1 / 117

Chapter 18 Bleeding and Shock

Chapter 18 Bleeding and Shock. Pathophysiology of Hemorrhage. Hemorrhage Simply means bleeding Can range from a “nick,” to a severely spurting artery, to a ruptured spleen External bleeding (visible hemorrhage) Internal bleeding. External Hemorrhage (1 of 2). External bleeding

rusti
Download Presentation

Chapter 18 Bleeding and Shock

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Chapter 18 Bleeding and Shock

  2. Pathophysiology of Hemorrhage • Hemorrhage • Simply means bleeding • Can range from a “nick,” to a severely spurting artery, to a ruptured spleen • External bleeding (visible hemorrhage) • Internal bleeding

  3. External Hemorrhage (1 of 2) • External bleeding • Usually due to a break in the skin • Extent or severity • Bleeding from a capillary • Bleeding from a vein • Bleeding from an artery

  4. External Hemorrhage (2 of 2) • Injuries • Do not always have serious hemorrhaging • Other injuries may cause more bleeding than expected.

  5. Internal Hemorrhage (1 of 3) • Internal bleeding • As a result of trauma • Nontraumatic • Cases of GI bleeding from the upper or lower GI tract • Ruptured ectopic pregnancies • Ruptured aneurysms

  6. Internal Hemorrhage (2 of 3) • Must be treated promptly • Signs do not always develop quickly. • Pay close attention to patient complaints of pain or tenderness, development of tachycardia, and pallor. • Be alert for the development of shock.

  7. Internal Hemorrhage (3 of 3) • Management • Focuses on: • Treatment of shock • Minimizing movement of the injured or bleeding part or region • Rapid transport • Eventually will need a surgical procedure to stop the bleeding

  8. Controlled VersusUncontrolled Hemorrhage (1 of 3) • Serious emergency • Search for life-threatening bleeding. • If the hemorrhage cannot be controlled in the field • Concentrate on attempting to control the bleeding as you rapidly transport the patient

  9. Controlled VersusUncontrolled Hemorrhage (2 of 3) • External bleeding • Most can be managed with direct pressure • Arterial bleeding may take 5 or more minutes of direct pressure to form a clot. • Use of a tourniquet

  10. Controlled VersusUncontrolled Hemorrhage (3 of 3) • Internal bleeding • Most cases are rarely fully controlled in the prehospital setting. • Rapid transport • Pneumatic antishock garment/military antishock trousers (PASG/MAST)

  11. The Significance of Bleeding (1 of 5) • Blood loss • Often difficult to determine • Looks different on different surfaces • Patient’s presentation and your assessment direct your care.

  12. The Significance of Bleeding (2 of 5) • Averages • Human adult male bodies contain approximately 70 mL/kg. • Adult female bodies contain approximately 65 mL/kg. • Body cannot tolerate an acute loss of more than 20% of this total blood volume.

  13. The Significance of Bleeding (3 of 5) • Averages (continued) • If a typical adult loses more than 1 L of blood: • Significant changes in vital signs will occur. • Increasing heart and respiratory rates • Decreasing blood pressure • Infants and children

  14. The Significance of Bleeding (4 of 5) • Compensation • Depends on the rate of bleeding • Healthy adult can donate one unit of blood in a period of 15 to 20 minutes without having ill effects. • If a similar blood loss occurs in a much shorter period, hypovolemic shock may rapidly develop.

  15. The Significance of Bleeding (5 of 5) • Serious if any of the following conditions are present • A significant MOI • Poor general appearance of the patient • Signs and symptoms of shock • Significant amount of blood loss • Rapid blood loss • Uncontrollable bleeding

  16. Physiologic Responseto Hemorrhage (1 of 4) • Bleeding from an artery • Bright red • Spurts in time with the pulse • Difficult to control • Bleeding from an open vein • Much darker • Flows steadily • Easier to manage

  17. Physiologic Responseto Hemorrhage (2 of 4) • Bleeding from damaged capillary vessels • Dark red • Oozes steadily but slowly • Venous and capillary bleeding is more likely to clot spontaneously. • On its own • Bleeding tends to stop rather quickly. • Response to internal clotting mechanisms and exposure to air

  18. Physiologic Responseto Hemorrhage (3 of 4) • Hemostasis • When vessels are lacerated • Open ends of the vessel begin to narrow. • Platelets aggregate at the site. • Bleeding will not stop if a clot does not form. • Direct contact with body tissues and fluids or the external environment commonly triggers the blood’s clotting factors.

