Bleeding and Shock

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Bleeding and ShockBleeding and ShockChapter 25Chapter 25


Case HistoryCase History

You are summoned to the scene of a shooting. You You are summoned to the scene of a shooting. You find a 58-year-old deli owner bleeding profusely from find a 58-year-old deli owner bleeding profusely from gunshot wounds to his arms and chest. The man is gunshot wounds to his arms and chest. The man is cool and pale with a rapid pulse and no discernible cool and pale with a rapid pulse and no discernible blood pressure. As you apply oxygen, he tells you blood pressure. As you apply oxygen, he tells you that he is thirsty and would like to have a drink of that he is thirsty and would like to have a drink of water.water.


Control BleedingControl Bleeding External bleedingExternal bleeding

Direct pressureDirect pressure Pressure pointPressure point TourniquetsTourniquets


ShockShock Internal bleeding can result in shock.Internal bleeding can result in shock.

A state of profound depression of vital processes A state of profound depression of vital processes of body caused by inadequate perfusion of vital of body caused by inadequate perfusion of vital organs with bloodorgans with blood


Anatomy and Physiology ReviewAnatomy and Physiology Review

Three major components of circulatory Three major components of circulatory system:system: The bloodThe blood The heart The heart The blood vesselsThe blood vessels


Heart and Great VesselsHeart and Great Vessels



BloodBlood Liquid (plasma) and cellular Liquid (plasma) and cellular

componentscomponents• Cellular componentsCellular components

Red blood cellsRed blood cells– Transport oxygenTransport oxygen

White blood cellsWhite blood cells– Combat infectionCombat infection

PlateletsPlatelets– Help control bleedingHelp control bleeding



Heart Heart Four chambersFour chambers

• Atria (receiving chambers)Atria (receiving chambers)• Ventricles (pumping chambers)Ventricles (pumping chambers)

Left ventricle pumps blood to aorta with each beat; Left ventricle pumps blood to aorta with each beat; circulates to bodycirculates to body

Right ventricle pumps blood throughout pulmonary arteries Right ventricle pumps blood throughout pulmonary arteries to lungs; unloads carbon dioxide, picks up fresh oxygento lungs; unloads carbon dioxide, picks up fresh oxygen


Chambers of the HeartChambers of the Heart



Blood vessels distribute blood to all parts of body and Blood vessels distribute blood to all parts of body and lungs.lungs. Arteries carry blood away from heart.Arteries carry blood away from heart. Veins carry blood back to heart.Veins carry blood back to heart.

Arteries branch into smaller vessels, ending as Arteries branch into smaller vessels, ending as capillaries.capillaries. Capillaries - one cell thick; exchange gas, nutrients, waste Capillaries - one cell thick; exchange gas, nutrients, waste

products with alveoliproducts with alveoli


Systemic and Pulmonary Systemic and Pulmonary CirculationCirculation


Arteries, Capillaries, and Arteries, Capillaries, and VeinsVeins


Major Systemic ArteriesMajor Systemic Arteries


CapillariesCapillaries


Major Systemic VeinsMajor Systemic Veins


Stroke Volume and Cardiac OutputStroke Volume and Cardiac Output

Circulation changes according to the body’s Circulation changes according to the body’s needs.needs.

Changes occur throughChanges occur through Increase in heart rateIncrease in heart rate Increase in force of contractionIncrease in force of contraction

Adequate blood volume is needed.Adequate blood volume is needed.


Stroke VolumeStroke Volume Amount of blood ejected from ventricle with Amount of blood ejected from ventricle with

each beateach beat Approximately 70 mlApproximately 70 ml

Related to:Related to: Adequate contractionAdequate contraction Venous returnVenous return


Cardiac OutputCardiac Output Stroke volume Stroke volume heart rate = cardiac output heart rate = cardiac output

SV HR = COSV HR = CO ExampleExample

• 70 ml (SV) 60 (HR) = 4200 ml or 4.2 L (CO)70 ml (SV) 60 (HR) = 4200 ml or 4.2 L (CO)

Cardiac output changes if stroke volume or heart rate Cardiac output changes if stroke volume or heart rate change.change.


