Download Bleeding and Shock

Bleeding and Shock
Chapter 11
Topic Overview

Review of Circulatory System
 External Bleeding
– Signs and Symptoms
– Care
 Internal Bleeding
– Signs and Symptoms
– Care
Topic Overview

Shock
– Signs and Symptoms
– Classic vs. Atypical
– Care
 Dressing and Bandages
– Purpose and Function
– Effects of improperly applied dressings,
splints and tourniquets.
Circulatory System

Review
– Heart
– Blood
– Blood Vessels
 Arteries
 Veins
 Capillaries
Key Terms

Perfusion
– Circulation of oxygenated blood to tissues
and organs
 Hypoperfusion
– Inadequate circulation of oxygenated blood
to tissues and organs.
Bleeding & Shock

Some Facts
– Trauma is the leading cause of death for
persons aged 1 to 44.
– A vital part of trauma care is recognizing
and treating signs and symptoms of
bleeding and shock
– Profuse bleeding and shock are lifethreatening problems requiring immediate
attention
Bleeding

External Bleeding
– Use Body Substance Isolation (BSI)
precautions
 Eye
Protection, Gloves, Gown, Mask
– Always wash hands following contact
 Waterless
cleans
Types of Bleeding

Arterial
– Bright red (oxygen rich), spurting, rapid,
profuse
– Clot formation is difficult
– Most difficult to control
– As blood pressure drops, spurting will also
drop
Types of Bleeding

Venous
– Usually steady flow (under lower pressure),
can be profuse
– Dark red oxygen poor
– Debris and air can be sucked into
wound
– Clotting rate is dependent on size of area
or vessels involved
– Bleeding easier to control
Types of Bleeding

Capillary
– Slow (oozing)
– Dark red
– Good chance of infection
– Clots easily
Blood Loss

Severity
– Signs & symptoms of hypoperfusion
– General impression of amount of loss
– Severe or uncontrolled blood loss will lead
to Shock (Hypoperfusion) and possibly
death
– Most Bleeding will stop by itself within 6-10
minutes (dependent on area of
involvement and vessels involved,
vasoconstriction & clotting)
External Severity
Age
Group
Average
Blood Volume
Serious Volume
Loss (Rapid)
Adult
5 – 6 liters
1 liter
Adolesce 2 – 3 ½ liters
nt
¾ liter
Child
1 ½ - 2 liters
1/2 liter
Infant
500-600 ml
100-200 cc
Care for External Bleeding

Care
– Body Substance Isolation Precautions
– Maintain airway
– Cover wound with a clean dressing to
reduce risk of infection
– Follow basic steps for controlling bleeding
Bleeding Control





Direct Pressure
Elevation
Pressure Bandage
Pressure Points
Absolute last resort - Tourniquet
Pressure Points

Arterial pressure points
– Brachial
– Femoral

Summon EMS if bleeding cannot be
controlled or if pressure points must be
used
Supplemental Methods of
Controlling Bleeding

Splints
– Pressure splints (air splints)
Supplemental Methods of
Controlling Bleeding

Tourniquet Precautions
– Wide versus narrow bandage
– Do Not remove or loosen
– Leave it in open view
– Do not apply over a joint
External Bleeding

Special Areas
– Bleeding from the nose, ears or mouth

Potential causes
–
–
–
–
–


Skull fractures
Facial fractures
Sinusitis (& other URT infections)
Hypertension
Coagulation Disorders
If bleeding or CSF is coming from the ears do not stop
flow
If CSF is coming from the nose DO NOT stop flow
External Bleeding

If bleeding from a head wound that resulted from a
fracture DO NOT apply direct pressure, do not attempt to
stop bleeding, cover with a bulky dressing
– Care for a Nosebleed


Sitting position leaning slightly forward
Apply direct pressure (may take 15 min.)
– Pinching nose or rolled gauze under nose
– Cold compresses
– Do not
 Pack nose
 Blow nose or
 Tilt head back
Dressings & Bandages

