Chapter 13 Hemorrhage and Shock

2. Chapter 13Hemorrhage and Shock

3. Objectives (1 of 8) • 1.6.35 Describe the anatomy of the skin, bones, vessels, and subcutaneous tissue as it relates to hemorrhage control. • 1.6.36 Discuss the benefits and complications of hemorrhage control by the following means: • Direct pressure • Tourniquets • Hemostats • 1.6.40 Define shock.

4. Objectives (2 of 8) • 1.8.1          Define shock based on aerobic and anaerobic metabolism. • 1.8.2          Discuss the prevention of anaerobic metabolism. • 1.8.3          Discuss red blood cell oxygenation in the lungs based on alveolar O2 levels and transportation across the alveolar capillary wall. • 1.8.4          Discuss tissue oxygenation based on tissue perfusion and release of oxygen.

5. Objectives (3 of 8) • 1.8.5          Discuss the role played by respiration, inadequate ventilation in the management of shock. • 1.8.6          Describe perfusion and the mechanisms of improvement of cardiac output based on the strength and rate of contractions. • 1.8.7          Discuss the fluid component of the cardiovascular system and the relationship between the volume of the fluid and the size of the container.

6. Objectives (4 of 8) • 1.8.8          Discuss the systemic vascular resistance, the relationship of diastolic pressure to the SVR and the effect of diastolic pressure on coronary circulation. • 1.8.9          Discuss the container size in its relationship to the fluid volume and the effect on blood returning to the heart. • 1.8.21 Describe the mechanism of the body response to perfusion change. • 1.8.22 Identify the role of the baroreceptor.

7. Objectives (5 of 8) • 1.8.23 Describe how the actions of the baroreceptor affect blood pressure and perfusion. • 1.8.24 Describe compensated shock. • 1.8.25 Describe uncompensated shock, both cardiac and peripheral effects. • 1.8.26 Discuss the assessment of the patient’s perfusion status, based on physical observations within the primary survey, including pulse, skin, temperature, and capillary refill.

8. Objectives (6 of 8) • 1.8.27 Discuss the relationship of the neurological exam to assessment of hypoperfusion and oxygenation. • 1.8.28 Describe the information provided by the following in physical examination: pulse, blood pressure, diastolic pressure, systolic pressure, skin color, appearance, temperature, and respiration.

9. Objectives (7 of 8) • 1.8.29 Discuss management of a shocky patient. Include red cell oxygenation, tissue ischemic sensitivity, IV fluids, and the pneumatic antishock garment. • 1.8.30 Describe the beneficial and detrimental effects of the pneumatic antishock garment. • 1.8.31 Describe the indications and contraindications for the pneumatic antishock garment.

10. Objectives (8 of 8) • S1.8.35 Demonstrate in order of priority the steps of shock resuscitation. • S1.8.36 Demonstrate the use of the pneumatic antishock garment (PASG).

11. Bleeding (Hemorrhage) • Can be external and obvious or internal and hidden. • Causes weakness and eventually shock and death. • Most common cause of shock after trauma.

12. Shock • A state of collapse and failure of the cardiovascular system in which blood circulation slows and eventually ceases. • Can be fatal. • Accompanies events like heart attacks and automobile crashes.

13. Perfusion (1 of 2) • Circulation within tissues in adequate amounts to meet the cells’ needs for oxygen, nutrients, and waste removal. • Some tissues and organs need a constant supply of blood whereas others can survive on very little when at rest.

14. Perfusion (2 of 2) • The heart demands a constant supply of blood. • The brain and spinal cord can survive for 4 to 6 minutes without perfusion. • The kidneys may survive 45 minutes. • The skeletal muscles may last 2 hours.

15. Cardiovascular System (1 of 3)

16. Cardiovascular System (2 of 3) • Function • Circulates blood • Delivers oxygen and nutrients • Carries away waste

17. Cardiovascular System (3 of 3) • Components • Pump (heart) • Container (vessels) • Fluid (blood)

18. Blood Vessels • Arteries • Arterioles • Capillaries • Venules • Veins

19. Blood • Contains: • Red blood cells • White blood cells • Platelets • Plasma

20. Scene Safety • Follow BSI precautions. • Wear gloves and eye protection in all situations. • Avoid direct contact with body fluids. • Thorough hand washing between patients and after runs is important.

21. External Bleeding • Hemorrhage = bleeding • Body cannot tolerate greater than 20% blood loss. • Blood loss of 1 L can be dangerous in adults; in children, loss of 100-200 mL is serious.

22. Internal Bleeding • Internal bleeding may not be readily apparent. • Assess patient’s • Mechanism of injury • Nature of illness

23. Mechanism of Injury Can Indicate Internal Bleeding • When mechanism of injury suggests that severe forces affected the abdomen and/or the chest. • As a result of falls, blast injuries, and automobile or motorcycle crashes. • With penetrating injury, such as a knife or gunshot wound.

24. Nature of Illness Can Suggest Internal Bleeding • In the abdomen as a result of irritable bowel syndrome, an aneurysm, or a ruptured ectopic pregnancy. • Gastrointestinal problems may cause vomiting of blood or bloody diarrhea.

