Bleeding and Volume Replacement Therapy

1. Bleeding andVolume 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. Minor bleeding • clean with water • apply antiseptic around the wound • apply sterile dressing

8. Bleeding • external • internal • from body orifices • mixed

9. 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

13. Internal bleeding • pain • signs of injury • signs of shock

14. Internal bleeding • positioning • call for emergency • nothing per os

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

16. Volume replacement therapy • crystalloid solutions • colloids solutions • volume substituents • volume expanders • blood

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

18. Colloid solutions • dextrans • gelatine • starch

19. 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 Colloid solutions

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

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

22. 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

23. Blood groups

27. 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

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

29. Acute bleeding

30. Shock

31. 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.

32. 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

33. 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

34. Classification of shock • Hypovolaemic shock • Cardiogenic shock • Anaphylactic shock • Septic shock • Neurogenic shock

35. Hypovolaemic shock • Haemorrhage • Plasma loss • Extracelular fluid loss

36. Symptoms of hypovolemia according to blood loss

37. Estimated blood loss in trauma

39. 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

40. 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

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

42. 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

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

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

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