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Chapter 13

Hemorrhage and Shock

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Objectives (1 of 8)

• 1.6.35 Describe the anatomy of the skin, bones, vessels, and subcutaneous tissue as it relates to hemorrhage control.

• 1.6.36 Discuss the benefits and complications of hemorrhage control by the following means:– Direct pressure – Tourniquets– Hemostats

• 1.6.40 Define shock.

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Objectives (2 of 8)

• 1.8.1          Define shock based on aerobic and anaerobic metabolism.

• 1.8.2          Discuss the prevention of anaerobic metabolism.

• 1.8.3          Discuss red blood cell oxygenation in the lungs based on alveolar O2 levels and transportation across the alveolar capillary wall.

• 1.8.4          Discuss tissue oxygenation based on tissue perfusion and release of oxygen.

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Objectives (3 of 8)

• 1.8.5          Discuss the role played by respiration, inadequate ventilation in the management of shock.

• 1.8.6          Describe perfusion and the mechanisms of improvement of cardiac output based on the strength and rate of contractions.

• 1.8.7          Discuss the fluid component of the cardiovascular system and the relationship between the volume of the fluid and the size of the container.

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Objectives (4 of 8)

• 1.8.8          Discuss the systemic vascular resistance, the relationship of diastolic pressure to the SVR and the effect of diastolic pressure on coronary circulation.

• 1.8.9          Discuss the container size in its relationship to the fluid volume and the effect on blood returning to the heart.

• 1.8.21 Describe the mechanism of the body response to perfusion change.

• 1.8.22 Identify the role of the baroreceptor.

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Objectives (5 of 8)

• 1.8.23 Describe how the actions of the baroreceptor affect blood pressure and perfusion.

• 1.8.24 Describe compensated shock.• 1.8.25 Describe uncompensated shock, both cardiac

and peripheral effects.• 1.8.26 Discuss the assessment of the patient’s perfusion

status, based on physical observations within the primary survey, including pulse, skin, temperature, and capillary refill.

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Objectives (6 of 8)

• 1.8.27 Discuss the relationship of the neurological exam to assessment of hypoperfusion and oxygenation.

• 1.8.28 Describe the information provided by the following in physical examination: pulse, blood pressure, diastolic pressure, systolic pressure, skin color, appearance, temperature, and respiration.

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Objectives (7 of 8)

• 1.8.29 Discuss management of a shocky patient. Include red cell oxygenation, tissue ischemic sensitivity, IV fluids, and the pneumatic antishock garment.

• 1.8.30 Describe the beneficial and detrimental effects of the pneumatic antishock garment.

• 1.8.31 Describe the indications and contraindications for the pneumatic antishock garment.

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Objectives (8 of 8)

• S1.8.35 Demonstrate in order of priority the steps of shock resuscitation.

• S1.8.36 Demonstrate the use of the pneumatic antishock garment (PASG).

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Bleeding (Hemorrhage)

• Can be external and obvious or internal and hidden.• Causes weakness and eventually shock and death.• Most common cause of shock after trauma.

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Shock

• A state of collapse and failure of the cardiovascular system in which blood circulation slows and eventually ceases.

• Can be fatal.• Accompanies events like heart attacks and automobile

crashes.

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Perfusion (1 of 2)

• Circulation within tissues in adequate amounts to meet the cells’ needs for oxygen, nutrients, and waste removal.

• Some tissues and organs need a constant supply of blood whereas others can survive on very little when at rest.

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Perfusion (2 of 2)

• The heart demands a constant supply of blood.• The brain and spinal cord can survive for 4 to 6 minutes

without perfusion.• The kidneys may survive 45 minutes.• The skeletal muscles may last 2 hours.

