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Introduction to
Hemorrhage and Shock
Hemorrhage
– Abnormal internal or external loss of
blood
Homeostasis
– Tendency of the body to maintain a
steady and normal internal environment
Shock
– INADEQUATE TISSUE PERFUSION
– Transition between homeostasis and
death
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage
Circulatory System
Hemorrhage Classification
Clotting
Factors Affecting Clotting
Hemorrhage Control
Stages of Hemorrhage
Hemorrhage Assessment
Hemorrhage Management
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Heart
Cardiac Cycle
– The repetitive pumping action that
produces pressure changes that circulate
blood throughout the body
Cardiac Output
– The total amount of blood separately
pumped by each ventricle per minute,
usually expressed in liters per minute
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Cardiac Output
Normal cardiac output = 5 to 6 liters per
minute (LPM).
Can increase up to 30 LPM in times of
stress or exercise.
Determined by multiplying the heart rate by
the volume of blood ejected by each
ventricle during each beat (stroke volume).
CO is influenced by:
– Strength of contraction
– Rate of contraction
– Amount of venous return available to the
ventricle (preload)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Circulatory System (1 of 4)
Heart
– Autonomic nervous system
Parasympathetic nervous system
Slows rate
Mediated by vagus nerve
Sympathetic nervous system
Increases rate
Cardiac plexus
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Circulatory System
Key Terms
Stroke Volume
Preload
Ventricular Filling
Starling’s Law of the heart
Afterload (End Diastolic Pressure or EDP)
Cardiac Output
– SV x HR
– 5 liters/minute
Fick Principle
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Circulation
Systolic Pressure
– Strength and volume of cardiac output
Diastolic Pressure
– More indicative of the state of constriction
of the arterioles
Mean Arterial Pressure
– 1/3 pulse pressure added to the diastolic
pressure
– Tissue perfusion pressure
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Circulation (2 of 2)
Vascular Control
– Increased sympathetic tone results in
increased vasoconstriction.
Microcirculation
– Blood flow in the arterioles, capillaries,
and venules.
– Sphincter functioning.
Most organ tissue requires blood flow
5 to 20% of the time.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Cardiac Physiology (1 of 2)
Oxygen Supply
– The myocardium receives its blood/oxygen
supply during the diastole phase of contraction.
The blood flows from the aorta through the two
coronaries into the relaxed myocardium.
Oxygen Demand
– 90% of the O2 demand, or work, of the heart is
performed during the isovolumetric phase of
contraction. In this phase, NO blood flows from
the heart into the aorta, until the pressure in the
heart is greater than the end diastolic pressure
(EDP).
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Cardiac Physiology (2 of 2)
Releases a polypeptide called atrial
natriuretic peptide (ANP)
Works antagonistically to renin-angiotensin
Four Effects
– Promotes Na+ and water loss at the kidneys
– Inhibits renin release and ADH, aldosterone
secretion
– Suppresses thirst
– Blocks action of angiotensin II and
norepinephrine
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Negative Feedback
Important negative feedback
mechanisms in maintaining tissue
perfusion are the:
– Baroreceptor reflexes
– Central nervous system ischemia
responses
– Hormonal mechanisms
– Reabsorption of tissue fluids
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Cardiovascular System
Regulation (1 of 3)
PNS and SNS always act in balance
Baroreceptors: monitor BP
Chemoreceptors
Hormone regulation
Reabsorption of tissue fluids
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Cardiovascular System
Regulation (2 of 3)
Parasympathetic Nervous System
Decrease
– Heart rate
– Strength of contractions
– Blood pressure
Increase
– Digestive system
– Kidneys
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Cardiovascular System
Regulation (3 of 3)
Sympathetic Nervous System
Increase
–
–
–
–
Body activity
Heart rate
Strength of contractions
Vascular constriction
Bowel and digestive viscera
Decreased urine production
– Respirations
– Bronchodilation
Increases skeletal muscle perfusion
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Baroreceptor Reflexes (1 of 5)
High in the neck, each carotid artery divides
into external and internal carotid arteries.
– At the bifurcation, the wall of the artery is thin
and contains many vine-like nerve endings.
The small portion of the artery is the carotid
sinus.
– Nerve endings in this area are sensitive to
stretch or distortion.
Serve as pressure receptors or baroreceptors.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Baroreceptor Reflexes (2 of 5)
Similar area found in the arch of the aorta.
