Chapter 20. Learning Objectives. Learning Objectives 9/18/2012. Bleeding and Shock

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1 Chapter 20 Bleeding and Shock Learning Objectives Describe structure & function of circulatory system Differentiate among arterial, venous, & capillary bleeding Describe methods of emergency medical care for external bleeding Establish relationship between BSI & bleeding 2 Learning Objectives Establish relationship between airway management, trauma patient Establish relationship between MOI & internal bleeding List signs of internal bleeding List steps in emergency medical care of patient with signs/symptoms of internal bleeding 3 1

2 Learning Objectives List signs & symptoms of shock Outline steps in emergency medical care of patient with signs/symptoms of shock (hypoperfusion) Explain sense of urgency to transport bleeding patients showing signs of shock (hypoperfusion) 4 Introduction Trauma - leading cause of death in United States for persons between 1 and 44 yrs Loss of blood volume accounts for many of these deaths External bleeding Internal bleeding Direct pressure - most important action to take to control external bleeding Internal bleeding results in a range of signs/symptoms that will alert to significant blood loss and shock 5 Anatomy & Physiology 3 major components of circulatory system Blood Heart Blood vessels Components function together to perfuse body with blood 6 2

3 Anatomy & Physiology Circulatory system Brings nutrients to cells Returns waste products to organs for elimination Distributes nutrients among body s organs Helps regulate body temperature Blood is made up of liquid (plasma) & cellular components 7 Anatomy & Physiology Heart - made up of 4 chambers 2 atria (receiving chambers) 2 ventricles (pumping chambers) Left ventricle, pump for circulation to body Right ventricle pumps blood throughout pulmonary arteries to lungs 8 Anatomy & Physiology Heart 2 circulations function at same time Blood vessels distribute blood to all parts of body, lungs Arteries carry blood away from heart Veins carry blood back to heart 9 3

Anatomy & Physiology Cardiac output Blood volume pumped by heart each minute Normal heart rate, 60 to100 beats/min Stroke volume is blood volume pumped out of heart with each beat 10 Anatomy &

4 Anatomy & Physiology Cardiac output Blood volume pumped by heart each minute Normal heart rate, 60 to100 beats/min Stroke volume is blood volume pumped out of heart with each beat 10 Anatomy & Physiology Cardiac output Smaller blood vessels (arterioles) open, close depending on local tissue needs 11 Anatomy & Physiology Cardiac output Blood pressure Force exerted by blood volume on walls of vessels 12 4

5 Anatomy & Physiology Cardiac output Blood pressure Systole Systolic BP Diastolic BP Children 13 Anatomy & Physiology Cardiac output Vascular space Determined by internal diameter of vessels and number of vessels open at given time Important to know the relationships between cardiac output, size of vascular space, and blood pressure Part of circulatory system fails, BP decreases Hypoperfusion can result Loss of blood volume can lead to: Hypoperfusion Hypovolemic shock 14 Anatomy & Physiology Cardiac output Normal tissue perfusion Blood flow matches body s energy requirements on organ by organ basis Blood perfuses tissues in sufficient quantity to meet each organ s needs 15 5

6 Anatomy & Physiology Cardiac output Effects of epinephrine Prepares body to meet many challenges ( fight/flight reaction) Also occurs when individual is injured and severely bleeding, is in respiratory distress, or is severely ill Cardiac output increased Blood flow to brain increased Pupils dilate Blood flow redistributed 16 Anatomy & Physiology Cardiac output Effects of epinephrine Respiratory rate increases May not elevate BP Increased cardiac output, adjusts tone of blood vessels Redistribution 17 Personal precautions Standard precautions for blood and bodily fluids Gloves Goggles Masks Gowns 18 6

7 Severity of blood loss Depletes RBCs Hemoglobin, necessary to carry O 2 Blood volume, necessary to fill vascular space Platelets, clotting factors, necessary to stop bleeding 19 Severity of blood loss Sudden blood loss 1 L (1000 ml) in adult, ½ L (500 ml) in child, 100 to 200 ml in infant is considered serious Severity based on signs, symptoms & general impression of amount of blood loss Left untreated, individuals who lose ½ blood volume experience circulatory arrest & death Earliest cause of shock & death in bleeding patient 20 Severity of blood loss Loss of blood cells Normally a person has 3 to 4 times amount of RBCs and hemoglobin necessary to sustain life Many patients with chronic diseases live with 1/2 normal levels of hemoglobin Anemic Low supply of hemoglobin 21 7