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Cardiovascular System (1 of 3)

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Cardiovascular System (2 of 3)

• Function– Circulates blood – Delivers oxygen and nutrients – Carries away waste

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Cardiovascular System (3 of 3)

• Components– Pump (heart) – Container (vessels) – Fluid (blood)

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Blood Vessels

• Arteries• Arterioles• Capillaries• Venules• Veins

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Blood

• Contains:– Red blood cells– White blood cells– Platelets– Plasma

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Scene Safety

• Follow BSI precautions.• Wear gloves and eye protection in all situations.• Avoid direct contact with body fluids.• Thorough hand washing between patients and after runs

is important.

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External Bleeding

• Hemorrhage = bleeding• Body cannot tolerate greater

than 20% blood loss.• Blood loss of 1 L can be

dangerous in adults; in children, loss of 100-200 mL is serious.

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Internal Bleeding

• Internal bleeding may not be readily apparent.• Assess patient’s

– Mechanism of injury– Nature of illness

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Mechanism of Injury Can Indicate Internal Bleeding

• When mechanism of injury suggests that severe forces affected the abdomen and/or the chest.

• As a result of falls, blast injuries, and automobile or motorcycle crashes.

• With penetrating injury, such as a knife or gunshot wound.

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Nature of Illness Can Suggest Internal Bleeding

• In the abdomen as a result of irritable bowel syndrome, an aneurysm, or a ruptured ectopic pregnancy.

• Gastrointestinal problems may cause vomiting of blood or bloody diarrhea.

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Signs and Symptoms of Internal Bleeding (1 of 2)

• Ecchymosis: Bruising• Hematoma: Bleeding beneath the skin• Hematemesis: Blood in vomit• Melena: Black, tarry stool

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Signs and Symptoms of Internal Bleeding (2 of 2)

• Hemoptysis: Coughing up blood• Pain, tenderness, bruising, guarding, or swelling• Broken ribs, bruises over the lower chest, or rigid,

distended abdomen

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Significance of Bleeding

• Body will not tolerate blood loss greater than 20% of blood volume.

• More than 1 L of blood loss in an adult causes increased heart rate and decreased blood pressure.

• Smaller amount of blood loss in infants and children causes significant effects.

• Low blood volume results in inadequate perfusion and death.

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Conditions With Possible Serious Bleeding

• Significant mechanism of injury.• Poor general appearance of patient.• Assessment reveals signs of shock.• Significant amount of blood loss noted.• The blood loss is rapid.• You cannot control external bleeding.

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Physiologic Response to Hemorrhage (1 of 2)

• Arterial– Blood is bright red and spurts.

• Venous– Blood is dark red and does not spurt.

• Capillary– Blood oozes out and is controlled easily.

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Physiologic Response to Hemorrhage (2 of 2)

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Blood Clotting

• Bleeding normally stops within 10 minutes.• Some medications interfere with clotting.• Some injuries will be unable to clot.• Patients with hemophilia lack clotting factors.

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Stage One Hemorrhage (1 of 2)

• Up to 15% intravascular loss.• Compensated by constriction of vascular bed.• Blood pressure maintained.• Normal pulse pressure, respiratory rate, and renal

output.

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Stage One Hemorrhage (2 of 2)

• Pallor of the skin.• Central venous pressure low to normal.

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Stage Two Hemorrhage (1 of 2)

• 15-25% intravascular loss.• Cardiac output cannot be maintained by arteriolar

constriction.• Reflex tachycardia.• Increased respiratory rate.• Blood pressure maintained.• Catecholamines increase peripheral resistance.

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Stage Two Hemorrhage (2 of 2)

• Increased diastolic pressure.• Narrow pulse pressure.• Diaphoresis from sympathetic stimulation.• Renal output near normal.

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Stage Three Hemorrhage

• 25-35% intravascular loss• Classic signs of hypovolemic shock

– Marked tachycardia– Marked tachypnea– Decreased systolic pressure– Decreased urine output– Alteration in mental status– Diaphoresis with cool, pale skin

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Stage Four Hemorrhage

• Loss greater than 35%.• Extreme tachycardia.• Pronounced tachypnea.• Significantly decreased systolic blood pressure.• Confusion and lethargy.• Skin is diaphoretic, cool, and extremely pale.