– Serves as a second important baroreceptor
Large arteries, large veins, and the wall of
the myocardium also contain less important
baroreceptors.
Baroreceptor reflexes help maintain blood
pressure by two negative feedback
mechanisms:
– By lowering blood pressure in response to
increased arterial pressure
– By increasing blood pressure in response to
decreased arterial pressure
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Baroreceptor Reflexes (3 of 5)
Normal blood pressure partially stretches the
arterial walls so that baroreceptors produce a
constant, low-frequency stimulation.
Impulses from the baroreceptors inhibit the
vasoconstrictor center of the medulla and
excite the vagal center when blood pressure
increases.
– Results in vasodilation in the peripheral circulatory
system and a decrease in the heart rate and force
of contraction.
Combined effect is a decrease in arterial pressure.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Baroreceptor Reflexes (5 of 5)
When baroreceptor stimulation ceases due
to a fall in arterial pressure, several
cardiovascular responses are evoked:
– Vagal stimulation is reduced and sympathetic
response is increased.
– The increase in sympathetic impulses results in
increased peripheral resistance and an increase
in heart rate and stroke volume.
Sympathetic discharges also produce generalized
arteriolar vasoconstriction, which decreases the
container size.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Chemoreceptor Reflexes
Chemoreceptors
– Monitor level of CO2 in CSF
– Monitor level of O2 in blood
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Chemoreceptor Physiology
Low arterial pressure leads to hypoxemia
and/or acidosis.
Hypoxemia/acidosis stimulate peripheral
chemoreceptor cells within the carotid and
aortic bodies.
– These bodies have an abundant blood supply.
When oxygen or pH decreases, these cells
stimulate the vasomotor center of the
medulla.
– The rate and depth of ventilation are also
increased to help eliminate excess carbon
dioxide and maintain acid-base balance.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
CV System and Hormone
Regulation (1 of 7)
Catecholamines
– Epinephrine
– Norepinephrine
– Actions
Alpha 1
Alpha 2
Beta 1
Beta 2
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
CV System and Hormone
Regulation (2 of 7)
Alpha 1
– Vasoconstriction
– Increased
peripheral vascular
resistance
– Increased preload
Alpha 2
– Regulates release
of NE
Beta 1
– Positive inotropy
– Positive
chronotropy
– Positive
dromotropy
Beta 2
– Bronchodilation
– Smooth muscle
dilation in bowel
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
CV System and Hormone
Regulation (3 of 7)
Antidiuretic Hormone (ADH)
– AKA: Arginine Vasopressin (AVP)
– Released
Posterior pituitary
Drop in BP or increase in serum osmolarity
– Action
Increase in peripheral vascular resistance
Increase water retention by kidneys
Decrease urine output
Splenic vasoconstriction
200 mL of free blood to circulation
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
CV System and Hormone
Regulation (4 of 7)
Angiotensin II
– Released
Primary chemical from kidneys
Lowered BP and decreased perfusion
– Action
Converted from renin into angiotensin I
Modified in lungs to angiotensin II
20-minute process
Potent systemic vasoconstrictor
1-hour duration
Causes release of ADH, aldosterone, and
epinephrine
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
CV System and Hormone
Regulation (5 of 7)
Aldosterone
– Release
Adrenal cortex
Stimulated by angiotensin II
– Action
Maintain kidney ion balance
Retention of sodium and water
Reduce insensible fluid loss
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
CV System and Hormone
Regulation (6 of 7)
Glucagon
– Release
Alpha cells of pancreas
Triggered by epinephrine
– Action
Causes liver and skeletal muscles to convert
glycogen into glucose
Gluconeogenesis
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
CV System and Hormone
Regulation (7 of 7)
Insulin
– Release
Beta cells of
pancreas
– Action
Facilitates transport
of glucose across
cell membrane
Erythropoietin
– Release
Kidneys
Hypoperfusion or
hypoxia
– Action
Increases
production and
maturation of RBCs
in the bone marrow
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Reabsorption of Tissue Fluids
(1 of 2)
Arterial hypotension, arteriolar constriction,
and reduced venous pressure during
hypovolemia lower the blood pressure in the
capillaries (hydrostatic pressure).
The decrease promotes reabsorption of
interstitial fluid into the vascular
compartment.