  19. Physiologic Responseto Hemorrhage (4 of 4) • Hemostatic system may fail • Medications • Severe injury • Only part of the vessel wall is cut. • Acute blood loss may result in death before vasoconstriction and clotting can help.

  20. Assessment of a Bleeding Patient (1 of 5) • Scene size-up • Begins assessment of any patient • General impression and initial assessment once the scene is deemed safe to enter • BSI • Gloves • Mask • Eyeshield • Gown

  21. Assessment of a Bleeding Patient (2 of 5) • Initial assessment • Determine the patient’s mental status. • Locate and manage immediate life threats. • Ensure that the patient has a patent airway. • If the patient has minor external bleeding, note it and move on.

  22. Assessment of a Bleeding Patient (3 of 5) • MOI • Trauma patients • May be best indicator of internal injury or bleeding

  23. Assessment of a Bleeding Patient (4 of 5) • Focused history • Elaborate on the patient’s chief complaint using the OPQRST mnemonic. • Obtain a history of the present illness using SAMPLE. • Look for signs of shock. • Ask the patient about medications and about any history of clotting insufficiency.

  24. Assessment of a Bleeding Patient (5 of 5) • Physical exam • Note the color of bleeding. • Try to determine its source. • Coffee-ground emesis • Melena • Hematochezia • Hematuria • Nonmenstrual vaginal bleeding

  25. Management of a Bleeding Patient (1 of 3) • Managing external hemorrhage • Steps to control hemorrhaging • Apply direct pressure over the wound. • Elevate the injury above the level of the heart if no fracture is suspected. • Apply a pressure dressing. • Apply pressure at the appropriate pressure point while maintaining direct pressure. • Tourniquet is generally a last resort.

  26. Management of a Bleeding Patient (2 of 3) • Bleeding from the nose, ears, and mouth • Epistaxis • May indicate a skull fracture • Applying pressure increases intracranial pressure. • Cover the bleeding site loosely with sterile gauze pad. • May contain cerebrospinal fluid

  27. Management of a Bleeding Patient (3 of 3) • Bleeding from other areas • Control bleeding through use of direct pressure and elevation. • Apply pressure dressings. • Use splints as necessary. • Pack large, gaping wounds with sterile dressings. • Keep the patient warm and in the appropriate position.

  28. Special Management Techniques (1 of 3) • Fractures • Most bleeding occurs because the sharp ends lacerate vessels, muscles, and other tissues. • As long as the fracture remains unstable, the bone end will move and continue to damage tissues and vessels. • Immobilizing is a priority in the prompt control of bleeding.

  29. Special Management Techniques (2 of 3) • Air splints • Can control the bleeding associated with severe soft-tissue injuries or fractures • Stabilize fractures • Act like a pressure dressing applied to an entire extremity rather than to a small, local area • Monitor circulation • Not appropriate for use on arterial bleeding

  30. Special Management Techniques (3 of 3) • Hemostats • May be helpful when a vessel has been severed • Simply apply hemostats to the ends of the vessel. • Tourniquets • Use for partial or complete amputation or when other methods of bleeding control have proved ineffective. • Can cause permanent damage

  31. Managing Internal Hemorrhage (1 of 2) • Definitive management • Occurs in the hospital • Prehospital management • Treating for shock and splinting injured extremities: • Keep the patient supine. • Open the airway. • Check breathing and pulse.

  32. Managing Internal Hemorrhage (2 of 2) • Prehospital management (continued) • Administer high-flow supplemental oxygen. • Assist ventilation if needed. • Splint broken bones or joint injuries. • Place blankets under and over the patient. • Consider giving pain medication. • Monitor the serial vital signs.

  33. Transportation of PatientsWith Hemorrhage • In case of hemorrhage • Not whether the patient will be transported • How fast the decision should be made • Where the patient should be taken

  34. Pathophysiology of Shock (1 of 4) • Hypoperfusion • Occurs when the level of tissue perfusion decreases below normal • Early decreased tissue perfusion may result in subtle changes long before a patient’s vital signs appear abnormal.

