Bleeding and Shock

1. Bleeding and Shock

2. Blood loss Body blood volume 9 lb newborn 12 oz coke can 60 lb child 2 liter bottle 125 lb adult 2 2-liter bottles

3. Circulatory System Responsible for distribution of blood to all parts of the body • Heart • Arteries • Capillaries • Veins • Perfusion • Hypoperfusion • Functions of the blood

4. Heart • Muscular organ that pumps blood, which supply oxygen and nutrients to the cells of the body • Arteries Carry oxygen-rich blood away from the heart • Capillaries Oxygen-rich blood is emptied from arteries into microscopically small capillaries, which supply every cell of the body

5. Veins Carry blood that has been depleted of oxygen and loaded with CO2 and wastes from capillaries • Perfusion Adequate blood throughout, which fills the capillaries and supplies the cells and tissues with oxygen and nutrients

6. Hypoperfusion aka shock Inadequate perfusion of the body’s tissues with oxygen and nutrients Functions of the blood • Transportation of gases • Nutrition • Excretion • Protection • Regulation

7. Bleeding Hemorrhage • Severe bleeding is a major cause of shock • During S A M P L E ask if on blood thinners i.e. coumadin, Plavix

8. External Bleeding • Use standard precautions • Classifications Arterial bleeding Venous bleeding Capillary

9. Severity of external bleeding • Physical size of the patient • Natural response constriction of vessels and clotting restrictive clothing

10. Care • ABCs • Standard precautions • Assess circulation radial pulse skin color temperature and condition

11. Control ; methods • Direct pressure • Elevation • Pressure points • Splinting *sharp ends of broken bones may cause tissue and vascular injury *Stabilizing may prevent further injury

12. Cold packs • PASG • Tourniquet • Blood pressure cuff • Provide O2

13. STAGES OF HEMORRHAGE CONTROLLED VS UNCONTROLLED • Stage 1 – controlled Up to 15% intravascular loss Compensated by constriction of the vascular bed ( blood vessels of…..) Blood pressure maintained

14. Normal pulse pressure change in blood pressure seen during contraction of the heart Normal respiratory rate Normal renal output Pallor of the skin Central venous pressure normal to low

15. Central Venous Pressure: reflects the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system. measured by connecting the patient's central venous catheter to a special infusion set which is connected to a small diameter water column. If the water column is calibrated properly the height of the column indicates the CVP.

16. STAGE 2 15 – 25% intravascular loss Intravascular loss: loss of blood volume; volume of blood plasma Cardiac output cannot be maintained by arteriolar constriction

17. Reflex tachycardia: heart beats faster in order to raise b/p. Increased respiratory rate Blood pressure maintained Catecholamines (epinephrine) increase peripheral resistance

18. Peripheral Resistance: Vascular resistance is a term used to define the resistance to flow that must be overcome to push blood through the circulatory system.

19. Increased diastolic pressure Narrow pulse pressure Diaphoresis from sympathetic stimulation Renal output almost normal

20. STAGE 3 – uncontrolled 25 – 35% intravascular loss Classic signs of hypovelemic shock Marked tachycardia Marked tachypnea Decreased systolic pressure 5 – 15 ml/hr urine output AMS Diaphoresis with cool, pale skin

21. STAGE 4 Loss >35% Extreme tachycardia Pronounced tachypnea Significantly decreased systolic b/p Confusion and letargy Skin is diaphoretic, cool, and extremely pale

22. ASSESSMENT • Bright red blood from wound, mouth, rectum, or other orifice • Coffee ground emesis • Melena; black tarry stool • Hematochzia; Maroon colored stool • Dizziness

23. Dizziness or syncope on sitting or standing Orthostatic hypotension Orthostatic hypotension: a form of hypotension in which a person's blood pressure suddenly falls when the person stands up. The decrease is typically greater than 20/10 mmHg

24. Signs and symptoms of hypovelemic shock • MANAGEMENT • ABCs • Bleeding from nose or ears after head trauma: Refrain from applying pressure Apply loose sterile dressing to protect against infection

25. Bleeding from other areas Control bleeding Direct pressure Elevation if appropriate Pressure points Tourniquet Splinting Apply sterile dressing and pressure dressing

26. Transport considerations • Psychological support/communication

27. PATHOPHYSIOLOGY, ASSESSMENT AND MANAGEMENT OF SHOCK • Shock Epidemiology: cause, factors morbidity / mortality Prevention strategies Pathophysiology: any disturbances of body functions