Dressings (should be sterile)
– Placed directly on wound
– Absorbs blood and other fluids
– Reduces risk of infection
– Types
2
X 2, 4 X 4
 Compress
 Universal
 Occlusive
Dressings and Bandages

Bandages
– Holds dressings in place
– Helps protect wound from infection
– Provides support to injury
– Types
 Tape
 Roller
bandages (widths: 1 to 6 inches)
– (Elastic not usually used for bleeding injuries)
 Triangular
bandage
Internal Bleeding

Severity Based On
– Mechanism of Injury
– Clinical Signs and
Symptoms
Internal Bleeding

Relationship to Mechanism of Injury (MOI)
– May not be obvious, may take time for signs &
symptoms to appear
– Blunt Trauma





Falls
Motorcycle crashes
Pedestrian impacts
Blast injuries
Look for contusions, abrasions, deformity. Impact marks, &
swelling
– Suspect internal bleeding in any serious injury
Internal Bleeding

Signs and Symptoms
– Significant MOI
– Bruising (Contusion)
 contusions
over abdomen or chest the size of
your fist - assume a 10% blood volume loss
– Painful, swollen, deformed extremities
– Anxiety & restlessness
– Bleeding from mouth, ears, nose, rectum,
vagina, or other orifice
Internal Bleeding

Signs & Symptoms
– Tender, rigid and/or distended abdomen
– Rebound tenderness
– Vomiting Blood
 Bright
Red
 Coffee-ground color or consistency
– Blood in stool
 Bright
red
 Dark, tarry
Internal Bleeding
– Nausea and vomiting
– Combativeness, clearly altered mental
status
– Weakness, faintness, dizziness
– Excessive thirst
– Cool, clammy skin
– Pale or ashen skin leading to cyanosis
– Shallow rapid breathing
Internal Bleeding
– Weak rapid pulse
– Delayed capillary refill
– Dilated sluggish pupils (late sign)
– Dropping blood pressure (late sign)
Internal Bleeding

Care
– Body Substance Isolation
– Airway care and oxygen
– Immediate transport to an appropriate
facility
– Apply direct pressure if injured area is on
an extremity
– Splint extremity
Internal Bleeding

Care
– For minor internal bleeding (bruising)
 Apply
cold compresses, reduce movement
Shock (Hypoperfusion)

Signs of Shock appear LATE
Waiting for signs to appear before
recognizing and treating may result
in the DEATH of your patient
Shock (Hypoperfusion)

Shock
– Results from the body’s
 inability
to maintain adequate perfusion
 inadequate removal of metabolic waste products
– May develop from internal or external blood
loss
– Peripheral perfusion is reduced due to the
reduction in circulating blood volume
Shock (Hypoperfusion)
– Reduced perfusion results in malfunction of
cells and organs
– Shock that is not recognized and treated
may result in death
– Body tries to compensate by shunting
blood away from areas of lesser need to
greater needs
 Explains
order of signs and symptoms
Shock (Hypoperfusion)
– Signs & symptoms may be present
immediately, become evident during the
physical exam or an ongoing assessment
Shock

Signs and Symptoms
– Restlessness, changes in mental status
– Pale, cool, clammy skin
– Nausea and vomiting
– Increased pulse rate
– Increased respiratory rate
 Decreasing
blood pressure is a LATE sign
Shock
– Dilated pupils
– Thirst
– Cyanosis
– Delayed capillary refill time
 Infants and Children
– Maintain blood pressure with up to 40%
blood volume loss
– By the time their pressure drops they are
near DEATH
Care for Shock








Body Substance Isolation
Activate EMS
Ensure patent airway, administer oxygen
Stabilize spine
Control any external bleeding
Elevate lower extremities 8-12 inches
(when indicated)
Prevent loss of body heat
NPO (food nor drink)
Care for Shock

Position patient
– Supine with legs elevated 8-12 inches
unless
 Anaphylactic
shock - upright
 Cardiogenic shock - upright or semi-recumbent
 Neurogenic shock - supine
 Lower extremity or pelvic injuries - supine
Specifics of Shock