– Considerable quantities of fluid may be drawn
into the circulation during hemorrhage.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Reabsorption of Tissue Fluids
(2 of 2)
Approximately 0.25 mL/min/kg of body
weight (1 L/hr in the adult male) can be
autotransfused from the interstitial
spaces after acute blood loss.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Vasculature
Lined with smooth muscle.
All vessels larger than capillaries have
layers of tissues (tunicae).
Maintains blood flow by changes in
pressure and peripheral vascular
resistance.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Peripheral Vascular
Resistance (Afterload)
The total resistance against which blood
must be pumped.
It is essentially a measure of friction
between the vessel walls and fluid, and
between the molecules within the fluid itself
(viscosity).
– Both oppose flow.
When resistance to flow increases, blood
pressure must increase for the flow to
remain constant.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Starling’s Law of the Heart
When the rate at which blood flows into the
heart from the veins (venous return)
changes, the heart automatically adjusts its
output to match inflow.
The more blood the heart receives the more
it pumps…
Increased end diastolic volume increases contractility.
Increases stroke volume.
– Increases cardiac output.
Starling curves at any end-diastolic volume.
Increased sympathetic input increases stroke volume.
Decreased sympathetic input decreases stroke
volume.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Resistance to Blood Flow
Increases with…
Increased fluid viscosity
Increased vessel length
Decreased vessel diameter
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Blood Flow Resistance (2 of 2)
Arterioles have a much smaller
diameter and offer the major
resistance to blood flow.
– Smooth muscles in the arteriole walls can
relax or contract.
– Can change the diameter of the vessel
as much as fivefold.
– Arterial blood pressure is regulated
primarily by the vasoconstriction or
vasodilation of these vessels.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Microcirculation (2 of 3)
Venules and
veins serve as
collecting
channels and
storage vessels
(capacitance).
Normally contain
70% of the blood
volume.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Microcirculation (3 of 3)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Mechanisms That Control
Blood Flow
Local control of blood flow by the
tissues
Nervous control of blood flow
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Local Control
Blood usually flows through capillaries
intermittently due to:
– The pulsatile manner of blood flow
resulting from cardiac pumping action
and vasomotion
– The intermittent constriction and dilation
of arterioles and precapillary sphincters
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Vasomotion (1 of 3)
Regulated primarily by the
concentration of oxygen in the tissues.
When oxygen concentration is low, the
cells lining and adjacent to the closed
capillaries secrete histamine, which is
thought to be responsible for arteriolar
smooth muscle vasodilation, causing
the capillary to open.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Vasomotion (2 of 3)
Histamine is quickly destroyed in the
blood and does not enter the general
circulation.
As cells become reoxygenated they
stop the histamine secretion, and the
capillary closes.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Vasomotion (3 of 3)
A decrease in oxygen concentration
leads to a local release of vasodilating
substances, which allows blood flow to
increase.
– This in turn increases the delivery of
oxygen and restores aerobic metabolism.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
CNS Ischemia Response
CNS ischemia response is activated when
blood flow to the vasomotor center of the
medulla is decreased.
– In the presence of ischemia, the neurons within
the medulla stimulate the sympathetic nervous
system.
Sympathetic vasoconstriction can elevate
arterial pressure for as long as 10 minutes.
The cerebral ischemia response functions
only in emergency situations.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Blood Components (2 of 2)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Clotting (1 of 2)
Three-Step Process
– Vascular phase
Vasoconstriction
– Platelet phase
Tunica intima damaged
Turbulent blood flow
Frictional damage to platelets
Agglutination and aggregation
– Coagulation
Release of enzymes
Extrinsic – nearby tissue
Intrinsic – damaged platelets
Fibrin release
Normal coagulation in 7–10 minutes
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Clotting (2 of 2)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Factors Affecting Clotting (1 of 2)
Movement of the wound site
Aggressive fluid therapy
– Increased BP and displaced clots
– Dilution of clotting factors
Low body temperature
– Ineffective clot formation
Medications
– ASA, heparin, Ticlid, warfarin (Coumadin)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Factors Affecting Clotting (2 of 2)
Nature of the wound
– Transverse (clean tear)
Vessels constrict and draw
inward
Reduction of the lumen
Reduction of blood loss
– Longitudinal (crush injury)
Constriction of the smooth
muscle
Enlarges the wound
Increases blood loss
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Shock
Cellular Level
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Four Stages
Stage 1: Vasoconstriction
Stage 2: Capillary and venule opening
Stage 3: Disseminated intravascular
coagulation
Stage 4: Multiple organ failure
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock and Hemorrhage
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Defining Shock (1 of 2)
Shock is best defined as
inadequate tissue perfusion.
