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Paramedic Care:
Principles & Practice
Volume 4
Trauma Emergencies
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Chapter 4
Hemorrhage and Shock
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Topics
Introduction to Hemorrhage and Shock
Hemorrhage
Shock
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Introduction to
Hemorrhage and Shock
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage
Hemorrhage is the loss of blood from the
vascular space
– Reduces the total blood volume
– Frequent result of trauma
– The most common cause of shock and death in
trauma patients
May be external (obvious) or internal (hard to detect)
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Circulatory System
Heart
– Two-sided
muscular pump
with four valves
and four
chambers
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Heart
Provides most of the driving force to move
blood through the cardiovascular system
– Cardiac output
Stroke volume x heart rate
– The heart rate is regulated by the autonomic
nervous system
Sympathetic
Parasympathetic
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Heart
Stroke volume is the amount of blood pumped
from the ventricle with each contraction.
Dependent on:
– Preload
– Afterload
– Cardiac contractility
The normal heart, at rest, beats about 70
times per minute and moves about 70 mL of
blood with each beat.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Circulatory System
The Vascular System
– A series of hollow tubes that distributes blood to
and from the various body tissues
– Consists of arteries, capillaries, and veins
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Arteries
Consist of three
distinct tissue layers
– Tunica adventicia
Strong, fibrous,
inelastic tissue
– Tunica media
Muscular layer
Arterioles have
greatest ability to
change diameter
– Tunica intima
Smooth inner surface
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Capillaries
Capillary flow provides
essential nutrients and
oxygen and removes
waste products.
– Only one-cell thick
Hydrostatic pressure
pushes the plasma into
the interstitial space.
– Filtration
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Veins
Collect blood and return
it to the heart
Contains the vast
majority of the total
blood volume
– Capacitance system
Able to constrict in early
stages of hemmorhage
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Circulatory System
Blood flows through the vascular system
because of the pressure differentials
– aorta> arterioles>capillaries>venous
system>vena cavae
Progressive reduction in pressure as blood is
moved through the circulatory system
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Blood
Blood is the tissue that circulates within the
cardiovascular system
– A mixture of cells, proteins, water, and other
suspended elements
Blood Volume
– Average adult male has a blood volume of 7% of
total body weight
– Average adult female has a blood volume of 6.5%
of body weight
– Normal adult blood volume is 4.5–5 L
Remains fairly constant in the healthy body
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Blood Components
Erythrocytes: 45%
– Hemoglobin
– Hematocrit
Miscellaneous
blood products:
<1%
– Platelets
– Leukocytes
Plasma: 54%
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Blood Components
Erythrocytes (RBC’s)
– The major blood cell—and the most common—is
the red blood cell.
Contains hemoglobin
A molecule to which oxygen attaches
– The red blood cell serves as an efficient
transporter of oxygen from the lungs to body cells.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Blood Components
Plasma
– Approximately 92% water
The liquid portion of blood
– Circulates salts, minerals, sugars, fats, and
proteins throughout the body
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Blood Components
Leukocytes (WBC’s)
– Defend the body against various pathogens
(bacteria, viruses, fungi, and parasites)
– Produced in bone marrow and lymph glands
Release reserves when pathogens invade the body
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Blood Components
Platelets
– Part of the body’s defense mechanism
– Formed in red bone marrow
– Work by swelling and adhering together to form
sticky plugs (initiating the clotting phenomenon)
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hemmorhage Classification
Hemorrhage is usually
classified by the type of
vessel injured
– Capillary, venous, or
arterial
Internal hemorrhage
cannot be classified by
type with the diagnostic
techniques available to
paramedics
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Clotting
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Clotting
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Clotting
The nature of the
wound also affects
how rapidly and well
the clotting
mechanisms
respond.
– Transverse wound
– Longitudinal wound
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Factors Affecting Clotting
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage Control
External Hemorrhage
– External hemorrhage is relatively easy to
recognize and control.
Bleeding from small vessels can often be controlled by
firmly bandaging a dressing in place.