  35. Pathophysiology of Shock (2 of 4) • Shock • State of collapse and failure of the cardiovascular system • Creates inadequate tissue perfusion • Cannot be seen • Not a specific disease or injury • Inadequate flow of blood to the body’s cells and failure to rid the body of metabolic wastes

  36. Pathophysiology of Shock (3 of 4) • Diagnosing shock • Evaluation of a patient’s level of organ perfusion is important. • If conditions causing shock are not promptly addressed, the patient will soon die. • Severity of disease or injury overwhelms the normal compensatory mechanisms.

  37. Pathophysiology of Shock (4 of 4) • Perfusion depends on: • Cardiac output • Systematic vascular resistance • Transport of oxygen

  38. Mechanisms of Shock (1 of 6) • Normal tissue perfusion • Requires three intact mechanisms: • Heart • Blood and body fluids • Blood vessels • If any one of those mechanisms is damaged, tissue perfusion may be disrupted, and shock will ensue.

  39. Mechanisms of Shock (2 of 6) • Cardiogenic shock • Arises because of failure of the heart • Cardiac arrest is the most drastic form. • May occur secondary to: • Myocardial infarction • Cardiac arrhythmias • Pulmonary embolism • Severe acidosis • A variety of other conditions

  40. Mechanisms of Shock (3 of 6) • Hypovolemic shock • Occurs because of a loss of fluid volume • Lost as blood, plasma, or electrolyte solution • Suspect in any patient with unexplained shock. • Treat the patient for hypovolemia first.

  41. Mechanisms of Shock (4 of 6) • Neurogenic shock • Failure of vasoconstriction • Sympathetic nervous system ordinarily controls the dilation and constriction. • In certain situations • Spinal cord injury • Pulmonary embolism • Gastric overdistention

  42. Mechanisms of Shock (5 of 6) • More than one cause • More than one component of the circulatory system may be affected in case of shock. • Some types of shock always result from combined deficits from both fluid leakage into the interstitial space and vasodilation.

  43. Mechanisms of Shock (6 of 6) • High risk • Patients known to have had trauma or bleeding • Elderly people • Patients with massive myocardial infarction • Pregnant women • Patients with a possible source for septic shock

  44. Compensationfor Decreased Perfusion (1 of 6) • Maintaining blood pressure • Central homeostatic mechanism • Baroreceptors • Stimulation by systolic pressure between 60 and 80 mm Hg • Sympathetic nervous system is also stimulated.

  45. Compensationfor Decreased Perfusion (2 of 6) • In response to hypoperfusion • Renin-angiotensin-aldosterone system • Antidiuretic hormone • Triggers salt and water retention • Increase in blood pressure and cardiac output • Spleen releases RBCs that are normally sequestered.

  46. Compensationfor Decreased Perfusion (3 of 6) • As hypoperfusion persists • Myocardial oxygen demand continues to increase. • Compensatory mechanisms fail. • Myocardial function worsens. • Tissue perfusion decreases. • Fluid may leak from the blood vessels.

  47. Compensationfor Decreased Perfusion (4 of 6) • The body’s own “medicines” • Epinephrine and norepinephrine • Released by the body as part of the global compensatory state • Administered by caregivers in cases of anaphylaxis, severe airway disease, and cardiac arrest

  48. Compensationfor Decreased Perfusion (5 of 6) • The body’s “medicines” (continued) • Release of epinephrine improves cardiac output. • Alpha-1 response to release of epinephrine includes: • Vasoconstriction • Increased peripheral vascular resistance • Increased afterload from the arteriolar constriction

  49. Compensationfor Decreased Perfusion (6 of 6) • The body’s “medicines” (continued) • Alpha-2 effects ensure a regulated release of alpha-1. • Effects of norepinephrine are primarily alpha-1 and alpha-2: • Center on vasoconstriction and increasing PVR • “Golden hour of trauma”

  50. Types of Shock (1 of 4) • Impairment of cellular metabolism • Inadequate oxygen and nutrient delivery to the metabolic apparatus • Results in the inability to properly use oxygen and glucose

More Related