22 Severity of blood loss Loss of blood volume Hemorrhage results in equal loss of blood volume and hemoglobin Body adjusts loss of ½ hemoglobin over time Sudden loss of ½ blood volume causes

8 22 Severity of blood loss Loss of blood volume Hemorrhage results in equal loss of blood volume and hemoglobin Body adjusts loss of ½ hemoglobin over time Sudden loss of ½ blood volume causes circulatory arrest With loss of ½ normal blood volume, there is insufficient blood available to fill smallest possible vascular space and circulation ceases 23 Types of bleeding Artery Capillary Vein 24 8

9 Types of bleeding Quality of blood flow If blood vessel walls are severed, bleeding results Rate of bleeding depends on size and type of vessel injured 25 Types of bleeding Color Recognizing types of bleeding is aided by color flowing from wound Location External veins are more superficial than arteries Arteries run deeper in body and along bony surfaces Clotting Normally begins 4 to 6 minutes after injury occurs Capillaries clot faster Partially severed arteries are least likely to clot; high pressure of blood flowing through 26 Control of bleeding Use standard precautions Loss of blood volume and hemoglobin is a critical event Recognition and control of external bleeding part of initial (primary) assessment Obvious external bleeding requires immediate attention; treated in conjunction with ABCs 27 9

allows attention to other tasks 29 Control of bleeding Air splint Applies direct pressure over

10 Control of bleeding Direct pressure Apply sterile dressing to wound Compress bleeding vessels 28 Control of bleeding Pressure bandage Apply once bleeding has been controlled with direct pressure; allows attention to other tasks 29 Control of bleeding Air splint Applies direct pressure over extremity Useful for large wound oozing blood Clear dressing allows observation under splint and periodic reassessment 30 10

11 Control of bleeding Elevation Controls bleeding in extremities, use in conjunction with direct pressure 31 Control of bleeding Splinting Broken bone fragments may continue to grate on blood vessels and increase bleeding if not immobilized Useful for bleeding control when fractures or injury deep into muscular tissues are suspected Apply pressure bandage to control external bleeding then splint extremity 32 Control of bleeding Pressure points Depending on wound s location, applying pressure directly over major artery that feeds body area may be helpful Bleeding from extremities Pressure applied collapses arteries and reduces or stops blood flow Adjunct to direct pressure in bleeding control 33 11

Pressure Point Upper Extremity Pressure Point Lower Extremity 34 Control of bleeding Tourniquets Last

blood flow beyond site No blood can flow beyond tourniquet BP cuff, inflated above systolic blood

distal tissue of O 2, Pressure of tourniquet transmitted to nerves 35 Skill 20-1: Applying a Tourniquet

12 Pressure Point Upper Extremity Pressure Point Lower Extremity 34 Control of bleeding Tourniquets Last resort for uncontrolled bleeding Constricting band applied over extremity with enough pressure to stop blood flow beyond site No blood can flow beyond tourniquet BP cuff, inflated above systolic blood pressure, can be used Place proximal to wound, do not apply directly over joint Stops blood flow, starving distal tissue of O 2, Pressure of tourniquet transmitted to nerves 35 Skill 20-1: Applying a Tourniquet Place piece of soft material, proximal to wound, as distal as possible Wrap around extremity twice, secure with half knot 36 12

Skill 20-1: Applying a Tourniquet Place stick or pencil in half-knot, secure with square knot Twist

Bilateral leg amputation caused by train accident and severe blood loss 38 Special areas of

airway Nosebleeds (epistaxis) can result from: Skull trauma Digital trauma Medical conditions

13 Skill 20-1: Applying a Tourniquet Place stick or pencil in half-knot, secure with square knot Twist stick until bleeding stops, securely attach to extremity 37 Skill 20-1: Applying a Tourniquet Bilateral leg amputation caused by train accident and severe blood loss 38 Special areas of bleeding Bleeding from nose and mouth deserves special consideration to ensure blood stays out of airway Nosebleeds (epistaxis) can result from: Skull trauma Digital trauma Medical conditions Nosebleeds can be serious enough to cause severe blood loss Most nosebleeds arise from anterior section of nose 39 13

sides of nostrils Have patient sit & lean forward to reduce

14 40 Special areas of bleeding Most nosebleeds arise from anterior section of nose Control bleeding Direct pressure both sides of nostrils Have patient sit & lean forward to reduce chance of aspiration Hold at least 5 minutes, so clotting can occur

