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Volume 4 Chapter 3: Hemorrhage and Shock

Introduction to Hemorrhage and Shock

Shock (1 of 2)• Shock is a state of inadequate tissue ____________________________________• Complicated transitional stage between normal life (homeostasis) and death• Ultimate ____________________________________ of all trauma and medical patients• Often presents with limited signs and symptoms

Shock (2 of 2)• Hemorrhage: blood loss• Hemorrhagic shock: inadequate perfusion (shock) resulting from

____________________________________ loss (internal or external) from vascular container• Frequent ____________________________________ of trauma• Common cause of shock and death in trauma patients

The Circulatory System3 Components of The Circulatory System:• The ____________________________________• The Vascular System (Blood Vessels)• The ____________________________________

The Heart (1 of 2)• Blood flow depends on functioning heart (pump)• ____________________________________ volume: volume of blood ejected from heart with each

beat• Stroke Volume is dependent on:

– ____________________________________–Cardiac contractility–Afterload

The Heart (2 of 2)• ____________________________________: blood flowing to heart

–Amount available to be pumped out• Cardiac contractility: strength of ____________________________________

– The more forceful the contraction, the greater the potential for increased output• ____________________________________ or peripheral vascular resistance: resistance to blood

flow out of heart

Figure 3-1 Factors Affecting Stroke Volume(Page 60)

The Vascular SystemThree types of vessels: • ____________________________________• Capillaries

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Capillaries• ____________________________________

Arteries (1 of 3)• Arteries distribute blood to various regions of body (pumped

____________________________________ from the heart)–All except the pulmonary artery carry oxygenated blood

• Contain about 13% of the blood volume• Smaller arteries (____________________________________) can vary lumen size and control blood

flow to organs.• Major determinants of peripheral vascular resistance.

Arteries (2 of 3)Mean Arterial Pressure:• The measurement of peripheral vascular ____________________________________• Formula:

–Diastolic BP + Diastolic BP + Systolic BP3

Arteries (3 of 3)Mean Arterial Pressure (cont’d):• Example: A patient has a BP of 90/60:

–MAP = 60 + 60 + 903

–MAP = 2103

–MAP = ____________mmHg

Capillaries• Capillaries are microscopic vessels large enough for red blood cells to pass through only in

____________________________________ file • Close proximity to all body cells• Contain about 7% of the vascular volume• Walls are ____________________________________ cell thick and allows for efficient gas and

metabolic movement in and out of vessels

Veins• ____________________________________ transport blood back to the heart

–With the exception of the pulmonary vein, veins carry unoxygenated blood• Contain 64% of blood volume (capacitance vessels)• Venous ____________________________________ effective in maintaining venous return (preload)

in early stages of hypovolemic (low volume) shock

The Blood (1 of 3)• The blood is a mixture of ____________________________________, cells, proteins, and suspended

elements• ____________________________________: fluid portion of blood

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____________________________________: fluid portion of blood–Accounts for about 55% of blood volume–Consists mostly of water, dissolved salts, proteins, and other necessary materials

The Blood (2 of 3)Red blood cells (____________________________________): • Responsible for oxygen transport• Accounts for about 45% of total blood volume• ____________________________________: the percentage of the total blood volume consisting of

RBCs• Erythrocytes contain hemoglobin responsible for oxygen transport from alveoli to cells.• Hemoglobin: iron-based compound that binds with oxygen for transport to body cells

The Blood (3 of 3)• Platelet: important for ____________________________________ and blood vessel repair

– If platelets are too plentiful, blood ____________________________________ can develop– If platelets are too decreased, significant bleeding can occur

Types of Hemorrhage (1 of 4)Capillary hemorrhage:• Blood ____________________________________ from wound• Caused by abrasion or ____________________________________ injury• Stops quickly• Blood bright red; well oxygenated