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Assessment

• Ensure an open and patent airway.• Have suction ready for bleeding of the mouth or facial

areas.• Note the color of bleeding and try to determine its

source.• Coffee-ground emesis is a sign of upper GI bleeding.

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Controlling External Bleeding

• Follow BSI precautions.• Ensure patient has an open airway and adequate

breathing.• Provide oxygen if necessary.• Assess location and color of blood.• There are several methods to control bleeding.

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Direct Pressure and Elevation

• Direct pressure is the most common and effective way to control bleeding.

• Apply pressure with gloved finger or hand.• Elevating a bleeding extremity often stops venous

bleeding.• Use both direct pressure and elevation whenever

possible.• Apply a pressure dressing.

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Pressure Points

• If bleeding continues, apply pressure on pressure point. • Pressure points are located where a blood vessel lies

near a bone.• Be familiar with the location of pressure points.

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Location of Pressure Points

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Splints

• Splints can help control bleeding associated with a fracture.

• Air splints can be used to control bleeding of soft-tissue injuries.

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Hemostats

• Use on retracted vessels.• Apply to end of vessel.

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Pneumatic Antishock Garment (PASG)

• Stabilizes fractures of the pelvis and proximal femurs.• Controls significant internal bleeding. • Controls massive soft-tissue bleeding of the lower

extremities.

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PASG Contraindications

• Pregnancy (do not inflate abdomen)• Pulmonary edema of cardiac origin• Acute heart failure• Penetrating chest injuries• Groin injuries• Major head injuries• Less than 30 minutes transport time

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Application of PASG

• Apply the garment so the top is below the lowest rib.• Enclose both legs and the abdomen.• Open the stopcocks.• Inflate with the foot pump.• Check patient’s vital signs.

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Applying a Tourniquet

• Fold a triangular bandage into 4” cravat.• Wrap the bandage.• Use a stick as a handle to twist and secure the

tourniquet.• Write “TK” and time and place on patient.

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Tourniquet Precautions

• Place as close to injury as possible, but not over joint.• Never use narrow material.• Use wide padding under the tourniquet.• Never cover a tourniquet with a bandage.• Do not loosen the tourniquet once applied.

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Bleeding From the Nose, Ears, and Mouth

• Causes:– Skull fractures– Facial injuries– Sinusitis– High blood pressure– Coagulation disorders– Digital trauma

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Controlling a Nosebleed

• Follow BSI precautions.• Help the patient sit and lean forward.• Apply direct pressure by pinching the patient’s nostrils.

– Or place a piece of gauze bandage between the patient’s upper lip and gum.

• Apply ice over the nose.• Provide transport.

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Bleeding From Skull Fractures

• Do not attempt to stop the blood flow.• Loosely cover bleeding site with sterile gauze.• If cerebrospinal fluid is present, a target sign will be

apparent.

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Shock

• Leads to inadequate circulation.• State of collapse and failure of the cardiovascular

system.• Without adequate blood flow, cells cannot get rid of

metabolic wastes.

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Signs of Shock

• Dull eyes• Dilated pupils• Weak, rapid pulse• Decreased blood pressure• Altered level of consciousness

• Change in mental status• Tachycardia• Weakness• Thirst• Nausea or vomiting• Cold, moist skin• Shallow, rapid breathing

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Compensation for Decreased Perfusion

• Baroreceptors• Chemoreceptors• Sympathetic nervous system

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Capillary Sphincters

• Regulate the blood flow through the capillary beds.• Sphincters are under the control of the autonomic

nervous system.• Regulation of blood flow is determined by cellular need.

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Stages of Shock

• Compensated shock/nonprogressive• Decompensated shock/progressive• Irreversible shock

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Signs and Symptoms of Compensated Shock

• Clammy skin• Pallor• Shallow, rapid breathing• Shortness of breath• Nausea or vomiting• Delayed capillary refill• Marked thirst

• Agitation• Anxiety• Restlessness• Feeling of impending doom• Altered mental status• Weak pulse

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Signs and Symptoms Decompensated Shock

• Falling blood pressure• Labored, irregular breathing• Ashen, mottled, cyanotic skin• Thready or absent pulse• Dull eyes, dilated pupils• Poor urinary output

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Irreversible Shock

• This is the terminal stage of shock.• A transfusion of any type will not be enough to save a

patient’s life.