– Can result from a variety of disease
states and injuries.
– Can affect the entire organism, or it can
occur at a tissue or cellular level.
“The rude unhinging of the machinery of Life”
Gross, 1877
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Defining Shock (2 of 2)
Shock is not adequately defined by:
–
–
–
–
–
Pulse rate
Blood pressure
Cardiac function
Hypovolemia
Loss of systemic vascular resistance
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage Classification
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
External Hemorrhage
Results from soft tissue injury.
Accounts for nearly 10 million emergency
department visits in the United States each year.
Most soft tissue trauma is accompanied by mild
hemorrhage and is not life threatening.
– Can carry significant risks of patient morbidity and
disfigurement
The seriousness of the injury is dependent on:
–
–
–
Anatomical source of the hemorrhage (arterial, venous,
capillary)
Degree of vascular disruption
Amount of blood loss that can be tolerated by the patient
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Internal Hemorrhage (1 of 2)
Can result from:
– Blunt or penetrating trauma
– Acute or chronic medical illnesses
Internal bleeding that can cause
hemodynamic instability usually occurs in
one of four body cavities:
–
–
–
–
Chest
Abdomen
Pelvis
Retroperitoneum
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Internal Hemorrhage (2 of 2)
Signs and symptoms that may suggest
significant internal hemorrhage include:
– Bright red blood from mouth, rectum, or
other orifice
– Coffee-ground appearance of vomitus
– Melena (black, tarry stools)
– Dizziness or syncope on sitting or
standing
– Orthostatic hypotension
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Physiological Response to
Hemorrhage
The body’s initial response to
hemorrhage is to stop bleeding by
chemical means (hemostasis).
– This vascular reaction involves:
Local vasoconstriction
Formation of a platelet plug
Coagulation
Growth of tissue into the blood clot that
permanently closes and seals the injured
vessel
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage Control
External Hemorrhage
– Direct pressure and pressure dressing
– General Management
Direct pressure
Elevation
Ice
Pressure points
Constricting band
Tourniquet
May use a BP cuff by inflating the cuff 20–30 mmHg
above the SBP
Release may send toxins to heart
Lactic acid and electrolytes
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Tourniquets are ONLY used
as a last resort!
OR ARE THEY?
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Internal Hemorrhage Control
Hematoma
– Epistaxis: Nose Bleed
Causes: trauma,
hypertension
Treatment: lean
forward, pinch nostrils
– Pocket of blood
between muscle and
fascia
UNEXPLAINED
SHOCK is BEST
attributed to abdominal
trauma
General Management
– Immobilization,
stabilization, elevation
–
–
–
–
–
Hemoptysis
Esophageal Varices
Melena
Diverticulosis
Chronic Hemorrhage
Anemia
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Hemorrhage
60% of body weight is fluid.
– 7% circulating blood volume (CBV) in
men
5 L (10 units)
– 6.5% CBV in women
4.6 L (9–10 units)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Hemorrhage
Stage 1
15% loss of CBV
– 70 kg pt = 500–750 mL
Compensation
–
–
–
–
Vasoconstriction
Normal BP, pulse pressure, respirations
Slight elevation of pulse
Release of catecholamines
Epinephrine
Norepinephrine
Anxiety, slightly pale and clammy skin
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Hemorrhage
Stage 2 (1 of 2)
15–25% loss of CBV
– 750–1250 mL
Early decompensation
– Unable to maintain BP
– Tachycardia and tachypnea
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Hemorrhage
Stage 2 (2 of 2)
Decreased pulse strength
Narrowing pulse pressure
Significant catecholamine release
–
–
–
–
Increase PVR
Cool, clammy skin and thirst
Increased anxiety and agitation
Normal renal output
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Hemorrhage
Stage 3 (1 of 2)
25–35% loss of CBV
– 1250–1750 mL
Late decompensation (early
irreversible)
– Compensatory mechanisms unable to
cope with loss of blood volume
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Hemorrhage
Stage 3 (2 of 2)
Classic Shock
– Weak, thready, rapid pulse
Narrowing pulse pressure
–
–
–
–
Tachypnea
Anxiety, restlessness
Decreased LOC and AMS
Pale, cool, and clammy skin
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Hemorrhage
Stage 4
>35% CBV loss
– >1750 mL
Irreversible
–
–
–
–
–
–
Pulse: Barely palpable
Respiration: Rapid, shallow, and ineffective
LOC: Lethargic, confused, unresponsive
GU: Ceases
Skin: Cool, clammy, and very pale
Unlikely survival
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Hemorrhage
Concomitant Factors (1 of 2)
Pre-existing condition
Rate of blood loss
Patient Types
– Pregnant
>50% greater blood volume than normal
Fetal circulation impaired when mother compensating
– Athletes
Greater fluid and cardiac capacity
– Obese
CBV is based on IDEAL weight (less CBV)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Hemorrhage
Concomitant Factors (2 of 2)
Children
– CBV 8–9% of body weight
– Poor compensatory mechanisms
– TREAT AGGRESIVELY!
