1. Shock and Bleeding

2. Shock and Bleeding By Kevin O’Loughlin, MICP
This Course Has Been Approved for 2.5 Hour of Continuing Education for:
First Responders
EMT-I
Paramedics

3. Continuing Education
To receive continuing education for this course you must complete the post test and evaluation available on the EMS Agency website San Joaquin County EMS- Training / Continuing Education.
Submit the completed test and evaluation to the EMS Agency and a CE certificate will be mailed to you.
There is no charge for this course.

4. LEARNING OBJECTIVES
Upon completion of this course, you will be able to:
Define shock and identify the different types of shock.
Discuss the signs, symptoms and treatment for shock.
Describe the three types of external bleeding.
Discuss the four ways to control bleeding.
Properly control bleeding and dress a wound utilizing the Emergency Bandage.
Stop bleeding with the SOF Tactical Tourniquet.

5. Instructor Contact Information
If you have questions regarding this course, please contact Kevin O’Loughlin, MICP, EMS Specialist. Phone (209) A response will be provided within 48 hours.

7. Routine Medical Care
Routine Medical Care is provided to all patients regardless of presenting complaint.
Standard precautions:
Application of body substance isolation precautions including the use of appropriate personal protective equipment (PPE) shall apply to all patients receiving care, regardless of their diagnosis or presumed infectious status

8. Routine Medical Care Body substance isolation precautions apply to:
Blood;
All bodily fluids, secretions, and excretions except sweat, regardless of whether or not they contain visible blood;
Non intact skin; and
Mucous membranes. Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in the prehospital setting.

9. Routine Medical Care Patient Assessment:
Primary Survey – which includes scene survey and ABC’s
Secondary Survey – which includes, history, medications, allergies and a head-to-toe survey.
Initiation of appropriate basic life support (BLS) treatment including, when appropriate:
Monitoring of vital signs:
Initial set.
Repeated every 5 – 10 minutes.

10. Routine Medical Care Hemorrhage control.
Initiation of spinal precautions.
Administration of oxygen.
Hemorrhage control.
Ensuring ALS transport response.
Initiation of specific treatments in accordance with San Joaquin County EMS Agency Policies and Procedures.

11. Shock
Defined as inadequate perfusion (blood flow) leading to inadequate oxygen delivery to tissues.

12. Physiology Basic unit of life = cell
Cells get energy needed to stay alive by reacting oxygen with fuel (usually glucose)
No oxygen, no energy
No energy, no life

13. Cardiovascular System
Transports oxygen, fuel to cells
Removes carbon dioxide, waste products for elimination from body
Cardiovascular system must be able to maintain sufficient flow through capillary beds to meet cell’s oxygen and fuel needs

14. What is needed to maintain perfusion?
Pump = Heart
Pipes = Blood Vessels
Fluid = Blood

15. How can Perfusion Fail?
Loss of Volume
Pump Failure
Pipe Failure

16. Types of Shock and Causes

17. Cardiogenic Shock Pump failure Heart’s output depends on
How often it beats (heart rate)
How hard it beats (contractility)
Rate or contractility problems cause pump failure

18. Cardiogenic Shock Causes Acute myocardial infarction
Very low heart rates (bradycardias)
Very high heart rates (tachycardias)

19. Neurogenic Shock Spinal cord injured Loss of peripheral resistance
Vessels below injury dilate

20. Hypovolemic Shock Loss of volume Causes Blood loss: trauma
Plasma loss: burns
Water loss: Vomiting, diarrhea, sweating, increased urine, increased respiratory loss

21. Psychogenic Shock Simple fainting (syncope)
Caused by stress, pain, fright
Heart rate slows, vessels dilate
Brain becomes hypoperfused
Loss of consciousness occurs

22. Septic Shock Results from body’s response to bacteria in bloodstream
Vessels dilate, become “leaky”

24. Anaphylactic Shock Results from severe allergic reaction
Body responds to allergen by releasing histamine
Histamine causes vessels to dilate and become “leaky”

25. Shock: Signs and Symptoms
Nausea, vomiting
Thirst
Diminished urine output
Dull eyes
Restlessness, anxiety
Increased pulse rate
Decreasing level of consciousness
Rapid, shallow respirations

