Bleeding and Volume Replacement Therapy J. Málek

Casualty treatment call for medical help vital functions control of major external bleeding general examination prevention of secondary injuries detailed examination

Blood in adults ml/kg, in children ml/kg oxygen and CO2 transport water and mineral balance transport of metabolites transport of hormones immunity

Blood red cells white cells thrombocytes plasma

Bleeding arterial, venous, capillary, mixed minor, major localisation normal, abnormal

Minor bleeding clean with water apply antiseptic around the wound apply sterile dressing

Bleeding external internal from body orifices mixed

Major external bleeding lay the victim down to supine position compress and elevate the bleeding site (if possible) –pressure dressing –manual compression –pressure points –tourniquet do not try to clean a large wound (remove only obvious debris) never remove a foreign body

Internal bleeding pain signs of injury signs of shock

Internal bleeding positioning call for emergency nothing per os

Bleeding from body orifices mouth nose ear haemoptoea vomiting of blood rectal bleeding/melaena vaginal bleeding

Volume replacement therapy crystalloid solutions colloids solutions –volume substituents –volume expanders blood

Crystalloid solutions advantages no allergic reactions easily available low effect on blood coagulation easily mobilised disadvantages move quickly from blood vessels no transport capacity for oxygen

Colloid solutions dextrans gelatine starch

Colloid solutions advantages stay longer in blood vessels rapid volume replacement (molecular weight dependent) easily available disadvantages allergic reaction possible various effect on blood coagulation difficulty in mobilisation no transport capacity for oxygen

Blood and blood products packed red cells fresh frozen plasma thrombocytes various factors

Risks of blood transfusion incompatibility infection allergy fever overloading bleeding problems immunity

Blood transfusion indication patient´s consent taking blood sample to transfusion dept. cross match in TD check documentation and transfusion bag security test biological test

Blood groups

Population O+ A+ B+ AB+ O− A− B− AB− Argentina [11] [11] 53.8%34.7%8.8%2.7%8.4%0.44%0.21%0.06% Australia [12] [12] 40%31%8%2%9%7%2%1% Belgium [13] [13] 38.1%34%8.5%4.1%7%6%1.5%0.8% Canada [14] [14] 39%36%7.6%2.5%7% 1.4%0.5% Denmark [15] [15] 35%37%8%4%6%7%2%1% Finland [16] [16] 27%38%15%7%4%6%2%1% France [17] [17] 36%37%9%3%6%7%1% Hong Kong, China [18] [18] 40%26%27%7%<0.3% Korea, South [19] [19] 27.4%34.4%26.8%11.2%0.1% 0.05% Netherlands [20] [20] 39.5%35%6.7%2.5%7.5%7%1.3%0.5% Poland [21] [21] 31%32%15%7%6% 2%1% Sweden [22] [22] 32%37%10%5%6%7%2%1% UK [23] [23] 37%35%8%3%7%6%2%1% USA [24] [24] 38%34%9%3%7%6%2%1%

Human red blood cells before (left) and after (right) adding serum containing anti-A antibodies. The agglutination reaction reveals the presence of the A antigen on the surface of the cells.

Transfusion Colecting blood sample from the patient Transfusion station –Blood group –Crossmatching –Delivery Ward –Check delivery list –Safety test –Biological test –Monitoring –Save blood pack for 24 hours

Indications for blood transfusions acute hemorrhage anemia bleeding disorders hematological diseases

Acute bleeding Blood lossReplacement <750 mlcrystalloid solutions 750 – 1500 mlcrystalloid solutions (colloid solutions or blood) >1500 mlcrystalloid solutions (colloid solutions) + blood

Shock

Definition Acute state in which tissue perfusion is inadequate to maintain the supply of oxygen and nutritients necessary for normal cell function, which results in widespread hypoxia.

Reasons for inadequate tissue perfusion A decreased circulating blood volume – hypovolaemic shock A failure of the heart to pump effectively – cardiogenic shock and obstructive shock A massive increase in peripheral vasodilatation – neurogenic shock Combination – septic shock, anaphylactic shock

Stages of shock Initial stage – anaerobic metabolism Compensatory stage – centralisation of circulation Progressive stage – increased acidosis, leakage of fluid from the capillaries and formation of microthrombes Refractory stage

Classification of shock Hypovolaemic shock Cardiogenic shock Anaphylactic shock Septic shock Neurogenic shock

Hypovolaemic shock Haemorrhage Plasma loss Extracelular fluid loss

Symptoms of hypovolemia according to blood loss Blood loss (ml)Symptoms <750none thirst, weakness, tachypnoea systolic pressure falls >2 000no pulse on periphery

Estimated blood loss in trauma Pelvis3 000 mL Femur1 000 mL Tibia 650 mL Abdominal injury2 000 – mL Thoracic injury2 000 – mL

Signs of haemorrhagic shock Pale, cold, clammy skin, decreased capilary refill Rapid, weak and thready pulse Thirst Decreased urine production Increased respiratory rate Change in mental status – late sign

First aid Prevent further blood loss Antishock or autotransfusion position Activation of emergency service Prevention of hypothermia Prevention of positioning trauma Treatment of other injuries, immobilisation of fractures Nil by mouth, no oral or i.m. medication

Medical treatment Intravenous access Surgery Fluid replacement Artificial ventilation Pharmacological support of shock organs Monitoring: BP, P, SaO2, CPV, urine output

Cardiogenic shock Heart failure, cardiomyopathy Decreased cardiac output First vasoconstriction, next vasodilatation due to acidosis Pulmonary oedema Cold, clammy and cyanotic skin Mortality 80 per cent

Anaphylactic shock Severe allergic reaction Degranulation of mast cells Vasodilatation, increased vascular permeability, oedema, bronchospasm

Septic shock Bacteria or bacterial toxins Released histamine and other mediators of inflammation Oxygen demand – supply mismatch Vasodilatation Tachycardia, hypotension, fever of hypothermia

Neurogenic (spinal) shock Loss of sympathetic nerve activity Massive vasodilatation