Types of Hemorrhage (2 of 4)Venous hemorrhage:• Flows more ____________________________________• Tends to stop in few minutes • Hemorrhage ____________________________________; oxygen depleted after passage though

capillary beds• Can sometimes be extensive because of size and number of vessels involved

Types of Hemorrhage (3 of 4)Arterial hemorrhage:• Flows very ____________________________________, often spurting from wound• Blood ____________________________________ red; well oxygenated• Blood volume lost can be significant because of ____________________________________ and the

vessel size• Bleeds longer

Types of Hemorrhage (4 of 4)

Hemostasis (1 of 7)____________________________________: the body’s response to local hemorrhage that occurs in 3 phases• Vascular phase• ____________________________________ phase

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____________________________________ phase• Coagulation phase

Hemostasis (2 of 7)Vascular phase:• Smooth muscle within walls ____________________________________ causing vessel to withdraw

into wound, –Causes a ____________________________________ wall, reducing the size of the opened wound

Hemostasis (3 of 7)Platelet phase:• Platelets aggregate, or ____________________________________ and adhere; slowing hemorrhage

from capillaries and small vessels

Hemostasis (4 of 7)Coagulation phase:• ____________________________________ factors activated and released into bloodstream resulting

in a complex cascade of events• Triggers series of chemical reactions and the formation of strong protein fibers

(____________________________________) that strand forming strong protein mesh

Hemostasis (5 of 7)• Wound type affects hemostasis and clot formation• Systemic ____________________________________ beneficial in controlling serious internal

hemorrhage– Increased blood ____________________________________ can result in increased blood loss

Figure 3-5 The Type of Blood Vessel Injury Often Affects the Nature of the Hemorrhage (Page 63)

Hemostasis (6 of 7)Factors Affecting Hemostasis:• Immediate immobilization (____________________________________) wound site aids clotting

process• Aggressive fluid therapy may ____________________________________ affect hemostasis

– Fine line between maintaining perfusion and increasing blood loss• As body ____________________________________ falls below normal, hemostasis slower and less

effective

Hemostasis (7 of 7)Factors Affecting Hemostasis (cont’d):• ____________________________________ to prevent or limit heart attack or stroke, slow clot

formation and increase risk for hemorrhage.–Aspirin, NSAIDs, ____________________________________, Plavix, Lovenox, warfarin, Prodoxa.

Hemorrhage Control (1 of 12)External hemorrhage:• Look for severe and continuing external hemorrhage• Capillary and venous bleeding from small vessels can be controlled by firmly

____________________________________ dressing over wound

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____________________________________ dressing over wound• More severe bleeding controlled with direct ____________________________________ on dressing

and wound

Hemorrhage Control (2 of 12)Tourniquets:• Tourniquets can be used on ____________________________________ when other methods have

failed –Only for life threatening bleeding

• When TQ is released and blood flow resumes, ____________________________________ products of metabolism move into central circulation, potentially worsening patient's condition

Hemorrhage Control (3 of 12)Tourniquet (cont’d):• Allow tourniquet to ____________________________________ in place until patient in emergency

department• Use ____________________________________ tourniquet or wide cravat, belt, blood pressure cuff

Hemorrhage Control (4 of 12)Internal hemorrhage:• Can occur from all forms of serious ____________________________________ and penetrating

trauma• Can be capillary, venous, or arterial blood loss• Blood can accumulate in ____________________________________ spaces resulting in contusion• Forced between layers of tissue (fascia); will form pocket of blood (hematoma)

Hemorrhage Control (5 of 12)Internal Hemorrhage (cont’d): • Indicators: localized injury signs and symptoms; ____________________________________ signs

and symptoms of blood loss and shock• If significant ____________________________________ to chest, abdomen, pelvis, be alert for

significant, continuing, uncontrolled blood loss

Hemorrhage Control (6 of 12)Internal Hemorrhage (cont’d): • Careful assessment; rapid transport to ____________________________________ center.• If in extremities, effective ____________________________________ can aid in bleeding control (if

time and manpower allow)