26. Shock: Signs and Symptoms
Hypovolemia will cause
Weak, rapid pulse
Pale, cool, clammy skin
Cardiogenic shock may cause:
Weak, rapid pulse or weak, slow pulse
Neurogenic shock will cause:
Weak, slow pulse
Dry, flushed skin
Sepsis and anaphylaxis will cause:
Weak, rapid pulse

27. Shock: Signs and Symptoms
Patients with anaphylaxis will usually:
Develop hives (urticaria)
Itch
Develop wheezing and difficulty breathing (bronchospasm)

28. Shock: Signs and Symptoms
Shock is NOT the same thing as a low blood pressure!
A falling blood pressure is a LATE sign of shock!

29. Shock: Signs and Symptoms
Obscure/less viewed symptoms of shock
Drop in end tidal carbon dioxide (ETCO2) level
Indicative of respiratory failure resulting in poor oxygenation, therefore, poor perfusion or Shock

30. Treatment Secure, maintain airway (ABC’s) High concentration oxygen
Assist ventilations
Control obvious bleeding
Stabilize fractures
Replace Fluids (paramedics only)
Prevent loss of body heat
Transport rapidly to appropriate facility

31. Treatment
Elevate lower extremities 8 to 12 inches Treatment in Hypovolemic shock
Do NOT elevate the lower extremities in Cardiogenic shock
Administer nothing by mouth, even if the patient complains of thirst

32. Bleeding
Severe bleeding or hemorrhage is a major cause of shock (hypoperfusion), which can be life threatening if the body loses an excessive amount of blood.
If the body loses enough blood, the cells of the body will not receive enough oxygen and begin to die.
Once cells begin to die, bigger cells such as organs will also fail and eventually the entire body will fail and death will occur.

33. Control of External Bleeding
Direct Pressure
gloved hand
dressing/bandage
Elevation
Arterial pressure points
Tourniquet (last resort)

34. Three Types Of External Bleeding:
Arterial
Venous
Capillary bleeding

35. Arterial bleeding
Usually bright red in color because it is rich in oxygen.
Bleeding from an artery is often profuse and spurting due to the high pressure from the heart as it contracts, forcing blood out to the rest of the body.
This is the reason why it is so hard to control and direct pressure will be required all the way to the hospital.

36. Venous bleeding
Usually dark red/maroon in color because it does not contain much oxygen.
The red blood cells have already left its oxygen behind with the cells of the body, picked up carbon dioxide and wastes, and are on their way back to the lungs to get rid of them and pick up more oxygen.
It is usually easy to control venous bleeding because the veins are under low pressure.
The main difficulty with venous bleeding is in the neck because it can actually suck in air and cause further complications.

37. Capillary bleeding
Usually slow and oozing due to their small size and low pressure.
Although there may be a significant amount of bleeding, the majority of capillary bleeding is considered to be minor and is easy to control.
Capillary bleeding is usually the result of an abrasion.
The color of capillary bleeding can be bright red or darker red depending on the amount of oxygen it is carrying.
The majority of problems that arise with capillary bleeding is infection due to due to contaminants becoming embedded in the skin.

38. Care For External Bleeding

39. Direct Pressure
Direct pressure is applied to the injury with sterile gauze.
If bleeding is profuse or seeps through the gauze, add more gauze, but do not remove the existing pieces.
This will prevent the clotting process from being interrupted

40. Elevation
If bleeding continues to be severe, the extremity or body part should be elevated above the level of the heart.
This will decrease the amount of blood flowing to the injury site by using gravity to help decrease the amount of blood flow.

41. Bleeding Continues
If bleeding continues, add more gauze to the existing dressing and tie a pressure bandage to the site of injury.

42. Pressure Points
If direct pressure, elevation, and pressure bandage fail to control bleeding, apply pressure to a pressure point of the injury if it is to an extremity.
This will aid in further decreasing the flow of blood to the injury site.

