Hemorrhage & ShockTerry White, RN

Review of HemorrhageLocationAnatomical Type & TimingCoagulationFibrinolysisAssessmentManagement

Review of HemorrhageLocationExternalInternalTraumaticNon-TraumaticExamples?

Review of HemorrhageAnatomical TypeArterialVenousCapillaryTimingAcuteChronic

Severity of HemorrhageComparison of Adult vs Child

Hematocrit% of RBC in blood (hematocrit)Normal: 37% - 47% (Female)40% - 54% (Male)

ThrombocytesPlateletsForm platelet plugscontact collagen & adhere to injured surfaceactivate plateletsaggregate to form platelet plug

CoagulationFormation of blood clotsProthrombin activatorProthrombin ThrombinFibrinogen Fibrinentrap platelets, blood cells & plasmaClot retraction

FibrinolysisBreaking up the clottissue plasminogen activator (tPA)plasminogen plasmin

Assessing HemorrhageCluesBright red blood from wound, mouth, rectum or other orificeHematemesisCoffee ground appearance of vomitusHematocheziaMelenaOrthostatic hypotensionDizziness or syncope on sitting or standingSigns and symptoms of hypovolemic shock

Management of HemorrhageAirway and Ventilatory SupportCirculatory SupportFrom nose or ears after head trauma = loose drsgControl bleedingdirect pressure, elevation, pressure pointstourniquetpacking of large woundssplintingPASGtransport to appropriate facility

ShockA rude unhinging of the machinery of lifeA brief pause in the act of dying

ShockInadequate peripheral perfusion leading to failure of tissue oxygenation may lead to anaerobic metabolism

ShockHomeostasiscellular state of balanceperfusion of cells with oxygen is one of its cornerstones

ShockAdequate Cellular OxygenationRed Cell OxygenationRed Cell Delivery To TissuesFick Principle

VO2COThe following variables are measured:VO2 consumption per minute using a spirometer (with the subject re-breathing air) and a CO2 absorber Cv, the oxygen content of blood taken from the pulmonary artery (representing deoxygenated blood blood) Ca, the oxygen content of blood from a cannula in a peripheral artery (representing oxygenated blood)

From these values, we know that:where CO = Cardiac Output, CA = Oxygen concentration of arterial blood and CV = Oxygen concentration of venous blood.

= xCA ()COxCV)(CO=VO2CACVThis allows us to say

Fick PrincipleAirs gotta go in and out.Bloods gotta go round and round.Any variation of the above is not a good thing!

ShockRed Cell OxygenationOxygen delivery to alveoliAdequate FiO2Patent airwaysAdequate ventilation

ShockRed Cell OxygenationOxygen exchange with bloodAdequate oxygen diffusion into bloodAdequate RBC flow past alveoliAdequate RBC mass/Hgb levelsAdequate RBC capacity to bind O2pHTemperature

ShockRed Cell Delivery To TissuesAdequate perfusionBlood volumeCardiac outputHeart rateStroke volume (pre-load, contractility, after-load)ConductanceArterial resistanceVenous capacitance

ShockRed Cell Delivery To TissuesAdequate RBC massAdequate Hgb levelsAdequate RBC capacity to unbind O2pHTemperatureDistance between capillaries and cells

ShockInadequate oxygenation or perfusion causes:Inadequate cellular oxygenationShift from aerobic to anaerobic metabolism

AEROBIC METABOLISMGlycolysis: Inefficient source of energy production; 2 ATP for every glucose; produces pyruvic acidOxidative phosphorylation: Each pyruvic acid is converted into 34 ATP

ANAEROBIC METABOLISMGlycolysis: Inefficient source of energy production; 2 ATP for every glucose; produces pyruvic acid

Anaerobic MetabolismOccurs without oxygenoxydative phosphorylation cant occur without oxygenglycolysis can occur without oxygencellular death leads to tissue and organ deathcan occur even after return of perfusion organ or organism death

