Bleeding and Shock

Chapter 11

Review of Circulatory System External Bleeding

– Signs and Symptoms– Care

Internal Bleeding– Signs and Symptoms– Care

Topic Overview

Topic Overview

Shock– Signs and Symptoms– Classic vs. Atypical– Care

Dressing and Bandages– Purpose and Function– Effects of improperly applied dressings,

splints and tourniquets.

Circulatory System

Review– Heart– Blood– Blood Vessels

ArteriesVeinsCapillaries

Key Terms

Perfusion– Circulation of oxygenated blood to tissues

and organs Hypoperfusion

– Inadequate circulation of oxygenated blood to tissues and organs.

Bleeding & Shock

Some Facts– Trauma is the leading cause of death for

persons aged 1 to 44.– A vital part of trauma care is recognizing

and treating signs and symptoms of bleeding and shock

– Profuse bleeding and shock are life-threatening problems requiring immediate attention

Bleeding External Bleeding

– Use Body Substance Isolation (BSI) precautions

Eye Protection, Gloves, Gown, Mask

– Always wash hands following contactWaterless cleans

Types of Bleeding

Arterial– Bright red (oxygen rich), spurting, rapid,

profuse– Clot formation is difficult– Most difficult to control– As blood pressure drops, spurting will also

drop

Types of Bleeding

Venous– Usually steady flow (under lower pressure),

can be profuse– Dark red oxygen poor– Debris and air can be sucked into

wound– Clotting rate is dependent on size of area

or vessels involved– Bleeding easier to control

Types of Bleeding

Capillary– Slow (oozing)– Dark red– Good chance of infection– Clots easily

Blood Loss

Severity– Signs & symptoms of hypoperfusion– General impression of amount of loss– Severe or uncontrolled blood loss will lead

to Shock (Hypoperfusion) and possibly death

– Most Bleeding will stop by itself within 6-10 minutes (dependent on area of involvement and vessels involved, vasoconstriction & clotting)

External Severity

Age Group

Average Blood Volume

Serious Volume Loss (Rapid)

Adult 5 – 6 liters 1 liter

Adolescent

2 – 3 ½ liters ¾ liter

Child 1 ½ - 2 liters 1/2 liter

Infant 500-600 ml 100-200 cc

Care for External Bleeding

Care– Body Substance Isolation Precautions– Maintain airway– Cover wound with a clean dressing to

reduce risk of infection– Follow basic steps for controlling bleeding

Bleeding Control

Direct Pressure Elevation Pressure Bandage Pressure Points Absolute last resort - Tourniquet

Pressure Points

Arterial pressure points – Brachial – Femoral

Summon EMS if bleeding cannot be controlled or if pressure points must be used

Supplemental Methods of Controlling Bleeding

Splints– Pressure splints (air splints)

Supplemental Methods of Controlling Bleeding

Tourniquet Precautions– Wide versus narrow bandage– Do Not remove or loosen– Leave it in open view– Do not apply over a joint

External Bleeding

Special Areas– Bleeding from the nose, ears or mouth

Potential causes– Skull fractures

– Facial fractures

– Sinusitis (& other URT infections)

– Hypertension

– Coagulation Disorders If bleeding or CSF is coming from the ears do not stop

flow If CSF is coming from the nose DO NOT stop flow

External Bleeding

If bleeding from a head wound that resulted from a fracture DO NOT apply direct pressure, do not attempt to stop bleeding, cover with a bulky dressing

– Care for a Nosebleed Sitting position leaning slightly forward Apply direct pressure (may take 15 min.)

– Pinching nose or rolled gauze under nose– Cold compresses– Do not

Pack nose Blow nose or Tilt head back

Dressings & Bandages

Dressings (should be sterile)– Placed directly on wound– Absorbs blood and other fluids– Reduces risk of infection– Types

2 X 2, 4 X 4CompressUniversalOcclusive

Dressings and Bandages

Bandages– Holds dressings in place– Helps protect wound from infection– Provides support to injury– Types

TapeRoller bandages (widths: 1 to 6 inches)

– (Elastic not usually used for bleeding injuries)Triangular bandage

Internal Bleeding

Severity Based On– Mechanism of Injury– Clinical Signs and

Symptoms

Internal Bleeding

Relationship to Mechanism of Injury (MOI)– May not be obvious, may take time for signs &

symptoms to appear– Blunt Trauma

Falls Motorcycle crashes Pedestrian impacts Blast injuries Look for contusions, abrasions, deformity. Impact marks, &

swelling

– Suspect internal bleeding in any serious injury

Internal Bleeding

Signs and Symptoms– Significant MOI– Bruising (Contusion)

contusions over abdomen or chest the size of your fist - assume a 10% blood volume loss

– Painful, swollen, deformed extremities– Anxiety & restlessness– Bleeding from mouth, ears, nose, rectum,

vagina, or other orifice

Internal Bleeding

Signs & Symptoms– Tender, rigid and/or distended abdomen– Rebound tenderness– Vomiting Blood