Fingertip pressure
– With careful application of direct pressure you can
halt virtually all hemorrhage.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage Control
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage Control
External Hemorrhage (cont.)
– If you consider using a tourniquet, be extremely
cautious.
The need for a tourniquet is rare.
– In the absence of perfusion, lactic acid, potassium,
and other anaerobic metabolites accumulate
Will be released into the circulation when released
– Use a wide-band if considering use
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Internal Hemorrhage
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Internal Hemorrhage
Signs and symptoms that suggest significant
internal hemorrhage include:
– Bright red blood from mouth, rectum, or other
orifice
– Coffee-ground appearance of vomitus
– Melena (black, tarry stools)
– Orthostatic hypotension
Chronic hemorrhage may result in anemia
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Internal Hemorrhage Control
General
Management
– Immobilization,
stabilization,
elevation
– Epistaxis: Nose
Bleed
Causes: trauma,
hypertension
Treatment: lean
forward, pinch
nostrils
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Hemorrhage
60% of body weight is fluid
Hemorrhage can be categorized into four
progressive stages
– Each individual’s response to blood loss may vary
It is important to identify:
– The length of time elapsed since the incident
– The stage of hemorrhage the victim is in when you
arrive
– How quickly the patient is moving from one stage
to another
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Hemorrhage
Stage 1
– 15% loss of CBV (circulating blood volume)
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Hemorrhage
Stage 2
– 15–25% loss of CBV
750–1250 mL
– Early decompensation
Unable to maintain BP
Tachycardia and tachypnea
– 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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Hemorrhage
Stage 3
– 25–35% loss of CBV
1250–1750 mL
– Late decompensation (early irreversible)
Compensatory mechanisms unable to cope with loss of
blood volume
– 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 Emergencies, 3rd. Ed.
© 2009 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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Hemorrhage
Concomitant Factors
– 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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Hemorrhage
Concomitant Factors
– Children
CBV 8–9% of body weight
Poor compensatory mechanisms
– Elderly
Decreased CBV
Medications
BP
Anticoagulants
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage Assessment
Assessment of the hemorrhage patient is
directed at identifying the source of the
hemorrhage.
– Halt any serious and controllable loss.
Examine the nature of the injury.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage Assessment
Scene Size-up
– Standard
precautions are
essential
– Evaluate the
mechanism of injury
Time elapsed since
injury
Determine the
amount and rate of
blood loss
© Jeff Forster
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage Assessment
Primary 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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage Assessment
Secondary Assessment
– Rapid Trauma Assessment
Full head to toe
Consider air medical if stage 2+ blood loss
– Focused Physical Exam
Guided by c/c
– Vitals, SAMPLE, and OPQRST
– Additional Assessment
Search for signs of internal bleeding
Bleeding from body orifice, melena, hematochezia
Orthostatic hypotension
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage Assessment
Ongoing Assessment
– Reassess vitals and mental status:
Q 5 min: UNSTABLE patients
Q 15 min: STABLE patients
– Reassess interventions:
Oxygen
ET
IV
Medication actions
– Trending: improvement vs. deterioration
Pulse oximetry
End-tidal CO2 levels
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage Management
Assure that the airway is patent and breathing
is adequate.
– Maintain the airway and provide the necessary
ventilatory support.
– Administer high-flow oxygen.
Assure that the patient has a palpable carotid
pulse.
Care for serious (arterial and heavy venous)
hemorrhage, immediately after you correct
airway and breathing problems.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage Management
Direct Pressure
– Controls all but the
most persistent
hemorrhage
– If bleeding saturates
the dressing, cover
it with another
dressing
If ineffective, may be
necessary to
visualize wound to
apply pressure
directly to site
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage Management
Topical Hemostatic
Agents
– Directly applied to a
bleeding wound
– Will help to slow or
stop the bleeding
– Products include:
Celox
HemCon
QuickClot
TraumaDEX
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage Management
Elevation
– Reduces the systolic blood pressure
– Use elevation only when there is an isolated
bleeding wound on a limb
Pressure Point
– Utilizes an arterial pulse point proximal to the
wound
– Decreases blood pressure distal to wound
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage Management
Tourniquet
– Consider using a tourniquet only as a last resort
when hemorrhage is prolonged and persistent.