Hemorrhage Control (7 of 12)Internal Hemorrhage (cont’d): • The drug tranexamic acid (____________________________________) is beginning to be used in

EMS: –Anti-fibrinolytic – Inhibits ____________________________________ (the process that prevents blood clotting)

Hemorrhage Control (8 of 12)

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Internal Hemorrhage (cont’d): • Patients with significant trauma develop ____________________________________: condition in

which blood's ability to clot is impaired• TXA can reduce trauma mortality by ____________________________________ fibrinolysis

Hemorrhage Control (9 of 12)Internal Hemorrhage (cont’d): • Evidence may present at body ____________________________________• Nasal cavity: mild to moderate hemorrhage (____________________________________)• Blood evacuated shortly after ingestion will be bright red in color

Hemorrhage Control (10 of 12)Internal Hemorrhage (cont’d): • Blood in gastrointestinal tract for long time will result in emesis that resembles wet

____________________________________ grounds in color and consistency• Lower respiratory injuries can result in coughing up bright red blood

(____________________________________).• Upper digestive system injury may cause blood to accumulate in stomach resulting in

emesis containing blood (____________________________________)

Hemorrhage Control (11 of 12)Internal Hemorrhage (cont’d): • Small or large bowel can result in frank rectal bleeding, blood mixed with stool

(____________________________________)• Blood that remains in bowel for some time will appear as black and tarry stool

(____________________________________).• Rectal injuries can occur in conjunction with pelvic fractures or direct trauma and may

cause severe bright red rectal hemorrhage

Hemorrhage Control (12 of 12)Internal Hemorrhage (cont’d): • Vaginal: may be associated with ____________________________________ (rare)• Urethral hemorrhage is generally ____________________________________ and may reflect

damage to prostate or urethra• Blood in urine may indicate injury to genitourinary tract

Classes of Hemorrhage (1 of 14)• Fluid accounts for about ___________% of the body's weight distributed among intracellular,

interstitial, intravascular spaces.• Hemorrhage categorized into four classes that relate to blood

____________________________________ lost in acute hemorrhage and result in "classic" signs and symptoms of hemorrhage and shock.

Classes of Hemorrhage (2 of 14)Class I Hemorrhage:• Blood loss of up to 15% (750mL) of circulating blood volume• Healthy patient can easily ____________________________________ for such blood volume loss

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Healthy patient can easily ____________________________________ for such blood volume loss• Blood pressure remains ____________________________________, as do pulse pressure, respiratory

rate, and urine output

Classes of Hemorrhage (3 of 14)Class I Hemorrhage (cont’d):• Body may show signs of catecholamine (epinephrine and norepinephrine) release causing:

–Nervousness/____________________________________–Marginally cool skin with slight pallor– Slight pulse ____________________________________

Classes of Hemorrhage (4 of 14)Class II Hemorrhage:• 15 to 30% (750 to 1,500mL) of blood volume lost• First-line compensatory responses can no longer maintain

____________________________________• Secondary mechanisms employed:

– ____________________________________ occurs; pulse pressure narrows; pulse strength diminishes

Classes of Hemorrhage (5 of 14)Class II Hemorrhage (cont’d):• Strong ____________________________________ release results in increased peripheral vascular

resistance do to vasoconstriction–Aids in maintenance of BP

• Increased restlessness/anxiety and thirst• ____________________________________ output remains normal• Respiratory rate increases

Classes of Hemorrhage (6 of 14)Class III Hemorrhage:• Blood loss of 30 to 40% (1,500 to 2,000mL) of blood volume• Compensatory mechanisms ____________________________________ to cope with loss; classic

signs of shock• Tachycardia more ____________________________________ as blood pressure begins to fall• Pulse barely palpable

Classes of Hemorrhage (7 of 14)Class III Hemorrhage (cont’d):• Patient may display dyspnea and ____________________________________• Anxiety, restlessness, thirst more pronounced• ____________________________________ status may be altered• Pale, cool, ____________________________________• Urinary output declines• Process rapidly becoming more difficult for body to sustain