Bright RedCoffee-ground color or consistency

– Blood in stoolBright redDark, tarry

Internal Bleeding

– Nausea and vomiting– Combativeness, clearly altered mental

status– Weakness, faintness, dizziness– Excessive thirst– Cool, clammy skin – Pale or ashen skin leading to cyanosis– Shallow rapid breathing

Internal Bleeding

– Weak rapid pulse– Delayed capillary refill– Dilated sluggish pupils (late sign)– Dropping blood pressure (late sign)

Internal Bleeding

Care– Body Substance Isolation– Airway care and oxygen– Immediate transport to an appropriate

facility– Apply direct pressure if injured area is on

an extremity– Splint extremity

Internal Bleeding Care

– For minor internal bleeding (bruising)Apply cold compresses, reduce movement

Shock (Hypoperfusion)

Signs of Shock appear LATE

Waiting for signs to appear beforerecognizing and treating may result

in the DEATH of your patient

Shock (Hypoperfusion) Shock

– Results from the body’s inability to maintain adequate perfusioninadequate removal of metabolic waste products

– May develop from internal or external blood loss

– Peripheral perfusion is reduced due to the reduction in circulating blood volume

Shock (Hypoperfusion)

– Reduced perfusion results in malfunction of cells and organs

– Shock that is not recognized and treated may result in death

– Body tries to compensate by shunting blood away from areas of lesser need to greater needs

Explains order of signs and symptoms

Shock (Hypoperfusion)

– Signs & symptoms may be present immediately, become evident during the physical exam or an ongoing assessment

Shock

Signs and Symptoms– Restlessness, changes in mental status– Pale, cool, clammy skin– Nausea and vomiting– Increased pulse rate– Increased respiratory rate

Decreasing blood pressure is a LATE sign

Shock

– Dilated pupils– Thirst– Cyanosis– Delayed capillary refill time

Infants and Children– Maintain blood pressure with up to 40%

blood volume loss– By the time their pressure drops they are

near DEATH

Care for Shock

Body Substance Isolation Activate EMS Ensure patent airway, administer oxygen Stabilize spine Control any external bleeding Elevate lower extremities 8-12 inches

(when indicated) Prevent loss of body heat NPO (food nor drink)

Care for Shock

Position patient– Supine with legs elevated 8-12 inches

unlessAnaphylactic shock - uprightCardiogenic shock - upright or semi-recumbentNeurogenic shock - supineLower extremity or pelvic injuries - supine

Specifics of Shock

Classifications– Hypovolemic - volume loss

Hemorrhagic - most commonNon-hemorrhagic – vomiting, diarrhea, etc.

– Cardiogenic ShockIneffective pump

Specifics of Shock

– ObstructiveTension pneumothorax, pulmonary contusion,

cardiac tamponade, pulmonary embolus

– DistributiveLoss of vascular tone due to sepsis, spinal

injury, anaphylaxis

Classic Presentation

24 y/o male with GSW to RUQ– Anxious

– Pale, Cool, Moist skin

– BP 88/50– P – 140, Thready– R – 24, Shallow

– Decreased cerebral perfusion

– Vasoconstriction

– Volume loss– Vasoconstriction– Hypoxemia, Acidosis

Presentation of Classic Shock

– At a Blood Loss of 10% - 15%Compensatory Effect

– Veins contract

Signs and Symptoms– None to transient

Presentation of Classic Shock

– At a Blood Loss of up to 30%Compensatory Effect

– Epinephrine response– Arteries constrict to maintain BP

Reduced blood flow to skin, gut & muscle Increased heart rate

Signs and Symptoms– Anxiety– Rapid, pulse becoming more thready with increased

volume loss

Presentation of Classic Shock

– At a Blood Loss of up to 30%Signs and Symptoms con’t.

– Cool, pale, clammy skin– Thirst– Weakness, faintness or dizziness– Rapid, shallow breathing– Delayed capillary refill– Normal BP

Presentation of Classic Shock

– At a Blood Loss of 30% to 45%Compensatory Effect

– Decompensation– Cardiac output falls to half of normal

Signs and Symptoms– Hypotension– Deteriorated mental status

Combativeness, restlessness– Rapid, shallow, (air-hungry) respirations

Presentation of Classic Shock

– At a Blood Loss Greater Than 45%Signs and Symptoms

– Fall in BP Total circulatory collapse

– Cardiac arrest

– Infants and ChildrenMaintain blood pressure until blood volume loss

is more than 40% Decompensate rapidly

Atypical Presentation

Caused by– Pathogenesis of Specific Type of Shock– Some Medications– Previous Medical History

Non-hemorrhagic Hypovolemic Shock

Non-hemorrhagic Hypovolemic– Loss of fluid other than blood– Diarrhea, vomiting, dehydration

