Understand the definition and major types of shock,Recognize signs and symptoms of shock,Recognize types of external bleeding (arterial,
venous, capillary),Recognize signs and symptoms of internal bleeding,Initiate treatment of shock by appropriately
positioning the patient and by stopping hemorrhage when possible,
Treat external hemorrhage appropriately by direct pressure, elevation, pressure points, and/or tourniquet, and
Apply a dressing and bandage.
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Shock is inadequate tissue perfusion with
oxygenated blood
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Not enough blood volume Pump failureAbnormalities of peripheral circulation (when
all small blood vessels dilate) Mechanical blockage of outflow from the
heart
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Most common type of shockInsufficient circulating volume
Primary cause = loss of blood or body fluids from an internal or external source
Hemorrhage, severe burns, severe dehydration
5Scalp laceration 3rd degree/full thickness burn
Failure of the heart to pump effectively1. Due to damage to the heart muscle2. Large myocardial infarction3. Arrhythmias (too fast or too slow)4. Cardiomyopathy5. Congestive heart failure (CHF)6. Cardiac valve problems
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Mechanical block to heart’s outflow Pulmonary embolusCardiac tamponadeTension pneumothorax
7Pulmonary embolus Cardiac tamponade
Similar to hypovolemic shock - insufficient intravascular volume of blood or “relative" hypovolemia result of dilation of all blood vessels so the
“tank” is much larger
8Urticaria/anaphylaxis Meningococcic sepsis
Septic shockOverwhelming infection leading to profound
systemic vasodilation Anaphylactic shock
Severe reaction to an allergen, antigen, drug or foreign protein, releasing histamine causing widespread vasodilation, hypotension and increased capillary permeability
Neurogenic shockRarest form of shock. Trauma to spinal cord resulting in loss of
autonomic and motor reflexes below injury level. Vessel walls relax uncontrolled, decreasing peripheral vascular resistance, result = vasodilation and hypotension
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If shock is “inadequate tissue perfusion with oxygenated
blood,” then . . .
. . . look at the tissues!
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Cardiovascular
Respiratory
Skin
CNS
Renal
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Global signs and symptoms:
• Anxiety, restlessness, altered mental state • Hypotension • Rapid, weak, thready pulse • Cool, clammy skin• Capillary refill > 3 seconds• Rapid and deep respirations• Hypothermia • Fatigue• Cold and mottled skin• Thirst and dry mouth• Vasoconstriction• Low urine output
Compensated - earlyInitial stage, body progressively compensated for
blood loss↑ pulse, vasoconstrictionWeak pulse, cool clammy skin, anxiety, thirst, weak
Decompensated – lateBody’s compensatory mechanisms no longer
maintain systemLoss of radial pulse, ↓ BP, loss of consciousness, ↓
respirations
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“All bleeding stops eventually”
Rapid, simple interventions are highly advantageous to the patient
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InternalBlunt force trauma
Contusions, lacerations, shear, fracturesPenetrating trauma
Punctures
ExternalGeneral trauma
Contusions, abrasions, lacerations, incisions, avulsions, amputation
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Arterial bleeding Usually bright red in color, rich in oxygen Often profuse and spurting Often hard to control - continuous direct pressure
required
Venous bleeding Usually dark red/maroon in color, does not contain much
oxygen Usually easy to control because veins are under low
pressure Venous bleeding in neck can draw in air and cause
further complications
Capillary bleeding Usually slow, oozing, small size and low pressure Generally minor and easy to control
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STOP the bleedingSupportive care measures
Positioning of victimEnsuring A-B-C’sMaintenance of body temp
Definitive management
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Apply direct pressure:• with gloved hand,• sterile dressing(s).
Bleeding stopped? YesNo
Elevate extremity:• above victim’s heart,continue direct pressure
Locate pressure point,apply pressure:• maintain direct pressureover wound
Treat for shock:• care for wound,• seek definitive care
Bleeding stopped?
Bleeding stopped?
No
Bleeding fromextremity?
No
Apply tourniquet(last resort)
Yes
No
Definitive therapy18
Apply pressure directly to wound site:Gloved hand, dressingIf dressing soaks thru, add
more gauze on top and press harder
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Apply direct pressure:• with gloved hand,• sterile dressing(s).
Bleeding stopped? YesNo
Elevate extremity:• above victim’s heart,continue direct pressure
Locate pressure point,apply pressure:• maintain direct pressureover wound
Treat for shock:• care for wound,• seek definitive care
Bleeding stopped?
Bleeding stopped?
No
Bleeding fromextremity?
No
Apply tourniquet(last resort)
Yes
No
Definitive therapy
If possible, raise wound site above level of victim’s heart
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Apply direct pressure:• with gloved hand,• sterile dressing(s).
Bleeding stopped? YesNo
Elevate extremity:• above victim’s heart,continue direct pressure
Locate pressure point,apply pressure:• maintain direct pressureover wound
Treat for shock:• care for wound,• seek definitive care
Bleeding stopped?
Bleeding stopped?
No
Bleeding fromextremity?
No
Apply tourniquet(last resort)
Yes
No
Definitive therapy
Find proximal “pressure point” and press on it (radial, ulnar, brachial, axillary, femoral arteries—not carotid)
Apply direct pressure to site
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Apply direct pressure:• with gloved hand,• sterile dressing(s).
Bleeding stopped? YesNo
Elevate extremity:• above victim’s heart,continue direct pressure
Locate pressure point,apply pressure:• maintain direct pressureover wound
Treat for shock:• care for wound,• seek definitive care
Bleeding stopped?
Bleeding stopped?
No
Bleeding fromextremity?
No
Apply tourniquet(last resort)
Yes
No
Definitive therapy
Apply band above injury site, tighten to stop bleeding:Last resort—riskyNote time of applicationReassess frequently
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Apply direct pressure:• with gloved hand,• sterile dressing(s).
Bleeding stopped? YesNo
Elevate extremity:• above victim’s heart,continue direct pressure
Locate pressure point,apply pressure:• maintain direct pressureover wound
Treat for shock:• care for wound,• seek definitive care
Bleeding stopped?
Bleeding stopped?
No
Bleeding fromextremity?
No
Apply tourniquet(last resort)
Yes
No
Definitive therapy
Goal: improve perfusion of brain and heartPosition patient: Have patient lie down and
elevate legs (moves blood into chest and head)
Keep warm if blanket availableGive nothing by mouth if any possibility of
internal injuries (may need emergency surgery)
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Administer supplemental oxygenObtain vascular access
Administer fluid/blood to “fill up the tank”Wound closure/managementImmobilizationSpecial situations
Release cardiac tamponadeTension pneumothorax
Find hidden sources of bleeding
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BP 90, P < 120O2 saturation > 92%Warm, moist skin, < 2 sec capillary refillConsciousness, no agitationUrine output 0.5 cc/kg/hr
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Shock = inadequate tissue perfusion
Find shock by looking at tissue perfusion
Categories of shockHypovolemicObstructiveDistributiveCardiogenic
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Most common source of shock = hemorrhage
Management of hemorrhagic shockStop the bleedingVascular accessVolumeReassess
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“Chance favors the prepared mind.”Louis Pasteur