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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

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Chapter 18 Bleeding and Shock

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  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

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