Bleeding and Shock

1. Chapter 25 Bleeding and Shock

2. Case History You are summoned to the scene of a shooting. You find a 58-year-old deli owner bleeding profusely from gunshot wounds to his arms and chest. The man is cool and pale with a rapid pulse and no discernible blood pressure. As you apply oxygen, he tells you that he is thirsty and would like to have a drink of water.

3. Control Bleeding • External bleeding • Direct pressure • Pressure point • Tourniquets

4. Shock • Internal bleeding can result in shock. • A state of profound depression of vital processes of body caused by inadequate perfusion of vital organs with blood

5. Anatomy and Physiology Review • Three major components of circulatory system: • The blood • The heart • The blood vessels

6. Heart and Great Vessels

7. Anatomy and Physiology Review • Blood • Liquid (plasma) and cellular components • Cellular components • Red blood cells • Transport oxygen • White blood cells • Combat infection • Platelets • Help control bleeding

8. Anatomy and Physiology Review • Heart • Four chambers • Atria (receiving chambers) • Ventricles (pumping chambers) • Left ventricle pumps blood to aorta with each beat; circulates to body • Right ventricle pumps blood throughout pulmonary arteries to lungs; unloads carbon dioxide, picks up fresh oxygen

9. Chambers of the Heart

10. Anatomy and Physiology Review • Blood vessels distribute blood to all parts of body and lungs. • Arteries carry blood away from heart. • Veins carry blood back to heart. • Arteries branch into smaller vessels, ending as capillaries. • Capillaries - one cell thick; exchange gas, nutrients, waste products with alveoli

11. Systemic and Pulmonary Circulation

12. Arteries, Capillaries, and Veins

13. Major Systemic Arteries

14. Capillaries

15. Major Systemic Veins

16. Stroke Volume and Cardiac Output • Circulation changes according to the body’s needs. • Changes occur through • Increase in heart rate • Increase in force of contraction • Adequate blood volume is needed.

17. Stroke Volume • Amount of blood ejected from ventricle with each beat • Approximately 70 ml • Related to: • Adequate contraction • Venous return

18. Cardiac Output • Stroke volume  heart rate = cardiac output • SV HR = CO • Example • 70 ml (SV) 60 (HR) = 4200 ml or 4.2 L (CO) • Cardiac output changes if stroke volume or heart rate change.

19. Blood Pressure and Perfusion • Blood pressure – force exerted on walls of vessels • Determinants of blood pressure: • Cardiac output • Size of vascular space • Measurements • Systolic and diastolic

20. Pressures in the Circulatory System

21. Hypotension • Cardiac output decreases and vascular space remains the same. • Decrease in blood pressure • Size of the vascular space increases and cardiac output remains the same. • Decrease in blood pressure

22. Effects of Epinephrine • Epinephrine release accounts for many of the signs of shock. • Increased cardiac output • Increased blood flow to brain • Increased respiratory rate • Dilated pupils • Redistributed blood flow • Shunted away from less vital organs and skin • Pale skin

23. Skin Signs Associated with Epinephrine Release

24. Personal Precautions • Eye protection • Gloves • Gown • Mask • Hand washing after each patient contact

25. Severity of Blood Loss • Based on: • Signs and symptoms • General impression of the amount of blood loss • Major blood loss = sudden loss of • Adult: 1 L • Child: 500 ml • Infant: 100 to 200 ml

26. Natural Response to Bleeding • Vessel contraction • Clotting • Serious injury may prevent effective clotting. • Uncontrolled bleeding or significant blood loss leads to shock (hypoperfusion) and possibly death.