Classifications
– Hypovolemic - volume loss
 Hemorrhagic
- most common
 Non-hemorrhagic – vomiting, diarrhea, etc.
– Cardiogenic Shock
 Ineffective
pump
Specifics of Shock
– Obstructive
 Tension
pneumothorax, pulmonary contusion,
cardiac tamponade, pulmonary embolus
– Distributive
 Loss
of vascular tone due to sepsis, spinal
injury, anaphylaxis
Classic Presentation

24 y/o male with
GSW to RUQ
– Anxious
– Pale, Cool, Moist
skin
– BP 88/50
– P – 140, Thready
– R – 24, Shallow
– Decreased cerebral
perfusion
– Vasoconstriction
– Volume loss
– Vasoconstriction
– Hypoxemia, Acidosis
Presentation of Classic Shock
– At a Blood Loss of 10% - 15%
 Compensatory
Effect
– Veins contract
 Signs
and Symptoms
– None to transient
Presentation of Classic Shock
– At a Blood Loss of up to 30%
 Compensatory
Effect
– Epinephrine response
– Arteries constrict to maintain BP
 Reduced blood flow to skin, gut & muscle
 Increased heart rate
 Signs
and Symptoms
– Anxiety
– Rapid, pulse becoming more thready with increased
volume loss
Presentation of Classic Shock
– At a Blood Loss of up to 30%
 Signs
–
–
–
–
–
–
and Symptoms con’t.
Cool, pale, clammy skin
Thirst
Weakness, faintness or dizziness
Rapid, shallow breathing
Delayed capillary refill
Normal BP
Presentation of Classic Shock
– At a Blood Loss of 30% to 45%
 Compensatory
Effect
– Decompensation
– Cardiac output falls to half of normal
 Signs
and Symptoms
– Hypotension
– Deteriorated mental status
 Combativeness, restlessness
– Rapid, shallow, (air-hungry) respirations
Presentation of Classic Shock
– At a Blood Loss Greater Than 45%
 Signs
and Symptoms
– Fall in BP
 Total circulatory collapse
– Cardiac arrest
– Infants and Children
 Maintain
blood pressure until blood volume loss
is more than 40%
 Decompensate rapidly
Atypical Presentation

Caused by
– Pathogenesis of Specific Type of Shock
– Some Medications
– Previous Medical History
Non-hemorrhagic Hypovolemic
Shock

Non-hemorrhagic Hypovolemic
– Loss of fluid other than blood
– Diarrhea, vomiting, dehydration
 Atypical
Signs & Symptoms
– Warm – low grade 101oF, (often febrile), dry skin
– Vital signs may be normal (if supine); orthostatic
hypotension
 Respirations may vary due to acidosis
– Vomiting – tend to become alkaline – respirations
will be more shallow
– Diarrhea – loss of carbs – tend to become acidic –
respirations tend to be deeper
Cardiogenic Shock

Cardiogenic Shock Classic Presentation
– Heart damage (AMI)
 Chest
pain
 Pulmonary edema
 Slow to normal heart rate
Cardiogenic Shock

Cardiogenic Shock Atypical
Presentation?
– Chest pain
– Normal to rapid heart rate
– No pulmonary edema
– Normal to low blood pressure
– Jugular vein distention
Obstructive Shock

Tension pneumothorax
– Look for JVD
 Pulmonary embolus
 Cardiac Tamponade
 Medication effects
– Anti-hypertensives
 Beta
blockers
– May block beta 1 (sympathetic response) and
mask signs of shock
Obstructive Shock

Medical History
– Hypertension
– BP may be normal, but what’s normal
– Pregnancy
 Increased
circulating volume of 50%
 Early signs of shock are late signs of shock
– Spleen removed
 Don’t
compensate as well
– Won’t see general decline, will crash quickly
Distributive Shock

