Shock and Bleeding in the Trauma Patient

1. Shock and Bleeding in the Trauma Patient April Morgenroth RN, MN

2. Shock: Hypoperfusion Hypoperfusion: A state where the body’s organs are not sufficiently perfused with oxygenated blood.

3. Nursing Priorities Establish “Rapid Dominance “ over states of hypoperfusion by: • Early recognition • Aggressive treatment • Prevention of progressive and decompensated stages of shock

4. Recognizing Shock Types of Shock: Distributive: • Neurogenic • Septic • Anaphylactic Cardiogenic: • MI, Cardiomyopathy, tamponade Hypovolemic: • Relative vs. Absolute

5. Key Points Pressure = amount of stuff in a given space Remember: Hypoperfusion= oxygenated blood not getting where it needs to go Blood is driven by pressures

6. Distributive Shock Insult Vasodilation Same Stuff/ More Space Hypotension

7. Causes of Distributive Shock • Neurogenic: • Head injuries • Spinal Cord injuries • Pain and drugs • Septic: • UTI • SIRS • Bacteremia • Anaphylactic • Bee stings • Drugs • Foods

8. The Autonomic Nervous System The autonomic nervous system controls the body’s involuntary functions: digestion, heartbeat, respirations… lildarlinzkidzdolls.homestead.com/

9. Neurogenic Shock Damage to the brain and spinal cord Loss of Sympathetic Tone: Parasympathetic Nervous System is Unopposed Uncontrolled Vasodilation Low Blood Pressure Hypoperfusion: Shock

10. Septic Shock Cytokines released in response to infection Vasodilation and increase capillary permeability Decreased SVR Decreased Pressure Decreased Perfusion

11. Anaphylactic Shock Allergen Massive Release of Mast Cells Systemic Vasodilation Increased Capillary Permeability Edema Hypotension

12. Hypovolemic Shock • Hypovolemic Shock= Decreased amount of fluid in the vascular space Absolute: external fluid loss Hemorrhage Burns Dieresis Relative: Internal fluid shift Internal bleeding Blood pooling

13. Hypovolemic Shock Decreased fluid in circulation Decreased preload in the heart Decreased stroke volume Decreased cardiac output

14. Hypovolemia: The Body’s Response The Body will always strive to work toward a state of homeostasis, as steady state of balance.

15. Respiratory Response Bleeding = Less red blood cells = Less oxygen carrying capacity CO2 • Patient becomes short of breath and tachypnic • Patient hyperventilates and blows off excessive carbon dioxide causing respiratory alkalosis

16. Compensated Shock • In compensated: • Body’s compensatory mechanisms temporarily maintain a steady state. • Vital organs perfused. • Blood pressure stable. • Blood is shunted from the periphery. • Sympathetic nervous system is activated. • You may start to see the following early signs. Anxious Tachypnea Blood pressure may be normal or somewhat low Tachycardia/rapid pulse Extremities may be cool and pale under the nail beds. http://www.ronjones.org/Health&Fitness/FunctionalTraining/anatomicalposition.htm

17. Clinical Manifestations of Progressive Shock 0 • Confusion, listlessness, apathy • decreased response to painful stimuli • Tachycardia • Beta blockers may blunt • Weak or absent peripheral pulses • Hypotension (SBP < 90) & falling • > 25% decrease in hypertensive pt • May need to use doppler or Arterial line • Resp rapid & shallow • Low urine output • Thirst • Skin cool & clammy, dusky, slow capillary refill

18. Decompensated Shock Slow deep respirations Altered level of consciousness • Decompensated Shock: • Body exhausts reserves • Damage is not reversible • Patient will eventually die. Pulse pressure narrows Blood pressure continues to fall arrhythmias Cold extremities Cyanosis

19. Metabolic Response As the body continues to fight against the altered state it begins to go into anaerobic metabolism This causes a build of lactic acid eventually leading to a metabolic acidosis O2 Metabolic acidosis and respiratory alkalosis can exist concurrently to some degree compensating for one another resulting in a relatively normal pH.