Blood Pressure and PerfusionBlood Pressure and Perfusion

Blood pressure – force exerted on walls of vesselsBlood pressure – force exerted on walls of vessels

Determinants of blood pressure:Determinants of blood pressure: Cardiac outputCardiac output Size of vascular spaceSize of vascular space

MeasurementsMeasurements Systolic and diastolicSystolic and diastolic


Pressures in the Pressures in the Circulatory SystemCirculatory System


HypotensionHypotension Cardiac output decreases Cardiac output decreases

and vascular space remains and vascular space remains the same.the same. Decrease in blood pressureDecrease in blood pressure

Size of the vascular space Size of the vascular space increases and cardiac output increases and cardiac output remains the same.remains the same. Decrease in blood pressureDecrease in blood pressure


Effects of EpinephrineEffects of Epinephrine Epinephrine release accounts for many of the signs Epinephrine release accounts for many of the signs

of shock.of shock. Increased cardiac outputIncreased cardiac output Increased blood flow to brain Increased blood flow to brain Increased respiratory rateIncreased respiratory rate Dilated pupilsDilated pupils Redistributed blood flowRedistributed blood flow

• Shunted away from less vital organs and skinShunted away from less vital organs and skin• Pale skinPale skin


Skin Signs Associated with Skin Signs Associated with Epinephrine ReleaseEpinephrine Release


Personal PrecautionsPersonal Precautions Eye protectionEye protection

GlovesGloves

GownGown

MaskMask

Hand washing after each Hand washing after each patient contactpatient contact


Severity of Blood LossSeverity of Blood Loss Based on:Based on:

Signs and symptomsSigns and symptoms General impression of the General impression of the

amount of blood lossamount of blood loss

Major blood loss = sudden Major blood loss = sudden loss ofloss of Adult: 1 LAdult: 1 L Child: 500 mlChild: 500 ml Infant: 100 to 200 mlInfant: 100 to 200 ml


Natural Response to Bleeding Natural Response to Bleeding Vessel contractionVessel contraction

ClottingClotting Serious injury may prevent effective clotting.Serious injury may prevent effective clotting.

Uncontrolled bleeding or significant blood loss leads Uncontrolled bleeding or significant blood loss leads to shock (hypoperfusion) and possibly death.to shock (hypoperfusion) and possibly death.


Types of BleedingTypes of Bleeding

Arterial Arterial Spurts from woundSpurts from wound

Bright redBright red

Most difficult to controlMost difficult to control


Types of BleedingTypes of Bleeding VenousVenous

Flows as steady streamFlows as steady stream

Dark redDark red

Can be profuseCan be profuse

Easy to control, in most Easy to control, in most cases cases


Types of BleedingTypes of Bleeding Capillary Capillary

Oozes from capillaryOozes from capillary

Dark redDark red

Often clots Often clots spontaneouslyspontaneously


Care of External BleedingCare of External Bleeding Body substance isolationBody substance isolation

Maintain airway/artificial Maintain airway/artificial ventilation.ventilation.

Bleeding controlBleeding control Direct pressureDirect pressure ElevationElevation Pressure pointPressure point TourniquetTourniquet


Tourniquet – PrecautionsTourniquet – Precautions

Use a wide bandage.Use a wide bandage. Never use wire, rope, or a beltNever use wire, rope, or a belt

Apply as close to the injury as possible.Apply as close to the injury as possible. Do not apply over any joint.Do not apply over any joint. Secure it tightly.Secure it tightly. Leave the tourniquet in open view. Leave the tourniquet in open view. Do not remove or loosen tourniquet unless Do not remove or loosen tourniquet unless

instructed by medical direction.instructed by medical direction.


Causes of Bleeding fromCauses of Bleeding fromEar, Mouth, and NoseEar, Mouth, and Nose

Injured skullInjured skull Facial traumaFacial trauma Digital trauma (e.g., nose picking)Digital trauma (e.g., nose picking) Sinusitis Sinusitis Upper respiratory tract infectionsUpper respiratory tract infections Hypertension (high blood pressure)Hypertension (high blood pressure) Coagulation disordersCoagulation disorders


Bleeding from Ears and Nose Bleeding from Ears and Nose Owing to Skull FractureOwing to Skull Fracture

Do not attempt to stop the blood flow.Do not attempt to stop the blood flow.