Septic
 Anaphylactic
 Neurogenic
 Atypical Signs & Symptoms
– Pink, Warm, Dry skin
– Rapid Capillary refill <1/2 – 1 sec.
– Respirations vary
Distributive Shock

Septic Shock
– Result of infection
 Common
–
–
–
–
causes - UTI / Pneumonia
Exotoxins cause vasodilation
Altered mental status, may be sudden
Rapid capillary refill, warm, dry skin
Normal BP with widened pulse pressure (120/50)
or hypotension
– Bounding pulse
Distributive Shock

Septic Shock
– Dehydration may alter presentation
 Mechanism
may be rapid respirations, fever,
or decreased fluid intake
 No rhonchi with pneumonia
Distributive Shock

Neurogenic Shock
– Easily missed
– Pathogenesis unique
 Damage
to medulla or spinal cord
 Can also be caused by spinal anesthesia
Distributive Shock

Sympathetic vs. Parasympathetic
– Thoracolumbar vs. Cervicosacral
– Injury location determines signs &
symptoms
– May lose entire sympathetic system
 Can
result in bizarre presentation
Distributive Shock

Assessment of Neurogenic Shock
– Pink, warm, dry skin below injury
– Bradycardia or normal heart rate
– Constricted pupils ( non-reactive)
– Diaphragmatic or absent breathing
– Severe hypotension
– Diarrhea
– Paralysis
Distributive Shock

Anaphylaxis
– Life threatening
allergic reaction that
causes shock and
airway swelling
– Common Causes
Distributive Shock

Anaphylactic Shock
– Common Signs & Symptoms
 Itching
 Hives
 Flushing
 Warm tingling feeling
 Swelling (Especially face, neck, hand, feet,
tongue
Distributive Shock

Anaphylactic Shock
 Tightness
in throat / chest
 Cough
 Rapid,
labored, noisy breathing
 Hoarseness
 Stridor and wheezing
 Increased heart rate
 Low blood pressure (late sign)
Distributive Shock

Anaphylactic Shock
– Generalized Findings
 Itchy,
watery eyes and runny nose
 Headache
 Sense of impending doom
Patient Assessment

Anaphylactic Shock
– Initial assessment
– Focused history and physical exam
– Baseline vitals and SAMPLE history
– Apply high flow oxygen
Patient Assessment & Care
– Determine patient need for epinephrine
and use
 Epinephrine
is needed if the patient
– has had a similar reaction to the same substance in
the past
– shows S & S of shock
– complains of respiratory distress
– has a prescribed epinephrine auto-injector
Patient Assessment

Anaphylactic Shock
– What is patient allergic to?
– What was patient exposed to?
– How was the patient exposed?
– What signs and symptoms (S & S) does the
patient have?
– How have the S & S progressed?
– What interventions has the patient
received?
Anaphylactic Shock

Relationship to Airway Management
– The patient may need aggressive airway
management immediately because of swelling in
the airway or respiratory compromise.
– The patient’s condition may be stable initially but
deteriorate to the point where he/she needs
aggressive airway management

Progressive airway swelling

Respiratory compromise
When Shock Doesn’t Look
Like Shock

“Classic” Shock presentation is limited
– Multiple factors may alter presentation
– If the person shows signs of altered
perfusion, treat for shock
– Resuscitate perfusion not blood pressure
– Don’t forget that Medical History and
Medications can alter presentation
Review Questions

Describe the following types of bleeding
– Arterial
– Venous
– Capillary
 Describe the care for external bleeding
 List the signs and symptoms of internal
bleeding
 Describe the care for internal bleeding
Review Questions





Define Shock (hypoperfusion)
List the signs and symptoms of shock in
the order in which they are likely to appear
(in a classic presentation)
Describe the care for shock
Define an allergic reaction and
anaphylactic shock
List some common causes of allergic
reactions
Review Questions

List the signs and symptoms of
anaphylactic reaction associated with the
skin, respiratory system, and
cardiovascular system
 Tell how to determine whether the patient
needs epinephrine