Atypical Signs & Symptoms– Warm – low grade 101oF, (often febrile), dry skin– Vital signs may be normal (if supine); orthostatic

hypotension Respirations may vary due to acidosis

– Vomiting – tend to become alkaline – respirations will be more shallow

– Diarrhea – loss of carbs – tend to become acidic – respirations tend to be deeper

Cardiogenic Shock

Cardiogenic Shock Classic Presentation– Heart damage (AMI)

Chest painPulmonary edemaSlow to normal heart rate

Cardiogenic Shock

Cardiogenic Shock Atypical Presentation?– Chest pain– Normal to rapid heart rate– No pulmonary edema – Normal to low blood pressure– Jugular vein distention

Obstructive Shock

Tension pneumothorax– Look for JVD

Pulmonary embolus Cardiac Tamponade Medication effects

– Anti-hypertensivesBeta blockers

– May block beta 1 (sympathetic response) and mask signs of shock

Obstructive Shock

Medical History– Hypertension– BP may be normal, but what’s normal– Pregnancy

Increased circulating volume of 50%Early signs of shock are late signs of shock

– Spleen removedDon’t compensate as well

– Won’t see general decline, will crash quickly

Distributive Shock

Septic Anaphylactic Neurogenic Atypical Signs & Symptoms

– Pink, Warm, Dry skin– Rapid Capillary refill <1/2 – 1 sec.– Respirations vary

Distributive Shock

Septic Shock– Result of infection

Common causes - UTI / Pneumonia– Exotoxins cause vasodilation– Altered mental status, may be sudden– Rapid capillary refill, warm, dry skin– Normal BP with widened pulse pressure (120/50)

or hypotension– Bounding pulse

Distributive Shock

Septic Shock– Dehydration may alter presentation

Mechanism may be rapid respirations, fever, or decreased fluid intake

No rhonchi with pneumonia

Distributive Shock

Neurogenic Shock– Easily missed– Pathogenesis unique

Damage to medulla or spinal cordCan also be caused by spinal anesthesia

Distributive Shock

Sympathetic vs. Parasympathetic– Thoracolumbar vs. Cervicosacral– Injury location determines signs &

symptoms– May lose entire sympathetic system

Can result in bizarre presentation

Distributive Shock

Assessment of Neurogenic Shock– Pink, warm, dry skin below injury– Bradycardia or normal heart rate– Constricted pupils ( non-reactive)– Diaphragmatic or absent breathing– Severe hypotension– Diarrhea– Paralysis

Distributive Shock Anaphylaxis

– Life threatening allergic reaction that causes shock and airway swelling

– Common Causes

Distributive Shock

Anaphylactic Shock– Common Signs & Symptoms

ItchingHivesFlushingWarm tingling feelingSwelling (Especially face, neck, hand, feet,

tongue

Distributive Shock

Anaphylactic ShockTightness in throat / chestCoughRapid, labored, noisy breathingHoarsenessStridor and wheezingIncreased heart rateLow blood pressure (late sign)

Distributive Shock

Anaphylactic Shock– Generalized Findings

Itchy, watery eyes and runny noseHeadacheSense of impending doom

Patient Assessment

Anaphylactic Shock– Initial assessment– Focused history and physical exam– Baseline vitals and SAMPLE history– Apply high flow oxygen

Patient Assessment & Care

– Determine patient need for epinephrine and use

Epinephrine is needed if the patient– has had a similar reaction to the same substance in

the past– shows S & S of shock– complains of respiratory distress– has a prescribed epinephrine auto-injector

Patient Assessment

Anaphylactic Shock– What is patient allergic to?– What was patient exposed to?– How was the patient exposed?– What signs and symptoms (S & S) does the

patient have?– How have the S & S progressed?– What interventions has the patient

received?

Anaphylactic Shock

Relationship to Airway Management– The patient may need aggressive airway

management immediately because of swelling in the airway or respiratory compromise.

– The patient’s condition may be stable initially but deteriorate to the point where he/she needs aggressive airway management

Progressive airway swelling Respiratory compromise

When Shock Doesn’t Look Like Shock

“Classic” Shock presentation is limited– Multiple factors may alter presentation– If the person shows signs of altered

perfusion, treat for shock– Resuscitate perfusion not blood pressure– Don’t forget that Medical History and

Medications can alter presentation

Review Questions

Describe the following types of bleeding– Arterial– Venous– Capillary

Describe the care for external bleeding List the signs and symptoms of internal

bleeding Describe the care for internal bleeding

Review Questions

Define Shock (hypoperfusion) List the signs and symptoms of shock in

the order in which they are likely to appear (in a classic presentation)

Describe the care for shock Define an allergic reaction and

anaphylactic shock List some common causes of allergic

reactions

Review Questions

List the signs and symptoms of anaphylactic reaction associated with the skin, respiratory system, and cardiovascular system

Tell how to determine whether the patient needs epinephrine