Classes of Hemorrhage (8 of 14)

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Class IV Hemorrhage:• Blood loss greater than 40% (2,000mL) of total blood supply• Pulse barely ____________________________________ in central arteries• ____________________________________ very rapid, shallow, and ineffective

Classes of Hemorrhage (9 of 14)Class IV Hemorrhage (cont’d):• Skin very cool, pale and diaphoretic • Urinary output ____________________________________• Very lethargic and ____________________________________ moving rapidly to unresponsiveness• Even with fluid resuscitation and blood transfusion, ____________________________________ is

unlikely

Table 3-1 Patient Signs Associated with Stages of Hemorrhage (Page 66)

Classes of Hemorrhage (10 of 14)• Preexisting conditions can affect volume of blood loss

– ____________________________________ status, medication, diseases, etc.• Blood loss ____________________________________ has profound effect on how quickly patient

moves from class I to class IV

Classes of Hemorrhage (11 of 14)Certain patient categories react differently to blood loss:• Pregnant women: have ____________________________________ blood volume

– Progress more slowly through the classes• Athlete: may have greater cardiac ____________________________________

– Progress more slowly through the classes• Obese patients: have a ____________________________________ volume close to 7% of their ideal

body weight, not actual weight– Progress more rapidly through the classes

Classes of Hemorrhage (12 of 14)Certain patient categories react differently to blood loss (cont’d):• Infants and young children: have ____________________________________ blood volume (in

percentage)– ____________________________________ the initial S/S of shock– But causes rapid ____________________________________

• Alcohol: vasodilation and slows the compensatory mechanisms– Progress more rapidly through the classes

Classes of Hemorrhage (13 of 14)Certain patient categories react differently to blood loss (cont’d):• Elderly: have ____________________________________ reserve volume

–May also be on ____________________________________ that inhibit compensatory mechanisms

–May progress more rapidly through the classes

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May progress more rapidly through the classes–More prone to hypothermia

Classes of Hemorrhage (14 of 14)• Hemorrhage (internal or external) can lead to ____________________________________• ____________________________________ shock: subclass of hypovolemic shock and is associated

with trauma

Stages of Shock• Stages of shock are based on body's ability to ____________________________________ and the

presenting signs and symptoms• Phases are progressive in severity• 3 Phases are:

–Compensated– ____________________________________– Irreversible

Compensated Shock (1 of 2)• Initial stage of shock in which body progressively compensates for continuing blood loss• ____________________________________

–May be attributed to pain or the trauma• Pulse rate increases

–May not be reliable as an increased pulse rate is a common reaction to pain and trauma• Narrowing pulse ____________________________________ often is the first reliable sign

Compensated Shock (2 of 2)• Pulse strength ____________________________________• Skin becomes cool and clammy and capillary refill time may increase• Progressing anxiety, restlessness, combativeness• ____________________________________ and weakness• Stage ends with a precipitous ____________________________________ in blood pressure

Decompensated Shock (1 of 2)• Begins when body's compensatory mechanisms can no longer maintain

____________________________________ resulting in inability to maintain BP• Extreme ____________________________________ with inadequate cardiac output

– Pulse becomes unpalpable• Blood pressure drops precipitously with vital organs becoming hypoperfused

Decompensated Shock (2 of 2)• Brain is ____________________________________ and patient becomes unconscious• ____________________________________ slow or cease• Body takes on a deathlike appearance

Irreversible Shock• Shortly after patient enters decompensated shock, lack of circulation begins to have

profound effects on body cells• As they are irreversibly damaged, the cells ____________________________________, tissues

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As they are irreversibly damaged, the cells ____________________________________, tissues dysfunction, organs dysfunction, and patient dies

• The transition between decompensated shock and irreversible shock is a ____________________________________ one and impossible to differentiate based on S/S