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When to Expect Shock

• Multiple severe fractures• Abdominal or chest injuries• Spinal injuries• Severe infection• Major heart attack• Anaphylaxis

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Hypovolemic Shock

• Content failure• Results from fluid or blood loss

– Blood is lost through external and internal bleeding.– Severe thermal burns cause plasma loss.– Dehydration aggravates shock.

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Treating Hypovolemic Shock

• Control obvious bleeding.• Splint any bone or joint injuries.• If no fractures, raise legs 6” to 12”.• Secure and maintain airway.• Give oxygen as soon as you suspect shock.• Transport rapidly.

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Distributive (Vasogenic) Shock

• Combined vessel and content failure– Some patients with severe bacterial infections,

toxins, or infected tissues contract septic shock.– Toxins damage vessel walls, causing leaking and

impairing ability to contract.– Leads to dilation of vessels and loss of plasma,

causing shock.

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Treating Septic Shock

• Transport as promptly as possible while giving all general support available.

• Give high-flow oxygen during transport.• Use blankets to conserve body heat.

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Anaphylactic Shock

• Occurs when a person reacts violently to a substance• Four categories of common causes:

– Injections– Stings– Ingestion– Inhalation

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Treating Anaphylactic Shock

• Administer epinephrine.• Provide prompt transport.• Provide all possible support.

– Oxygen– Ventilatory assistance

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Cardiogenic Shock

• Pump failure– Inadequate function of the heart or pump failure– Causes a backup of blood into the lungs– Results in pulmonary edema– Pulmonary edema leads to impaired ventilation

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Treating Cardiogenic Shock

• Patient may breathe better in a sitting or semi-sitting position.

• Administer high-flow oxygen.• Assist ventilations as necessary.• Have suction nearby in case the patient vomits.• Transport promptly.

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Spinal Shock

• Poor vessel function– Damage to the cervical spine may affect control of

the size and muscular tone of blood vessels– The vascular system increases

• Blood in the body cannot fill the enlarged system• Neurogenic shock occurs

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Treating Neurogenic Shock

• Maintain airway and assist breathing as needed.• Keep patient warm.• Transport promptly.

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Respiratory Insufficiency

• Patient with a severe chest injury or airway obstruction may be unable to breathe adequate amounts of oxygen.

• Insufficient oxygen in the blood will produce shock.

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Treating Respiratory Insufficiency

• Secure and support the airway.• Clear airway of any obstructions.• Ventilate if needed with a BVM device.• Administer oxygen.• Transport promptly.

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Perfusion

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Psychogenic Shock

• Caused by sudden reaction of nervous system that produces a temporary, generalized vascular dilation.

• Fainting or syncope.• Can be brought on by causes ranging from fear or bad

news to unpleasant sights.

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Treating Psychogenic Shock

• It is usually self-resolving.• Assess patient for injuries from fall.• If patient has difficulties after regaining consciousness,

suspect another problem.

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Treating Shock (1 of 3)

• Make certain patient has open airway.

• Keep patient supine.• Control external bleeding.• Splint any broken bones or

joint injuries.

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Treating Shock (2 of 3)

• Always provide oxygen.• Place blankets under and

over patient.• If there are no broken bones,

elevate the legs 6” to 12”.• Do not give the patient

anything by mouth.

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Treating Shock (3 of 3)

• Establish two large-bore IVs.• Consider PASG.• Listen to breath sounds and heart tones.

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Management of Shock

• Follow BSI precautions.• Maintain airway and administer oxygen.• Control external bleeding and care for any internal

bleeding.• Monitor and record vital signs.• Elevate legs and keep patient warm.• Transport immediately to hospital.