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
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