Table 3-2 The Stages of Shock (Page 79)

Types of Shock5 Types of Shock are:• ____________________________________• Cardiogenic• ____________________________________• ____________________________________• Septic

Hypovolemic Shock• Significant reduction in ____________________________________ of cardiovascular system• ____________________________________ common cause; fluid loss from other pathologies can

occur– If from fluid loss it is commonly referred to as non-hemorrhagic hypovolemic shock

• Hemorrhagic shock specific subset of hypovolemia caused by blood loss

Cardiogenic Shock• Results from ____________________________________ insufficiency• Any cardiac pathology profound impact on circulation• May present with signs and symptoms of myocardial infarction or pulmonary edema and

with classic signs and symptoms of shock• Cardiac ____________________________________ may be present• Prognosis very poor; 80 percent mortality rate

Neurogenic Shock (1 of 2)• Results from ____________________________________ in communication pathway between central

nervous system and the body • Most commonly caused by a spinal or head injury• Results in ____________________________________• Tachycardia and rising diastolic blood pressure expected with other shock states may

____________________________________ occur

Neurogenic Shock (2 of 2)• Skin below nervous system injury warm, ____________________________________ and pink• Skin ____________________________________ it displays pallor, coolness, clamminess• Commonly characterized by normal or ____________________________________ heart rate with

low BP

Anaphylactic Shock• Introduction of ____________________________________ substance into body causes massive

histamine release• Over exaggerated response due to a ____________________________________ threat

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Over exaggerated response due to a ____________________________________ threat• Causes general vasodilation, leaking blood vessels, and edema

Septic Shock• Results from massive ____________________________________ releasing toxins that adversely

affect vascular system's ability to control blood vessels and distribute blood• Blood vessels ____________________________________ and leak• Results in multiple organ death

Assessment of the Patient with Hemorrhage and Shock

Scene Size Up• BSI• Scene ____________________________________• Evaluate mechanism of injury (MOI) considering for potential of external and internal

hemorrhage• Determine time elapsed between injury and assessment• Maintain ____________________________________ oversight

Primary Assessment (1 of 5)• Assess initial mental status; determine alertness, orientation, responsiveness• ____________________________________

–Administer oxygen if S/S of shock present• Look at patient's ____________________________________ condition• Control significant breathing

Primary Assessment (2 of 5)• Patient priorities, using C U P S acronym

– (C) ____________________________________– (U) Unstable– (P) ____________________________________ unstable– (S) Stable

• Consider rapid trauma assessment

Secondary Assessment (1 of 6)• Critical trauma patients should ____________________________________ receive a secondary

assessment on scene– For these patients, perform a rapid trauma assessment managing life threats and begin

rapid ____________________________________• Stable trauma patients should receive a focused trauma assessment

Secondary Assessment (2 of 6)Rapid Trauma Assessment:• Quickly palpate the body from head to toe looking for life

____________________________________• Often guided by the ____________________________________• Correct life threats

– Sucking neck wound, tension pneumothorax, sucking chest wound,

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Sucking neck wound, tension pneumothorax, sucking chest wound, ____________________________________ chest, serious bleeding, etc.

• Stabilized fractures of the pelvis or femur

Secondary Assessment (3 of 6)Rapid Trauma Assessment (cont’d):• Key is to find and treat ____________________________________ life threats and to minimize scene

time• Blood pressure and history taken ____________________________________

____________________________________• Treatments such as IVs, intubation, splinting of injuries (other than spine, pelvic and femur)

etc. performed en route–Unless there are extenuating circumstances such as entrapment or inability to control

the airway with BLS procedures

Secondary Assessment (4 of 6)Focused trauma assessment:• Patients ____________________________________ signs or symptoms of serious injury or blood

loss• Focus exam on ____________________________________ area• Obtain baseline vital signs, patient history, prepare and transport• Scene ____________________________________ is generally not a significant concern