28. Perfusion • Depends on cardiac output, systemic vascular resistance and transport of oxygen • Cardiac output = HR x SV • Stroke Volume: amount of blood ejected in one cardiac contraction

29. BP = CO x SVR SVR:

30. Hypoperfusion can result from: inadequate CO Excessive systemic vascular resistance Inability of RBCs to deliver O2 to cells

31. Compensation for decreased perfusion • Baroreceptors sense decreased flow and activate vasomotor center Baroreceptors: sensors located in the blood vessels detects the pressure of blood flowing through them, and can send messages to the central nervous system to increase or decrease total peripheral resistance and cardiac output

32. Vasomotor center: a portion of the medulla oblongata that regulates blood pressure Normally stimulated between 60-80 mmHg systolic (lower in children) Located in carotid sinuses and aortic arch

33. Decrease in systolic pressure less that 80 mmHg stimulates vasomotor center to increase arterial pressure • Chemoreceptors are stimulated by decrease in PaO2 and increase in PaCO2

34. Chemoreceptors: • Chemoreceptors in the medulla oblongata, carotid arteries and aortic arch, detect the levels of carbon dioxide in the blood, in the same way as applicable in the Breathing Rate section. • In response to this high concentration, a nervous impulse is sent to the cardiovascular centre in the medulla, which will then feedback to the sympathetic ganglia, increasing nervous impulses here, and prompting the sinoatrial node to stimulate more contractions of the myogenic cardiac muscle, increasing heart rate by causing the secretion of nor-adrenaline directly on to the sinoatrial node.

35. Failure of compensation to preserve perfusion Preload (pressure within the ventricles during diastole ; influences the force of the next contraction) decreases Cardiac output decreases Myocardial blood supply and oxygenation decrease

36. Myocardial perfusion decreases • Cardiac output decreases further • Coronary artery perfusion decreases • Myocardial ischemia

37. Capillary and cellular changes – ischemia – minimal blood flow to capillaries • STAGES OF SHOCK • Compensated or nonprogressive Characterized by signs and symptoms of early shock Arterial b/p normal or high Treatment will typically result in recovery

38. DECOMPENSATED OR PROGRESSIVE • Characterized by signs and symptoms of late shock • Arterial blood pressure is abnormally low • Treatment sometimes result in recovery

39. IRREVERSIBLE • Characterized by signs and symptoms of late shock • Arterial blood pressure is abnormally low • Even aggressive treatment does not always result in recovery

40. Hypovelemic • Hemorrhage • Plasma loss • Fluid and electrolyte loss • Shock may be the result of hidden volume loss chest injury abdominal injury other violent injury

41. Treatment Focus primarily on volume replacement • ASSESSMENT • Early or compensated Tachycardia Pale, cool skin diaphoresis

42. LOC Normal Anxious or apprehensive • B/P maintained • Narrow pulse pressure systolic – diastolic reflects tone of the arterial system

43. Positive orthostatic tilt test lie, sit, stand • Dry mucosa • Complaints of thirst • Weakness Possible delay of capillary refill

44. LATE OR PROGRESSIVE DECOMPENSATED / UNCOMPENSATED • Extreme tachycardia • Extreme pale, cool skin • Diaphoresis • Significant decrease in LOC • Hypotension • Dry mucosa • Nausea

45. Cyanosis with white waxy-looking skin • IRREVERSIBLE • Becomes bradycardic • Profound hypotension B/P continues to fall in spite of interventions

46. Management • ABCs • Hemorrhage control • Intravenous volume expanders Types isotonic hypertonic synthetic Rate of administration

47. External hemorrhage that can be controlled • External hemorrhage that cannot be controlled • Internal hemorrhage blunt trauma penetrating trauma • Volume needed for replacement

48. Transport considerations indications for rapid transport indications for transport to a trauma center considerations for air medical transportation

49. Special situations involving bleeding Head injury • Do not apply pressure to ears and nose but allow drainage to flow freely Nosebleed • Have pt. sit and lean forward • Direct pressure • Keep calm and quiet • Do not let pt. lean back • If pt. is uncomfortable; recovery position, prepare to suction and manage airway

50. Internal Bleeding • Perform a through history and exam Mechanism of blunt trauma that may cause internal bleeding • Falls • MVA or motorcycle crashes • Auto-pedestrian collisions • Blast injuries