Ultimate Effects of Anaerobic Metabolism

Maintaining perfusion requires:VolumePumpVesselsFailure of one or more of these causes shock

ShockHypovolemic Shock = Low VolumeTraumaNon-traumatic blood loss VaginalGIGUBurnsDiarrheaVomitingDiuresisSweatingThird space lossesPancreatitisPeritonitisBowel obstruction

ShockCardiogenic Shock = Pump Failure

Acute M ICHFBradyarrhythmiasTachyarrhythmiasMechanical obstruction (distributive shock)Cardiac tamponadeTension pneumothoraxPulmonary embolism

ShockVasogenic Shock = Low Resistance

Spinal cord traumaneurogenic shockDepressant drug toxicitySimple fainting

ShockMixed ShockSeptic ShockOverwhelming infectionInflammatory response occursBlood vesselsDilate (loss of resistance)Leak (loss of volume)

ShockMixed ShockSeptic ShockFeverIncreased O2 demandIncreased anaerobic metabolismBacterial toxinsImpaired tissue metabolism

ShockMixed ShockAnaphylactic ShockSevere allergic reactionHistamine is releasedBlood vesselsDilate (loss of resistance)Leak (loss of volume)

ShockMixed ShockAnaphylactic ShockHistamine releaseExtravascular smooth muscle spasmLaryngospasmBronchospasm

ShockProgressive syndromeThree phasesCompensatedDecompensatedIrreversible

ShockSigns and symptoms due to:HypoperfusionCompensatory responses

Compensated ShockBaroreceptors detect fall in BPUsually 60-80 mm Hg (adult)Sympathetic nervous system activatesWhat are the primary SNS Neurotransmitters & their effects?

Compensated ShockCardiac effectsIncreased force of contractionsIncreased rateIncreased cardiac output

Compensated ShockPeripheral effectsArteriolar constrictionPre-/post-capillary sphincter contractionIncreased peripheral resistanceShunting of blood to core organs

Compensated ShockDecreased renal blood flowRenin released from kidney arterioleRenin & Angiotensinogen combineConverts to Angiotensin IAngiotensin I converts to Angiotensin IIPeripheral vasoconstrictionIncreased aldosterone release (adrenal cortex)promotes reabsorption of sodium & water

Compensated ShockDecreased blood flow to hypothalamusRelease of antidiuretic hormone (ADH or Arginine Vasopressin) from posterior pituitaryRetention of salt, waterPeripheral vasoconstriction

Compensated ShockInsulin secretion caused by epinephrinecontributes to hyperglycemiaGlucagon release caused by epinephrinepromotes liver glycogenolysis & gluconeogenesisACTHstimulates adrenal cortex release of cortisol glucose production

Compensated ShockPeripheral capillaries contain minimal bloodStagnationAerobic metabolism changes to anaerobicExtracellular potassium shifts begin

Compensated ShockPresentationRestlessness, anxiety Earliest sign of shockTachycardia ?Bradycardia in cardiogenic, neurogenic

Compensated ShockPresentationNormal BP, narrow pulse pressure Falling BP = late sign of shockMild orthostatic hypotension (15 to 25 mm Hg)Possible delay in capillary refill

Compensated ShockPresentationPale, cool skin CardiogenicHypovolemicFlushed skin AnaphylacticSepticNeurogenic

Compensated ShockPresentationSlight tachypneaRespiratory compensation for metabolic acidosis

Compensated ShockPresentationNausea, vomitingThirstDecreased body temperatureFeels coldWeakness

Decreased Cardiac OutputAldosterone, ADH ReleaseCatecholamine ReleaseIncreased Blood VolumeIncreased PVRIncreased Cardiac OutputIncreased Myocardial Work, O2 DemandIncreased Volume LossMyocardial IschemiaCompensated Shock Leading to Decompensation

Decompensated ShockPresentationCardiac EffectsDecreased RBC oxygenationDecreased coronary blood flowMyocardial ischemiaDecreased force of contraction