Apply a loose dressing.Apply a loose dressing.

Limit exposure to sources of infection.Limit exposure to sources of infection.


Internal Bleeding – SeverityInternal Bleeding – Severity Injured or damaged internal organs Injured or damaged internal organs

commonly lead to extensive bleeding.commonly lead to extensive bleeding. Bleeding is often concealed.Bleeding is often concealed.

Fractures may also lead to serious Fractures may also lead to serious internal blood loss.internal blood loss.

Suspicion and severity based onSuspicion and severity based on Mechanism of injury Mechanism of injury Clinical signs and symptoms Clinical signs and symptoms


Relationship of Internal Bleeding Relationship of Internal Bleeding to Mechanism of Injuryto Mechanism of Injury

Blunt traumaBlunt trauma FallsFalls Motorcycle crashesMotorcycle crashes Pedestrian impactsPedestrian impacts Automobile collisionsAutomobile collisions Blast injuriesBlast injuries Contusions, abrasions, deformity, impact marks, and swellingContusions, abrasions, deformity, impact marks, and swelling Penetrating trauma Penetrating trauma


Signs and Symptoms —Signs and Symptoms —Internal BleedingInternal Bleeding

Pain, tenderness, swelling, or discolorationPain, tenderness, swelling, or discoloration

Bleeding from the mouth, rectum, vagina, or Bleeding from the mouth, rectum, vagina, or other orificeother orifice

Vomiting bright red or dark “coffee ground”-Vomiting bright red or dark “coffee ground”-colored bloodcolored blood

Dark, tarry stools or stools with bright red bloodDark, tarry stools or stools with bright red blood

Tender, rigid, and/or distended abdomenTender, rigid, and/or distended abdomen


Sites of Hidden Blood LossSites of Hidden Blood Loss

SiteSite Amount of Blood LossAmount of Blood Loss % of blood volume% of blood volumeThoraxThorax 2 Liters2 Liters 40%40%AbdomenAbdomen >1 Liter>1 Liter 50%50%FemurFemur >1 Liter>1 Liter 20%20%PelvisPelvis 0.5 Liters/Fracture0.5 Liters/Fracture 10%/Fracture10%/FractureSkullSkull Not significant unless infantNot significant unless infant


ShockShock

Failure of circulatory system to Failure of circulatory system to adequately perfuse and oxygenate the adequately perfuse and oxygenate the

tissues of the bodytissues of the body


Causes of ShockCauses of Shock Pump failurePump failure

Low blood volumeLow blood volume

Vasodilation or Vasodilation or obstructionobstruction


Shock — SeverityShock — Severity Inadequate perfusion of cellsInadequate perfusion of cells

Cell and organ malfunction and deathCell and organ malfunction and death

Prompt recognition is criticalPrompt recognition is critical


Shock — Severity Shock — Severity Peripheral perfusion is drastically reducedPeripheral perfusion is drastically reduced

Due to the reduction in circulating blood volumeDue to the reduction in circulating blood volume

Trauma patients develop shock (hypoperfusion) from Trauma patients develop shock (hypoperfusion) from loss of blood from both internal and external sites.loss of blood from both internal and external sites. Hypovolemic or hemorrhagic shockHypovolemic or hemorrhagic shock


Peripheral Perfusion Peripheral Perfusion Weak, thready, or absent Weak, thready, or absent

peripheral pulsesperipheral pulses

Pale, cool, clammy skinPale, cool, clammy skin

Delayed capillary refill >2 Delayed capillary refill >2 secondsseconds Infants and children onlyInfants and children only Normal ambient air Normal ambient air

temperaturetemperature


Signs and Symptoms — Signs and Symptoms — ShockShock

Mental statesMental states

RestlessnessRestlessness

AnxietyAnxiety

Altered mental statusAltered mental status


Vital SignsVital Signs Increased pulse rate (early sign), Increased pulse rate (early sign),

weak, and threadyweak, and thready

Increased breathing rateIncreased breathing rate ShallowShallow LaboredLabored IrregularIrregular

Decreased blood pressure (late sign)Decreased blood pressure (late sign)


Other Signs and SymptomsOther Signs and Symptoms

Dilated pupilsDilated pupils Marked thirstMarked thirst Nausea and vomitingNausea and vomiting Pallor with cyanosis to the lips Pallor with cyanosis to the lips