– Apply a blood pressure cuff just proximal to the
hemorrhage site.
Inflate to apply pressure 20-30mmHg greater than the
systolic blood pressure
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding Assessment
Click here to view an animation on bleeding assessment.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Specific Wound
Considerations
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Specific Wound
Considerations
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Transport Considerations
Consider rapid transport if:
–
–
–
–
Suspected serious blood loss
Suspected serious internal bleeding
Decompensating shock
If in doubt, rapid transport indicated
Other Considerations
– Sympathetic response
– Anxiety
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Shock
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Shock
Shock is best defined as inadequate tissue
perfusion
– Transitional stage between normal life, called
homeostasis, and death
– 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
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cellular Metabolism
Cells carry out all the functions performed by
the body
– Requires oxygen and essential nutrients such as
carbohydrates, lipids, and proteins
– Produce waste which must be removed
– Cells derive most of their energy for essential cell
tasks from a molecule called ATP
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cellular Metabolism
ATP is a product of the cellular breakdown of
glucose
– Breakdown occurs in three steps
Glycolysis
Does not require oxygen
Produces pyruvic acid and 2 ATP’s
Kreb’s Cycle
Requires oxygen
Converts pyruvic acid into water, carbon dioxide and 2 ATP’s
Electron transport chain
Occurs in mitochondria
Results in the production of 32 ATPS
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cellular Metabolism
If oxygen and glucose are in good supply, the
cell has ample energy to perform its functions
If oxygen is in short supply, the cells generate
energy only from glycolysis, thereby gaining
only a small amount of energy and
accumulating pyruvic acid
– Converts to lactic acid
– Accumulation results in metabolic acidosis
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Oxygen Transport
Transport involves ventilation, external
respiration, circulation and internal
respiration.
The environment provides 21 percent oxygen
under the normal atmospheric (at sea level)
pressure.
– Certain conditions may result in less available
oxygen.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Oxygen Transport
Air moves from the environment to the alveoli
by ventilation.
– Requires patent airways and functional “bellows”
system.
At the alveoli, oxygen must traverse the
alveolar/capillary membrane.
– Diffusion
– Movement of oxygen from the alveolus to the red
blood cell is external respiration.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Oxygen Transport
Oxygen must uptake on the hemoglobin
molecule.
– Efficiently carries 97% of the oxygen
– Remaining 3% dissolves in plasma
The cardiovascular system then moves the
red blood cells from the pulmonary system,
through the heart, through the arterial system
and into the tissues.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Oxygen Transport
In the capillaries oxygen diffuses across the
capillary wall, into the interstitial fluid and then
to the cell.
– Internal respiration
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cellular Metabolism
The cardiovascular system is also
responsible to help maintain other elements
of the homeostatic environment
– Removal of CO2 and water
– Heat regulation
– Provides the glucose necessary for the cellular
metabolism
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Digestion, Filtration, Hormone
Production, Excretion
The digestive system absorbs carbohydrates
and lipids (fats), moving them through the
portal system to the liver for processing.
The pancreas regulates blood glucose.
– Glucagon increases blood glucose
– Insulin decreases blood glucose
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Digestion, Filtration, Hormone
Production, Excretion
Role of the Kidneys
– Regulating the body’s fluid/electrolyte balance
Excreting excess sodium, potassium, chloride, calcium,
bicarbonate, and magnesium
– Excreting the waste products of metabolism
– Excrete or retain water
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Circulation
The cardiovascular system
– Responsible for assuring that the necessary
materials travel to and from the body’s cells
– Cardiac output
Preload, cardiac contractility, and afterload
Systolic blood pressure is most indicative of the strength
and volume of cardiac output
Lowest pressure in the arteries is the diastolic blood
pressure
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Circulation
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Circulation
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Microcirculation
Venules and veins serve as collecting
channels and storage vessels (capacitance)
Normally contain 70% of the blood volume
Muscular movement aids in blood return to the
heart
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Circulation
Respiration also facilitates blood return to the
heart
– Changes in pressure draws blood towards the
heart
Thoracoabdominal pump
In states of hypovolemia, blood return to the
heart is diminished
– Reduces cardiac output, arterial blood pressure,
and the body’s ability to direct blood flow to critical
organs
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cardiovascular
System Regulation
The human body is controlled by the
autonomic branch of the nervous system.
