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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