Secondary Assessment (5 of 6)Additional assessment considerations:• Watch for signs of orthostatic hypotension

– Perform “____________________________________ test”– Tilt test is considered positive if:

▪ SBP ____________________________________ more than 15 to 20mmHg, and/or▪ Pulse rate ____________________________________ by more than 20bpm, and/or▪ Patient experiences light-headedness

Secondary Assessment (6 of 6)Additional assessment considerations (cont’d):• Do ____________________________________ perform tilt test is patient is already showing S/S of

____________________________________• Do not perform tilt test is patient is immobilized on a LSB

Patient Medical History• Question patient regarding chief complaint and past medical history• Pay attention to complaints of weakness, ____________________________________, or nausea that

may be signs of shock• Pay attention to preexisting medical problems, ____________________________________, last oral

intake, other medical information• Try to determine cause of incident• ____________________________________

Detailed Physical Exam

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• Performed only ____________________________________ all priorities addressed and the patient is en route to a trauma center

• Assess from head to toe looking for ____________________________________ signs of injury–As it pertains to patient’s condition and MOI

Reassessment (1 of 2)• At least every 5 minutes with critical, unstable, potentially unstable patients• Every 15 minutes with stable ones• Reevaluate general ____________________________________• Reassess mental status, airway, breathing, circulation• Check for ____________________________________ in patient’s condition and trends

Reassessment (2 of 2)• Additional set of vital signs, Glasgow Coma Scale score, oximetry and capnography

readings• Compare each finding with earlier ones to detect changes and

____________________________________• Attention to pulse rate and ____________________________________ pressure• Check adequacy and effectiveness of interventions performed• Check ____________________________________ and treatments

Management of the Patient with Hemorrhage and Shock

Hemorrhage Management (1 of 2)• Ensure ____________________________________ patent• Breathing adequate or establish and maintain airway• Provide ventilatory support; administer supplemental ____________________________________• Use pulse-oximetry, capnography, patient's signs and symptoms

Hemorrhage Management (2 of 2)• Treat serious (arterial and heavy venous) hemorrhage ____________________________________• Quickly apply dressings• If IV initiation will result in delayed transport, provide during

____________________________________• Care for injuries in established priority order previously established

Direct Pressure (1 of 2)• Controls all but most ____________________________________ hemorrhage• When blood loss control ____________________________________, direct pressure has not been

applied to hemorrhage source• Head wound with open fracture and brain injury: do not place pressure directly on

fractured skull or brain

Direct Pressure (2 of 2)• If serious bleeding from eye orbits, avoid placing pressure directly on

____________________________________ of eye• Avoid pressure on ____________________________________, larynx, airway structures

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Avoid pressure on ____________________________________, larynx, airway structures–May lead to airway constriction and hypoxia

• Limb splinting and ____________________________________ splints can aid in bleeding control on extremities

• Dressings held in place with pressure bandage

Elevation and Pressure Points• If direct pressure does not halt minor-to-moderate extremity hemorrhage, consider

elevation–Only if isolated bleeding and movement will not aggravate injury–Consult protocols

• If bleeding persists, find arterial pulse point proximal to wound; apply firm pressure– Pressure must be maintained

Topical Hemostatic Agents (1 of 2)• Approved by FDA• Can be used when direct pressure is ineffective and/or on an area where a tourniquet

____________________________________ be applied. • Support blood ____________________________________; help control further blood loss• Apply directly or indirectly to active hemorrhage• May not be effective on ____________________________________ bleeds due to the pressures

Topical Hemostatic Agents (2 of 2)• Comes in two forms:

–As a ____________________________________ impregnated with the hemostatic agent–A ____________________________________ that is poured directly into the wound

▪ Not recommended for EMS• After application, direct pressure for at least 3 minutes is required

Topical Hemostatic Agents Such as Quikclot Can be Used with Pressure Dressings to Control Bleeding