– Parasympathetic branch
– Sympathetic branch
These two systems act in balance
Many sympathetic nervous system activities
are aimed at defending the organism.
– These mechanisms may be detrimental in shock
states
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cardiovascular
System Regulation
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cardiovascular
System Regulation
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cardiovascular
System Regulation
A system of
receptors,
autonomic centers,
and nervous and
hormonal
interventions
maintains control
over the
cardiovascular
system
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cardiovascular
System Regulation
Baroreceptors in the aortic arch and in the
carotid sinuses monitor the arterial blood
pressure
Chemoreceptors monitor carbon dioxide
levels in the bloodstream
Three specific centers help regulate
cardiovascular function
– Cardioacceleratory center, the cardioinhibitory
center, and the vasomotor center
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cardiovascular
System Regulation
Hormonal Regulation
– Epinephrine and norepinephrine are sympathetic
agents
Most rapid hormonal response to hemorrhage
Both have A1 properties
causes vasoconstriction
Epinephrine has beta-1 and beta-2 properties
B1= increased rate, strength, and conductivity
B2= broncodilation
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hormonal Regulation
Antidiuretic Hormone (ADH)
– 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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hormonal Regulation
Angiotensin
– Released
Primary chemical from kidneys
Stimulus is lowered BP and decreased perfusion
– Action
Converted from renin into angiotensin I
Modified in lungs to angiotensin II
Potent systemic vasoconstrictor
Causes release of ADH, aldosterone, and epinephrine
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hormonal Regulation
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hormonal Regulation
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hormonal Regulation
Insulin
Erythropoietin
– Release
– Release
Beta cells of
pancreas
– Action
Facilitates transport
of glucose across
cell membrane
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hormonal Regulation
Adrenocorticotropic hormone
– Stimulates the release of glucocorticoids from the
adrenal cortex
Increases glucose production
Reduces the body’s inflammation response
Prolongs clotting time, wound healing, and infection
fighting processes
Growth hormone
– Promotes the uptake of glucose and amino acids
in the muscle cells
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Body’s Response
to Blood Loss
As stroke volume decreases, cardiac output
decreases resulting in decreased systolic BP
– Carotid and aortic baroreceptors recognize this
decrease in blood pressure
Stimulate the cardiovascular center of the medulla
oblongata
Mechanisms compensate for small blood
losses
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Body’s Response
to Blood Loss
Cellular Ischemia
– Constriction of arterioles means that less and less
blood is directed to the noncritical organs
Results in hypoxia
– Anaerobic metabolism results
Followed by ischemia
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cellular Ischemia
If blood loss continues, waste products
accumulate and blood becomes acidic.