Infants and ChildrenInfants and Children Infant or child in shock has less reserveInfant or child in shock has less reserve

Can maintain blood pressure until 50% loss Can maintain blood pressure until 50% loss of blood volumeof blood volume When blood pressure drops, they are close to When blood pressure drops, they are close to

deathdeath


Emergency Medical CareEmergency Medical Care

Take personal protection measures.Take personal protection measures. Maintain airway.Maintain airway. Administer oxygen.Administer oxygen. Control bleeding.Control bleeding. Elevate legs, if condition permits.Elevate legs, if condition permits. Splint fractures, if time permits.Splint fractures, if time permits. Maintain body temperature.Maintain body temperature. Immediate transport is critical.Immediate transport is critical.


Hypovolemic ShockHypovolemic Shock Fluid or blood lossFluid or blood loss

Several causes of fluid lossSeveral causes of fluid loss

VomitingVomiting

DiarrheaDiarrhea

Metabolic problemsMetabolic problems


Signs of DehydrationSigns of Dehydration ThirstThirst

Lack of tearing or sweatingLack of tearing or sweating

Dry tongueDry tongue

Tenting of the skinTenting of the skin


Signs and Symptoms — Signs and Symptoms — Hypovolemic ShockHypovolemic Shock

Anxiety, restlessness, combativeness, or altered mental Anxiety, restlessness, combativeness, or altered mental statusstatus

Weakness, faintness, or dizzinessWeakness, faintness, or dizziness

ThirstThirst

Shallow, rapid breathingShallow, rapid breathing

Rapid, weak pulseRapid, weak pulse


Signs and Symptoms — Signs and Symptoms — Hypovolemic ShockHypovolemic Shock

Pale, cool, clammy skinPale, cool, clammy skin

Capillary refill >2 secondsCapillary refill >2 seconds

Decreasing blood pressure (late sign)Decreasing blood pressure (late sign)

Dilated pupils that are sluggish to respondDilated pupils that are sluggish to respond

Nausea and vomitingNausea and vomiting


Stages of Hypovolemic ShockStages of Hypovolemic Shock

10% to 15% blood loss 10% to 15% blood loss Venous constrictionVenous constriction No signs of shockNo signs of shock Rely on mechanism of injury to suspect criticalityRely on mechanism of injury to suspect criticality

<<30% blood loss30% blood loss Increased pulse rateIncreased pulse rate Pale skinPale skin Delayed capillary refill (children)Delayed capillary refill (children)


Stages of Hypovolemic ShockStages of Hypovolemic Shock

30% to 45% blood loss30% to 45% blood loss Blood pressure dropsBlood pressure drops Altered mental statusAltered mental status

>45% blood loss>45% blood loss Circulatory collapseCirculatory collapse Cardiac arrestCardiac arrest


Emergency Medical CareEmergency Medical Care

Take personal protection measures.Take personal protection measures. Maintain airway.Maintain airway. Administer oxygen.Administer oxygen. Control bleeding.Control bleeding. Elevate legs, if condition permits.Elevate legs, if condition permits. Manage fractures with splints, if time permits.Manage fractures with splints, if time permits. Maintain body temperature.Maintain body temperature. Immediate transport is critical.Immediate transport is critical.


Shock Caused by Dilated Shock Caused by Dilated VesselsVessels

AnaphylacticAnaphylactic

PsychogenicPsychogenic

SpinalSpinal


Septic ShockSeptic Shock Shock is caused by massive infection.Shock is caused by massive infection.

Infection causes vasodilation.Infection causes vasodilation.

Fluid leaks through blood vessel walls causing Fluid leaks through blood vessel walls causing hypovolemia.hypovolemia.


SummarySummary Evidence of bleeding in shock is elicited during patient Evidence of bleeding in shock is elicited during patient

assessment.assessment.

Control of external bleeding includesControl of external bleeding includes Direct pressureDirect pressure ElevationElevation Pressure pointsPressure points Tourniquet (as a last resort)Tourniquet (as a last resort)

Early recognition of internal bleeding and shock is critical to Early recognition of internal bleeding and shock is critical to patient survival.patient survival.

Bleeding and Shock

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