Tourniquets (1 of 2)• ____________________________________ resort when hemorrhage prolonged and persistent or

when multiple patients are present or when patient has other significant injuries also requiring immediate interventions and manpower is limited

• Used ONLY on ____________________________________• Apply commercial tourniquet proximal to hemorrhage site; firmly secure

Tourniquets (2 of 2)• Apply just ____________________________________ to the injury• Do not apply over a ____________________________________• Ensure bleeding does not continue after you apply tourniquet

Figure 3-11 Use a Tourniquet as a Last Resort When Hemorrhage is Prolonged and Persistent

Specific Wound Characteristics (1 of 7)Head Injuries:

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Head Injuries: • ____________________________________ is rich in blood vessels and can bleed profusely• Skull fracture may result in bleeding or fluids leaking from ears and nose; • Facial injuries threatening ____________________________________• Direct pressure on a skull fracture can damage brain

Specific Wound Characteristics (2 of 7)Head Injuries (cont’d):• Fluid drainage from ears and nose may be secondary to ____________________________________

fracture.• Cover area with soft, porous dressing, bandage ____________________________________ in place,

permit some blood to flow from wound.

Specific Wound Characteristics (3 of 7)Eye Injuries:• Avoid ____________________________________ eye globe.• If ruptured, globe can lose irreplaceable ____________________________________ contents• Apply pressure only to intact and stable bony orbital rim

Specific Wound Characteristics (4 of 7)Neck Wounds:• Open neck wound run a risk of ____________________________________ drawn into venous

circulation, with life-threatening consequences• Cover with ____________________________________ dressing• Do not employ circumferential bandages to create direct pressure

Specific Wound Characteristics (5 of 7)Neck Wounds (cont’d):• ____________________________________ pressure controls most, if not all, neck bleeding.• ____________________________________ compressing trachea, larynx, other structures that may

cause airway compromise.

Specific Wound Characteristics (6 of 7)Gaping Wounds: • Often present bleeding control problems• Create a ____________________________________ of dressing materials based on volume and

shape of wound• Bandage dressing ____________________________________ in place• Consider hemostatic agent

Specific Wound Characteristics (7 of 7)Crush Injuries: • Bleeding source may be ____________________________________ to locate• Vessel damage may prevent clotting mechanisms from being effective• Place dressing around and over crushed area and use a ____________________________________

splint (if available) to hold in place. If not, secure with a pressure bandage• Consider ____________________________________ agent

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Consider ____________________________________ agent• Consider tourniquet if on extremity

Transport Considerations• Rapid transport all serious external hemorrhage that cannot control and all suspected

serious internal hemorrhage• When in doubt, ____________________________________• Serious hemorrhage has significant psychological impact on patients

– ____________________________________ and reassure patient

Shock Management (1 of 16)Airway and Breathing Management:• Ensure secure and patent airway• Good ventilations with supplemental oxygen; maintain saturation of at least 95-96%• ____________________________________ airway as needed• Endotracheal intubations, ____________________________________ should be used• Rapid sequence intubation (RSI) considered

Shock Management (2 of 16)Airway and Breathing Management (cont’d):• If moving air ineffectively (rate < ___________/minute or inadequate volume), provide

positive-pressure ventilations• Improve oxygen saturation: consider positive end-expiratory pressure (PEEP) or continuous

positive airway pressure (____________________________________)• Diagnose and treat tension pneumothorax with a pleural decompression

Shock Management (3 of 16)Airway and Breathing Management (cont’d):• Ensure unconscious and unresponsive patient has palpable

____________________________________ pulse• If not, initiate CPR, attach monitor-defibrillator (or AED), employ advanced life support

measures

Shock Management (4 of 16)Hemorrhage Control:• Rapid control of significant ____________________________________ hemorrhage• Use technique or combination of techniques previously discussed

Shock Management (5 of 16)Fluid Resuscitation:• Field treatment of choice for significant blood loss in trauma is whole