– Increase in depth and rate of respirations
– Decreased LOC
– Increased circulating catecholamines causes
anxiousness, restlessness, and possibly a
combative patient
– Decreased myocardial oxygen supply
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cellular Ischemia
If the blood loss stops, the blood draws fluid
from within the interstitial space
– Up to 1 L per hour
Kidneys reduce urine output
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Body’s Response
to Blood Loss
Capillary Microcirculation
– Sympathetic stimulation and reduced perfusion to
the kidneys, pancreas, and liver cause the release
of hormones
Angiotensin II causes reduced blood flow
– Perfusion is further limited to only those organs
most critical to life
More cells begin to use anaerobic metabolism for energy
= Increased acids
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Capillary Microcirculation
The build-up of lactic acid and carbon dioxide
relaxes the precapillary sphincters
Postcapillary sphincters remain closed
Capillary and cell membranes begin to break
down
Red blood cells begin to clump together
– Rouleaux
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Body’s Response
to Blood Loss
Capillary Washout
– Acidosis finally causes relaxation of the
postcapillary sphincters
– Washout causes profound metabolic acidosis and
microscopic emboli
– Body moves quickly and then irreversibly toward
death
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Shock
Process of shock can be divided into three
stages:
– Compensated
– Decompensated
– Irreversible
Stages are progressively more serious
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Shock
Compensated
Shock
– The body is
capable of
meeting its critical
metabolic needs
through a series
of progressive
compensating
actions.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Compensated Shock
The first recognizable response to serious
blood loss is an increase in pulse rate.
– The first sign usually attributable to shock is a
narrowing pulse pressure.
Vasoconstriction causes the patient’s skin to
become pale, cyanotic, or ashen.
The victim becomes anxious, restless, or
combative.
The patient may experience air hunger and
tachypnea.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Shock
Decompensated Shock
– Mechanisms that initially compensated for blood
loss now fail
– Systolic BP drops significantly
– Increasing tachycardia and vasoconstriction are
ineffective
Vital organs are no longer perfused
– Patient displays a rapidly dropping level of
responsiveness
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Shock
Irreversible Shock
– The body’s cells are so badly injured and die in
such quantities that the organs cannot carry out
their normal functions.
– Aggressive resuscitation will be ineffective.
– The longer a patient is in decompensated shock,
the more likely he has moved to irreversible
shock.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Stages of Shock
Click here to view an animation on hypovolemic shock.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Etiology of Shock
Shock can have many causes
Classifications according to origin:
– Hypovolemic, distributive, obstructive,
cardiogenic, and respiratory
Patients in shock present with similar signs
and symptoms and suffer similar systemic
complications.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Etiology of Shock
Hypovolemic
– Caused by any significant reduction in the
cardiovascular system volume
– Causes
Hemorrhage (internal or external)
Plasma losses
Protracted vomiting, diarrhea, sweating, and urination
“Third-space” losses
Fluid shifts into various body compartments
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Etiology of Shock
Distributive Shock
– Mechanisms that interfere with the ability of the
vascular system to distribute the cardiac output
– Causes
Neurogenic
Anaphylactic
Sepsis
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Etiology of Shock
Obstructive
– Results from interference with the blood flowing
through the cardiovascular system
– Causes
Tension pneumothorax
Cardiac tamponade
Pulmonary emboli
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Etiology of Shock
Cardiogenic Shock
– Results from a problem with the cardiovascular
pump
– Causes
Infarction
Disturbances in the cardiac electrical system
Failure of the valves
Cardiac rupture
Reduced cardiac pumping action
– May present with the signs and symptoms of
myocardial infarction or pulmonary edema
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Etiology of Shock
Respiratory Shock
– Occurs when the respiratory system is not able to
bring oxygen into the alveoli and remove carbon
dioxide
– Causes
Flail chest
Respiratory muscle paralysis
Pneumothorax
Pulmonary edema
Tension pneumothorax
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Etiology of Shock
Neurogenic Shock
– Results from an interruption in the communication
pathway between the central nervous system and
the rest of the body
– Causes
Spinal injury
Skin remains warm and dry above injury site
Head injury
Temporary or permanent
– Body’s compensatory mechanisms are often
affected
Tachycardia and increased diastolic are not present
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Assessment
You must be able to recognize shock as early
as possible in your patient assessment.
Search out the signs and symptoms of shock
in each phase of the assessment process.
Carefully monitor for the development or
progression of shock.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Assessment
Scene Size-up
– Analyze the forces that caused the trauma.
Possibility of both external and internal injury.
– Look for mechanisms that might result in internal
chest, abdominal, or pelvic injuries.
– Observe for external hemorrhage.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Assessment
Initial Assessment
– Determine the patient’s level of consciousness,
responsiveness, and orientation.