27. Types of Bleeding • Arterial • Spurts from wound • Bright red • Most difficult to control

28. Types of Bleeding • Venous • Flows as steady stream • Dark red • Can be profuse • Easy to control, in most cases

29. Types of Bleeding • Capillary • Oozes from capillary • Dark red • Often clots spontaneously

30. Care of External Bleeding • Body substance isolation • Maintain airway/artificial ventilation. • Bleeding control • Direct pressure • Elevation • Pressure point • Tourniquet

31. Tourniquet – Precautions • Use a wide bandage. • Never use wire, rope, or a belt • Apply as close to the injury as possible. • Do not apply over any joint. • Secure it tightly. • Leave the tourniquet in open view. • Do not remove or loosen tourniquet unless instructed by medical direction.

32. Causes of Bleeding fromEar, Mouth, and Nose • Injured skull • Facial trauma • Digital trauma (e.g., nose picking) • Sinusitis • Upper respiratory tract infections • Hypertension (high blood pressure) • Coagulation disorders

33. Bleeding from Ears and Nose Owing to Skull Fracture • Do not attempt to stop the blood flow. • Apply a loose dressing. • Limit exposure to sources of infection.

34. Internal Bleeding – Severity • Injured or damaged internal organs commonly lead to extensive bleeding. • Bleeding is often concealed. • Fractures may also lead to serious internal blood loss. • Suspicion and severity based on • Mechanism of injury • Clinical signs and symptoms

35. Relationship of Internal Bleeding to Mechanism of Injury • Blunt trauma • Falls • Motorcycle crashes • Pedestrian impacts • Automobile collisions • Blast injuries • Contusions, abrasions, deformity, impact marks, and swelling • Penetrating trauma

36. Signs and Symptoms —Internal Bleeding • Pain, tenderness, swelling, or discoloration • Bleeding from the mouth, rectum, vagina, or other orifice • Vomiting bright red or dark “coffee ground”-colored blood • Dark, tarry stools or stools with bright red blood • Tender, rigid, and/or distended abdomen

37. Sites of Hidden Blood Loss Site Amount of Blood Loss % of blood volume Thorax 2 Liters 40% Abdomen >1 Liter 50% Femur >1 Liter 20% Pelvis 0.5 Liters/Fracture 10%/Fracture Skull Not significant unless infant

38. Shock Failure of circulatory system to adequately perfuse and oxygenate the tissues of the body

39. Causes of Shock • Pump failure • Low blood volume • Vasodilation or obstruction

40. Shock — Severity • Inadequate perfusion of cells • Cell and organ malfunction and death • Prompt recognition is critical

41. Shock — Severity • Peripheral perfusion is drastically reduced • Due to the reduction in circulating blood volume • Trauma patients develop shock (hypoperfusion) from loss of blood from both internal and external sites. • Hypovolemic or hemorrhagic shock

42. Peripheral Perfusion • Weak, thready, or absent peripheral pulses • Pale, cool, clammy skin • Delayed capillary refill >2 seconds • Infants and children only • Normal ambient air temperature

43. Signs and Symptoms — Shock • Mental states • Restlessness • Anxiety • Altered mental status

44. Vital Signs • Increased pulse rate (early sign), weak, and thready • Increased breathing rate • Shallow • Labored • Irregular • Decreased blood pressure (late sign)

45. Other Signs and Symptoms • Dilated pupils • Marked thirst • Nausea and vomiting • Pallor with cyanosis to the lips

46. Infants and Children • Infant or child in shock has less reserve • Can maintain blood pressure until 50% loss of blood volume • When blood pressure drops, they are close to death

47. Emergency Medical Care • Take personal protection measures. • Maintain airway. • Administer oxygen. • Control bleeding. • Elevate legs, if condition permits. • Splint fractures, if time permits. • Maintain body temperature. • Immediate transport is critical.

48. Hypovolemic Shock • Fluid or blood loss • Several causes of fluid loss • Vomiting • Diarrhea • Metabolic problems

49. Signs of Dehydration • Thirst • Lack of tearing or sweating • Dry tongue • Tenting of the skin

50. Signs and Symptoms — Hypovolemic Shock • Anxiety, restlessness, combativeness, or altered mental status • Weakness, faintness, or dizziness • Thirst • Shallow, rapid breathing • Rapid, weak pulse