Elderly
– Decreased CBV
– Medications
BP
Anticoagulants
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage Assessment (1 of 5)
Scene Size-up
– Is it safe?
BSI
– Blood loss? Estimate?
Law enforcement
– Mechanism of Injury/Nature of Illness
Should only be used in conjunction with vital signs and
other clinical signs of injury to determine the probability of
injury
– Number of Patients
– Need for Additional Resources
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage Assessment (2 of 5)
Initial Assessment
– General Impression
Obvious Bleeding
– Mental Status
– CABC
– Interventions
Manage as you go
O2
Bleeding control
Shock
BLS before ALS!
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage Assessment (4 of 5)
Fractures and Blood Loss
Pelvic fracture:
Femur fracture:
Tibia/fibula fracture:
Hematomas and contusions:
2,000 mL
1,500 mL
500–750 mL
500 mL
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Management
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Specific Wound Considerations
(1 of 2)
Head Wounds
Neck Wounds
– Presentation
– Presentation
Severe bleeding
Skull fracture
– Management
Gentle direct
pressure
Fluid drainage from
ears and nose
Large vessel can
entrap air
– Management
Consider direct
digital pressure
Occlusive dressing
DO NOT pack
Cover and
bandage loosely
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Specific Wound Considerations
(2 of 2)
Gaping Wounds
– Presentation
Multiple sites
Gaping prevents
uniform pressure
– Management
Bulky dressing
Trauma dressing
Sterile, nonadherent surface to
wound
Compression
dressing
Crush Injury
– Presentation
Difficult to locate
source of bleeding
Normal hemorrhage
control mechanism
non-functional
– Management
Consider an airsplint and pressure
dressing
Consider tourniquet
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Transport Considerations
Consider rapid transport:
– Suspected serious blood loss
– Suspected serious internal bleeding
– Decompensating shock
AMS, pulse, narrowing pulse pressure
– WHEN IN DOUBT, TRANSPORT.
Other Considerations
– Sympathetic response
– Anxiety
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Management (1 of 2)
Airway and Breathing
–
–
–
–
–
NRB
PPV (overdrive respiration)
ET
CPAP
PEEP
Hemorrhage Control
Fluid Resuscitation
–
–
–
–
–
Any injury to the
head or torso is
ALSO considered an
injury to the spine.
Catheter size and length
Large bore
20 mL/kg of NS or LR
Polyhemoglobins
STABILIZE VITALS to SBP of 80 mmHg or 90 mmHg in head
injuries.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Management (2 of 2)
Temperature Control
– Conserve core temperature
– Warm IV fluids
PASG
– Action
Increase PVR
Reduce vascular volume
Increase central CBV
Immobilize lower extremities
– Assess
Pulmonary edema
Pregnancy
Vital signs
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Management
Permissive Hypotension
– Traditional-establishing large-bore IVs (preferably
bilaterally) and then rapidly infuse crystalloids.
– Formula-use the systolic blood pressure (SBP), heart rate
(HR) or both. Abnormal ,use IV crystalloids, bring
measurement back to an expected number.
– The question should be: What is the best resuscitation
strategy to keep the victim alive until hemostasis can be
achieved?
– SBP measurement
– Two Studies
JAMA-MAP of 50
HypoRESUS-Systolic of 70 with 250 bolus
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Management
TXA
–
–
–
–
–
Tranexamic Acid
Anti-Clot buster
CRASH 2 (piggyback)/ MATTERs (SIVP)
Caution
Class I recommendation in the U.S.
military’s Tactical Combat Casualty Care
guidelines
Bledsoe et al., Paramedic Care Principles & Practice Volume 4:Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