– Assess the airway for patency and breathing for
adequacy.
Administer high-concentration oxygen.
– Note the heart rate and pulse strength.
Skin color and temperature.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Initial Assessment
Pulse oximetry
– If you note erratic or intermittent readings with the
device, suspect increasing cardiovascular
compensation.
Capnography
– Decreased ETCO2 levels
Reflect cardiac arrest, shock, pulmonary embolism, or
incomplete airway obstruction
– Increased ETCO2 levels
Reflect hypoventilation, respiratory depression, or
hyperthermia
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Focused History and
Physical Exam
Vary with the patient’s priority as determined
by the initial assessment
Patients who have no significant mechanism
of injury
– Perform an assessment focused on the area of
injury
Trauma patients who have signs or
symptoms of serious injury
– Continue spinal motion restriction and perform a
rapid trauma assessment
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Rapid Trauma Assessment
When you have a
trauma patient with
significant signs and
symptoms of injury,
perform a rapid
trauma assessment.
© Jeff Forster
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Rapid Trauma Assessment
Inspect and palpate the patient from head to
toe.
Pay special attention to the areas most likely
to produce serious, life-threatening injury.
Rule out the possibility of obstructive shock.
Set the patient’s priority for transport and for
injury care.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Detailed Patient Assessment
Consider the detailed physical exam only
after all priorities have been addressed and
the patient is either en route to the trauma
center or during prolonged extrication.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Ongoing Assessment
Perform serial ongoing assessments
– Mental status, airway, breathing, and circulation
– Perform the ongoing assessment every 5 minutes
in the serious trauma patient
Pay particular attention to the pulse rate and
pulse pressure
Check the adequacy and effectiveness of any
interventions you have performed
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Airway and Breathing
Management
Assure good
ventilations with
supplemental high-flow,
high-concentration
oxygen
Overdrive respiration
may be indicated with:
– Rib fractures
– Flail chest
– Spinal injury with
diaphragmatic
respirations
– Head injury
© Craig Jackson/In the Dark Photography
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Airway and Breathing
Management
Positive end-expiratory pressure (PEEP) and
continuous positive airway pressure (CPAP)
Protect the airway with an oral airway, nasal
airway or possibly, endotracheal intubation
Provide pleural decompression as necessary
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Hemorrhage Control
Provide ongoing hemorrhage control as
previously described.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Fluid Replacement
The field treatment of choice for significant
blood loss in trauma is whole blood.
– Generally not practical in the field setting
– Most practical fluid for prehospital administration is
an isotonic crystaloid
Polyhemoglobins
–
–
–
–
Contain either animal or human hemoglobin
Prolonged shelf life
Relatively inexpensive
Efficacy not well established
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Fluid Replacement
Isotonic Fluid Replacement
– The standard for shock treatment in the
prehospital setting
– Current approach to fluid administration
Begin fluid resuscitation when blood pressure falls to
below 75 percent of normal or about 90mmHg systolic.
Observe the patient’s level of consciousness and other
signs and symptoms.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Isotonic Fluid Replacement
Employ aggressive fluid resuscitation
– Use lactated Ringer’s solution or normal saline via
two lines
– Administer until blood pressure returns to 100
mmHg and the level of consciousness increases
In children, infuse 20 mL/kg of body weight
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Isotonic Fluid Replacement
Consider the internal
lumen size of both the
catheter and the
administration set
– Utilize largest bore
possible
– Catheter length and fluid
pressure
Ideal catheter for the
shock patient is relatively
short, 1 1/2" or shorter
Cautiously control fluid
volume
– Maintain V/S, don’t
increase them
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Management
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
© Craig Jackson/In the Dark Photography
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Shock Management
Pharmacological Intervention
– Pharmacological interventions are generally
limited
– Cardiogenic shock
Fluid challenge
Dopamine
– Distributive shock
Fluid challenge
Dopamine
PASG
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Summary
Introduction to Hemorrhage and Shock
Hemorrhage
Shock
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