15 Special areas of bleeding Skull fractures sometimes accompanied by bleeding from ears or nose Discharge may be blood, mixed with cerebrospinal fluid (CSF) Do not attempt to stop bleeding Use loose sterile dressing to prevent entry of outside debris 43 Special areas of bleeding Bleeding from mouth; could contribute to aspiration or airway obstruction Suction Position patient, allow for drainage of blood and other fluids If spinal injury is suspected, log-roll patient while maintaining spinal immobilization 44 Internal Bleeding Signs Vomiting blood Heavy vaginal or rectal bleeding Dark, tarry stools Painful swelling of limb 45 15

16 Internal Bleeding Signs Common mechanisms Major trauma, blunt or penetrating Falls Motorcycle or vehicle crashes Striking of pedestrian Blast injuries Knife and gunshot wounds Fractures, large amount blood loss 46 Internal Bleeding Signs Skull fractures Rarely significant bleeding within skull; cranium is nonexpandable space Exceptions are open wounds or skull fractures in infants 47 Internal Bleeding Signs Medical conditions Stomach and duodenum ulcers History of abdominal aneurysm Ruptured ectopic pregnancy 48 16

17 Internal Bleeding Signs Potential sites of hidden blood loss Hemithorax Abdomen Femur Pelvis Skull 49 Internal Bleeding Prehospital management Recognize existence Maintain oxygenation and ventilation Control external bleeding Rapid transport Watch for signs and symptoms of shock 50 Shock Failure of circulatory system to adequately perfuse and oxygenate body tissues Caused by disruption of any components of circulatory system Onset can be immediate or delayed Early recognition is important Be familiar with signs/symptoms Ability to assess shock is aided by knowledge of compensatory mechanisms body uses to survive 51 17

18 Shock Classification of shock Heart Blood volume Vascular system 52 Shock Classification of shock Cardiogenic shock Heart or pump failure Most common cause is myocardial infarction (MI) Decreased cardiac output caused by abnormal heart rhythms Pump failure effects seen on both arterial and venous sides of circulation Distended neck veins result from systemic side of circulation Pulmonary side back up evidenced by fluid in lungs 53 Shock Classification of shock Hypovolemic shock Caused by low blood volume Most life-threatening cause is severe and rapid bleeding, or hemorrhage 54 18

19 Shock Classification of shock Signs & symptoms of blood loss Dynamic changes to circulatory system Degree determines type of compensatory mechanisms body uses to maintain blood flow Constriction of veins Constriction of arteries Increased heart rate Increased rate of breathing 55 Shock Classification of shock Blood loss 10% to15% First response, constriction of circular muscles in venous system Veins change space blood must occupy to compensate for blood volume loss No signs or symptoms may be present Most difficult to evaluate 56 Shock Classification of shock Blood loss - up to 30% Constriction of veins insufficient to compensate and maintain perfusion Less blood returns to heart, cardiac output decreases; less blood pumped out with each beat Body senses imminent fall in BP BP is maintained within normal range, signs of epinephrine release are evident 57 19

20 Shock Classification of shock Blood loss - up to 30% Patient further stressed by attempting to sit or stand from lying position; feels weaker, faint, or dizzy and must lie down Capillary refilling time useful; helps gauge blood loss Do not allow to drink fluid Normal BP when supine misleading 58 Shock Classification of shock Blood loss 30% to 45% Compensatory mechanisms working to maximum capacity, blood return to heart falls Mental status deteriorating Gasp for air Heart starts to fail BP is falling despite heart s efforts Heart rate slows as shock progresses Patient still has more than ½ the normal hemoglobin Sudden loss of volume is critical factor in acute hemorrhage 59 Shock Classification of shock Blood loss greater than 45% Circulatory system collapses Constriction of venous and arterial vessels Patient becomes hypotensive, constricting muscles in vascular tree are less perfused Muscle become exhausted, vessels dilate Decrease in BP results in total circulatory collapse then cardiac arrest Hospital intervention within minutes or death is certain 60 20

21 Shock Classification of shock Infants & children Can maintain their blood pressure until blood volume is depleted by more than one half Young healthy hearts can compensate even after extensive bleeding When blood pressure does decrease; they may decompensate rapidly 61 Shock Classification of shock Vasodilatory shock Circulatory system fails Anaphylaxis & spinal injury Psychogenic shock Septic shock 62 Shock Classification of shock Time constraints Shock must be diagnosed and treated rapidly to prevent tissue damage and death Goal - recognize, treat, transport patients in shock before they become hypotensive; best chance for survival To accomplish this you need assessment skills that recognize early signs of shock 63 21

