EMT Basic Hemorrhage and Shock

Bleeding and Shock

Bleedin’ Like a Mug

Three main parts

Pump

Container

Fluid

= The Heart

= The Vessels

= The Blood

HeartPump

Moves blood through the system

Role in blood pressure maintenance (CO = HR X SV)

VesselsContainer

Carry blood to peripheral tissues and back to the heart

Gas exchange

Role in blood pressure maintenance (PVR)

Blood

Fluid

Transportation of gases

Regulation of pH

Restriction of blood loss

Defense agent against toxins and pathogens

Stabilization of body temperature

Remember!COCO = HR X SV

BPBP = CO X PVR

Blood Volumes

Adult – 70 ml/kg

Child – 80 ml/kg

Infant – 80 ml/kg

Related to blood loss severity15% loss is considered to be significant and can

lead to shock

Blood Volumes

What is significant?Adult weighing 154 lbs (70 kg)

70kg * 70 ml = 4900 ml

4900ml * 0.15 = 735 ml blood loss

Infant weighing 22 lbs (10 kg)

10 kg * 80ml = 800 ml

800 ml * 0.15 = 120 ml blood loss800 ml * 0.15 = 120 ml blood loss

Hemorrhage

Hemorrhage occurs when there is a

disruption, or "leak," in the vascular system

TERMS

Shock (hypoperfusion)The insufficient supply of oxygen and other nutrients

to some of the body’s cells that result in inadequate circulation of blood

EpistaxisBleeding from the nose resulting from injury,

disease, or the environment; a nose bleed

TERMS

PerfusionThe delivery of oxygen and other nutrients to the

cells of all organ systems, which results from the constant adequate circulation of blood through the capillaries.

HemorrhageThe escape of blood from the vessels; bleeding

HemorrhageBlunt trauma to the chest or abdomen

Hemorrhage

Penetrating trauma to the chest or abdomen

Hemorrhage

Pelvic or Femur fractures

Hemorrhage

•GI Bleeds

•Ectopic pregnancy

•AAA (abdominal aortic aneurysm)

Hemorrhage

Any other significant mechanism of injury when multi-system

trauma is suspected

Hemorrhage

Externalseriousness depends

– anatomical source of the hemorrhage

– degree of vascular disruption

– amount of blood loss tolerated

Hemorrhage

Internal• occurs in abdomen, chest, or retroperitoneum

• can be caused by chronic medical problems

• associated with higher morbidity and mortality

The Injury Occurs....Initial Response

The Body’s Initial ResponseWhen bleeding starts the body

tries to stop it through,

Hemostasis

hemo -Blood,

Stasis - stop, slow down

The Body’s Initial Response

Local vasoconstriction at the bleeding site

Formation of a platelet plug

The Body’s Initial Response

Coagulation

Growth of fibrous tissue into the blood clot

The Body’s Initial ResponseIf the bleeding is

severe, these mechanisms fail

resulting in shock.

Shock

““Rude unhinging of the Rude unhinging of the machinery of life”machinery of life”

“Momentary pause in the act of death”

Inadequate Capillary Perfusion

Very complex group of physiological

abnormalities…is not adequately defined by

pulse rate, b/p, or cardiac function

Progression of Shock

Stage 1 - VasoconstrictionStage 1 - Vasoconstriction

Blood volume decreases by 15%

Oxygen delivery to the cells decreases

Anaerobic metabolism begins

Stage 1 - VasoconstrictionCapillaries begin to

leak

Skin becomes pale and sweaty

Stage 1 - VasoconstrictionStage 1 - Vasoconstriction

Respiratory rate, BP, heart rate, and renal

output remains normal early on

Late in stage 1, pulse becomes weak and thready (sympathetic stimulation)

Stage 1 - Vasoconstriction

Stage 1 is reversible if the hemorrhage is

controlled

Stage 2 - Capillary/Venule Opening

15 - 25% blood loss

Pre-capillary sphincters relax, post capillary

sphincters resist relaxation

Blood pools in the capillaries

Stage 2 - Capillary/Venule Opening

Soon blood flow bypasses the capillaries altogether (into venules),

capillary refill time increases

Capillaries and venules continue to dilate while

larger arterioles continue to constrict

Stage 2 - Capillary/Venule Opening

Capillary/venule capacity can become great

enough to reduce blood return to heart

Stage 2 - Stage 2 - Capillary/Venule OpeningCapillary/Venule Opening

Heart rate increases in an attempt to maintain

cardiac output but near the end of this stage, output begins to fall.

Stage 2 - Stage 2 - Capillary/Venule OpeningCapillary/Venule Opening Blood pressure may be

normal to the end of stage 2, but pulse

pressure begins to fall !