25. Signs and Symptoms of Internal Bleeding (1 of 2) • Ecchymosis: Bruising • Hematoma: Bleeding beneath the skin • Hematemesis: Blood in vomit • Melena: Black, tarry stool

26. Signs and Symptoms of Internal Bleeding (2 of 2) • Hemoptysis: Coughing up blood • Pain, tenderness, bruising, guarding, or swelling • Broken ribs, bruises over the lower chest, or rigid, distended abdomen

27. Significance of Bleeding • Body will not tolerate blood loss greater than 20% of blood volume. • More than 1 L of blood loss in an adult causes increased heart rate and decreased blood pressure. • Smaller amount of blood loss in infants and children causes significant effects. • Low blood volume results in inadequate perfusion and death.

28. Conditions With Possible Serious Bleeding • Significant mechanism of injury. • Poor general appearance of patient. • Assessment reveals signs of shock. • Significant amount of blood loss noted. • The blood loss is rapid. • You cannot control external bleeding.

29. Physiologic Response to Hemorrhage (1 of 2) • Arterial • Blood is bright red and spurts. • Venous • Blood is dark red and does not spurt. • Capillary • Blood oozes out and is controlled easily.

30. Physiologic Response to Hemorrhage (2 of 2)

31. Blood Clotting • Bleeding normally stops within 10 minutes. • Some medications interfere with clotting. • Some injuries will be unable to clot. • Patients with hemophilia lack clotting factors.

32. Stage One Hemorrhage (1 of 2) • Up to 15% intravascular loss. • Compensated by constriction of vascular bed. • Blood pressure maintained. • Normal pulse pressure, respiratory rate, and renal output.

33. Stage One Hemorrhage (2 of 2) • Pallor of the skin. • Central venous pressure low to normal.

34. Stage Two Hemorrhage (1 of 2) • 15-25% intravascular loss. • Cardiac output cannot be maintained by arteriolar constriction. • Reflex tachycardia. • Increased respiratory rate. • Blood pressure maintained. • Catecholamines increase peripheral resistance.

35. Stage Two Hemorrhage (2 of 2) • Increased diastolic pressure. • Narrow pulse pressure. • Diaphoresis from sympathetic stimulation. • Renal output near normal.

36. Stage Three Hemorrhage • 25-35% intravascular loss • Classic signs of hypovolemic shock • Marked tachycardia • Marked tachypnea • Decreased systolic pressure • Decreased urine output • Alteration in mental status • Diaphoresis with cool, pale skin

37. Stage Four Hemorrhage • Loss greater than 35%. • Extreme tachycardia. • Pronounced tachypnea. • Significantly decreased systolic blood pressure. • Confusion and lethargy. • Skin is diaphoretic, cool, and extremely pale.

38. Assessment • Ensure an open and patent airway. • Have suction ready for bleeding of the mouth or facial areas. • Note the color of bleeding and try to determine its source. • Coffee-ground emesis is a sign of upper GI bleeding.

39. Controlling External Bleeding • Follow BSI precautions. • Ensure patient has an open airway and adequate breathing. • Provide oxygen if necessary. • Assess location and color of blood. • There are several methods to control bleeding.

40. Direct Pressure and Elevation • Direct pressure is the most common and effective way to control bleeding. • Apply pressure with gloved finger or hand. • Elevating a bleeding extremity often stops venous bleeding. • Use both direct pressure and elevation whenever possible. • Apply a pressure dressing.

41. Pressure Points • If bleeding continues, apply pressure on pressure point. • Pressure points are located where a blood vessel lies near a bone. • Be familiar with the location of pressure points.

42. Location of Pressure Points

43. Splints • Splints can help control bleeding associated with a fracture. • Air splints can be used to control bleeding of soft-tissue injuries.

44. Hemostats • Use on retracted vessels. • Apply to end of vessel.

45. Pneumatic Antishock Garment (PASG) • Stabilizes fractures of the pelvis and proximal femurs. • Controls significant internal bleeding. • Controls massive soft-tissue bleeding of the lower extremities.

46. PASG Contraindications • Pregnancy (do not inflate abdomen) • Pulmonary edema of cardiac origin • Acute heart failure • Penetrating chest injuries • Groin injuries • Major head injuries • Less than 30 minutes transport time

47. Application of PASG • Apply the garment so the top is below the lowest rib. • Enclose both legs and the abdomen. • Open the stopcocks. • Inflate with the foot pump. • Check patient’s vital signs.

48. Applying a Tourniquet • Fold a triangular bandage into 4” cravat. • Wrap the bandage. • Use a stick as a handle to twist and secure the tourniquet. • Write “TK” and time and place on patient.

49. Tourniquet Precautions • Place as close to injury as possible, but not over joint. • Never use narrow material. • Use wide padding under the tourniquet. • Never cover a tourniquet with a bandage. • Do not loosen the tourniquet once applied.

50. Bleeding From the Nose, Ears, and Mouth • Causes: • Skull fractures • Facial injuries • Sinusitis • High blood pressure • Coagulation disorders • Digital trauma