Decompensated ShockPresentationPeripheral effectsRelaxation of precapillary sphinctersContinued contraction of postcapillary sphinctersPeripheral pooling of bloodPlasma leakage into interstitial spaces

Decompensated ShockPresentationPeripheral effectsContinued anaerobic metabolismContinued increase in extracellular potassiumRouleaux formations of RBCspile up like coinsCold, gray, waxy skin

Decompensated ShockPresentationListlessness, confusion, apathy, slow speechTachycardia; weak, thready pulseDecreased blood pressureModerate to severe orthostatic hypotensionDecreased body temperatureTachypnea

Irreversible ShockPost-capillary sphincter relaxationLoss of peripheral vascular resistance

Irreversible ShockWashout of accumulated productsHydrogen ionPotassiumRouleaux formationsCarbon dioxideRouleaux formations microembolize in lungsSystemic metabolic acidosis occursCardiac Output decreases further

Irreversible ShockPresentationConfusion, slurred speech, unconsciousSlow, irregular, thready pulseFalling BP; diastolic goes to zeroCold, clammy, cyanotic skinSlow, shallow, irregular respirationsDilated, sluggish pupilsSeverely decreased body temperature

Irreversible ShockIrreversible shock leads to:Renal failureHepatic failureDisseminated intravascular coagulation (DIC)Multiple organ systems failureAdult respiratory distress syndrome (ARDS)Death

Disseminated Intravascular Coagulation (DIC)Decreased perfusion causes tissue damage/necrosisTissue necrosis triggers diffuse clottingDiffuse clotting consumes clotting factorsFibrinolysis beginsSevere, uncontrolled systemic hemorrhage occurs

Adult Respiratory Distress Syndrome (ARDS)AKA: Shock Lung, Da Nang LungDecreased perfusion damages alveolar and capillary wallsSurfactant production decreasesFluid leaks into interstitial spaces and alveoliGas exchange impairedWork of breathing increases

Shock ClassificationsHypovolemicCardiogenicVasogenic (Distributive)Neurogenic

Shock ClassificationsHypovolemic CausesHemorrhagePlasmaFluid & ElectrolytesEndocrine

Shock ClassificationsCardiogenic CausesContractilityRateObstructive (Preload/Afterload)Tension pneumothoraxPericardial tamponadePulmonary embolismSevere Hypertension

Shock ClassificationsVasogenic (distributive)Increased venous capacitancelow resistance, vasodilationanaphylaxissepsis

Shock ClassificationsNeurogenic (spinal shock)loss of spinal cord function below site of injuryloss of sympathetic tonecutaneous vasodilationrelative bradycardia

Key Issues In ShockTissue ischemic sensitivityHeart, brain, lung: 4 to 6 minutesGI tract, liver, kidney: 45 to 60 minutesMuscle, skin: 2 to 3 hoursResuscitate Critical Tissues First!

Key Issues In ShockRecognize & Treat during compensatory phaseBest indicator of resuscitation effectiveness = Level of ConsciousnessRestlessness, anxiety, combativeness = Earliest signs of shock

Key Issues In ShockFalling BP = LATE sign of shockBP is NOT same thing as perfusionPallor, tachycardia, slow capillary refill = Shock, until proven otherwise

Key Issues In ShockIsolated head trauma does NOT cause shock(possible in peds)

General Shock ManagementAirwayOpen, Clear, MaintainedConsider Intubation

General Shock ManagementHigh concentration oxygen Oxygen = Most Important Drug in ShockAssist ventilation as needed When in Doubt, VentilateBVMDecompress Tension Pneumothorax

General Shock ManagementEstablish venous access Replace fluidGive drugs, as appropriateDont delay definitive therapy Maintain body temperatureCover patient with blanket if neededAvoid cold IV fluids

General Shock ManagementMonitorMental StatusPulseRespirationsBlood PressureECG

Hypovolemic ShockControl severe external bleedingElevate lower extremities Avoid TrendelenburgPneumatic anti-shock garment

Hypovolemic ShockTwo large bore IV linesInfuse Lactated Ringers solutionTitrate BP to 90-100 mm Hg

Hypovolemic ShockDo NOT delay transport Start IVs enroute to hospitalWhere does stabilization of critical trauma occur?