Stage 2 - Stage 2 - Capillary/Venule OpeningCapillary/Venule Opening

As the blood pools in the capillaries, the tissues continue to extract all

available oxygen and lactic acid builds

Respiratory system attempts to compensate

by increasing respirations

Stage 2 - Capillary/Venule Opening

Stage 2 is still reversible Stage 2 is still reversible with proper fluid with proper fluid

resuscitationresuscitation

Stage 3 - Disseminated Intravascular Coagulation

25 -35% blood loss

Acidosis increases, pH continues to fall, red blood cells begin

to cluster together

Stage 3 - Disseminated Stage 3 - Disseminated Intravascular CoagulationIntravascular Coagulation

These clusters occlude capillaries and prevent

distribution of oxygen or removal of metabolic

wastes

Stage 3 - Disseminated Stage 3 - Disseminated Intravascular CoagulationIntravascular Coagulation

Distal tissues have now fully switched to

anaerobic metabolism and lactic acid

production increases

Stage 3 - Disseminated Stage 3 - Disseminated Intravascular CoagulationIntravascular Coagulation

Cells can no longer produce the energy to

maintain their membranes

Water and sodium leak into the cell and

potassium leaks out

Stage 3 - Disseminated Stage 3 - Disseminated Intravascular CoagulationIntravascular Coagulation

Cells begin to swell and die.

Capillaries in the pulmonary vascular

leak fluid into the alveoli (eventually causes respiratory failure)

Stage 3 - Disseminated Intravascular Coagulation

Altered mental status occurs because of the

hypoxia

Stage 3 - Disseminated Stage 3 - Disseminated Intravascular CoagulationIntravascular Coagulation

All the classic signs of hypovolemic shock are present:

Tachycardia

Tachypnea

Decreased systolic pressure (first time pt shows this)

Stage 3 - Disseminated Stage 3 - Disseminated Intravascular CoagulationIntravascular Coagulation

Diaphoresis continues with cool, pale skin

Still reversible (mortality high)

Cannot be reversed without the

administration of blood

Stage 4 - Multiple Organ Failure

Greater than 35% blood loss

Blood pressure falls dramatically; patient is diaphoretic, cool, and

extremely pale

Stage 4 - Multiple Organ FailureStage 4 - Multiple Organ FailureIf the given area of capillary occlusion

persists for more than 1 to 2 hours, changes occur

that are irreversible

Stage 4 - Multiple Organ FailureThose changes create conditions that make it impossible for the cells that have survived this long to obtain enough energy to continue to

survive

Stage 4 - Multiple Organ FailureStage 4 - Multiple Organ FailureIf enough cells within an organ die, that organ will

fail

The first two to go are usually the liverliver and the

kidneykidney

Stage 4 - Multiple Organ Failure

The mental status continues to decrease

Clotting red blood cells produce pulmonary

hemorrhages leading to a decreasing respiratory

rate, then failure.

Stage 4 - Multiple Organ FailureStage 4 - Multiple Organ FailureCapillary blockage and

hypoxia causes a decreasing heart rate

then heart failure

The Body’s Response to Shock

Compensated Shock

Some decreased tissue perfusion, but body's compensatory

responses are sufficient to overcome

the decrease

Compensated Shock

Increase in catecholamine

production maintains cardiac output and a normal systolic blood

pressure

Uncompensated Shock

Uncompensated shock occurs when the body

is no longer able to maintain systemic

blood pressure

Uncompensated Shock

As the body's compensatory

mechanisms begin to fail, both systolic and

diastolic pressure drop and cerebral blood flow

decreases

Irreversible Shock

Patients with irreversible shock as a result of massive cellular damage do not survive

Cells and the vital organs begin to die from the lack of energy

Compensated Uncompensated Irreversible

Heart Rate Mild Tachycardia

Moderate tachycardia

Bradycardia, severe

dysrhythmia

Level of Consciousness

Lethargy, confusion,

combativeness Confusion Coma

Skin Delayed

capillary refill, cool skin

Delayed capillary refill, cold

extremities, cyanosis

Pale, cold, clammy skin

Blood Pressure Normal or slightly elevated

Decreased systolic and diastolic

Frank hypotension

Assessment and Management

Primary Assessment

Airway - opened and patency maintained

Breathing - insure adequate oxygenation and ventilation

Primary Assessment

Circulation - assess for and correct uncontrolled bleeding

–Direct pressure–Elevation–Pressure points–Tourniquet–Splinting–PASG

Primary AssessmentDisability - evaluation of the patient's level of consciousness

Expose and Examine - visual inspection can reveal life-threatening conditions hidden by clothing

Secondary AssessmentSecondary Assessment

Secondary AssessmentSecondary Assessment

Any abnormality that interferes with adequate ventilation

should be corrected

After controlling blood loss, volume replacement can begin

Assessment of Internal HemorrhageAssessment of Internal Hemorrhage

Bright red blood

Coffee ground emesisMelena - (black, tarry stools)

Hematochezia - (passage of red blood through the rectum)

Pneumatic Antishock Garment

PASG

Physiologic Changes with PASG

•Artificially increases peripheral vascular resistance

Arrests hemorrhage

•Stabilize pelvic and lower-

extremity fractures

Indications

•Hypoperfusion with an unstable

pelvis•Conditions of decreased SVR

not corrected by other means•As approved locally by medical

direction

Contraindications

No abdominal section with advanced pregnancy, impaled object in abdomen, or evisceration

Ruptured diaphragm

Chest trauma

Pulmonary edema

Cardiogenic shock

Management of Hemorrhage

1. ABCs, Oxygen 100% NRB

2. Control obvious bleeding

3. Restrict movement of the patient

4. Begin transport ASAP

5.5. Keep patient warmKeep patient warm

6. Consider Trendelenberg position

7. PASG

QUESTIONS ?