Bleeding and Shock

1. Bleeding and Shock Pipes, pump, and fluid…really, it’s that simple!

2. The Second Rule of EMS…. …eventually the bleeding will stop!

3. Cardiovascular System Heart Arteries Veins Capillaries Blood

4. Cardiovascular System • Transports O2 and fuel to the cells, tissues, and organs. • Removes CO2 and wastes from the cells for elimination from the body. • Must be able to maintain sufficient flow through the capillary beds to meet the cell’s O2 and fuel needs

5. Internal External Bleeding

6. Internal Bleeding Trauma Clotting disorders Rupture of blood vessels Fractures (injury to nearby vessels) Can result in rapid progression to hypovolemic shock & death!

7. Internal Bleeding S/S Think about MOI or NOI! Anxiety, restlessness, irritability Pale, diaphoretic skin Sustained tachycardia Hypotension Unstable vitals signs (postural changes)

8. Internal Bleeding S/S Vomiting bright red blood or coffee ground material Bleeding form any body orifice Dark, tarry stools (melena) Tender, rigid, or distended abdomen Pain, discoloration, swelling, tenderness at injury site

9. Managing Internal Bleeding ABC’s High concentration oxygen Assist ventilations Control external bleeding Stabilize fractures RICE Transport rapidly to appropriate facility

10. External Bleeding • Arterial Bleed • Bright red, spurting • Venous Bleed • Dark red, steady flow • Capillary Bleed • Dark red, oozing

11. Control of External Bleeding Direct Pressure: Gloved hand Or Dressing and bandage

12. Control of External Bleeding Elevation: Raise extremity above the level of the heart

13. Control of External Bleeding Pressure Dressing: Use bandage to secure dressing in place

14. Arterial Pressure Points • Upper extremity: • Brachial • Radial • Lower extremity: • Femoral • Popliteal

15. Tourniquets Final resort when all else fails Used for amputations 3-4” wide (blood pressure cuffs) Write “TK” and time of application on forehead of patient Notify other personnel Once applied, DO NOT REMOVE

16. Epistaxis (Nosebleed) • Causes • Fractured skull • Facial injuries • Sinusitis, other URIs • High BP • Clotting disorders • Digital insertion (nose picking)

17. Management of Epistaxis Sit up, lean forward Pinch nostrils together Keep in sitting position Keep quiet Apply ice over nose (15 min) Can result in life-threatening blood loss!

18. SHOCK Inadequate perfusion(blood flow) leading to inadequate oxygen delivery to tissues

19. Physiology • Cell is the basic unit of life • Cells get energy needed to stay alive by reacting oxygen with fuel (usually glucose) • No oxygen, no energy • No energy, no life

20. Perfusion Failure Pump Failure (heart) Pipe Failure (vessels) Loss of Volume (blood)

21. Stages of Shock Compensated Shock Decompensated Shock Irreversible Shock

22. Compensated Shock • Body still compensates for blood loss • Pulse rate increases • Pulse strength decreases • Pale, diaphoretic skin • Anxiety, restlessness, combativeness • Thirst, weakness, eventual air hunger

23. Decompensated Shock • Body compensatory mechanisms fail • Unpalpable pulse • Precipitous drop in blood pressure • Patient becomes unconscious • Respirations slow or cease

24. Irreversible Shock • Lack of circulation causes: • Cellular death • Tissue dysfunction • Organ dysfunction • Patient death

25. Shock: Etiology

26. Psychogenic • Hypovolemic • Distributive • Obstructive • Cardiogenic • Respiratory • Neurogenic

27. Psychogenic Shock • Simple fainting (syncope) • Caused by stress, fright, pain • Heart rate slows, vessels dilate • Brain becomes hypo-perfused • Loss of consciousness occurs • Patient usually recovers by self

28. Psychogenic Shock S/S • Anxiety, restlessness, irritability • Rapid pulse • Normal or low blood pressure • Hyperventialtion

29. Hypovolemic Shock • Loss of volume • Causes: • Blood loss from trauma • Plasma loss from burns • Fluid/electrolyte loss from vomiting, diarrhea, sweating, increased urine output, increase respiratory loss • “Third space” fluid shifts

30. Hypovolemic Shock S/S • Anxiety, restlessness, irritability • Rapid, weak pulse • Change in mental status • Signs of inadequate perfussion (diaphoresis, cyanosis, pale/clammy skin) • Increased respiratory rate

31. Distributive Shock: Septic • Results from body’s response to bacteria in bloodstream • Vessels dilate, become “leaky”

32. Distributive Shock: Septic S/S • Anxiety, restlessness, irritability • Febrile, warm skin • Hypotension • Tachycardia • Increased respiratory rate • Change in mental status

33. Distributive Shock: Anaphylactic • Results from severe allergic reactions • Body responds to allergen by releasing histamine • Histamine release causes vessels to dilates and become “leaky

34. Distributive Shock:Anaphylactic S/S • Sudden onset • Mild itching, rash, uticaria, hives • Burning sensation (skin) • Hypotension • Generalized edema • Angiodema, airway compromise • Respiratory distress • Coma, rapid death

35. Obstructive Shock • Interference with blood flow through the cardiovascular system • Tension pneumothorax • Cardiac tamponade • Pulmonary embolism

36. Obstructive Shock S/S • Anxiety, irritability, restlessness • Weak, irregular pulse • Chest pain, shortness of breath • Hypotension • Pale, cool, clammy skin • JVD, discoloration above nipple line

37. Cardiogenic Shock • Pump failure • Heart’s output depends on • How often it beats (heart rate) • How hard it beats (contractility) • Rate or contractility problems cause pump failure

38. Cardiogenic Shock S/S • Causes • Acute myocardial infarction • Very low heart rates (bradycardias) • Very high heart rates (tachycardias) Why would a high heart rate caused decreased output? Hint: Think about when the heart fills.

39. Cardiogenic Shock S/S • Chest pain • Weak, irregular pulse • Hypotension (HTN with CHF) • Cyanosis, signs of inadequate perfusion • Cool, clammy skin • Anxiety

40. Respiratory Shock • Failure of respiratory system to supply oxygen to or remove CO2 from the alveoli • Airway obstruction • Flail chest, SCW • Pneumothorax • Respiratory muscle paralysis

41. Respiratory Shock S/S • Anxiety, restlessness, irritability • Rapid, weak pulse • Hypotension • Change in mental status • Signs of inadequate perfussion • Increased respiratory rate • Bronchoconstrcition (wheezes)

42. Neurogenic Shock • Spinal cord injuries that result in the interruption of communication pathways between CNS and rest of body • Vessels below the injury site dilate leading to decreased vascular resistance

43. Neurogenic Shock S/S • Anxiety, restlessness, irritability • Bradycardia • Hypotension • Skin above injury site: pale, cool, clammy • Skin below injury site: warm, pink, dry • Signs of spinal injury

44. Treatment • ABC’s • Apply O2, assist ventilations as needed • Keep patient in position of comfort • Control bleeding, stabilize fractures • Prevent loss of body heat • Assist with medications • Nothing by mouth • Calm and reassure

45. Treatment • Elevate lower extremities 8 to 12 inches in hypovolemic shock • Do NOT elevate the lower extremities in cardiogenic shock Why the difference in management?

46. Shock is NOT the same as low pressure A falling blood pressure is a LATE sign of shock!