Management After attention to ABCs, treat for shock High concentration supplemental O 2 Elevate legs 8 to12 Splint bone or joint injury Maintain body temperature with blankets Many patients with

22 Management After attention to ABCs, treat for shock High concentration supplemental O 2 Elevate legs 8 to12 Splint bone or joint injury Maintain body temperature with blankets Many patients with hypovolemic shock can be resuscitated with timely treatment Bring patients to definitive therapy ASAP 64 Management After ABCs Pneumatic antishock garment (PASG) 65 Management After ABCs PASG Indications Once widely used throughout United States, its use is currently controversial May be used if signs of are shock present, lower abdomen tender and pelvic injury is suspected with no evidence of chest injury Other experts limit use to pelvic fractures & shock 66 22

23 Management After ABCs PASG Indications May be used as a pressure splint to help control bleeding in massive soft tissue injuries to lower extremity Severe hypovolemic shock (systolic pressure less than 50 mm Hg)/palpable pulse with no measurable BP May be used if the source of bleeding in pelvis or abdomen May help with bleeding from abdominal aortic aneurysm 67 Management After ABCs PASG Removal Once applied, should not be deflated in field unless instructed by physician 68 Management After ABCs PASG Contraindications Penetrating chest injuries Diaphragm rupture Cardiac tamponade Significant chest injury or abnormal breath sounds Cardiac shock Acute MI Pulmonary edema Conditions involving abdomen 69 23

Skill 20-2: Applying the PASG Examine patient s abdomen & legs to determine

below lowest rib Fasten Velcro straps Connect foot pump and inflate legs and

24 Skill 20-2: Applying the PASG Examine patient s abdomen & legs to determine extent of injuries Lay PASG open on stretcher, then lay patient on PASG using log-roll. 70 Skill 20-2: Applying the PASG Align top of abdominal section of PASG just below lowest rib Fasten Velcro straps Connect foot pump and inflate legs and (if not contraindicated) abdomen 71 Traumatic Cardiopulmonary Resuscitation Follow local protocols Found pulseless, often treated as expectant 72 24

25 Summary Circulatory system Transport system of body Delivers O 2 Nutrients to tissues Returns waste products of metabolism (carbon dioxide), cellular wastes to lungs, kidneys for excretion Heart, blood, blood vessels Blood Plasma white blood cells (combat infection) Red blood cells (transport O 2, CO 2 attached to hemoglobin) Platelets (clotting) 73 Summary BP has 2 components; systolic pressure, exerted on walls of artery when ventricle contracts; diastolic pressure, exerted on walls of artery when ventricle relaxes External bleeding controlled by direct pressure, elevation, pressure points, tourniquet (last resort) Pressure bandage applied for continuous control of bleeding 74 Summary Anterior nosebleeds (epistaxis) controlled by pinching nose while patient leans forward to avoid aspiration, swallowing of blood Internal bleeding recognized when patient vomits/coughs up blood/bleeding from other body openings Blood loss of 10% to15% results in constriction of venous system, may not present with any signs/symptoms 75 25

26 Summary Blood loss of 15% to 30% results in weakness; anxiety; rapid, thready pulse; pale, cool, clammy skin; delayed capillary refilling time (children); thirst, abnormal BP Blood loss of 30% to 45% results in hypotension, altered mental state, combativeness, restlessness, rapid, shallow breathing Shock, failure of circulatory system to adequately perfuse body s tissues 76 Summary Shock caused by loss of blood volume, failure of heart/dilation of blood vessels General emergency care for shock includes O 2, leg elevation (8 to12 ), prevention of heat loss, rapid transport PASG can increase BP by increasing systemic vascular resistance 77 Summary PASG can exacerbate bleeding from penetrating thoracic injuries by raising BP before bleeding controlled 78 26

27 Questions? 79 27

Bleeding and Shock * CME Version * Aaron J. Katz, AEMT-P, CIC

Bleeding and Shock *** CME Version *** Aaron J. Katz, AEMT-P, CIC www.es26medic.net Circulatory System Composed of heart, blood vessels and blood A closed system Pumps oxygenated blood and nutrients to