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Chapter 25 Bleeding and Shock Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 1 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. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 2 Control Bleeding External bleeding Direct pressure Pressure point Tourniquets Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 3 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 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 4 Anatomy and Physiology Review Three major components of circulatory system: The blood The heart The blood vessels Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 5 Heart and Great Vessels Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 6 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 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 7 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 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 8 Chambers of the Heart Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 9 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 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 10 Systemic and Pulmonary Circulation Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 11 Arteries, Capillaries, and Veins Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 12 Major Systemic Arteries Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 13 Capillaries Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 14 Major Systemic Veins Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 15 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. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 16 Stroke Volume Amount of blood ejected from ventricle with each beat Approximately 70 ml Related to: Adequate contraction Venous return Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 17 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. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 18 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 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 19 Pressures in the Circulatory System Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 20 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 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 21 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 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 22 Skin Signs Associated with Epinephrine Release Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 23 Personal Precautions Eye protection Gloves Gown Mask Hand washing after each patient contact Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 24 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 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 25 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. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 26 Types of Bleeding Arterial Spurts from wound Bright red Most difficult to control Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 27 Types of Bleeding Venous Flows as steady stream Dark red Can be profuse Easy to control, in most cases Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 28 Types of Bleeding Capillary Oozes from capillary Dark red Often clots spontaneously Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 29 Care of External Bleeding Body substance isolation Maintain airway/artificial ventilation. Bleeding control Direct pressure Elevation Pressure point Tourniquet Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 30 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. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 31 Causes of Bleeding from Ear, Mouth, and Nose Injured skull Facial trauma Digital trauma (e.g., nose picking) Sinusitis Upper respiratory tract infections Hypertension (high blood pressure) Coagulation disorders Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 32 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. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 33 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 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 34 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 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 35 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 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 36 Sites of Hidden Blood Loss Site Thorax Abdomen Femur Pelvis Skull Amount of Blood Loss % of blood volume 2 Liters 40% >1 Liter 50% >1 Liter 20% 0.5 Liters/Fracture 10%/Fracture Not significant unless infant Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 37 Shock Failure of circulatory system to adequately perfuse and oxygenate the tissues of the body Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 38 Causes of Shock Pump failure Low blood volume Vasodilation or obstruction Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 39 Shock — Severity Inadequate perfusion of cells Cell and organ malfunction and death Prompt recognition is critical Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 40 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 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 41 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 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 42 Signs and Symptoms — Shock Mental states Restlessness Anxiety Altered mental status Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 43 Vital Signs Increased pulse rate (early sign), weak, and thready Increased breathing rate Shallow Labored Irregular Decreased blood pressure (late sign) Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 44 Other Signs and Symptoms Dilated pupils Marked thirst Nausea and vomiting Pallor with cyanosis to the lips Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 45 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 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 46 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. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 47 Hypovolemic Shock Fluid or blood loss Several causes of fluid loss Vomiting Diarrhea Metabolic problems Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 48 Signs of Dehydration Thirst Lack of tearing or sweating Dry tongue Tenting of the skin Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 49 Signs and Symptoms — Hypovolemic Shock Anxiety, restlessness, combativeness, or altered mental status Weakness, faintness, or dizziness Thirst Shallow, rapid breathing Rapid, weak pulse Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 50 Signs and Symptoms — Hypovolemic Shock Pale, cool, clammy skin Capillary refill >2 seconds Decreasing blood pressure (late sign) Dilated pupils that are sluggish to respond Nausea and vomiting Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 51 Stages of Hypovolemic Shock 10% to 15% blood loss Venous constriction No signs of shock Rely on mechanism of injury to suspect criticality <30% blood loss Increased pulse rate Pale skin Delayed capillary refill (children) Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 52 Stages of Hypovolemic Shock 30% to 45% blood loss Blood pressure drops Altered mental status >45% blood loss Circulatory collapse Cardiac arrest Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 53 Emergency Medical Care Take personal protection measures. Maintain airway. Administer oxygen. Control bleeding. Elevate legs, if condition permits. Manage fractures with splints, if time permits. Maintain body temperature. Immediate transport is critical. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 54 Shock Caused by Dilated Vessels Anaphylactic Psychogenic Spinal Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 55 Septic Shock Shock is caused by massive infection. Infection causes vasodilation. Fluid leaks through blood vessel walls causing hypovolemia. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 56 Summary Evidence of bleeding in shock is elicited during patient assessment. Control of external bleeding includes Direct pressure Elevation Pressure points Tourniquet (as a last resort) Early recognition of internal bleeding and shock is critical to patient survival. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 57
