Bleeding and Shock Home. Blood and its function zTransports gases-brings oxygen to the cells and takes carbon dioxide back to the lungs zTransports nutrients.

Bleeding and Shock

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Blood and it’s function

Transports gases-brings oxygen to the cells and takes carbon dioxide back to the lungs

Transports nutrients and waste products

Protection-carries antibodies and WBC’sRegulation-transports regulatory

hormones, chemicals, etc

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Blood Vessels

Arteries Thick muscular walls Maintains high pressures Carries oxygen from lungs

Capillaries Thin walls Location of oxygen exchange between blood and cells

Veins Lower pressure than arteries Bring carbon dioxide back to the lungs Have one way valves

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Blood Volumes

Blood volumes Average of 4.5-5 Liters Average adult male-7% total body weight Average adult female-6.5% total body

weightSerious blood loss

Adult-rapid loss of 1 Liter can be serious Child-500 cc Infant-150 cc

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Types of Shock

Hypovolemic-decreased circulating volume caused by bleeding, dehydration, burns, etc

Cardiogenic-inadequate pumping due to mechanical problems (MI, valve disease, contusion), electrical problems (irregular heartbeat, dysrhythmia) or congestive heart failure

Anaphylactic-massive histamine response from exposure to antigen causing arterioles and capillaries to dilate and intravascular fluid to leak out

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Types of Shock (cont..)

Septic-toxins from severe bacterial infection alters permeability of the vessels causing third spacing

Neurogenic-uncontrolled dilation of the vessels caused by a spinal cord injury

Remember: Shock can be related to a leaky tank (hypovolemic), a bad pump (cardiogenic), a change in the piping (neurogenic), or additives that can affect many things (septic or anaphylaxis).

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The Stages of Shock

Compensated The body is able to “compensate” for the

decrease in perfusionUncompensated

Compensation mechanisms are starting to fail

Irreversible Cell, tissue, and organ death begin due to

lack of perfusion

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Compensated Shock

Cardiac output and systolic blood pressure are maintained

Signs and Symptoms Mental Status-anxiety, restlessness,

combativeness Vital Signs- slightly increased

respirations and pulse, slightly delayed cap refill, cool skin

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Uncompensated Shock

Blood pressure begins to decrease and patient condition worsens

Signs and Symptoms Mental Status-lethargy, confusion,

unconsciousness Vital Signs-decreased blood pressure,

increased heart rate and respirations, delayed cap refill, pale, cold and clammy skin, narrowing pulse pressures, cyanosis, weak and thready pulse

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Irreversible Shock

Cell ischemia and death occur leading to organ death

May begin from one day up to three weeks after the initial event

If patient reaches this stage, they will most likely die

Signs and Symptoms Mental Status-unconscious, coma Vital Signs-bradycardia, profound and severe

hypotension, dysrhythmias

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Internal Bleeding

Internal BleedingGastrointestinal-could have many causes

• coffee ground or bright red emesis• dark, tarry or bright red stool

Trauma-blunt or penetrating• bruising over the abdomen or chest• swollen and painful extremities

– 2 units of blood can be contained in the lower leg– 4 units of blood can be contained in the femur area

• closed head injuries won’t cause hypovolemia

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External Bleeding

Arterial-profuse amounts of bright red blood often spurting with the pulse can cause hypovolemia if not treated immediately

Venous-steady flow of dark red or maroon colored blood, can be profuse can cause hypovolemia if left untreated

Capillary-slow, small amount of reddish blood that oozes from the wound usually stops on own with minimal blood loss

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Controlling Bleeding to the Extremity

1. Direct pressure.

2. Elevation.

3. Pressure bandage.

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If that doesn’t work...

4. Pressure point.

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Special Considerations Nosebleed

Have patient sit upright and leaning forward slightly Pinch as much of the nose as possible and hold for 5-10 minutes

Vaginal bleeding Do not hold direct pressure or pack Use OB pad or towel externally

Mouth injuries Do not hold pressure Suction as needed

Head injuries Head wounds tend to bleed profusely Do not press hard if crepitus is present or area is mushy If bleeding from nose or ears related to HI, loosely place gauze externally

to absorb blood

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Treating Hypovolemic Shock

Apply high flow oxygen Red blood cells account for 45% of the the

blood and carry 99% of the oxygen

Control external bleedingApply MAST if indicated

TEMS protocol-MAST can be inflated in the presence of a pelvic fracture and/or bilateral femur fractures with signs of shock (including a systolic BP less than 80 mmHg) at all levels

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Treating Hypovolemic Shock (cont..)

Elevate the lower extremities 8-12 inches Do not elevate in presence of head, spine,

chest, abdominal or lower extremity injuries

Maintain body temperatureProvide rapid transportAnd of course, IV therapy

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IV Therapy and Shock

Two large bore 16-18 gauge Lactated Ringers and/or Normal Saline

Bleeding is controlled-external bleeding 250 cc bolus and reassess (BP and lung sounds) Maintain BP>90 mmHg and/or pulse <120

Suspected uncontrolled bleeding-internal IV fluids to maintain systolic BP at 80-90 mmHg

Head injury Maintain Systolic BP of 110 if GCS <8

Burns Carefully monitor and document IV fluids

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Minimum Systolic Blood Pressures

<10 kg (22 lbs) = 50 mmHg10-20 kg (25-44 lbs) = 70

mmHg20+ kg (44+ lbs) = 90

mmHg

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In Closing...

Patients with signs and symptoms of shock must be rapidly transported to the hospital for definitive care.

Do not delay transport for IV access!

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References

Mosby’s Paramedic Textbook by M. J. Sanders, 1994 Mosby-Year Book Inc., St Louis

Brady Emergency Care 8th edition by M. F. O’ Keefe et al, 1998 Brady/Prentice Hall, New Jersey

Tidewater EMS Council Inc, Regional Medical Protocols, 2001