20. Assessment for Shock 0 • Recent history of event putting pt at risk • Assess for clinical manifestations • General appearance & skin • LOC & orientation • Vitals • Urine output • Foley if at risk, or evidence of shock • Bleeding (external or internal) or fluid loss • Signs of cardiac dysfunction • Hemodynamic parameters • ABGs & oxygen saturation

21. Aggressive Treatment Always begin with ABCs: airway, breathing, circulation Airway: establish and maintain the airway Breathing: be prepared to support breathing with supplemental O2, manual ventilation may be needed Circulation: be prepared for massive fluid resuscitation and make plans for circulatory support

22. Basic Treatment

23. Fluid ResuscitationMore Stuff in the Space B L OOD L O S T = • Three liters of normal saline replaces 1 liter of blood lost for intravascular volume to come out even. • Fluid shifts and much of it is displaced into the surrounding tissues

25. Fluid Resuscitation Obtain I.V. access Two Large Bore I.V.s 18 gauge or larger Choose a large vein LR Choose the most appropriate I.V. fluid for the situation

26. Fluid ResuscitationInfusion Rates In severe cases of hypovolemic shock, fluids may initially need to be run wide open as fast as possible. Assess the patient frequently and document their response to interventions • Heart rate • Blood Pressure Normalize • Respiratory Rate • Skin Temperature Once the patient becomes more stable the infusion rate may be slowed.

27. Fluid Volume Overload Fluid volume overload can result from rapid aggressive fluid resuscitation. • Keep Track of : • Vital signs • Intake and Output • Weight gain or loss • Look for: • Pitting edema • Increased respiratory rate • Orthopnea • Wet sounding lungs • Pink frothy sputum • Massive weight gain seejanenurse.files.wordpress.com/2007/07/lung If you see signs and symptoms of fluid overload you may need to slow infusion rate and/or stop fluids if the patient is stable enough. The patient may need careful dieresis once stable.

28. Circulatory Support Space/Vasoconstriction • Medications: • Vasopressors: • Dopamine • Norepinepherine/ Levophed • Vasopressin • Considerations: • Use of these meds requires intense monitoring and titration. • Monitor: EKG, BP, HR, RR, O2, hemodynamics, peripheral pulses. • Prolonged use at higher doses can cause peripheral tissue damage related to ischemia.

29. Aggressive Care Constant Assessment: • Indentify the cause! • Notice signs and symptoms early Aggressive Treatment: • Treat the cause effectively • Support the body systems

30. Hemorrhage Control

31. Direct Pressure Application of direct pressure to a open wound helps to control bleeding and can help to speed the body’s natural process of clot formation. • Use sterile or clean dressing to apply direct pressure over the bleeding wound. • Be careful with wounds to the chest and neck, too much pressure can impair breathing.

32. Pressure Dressings • Place sterile dressing directly over the wound. • Stack bulky dressings on top. • Wrap a gauze dressing snuggly around the wound. • Reassess: • Sensory, motor, circulatory function distal to the wound • Tie the rolled gauze with the knot directly over padding previously placed over the wound. • If gauze becomes soaked add more on top.

33. Use of the Tourniquet Tournquets should only be used with other method of hemorrhage control have failed. • Attempt to control bleeding with direct pressure, and pressure dressing before using a tourniquet. • Wrap the wound snuggly • Pile dressings over the wrap • Wrap the ends around a stick • Use the stick to twist the tourniquet tighter until bleeding is controlled Wrap wound again leaving two long ends.

34. Use of the Tourniquet Inappropriate use of a tourniquet can be very dangerous! . • Tie a knot to secure the stick in place • Be sure to label with date and time of application • Reassess the patient frequently and document your findings

35. Internal Bleeding • Internal bleeding: bleeding out of vessels into tissue. • Early Recognition + Early Intervention = Better Outcome • Mechanism of injury: crushing injury, impact, blows to the head, chest, abdomen, car vs. pedestrian accident • Signs: • Hematoma • Edema • Area under the skin may be firm • Pain • Signs of shock • Vomiting or coughing up blood • Pain directly over an organ Emergency: Pt may need surgery, call doctor immediately Patients with internal bleeding can die very quickly if they are not treated immediately!