____________________________________–Not practical in most EMS services

• Practical fluid for prehospital administration is an isotonic crystalloid–Normal saline (NS) or Lactated Ringers (LR)–Replaces ____________________________________ but has no oxygen carrying

Shock Management (6 of 16)

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Fluid Resuscitation (cont’d):• ____________________________________ and synthetic solutions may have some applications• Synthetic agents that can carry oxygen being tested• ____________________________________ fluid administration: classic signs and symptoms of

shock; controlled isolated external hemorrhage

Shock Management (7 of 16)Fluid Resuscitation (cont’d):• Hemodynamically stable patient may have ____________________________________, tachypnea,

decreased urine output and still be in shock• Hemodynamically normal patients do not have signs of ____________________________________

tissue perfusion

Shock Management (8 of 16)Isotonic Fluid Administration:• Indicated for the patient with the classic S/S of shock and isolated but controlled external

hemorrhage• Use aggressive fluid therapy using ___________ or ___________ via one line• Goal is to restore organ perfusion; not blood pressure

Shock Management (9 of 16)Isotonic Fluid Administration (cont’d):• Risks of continued infusion of large volumes of isotonic fluids:

–Dilution of the ____________________________________ factors–Decreases the hematocrit– Increases ____________________________________ due to increased BP– ____________________________________ the patient outcomes

Shock Management (10 of 16)Isotonic Fluid Administration (cont’d):• Generally, adults require 1 to 2 liters of fluid• Given in boluses of ___________ mL to 1 Liter at a time

– Fluid run wide open W/O–With close observation of ____________________________________ sounds between boluses– Bolus ____________________________________ only if needed

• Children are given boluses at ___________mL/kg repeated as needed

Shock Management (11 of 16)Isotonic Fluid Administration (cont’d):• Patients in hypovolemic shock respond to intravenous fluids in one of three ways:

–Rapid response: stabilize ____________________________________ after 1st bolus–____________________________________ response: respond favorably initially and then

deteriorate again–Minimal or no response: fluid achieves no change

Table 3-3 Response to Initial Fluid Resuscitation (2 L of Isotonic Crystollids in Adults; 20 mL/Kg in Children) (Page 79)

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20 mL/Kg in Children) (Page 79)

Shock Management (12 of 16)Isotonic Fluid Administration (cont’d):• Use as ____________________________________ of a bore possible IV catheter connected to

trauma (10 drop set) or blood tubing to ensure unimpeded flow and non–flow-restrictive saline lock if system so requires

• Objective in field is not return of normal vital signs, but ____________________________________ of vital signs until patient reaches trauma center

• Monitor fluid volume

Shock Management (13 of 16)Temperature Control:• In trauma, patients lose heat more rapidly than normal and heat

____________________________________ is low• Heat-generating reflexes (____________________________________) ineffective and

counterproductive to shock care process• Hypothermia reduces effectiveness of clotting mechanism which can worsen and prolong

hemorrhage

Shock Management (14 of 16)Temperature Control (cont’d):• Cover patient with ____________________________________• Keep ambulance very ____________________________________• If you infuse fluids, ensure they are not cold

– Ideally at body temperature but no more than 104 degrees

Shock Management (15 of 16)Pharmacological Intervention:• The use of ____________________________________ for shock management is limited, especially in

hypovolemic patients• Hypovolemic shock: blood replacement should be used ____________________________________

to vasopressors• Cardiogenic shock: fluid challenge, vasopressors, cardiac drugs indicated

Shock Management (16 of 16)Pharmacological Intervention (cont’d):• Spinal and obstructive shock: ____________________________________ fluids• Distributive shock: consider IV fluids or ____________________________________

Conclusion• Significant hemorrhage and its serious consequence, shock, are genuine threats to trauma

patient's life.• Signs of these threats are often subtle or hidden, especially if bleeding is internal• A thorough patient assessment is required• Treatment of shock requires rapid transport with most treatments performed en route

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