock Initial stage – anaerobic metabolism Compensatory stage – centralisation of circulation Progressive stage – increased acidosis, leakage of fluid from the capillaries and formation of microthrombes Refractory stage

39. Classification of shock Hypovolaemic shock Cardiogenic shock Anaphylactic shock Septic shock Neurogenic shock

40. Hypovolaemic shock Haemorrhage Plasma loss Extracelular fluid loss

41. Symptoms of hypovolemia according to blood loss Blood loss (ml)Symptoms <750none -1 500thirst, weakness, tachypnoea -2 000systolic pressure falls >2 000no pulse on periphery

42. Estimated blood loss in trauma Pelvis3 000 mL Femur1 000 mL Tibia 650 mL Abdominal injury2 000 – 4 000 mL Thoracic injury2 000 – 4 000 mL

45. Signs of haemorrhagic shock Pale, cold, clammy skin, decreased capilary refill Rapid, weak and thready pulse Thirst Decreased urine production Increased respiratory rate Change in mental status – late sign

46. First aid Prevent further blood loss Antishock or autotransfusion position Activation of emergency service Prevention of hypothermia Prevention of positioning trauma Treatment of other injuries, immobilisation of fractures Nil by mouth, no oral or i.m. medication

47. Medical treatment Intravenous access Surgery Fluid replacement Artificial ventilation Pharmacological support of shock organs Monitoring: BP, P, SaO2, CPV, urine output

48. Cardiogenic shock Heart failure, cardiomyopathy Decreased cardiac output First vasoconstriction, next vasodilatation due to acidosis Pulmonary oedema Cold, clammy and cyanotic skin Mortality 80 per cent

49. Anaphylactic shock Severe allergic reaction Degranulation of mast cells Vasodilatation, increased vascular permeability, oedema, bronchospasm

50. Epipen

51. Septic shock Bacteria or bacterial toxins Released histamine and other mediators of inflammation Oxygen demand – supply mismatch Vasodilatation Tachycardia, hypotension, fever of hypothermia

52. Neurogenic (spinal) shock Loss of sympathetic nerve activity Massive vasodilatation