Cardiogenic ShockSupine, or head and shoulders slightly elevatedDo NOT elevate lower extremities

Cardiogenic ShockKeep open line, micro-drip setFluid challenge based on cardiovascular mechanism and historyTitrate to BP ~ 90 mm Hg

Cardiogenic ShockTreat the underlying cause if possibleTreat rate, then rhythm, then BPCorrect bradycardia or tachycardiaCorrect irregular rhythmsTreat BPCardiac contractilityDobutamine, DopaminePeripheral resistanceDopamine, Norepinephrine

Cardiogenic ShockObstructive ShockTreat the underlying causeTension PneumothoraxPericardial TamponadeIsotonic fluids titrated to BP w/o pulmonary edemaControl airwayIntubation

Shock Management Avoid vasopressors until hypovolemia ruled out, or corrected

Shock ManagementSqueezing partially empty tank can cause ischemia, necrosis of kidney and bowel

Vasogenic ShockConsider need to assist ventilationsPatient supine; lower extremities elevatedAvoid Trendelenburg

Vasogenic ShockInfuse isotonic crystalloid Top off tankConsider PASGConsider possible hypovolemiaConsider vasopressors

Vasogenic ShockMaintain body temperature Hypothermia may occur

Vasogenic ShockAnaphylaxisSuppress inflammatory responseAntihistaminesCorticosteroidsOppose histamine responseEpinephrinebronchospasm & vasodilationReplace intravascular fluidIsotonic fluid titrated to BP ~ 90 mm

Pneumatic AntiShock Garment (PASG)FunctionPrimary effect is increased PVRHemorrhage control throughDirect pressureFracture stabilizationIncreased intra-abdominal pressureLittle effect from autotransfusion

Pneumatic AntiShock GarmentIndicationsMultiple lower extremity fracturesPelvic fracturesAbdominal injuriesAbdominal aortic aneurysmRefractory decompensated shock

Pneumatic Antishock GarmentContraindicationsAbsolutePulmonary edema

Pneumatic Antishock GarmentContraindicationsRelativeClosed head injuryThoracic hemorrhageImpaled object (abdomen, chest?)Pregnancy (abdominal section)EviscerationRuptured diaphragmCardiogenic shock

Shock in ChildrenSmall blood volumeIncreased hypovolemia riskVery efficient compensatory mechanisms Failure may cause sudden shockPallor, altered LOC, cool skin = shock UPO

Shock in ChildrenAvoid massive fluid infusionUse 20 cc/kg bolusesHigh surface to volume ratioIncreased hypothermia risk

Shock in the ElderlyPoor cardiovascular condition Rapid decompensationSepsis more likelyHypoperfusion can cause: CVAAMISeizuresBowel InfarctionsRenal failure

Shock in the ElderlyAssessment more difficultPeripheral vascular diseaseWeak pulsesAltered sensoriumHypertension masking hypoperfusionBeta-blockers masking hypoperfusionFluid infusion may produce volume overload/CHF

Shock in OB PatientsPulse increases 10 to 15 bpmBP lower than in non-pregnant patientBlood volume increased by 45% Slower onset of shock signs/ symptomsFluid resuscitation requires greater volume

Shock in OB PatientsOxygen requirement increased 10 to 20%Pregnant uterus may compress vena cava, decreasing venous return to heart Place women in late-term pregnancy on left-sideFetus can be in trouble even though mother looks well-perfused

Transport ConsiderationsIndications for Rapid TransportIndications for Trauma Center TransportConsiderations for Air Medical Transport