43. Pressure Points

44. Tourniquet
A tourniquet should only be applied after all other means have failed to control life threatening blood loss .
Tourniquets are to be used in rare circumstances and only by trained EMS personnel. Once applied a tourniquet may only be removed by direct physician order.
Application of a tourniquet greatly increases loss of limb below the tourniquet since blood flow is stopped to the area.

45. OLD VS. NEW Simple one handed application
Complicated and takes more than two hands to apply correctly

46. SOF Tactical Tourniquet Components
Windlass
Safety Screw
Windlass
Strap
Buckle
Tri-Rings
Strap

47. Applying the SOF Tactical Tourniquet
1. Pull Strap until Tourniquet is tight around the injured extremity
2. Twist the aluminum windlass until the bleeding is controlled

48. Applying the SOF Tactical Tourniquet
3. Secure the windlass in the tri-ring
4. Tighten the safety screw

49. Applying the SOF Tactical Tourniquet
It is not necessary to secure the windlass on both tri-rings.
Once secured reassess the limb for bleeding.
Document the time the tourniquet was applied on the PCR or START triage tag.

50. SOF Tactical Tourniquet Training Video
To view video click on link below:
Note: The first link is required for this course, the second video link provides additional instruction on the use and care of the tourniquet.
SOF Tactical Tourniquet Application
SOF Tactical Tourniquet Instruction
Answers to some exam questions come from this video

51. Emergency Bandage

52. Emergency Bandage
The Emergency Bandage consolidates numerous treatment equipment into a single unit and provide in one device:
Non-adherent pad: Eliminating the risk of causing pain and having the wound re-opened upon removal of the bandage.
Pressure Applicator: Creating the immediate direct pressure to the wound site.
Secondary Sterile Dressing: Keeping the wound area clean and maintaining the pad and pressure on the wound firmly in place, including immobilization of the injured limb or body part.

53. Emergency Bandage
Closure Bar: Enabling closure and fixation of the Emergency Bandage at any point, on all parts of the body: no pins and clips, no tape, no Velcro, no knots.
Quick and easy application and Self-application. Designed with the end-user in mind; for the first-aid trained and the lay care-giver.
Significant per treatment time and cost savings.

54. Emergency Bandage
The Emergency Bandage has efficient blood staunching capability and offers ease of operation:
The application of immediate direct pressure to the wound site is achieved by wrapping the elasticized woven leader over the topside of the bandage pad where the specially designed pressure bar is situated. The pressure bar is designed to readily accept and hold the wrapping leader.

55. Emergency Bandage
After engagement of the pressure bar, wrapping the leader in any direction around the limb or body part and onto the pressure bar forces the pressure bar down onto the pad creating the direct pressure needed to bring about homeostasis.
The sterile, non-adherent pad is placed on the wound.

56. Emergency Bandage
In addition to its primary function, the pressure bar also facilitates bandaging. The elastic bandage uses the rigid shape of the pressure bar to change direction while bandaging, thus affording the caregiver more options for effective dressing of the wound.
Subsequent wrappings of the leader secures and maintains the pad in place over the wound, and by covering all the edges of the pad acts as a sterile secondary dressing. The bandage leader is woven to remain at its full width and will not bunch up or twist itself into a rope.

57. Emergency Bandage
The closure system of the bandage is multi-functional yet simple, quick, and familiar. Situated at the end of the leader is a closure bar (dowel with hooking clips) at each end to secure the wrapping leader the same way that a pen is secured in a shirt pocket. The closure bar holds the bandage securely in place over the wound site.

58. Emergency Bandage
If additional pressure is required the closure bar is easily removed from its first closure position and inserted between previous layers of the leader directly above the protruding pressure bar and rotated.
This rotation of the closure bar acts to further press down the pressure bar onto the wound to exert blood-staunching pressure. The closure bar is used as before to secure the dressing.

59. Emergency Bandage Training Video
To view video click on link below:
Emergency Bandage Application
Answers to some exam questions come from this video.

60. Post Test and Course Evaluation
To complete the post test and evaluation, please click on the following links:
Examination for Shock and Bleeding
Online Continuing Education Course Evaluation
Once you have completed both, please mail to: San Joaquin County EMS Agency, PO Box 220, French Camp, CA or it can be faxed to