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Chapter 18
Bleeding and Shock
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Topics
Bleeding
Shock
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding
Protection against infection
How the body responds to blood loss
External bleeding
Internal bleeding
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding
Protection against infection
– Body substance isolation
Gloves
Protective eyewear and mask as indicated
Keep open wounds covered
Hand washing
Decontamination
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding
How the body responds to blood loss
– Serious bleeding
1 liter in an adult
0.5 liters in a child
100–200 cc in an infant
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding
How the body responds to blood loss
– Determining severity
Size of blood vessel and how fast it is
bleeding
Arterial versus venous bleeding
Internal versus external bleeding
If the bleeding is a threat to airway or
breathing
The patient’s physical condition
Bleeding is severe when pulse or respirations
increase, mental status changes, skin color
becomes pale
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding
External bleeding
– Types of bleeding
– First Responder care
– Other methods of bleeding control
– Nosebleeds
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding
External bleeding
– Types of bleeding
Arterial
Venous
Capillary
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding
External bleeding
– Arterial
Bright red
Spurting
Coincides with the patient’s pulse
Difficult to control
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding
External bleeding
– Venous
Dark red
Flows steadily
May be profuse, easier to control
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding
External bleeding
– Capillary
Dark red
Oozes slowly
Usually clots spontaneously
Can be profuse if large area is involved
May have a high risk of infection
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding
External bleeding
– First Responder care
Apply direct pressure with
hand and gauze
Elevate the extremity above
the level of the heart
Apply another dressing if the
patient bleeds through the
first one
Use pressure points
Support the patient as
needed
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding
External bleeding
– Other methods of bleeding control
Splints
Prevents movement of fracture site to prevent
further damage to blood vessels
Tourniquets
Last resort when other methods fail to control
bleeding
Can result in loss of the extremity
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding
External bleeding
– Tourniquets
Use a bandage 4’’ thick and 6–8 layers deep
Wrap the extremity twice as close to the wound as
possible
Tie off bandage, place a rod above the knot and tie
again
Twist until the bleeding stops and tie off the rod
Document the time and report it to transporting EMS
providers
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding
External bleeding
– Nosebleeds
Can result in shock
or threats to airway
and breathing
Position the patient
Pinch the nostrils
Apply a cold
compress
Exceptions with
nasal fractures or
skull fractures
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding
Internal bleeding
Patient assessment
First Responder care
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding
Internal bleeding
– Concealed inside the body
– Results from damage to internal organs
– Caused by blunt or penetrating trauma
– Abnormal clotting
– Ruptured blood vessels
– Fractures
– Can be severe
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding
Internal bleeding
– Patient assessment
Signs and symptoms
Discolored, tender, swollen, or hand tissue
Pale, cool, clammy skin
Vomiting of bright red or dark blood
Mental status changes
Dark tarry or bright red stools
Changes in vital signs
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding
Internal bleeding
– First Responder care
Maintain open airway and adequate breathing
Control external bleeding
Keep patient warm
Treat for shock
Comfort the patient
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Shock
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Shock
Types
Patient assessment
First Responder care
Anaphylactic shock
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Shock
State of hypoperfusion
– Results from inadequate delivery of
oxygen and nutrients to the cells
– Caused by
Failure of the heart
Abnormal dilation of the blood vessels
Blood volume loss
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Shock
Patient assessment
– Compensated
– Decompensated
– Irreversible
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Shock
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Shock
Compensated shock
– Maintain normal function
– Pale skin
– Slightly rapid
heart rate
– Normal blood
pressure
– Anxiety
– Delayed capillary
refill in infant or child
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Shock
Decompensated shock
– Body can no longer compensate for hypoperfusion
– Blood shunted to keep vital organs perfused
Tissue in extremities
produce toxic by-products
Mental status changes
Increase heart rate
Decreased blood
pressure (late sign)
Cool, moist skin that
is pale, gray or cyanotic,
and mottled
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Shock
Irreversible shock
– Cells die
– Blood further shunted to brain and heart
– Unable to maintain blood pressure causing
blood to pool
Extremely low blood pressure
Very rapid heart rate
– Vital organ damage is permanent
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Shock
First Responder care
–
–
–
–
–
Maintain open airway and adequate ventilations
Prevent further blood loss
Elevate lower extremities
Prevent heat loss
Provide specific care and calm the patient
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Shock
Anaphylactic shock
– Patient assessment
Skin
Respiratory system
Circulatory system
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Shock
Anaphylactic shock
– Caused by severe allergic reaction
May have respiratory or circulatory
compromise, or both
The faster the onset of symptoms, the greater
the risk of a fatal reaction
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Shock
Anaphylactic shock
– First responder care
Ensure ALS response
Treat life-threats
Maintain open airway and adequate ventilations
Assist patient with epinephrine auto-injector
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Summary
Ensure appropriate BSI precautions
Determine severity of blood loss and
types of bleeding
Control the bleeding as appropriate
Provide care as needed for both
internal and external hemorrhage
Assess for and appropriately treat
patients with shock
Limmer, First Responder: A Skills Approach, 7th ed.
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