1. Bleeding and Shock
Chapter 11

2. Topic Overview Review of Circulatory System External Bleeding
Signs and Symptoms
Care
Internal Bleeding

3. Topic Overview Shock Signs and Symptoms Classic vs. Atypical Care
Dressing and Bandages
Purpose and Function
Effects of improperly applied dressings, splints and tourniquets.

4. Circulatory System Review Heart Blood Blood Vessels Arteries Veins
Capillaries

5. Key Terms
Perfusion
Circulation of oxygenated blood to tissues and organs
Hypoperfusion
Inadequate circulation of oxygenated blood to tissues and organs.

6. Bleeding & Shock Some Facts
Trauma is the leading cause of death for persons aged 1 to 44.
A vital part of trauma care is recognizing and treating signs and symptoms of bleeding and shock
Profuse bleeding and shock are life-threatening problems requiring immediate attention

7. Bleeding External Bleeding
Use Body Substance Isolation (BSI) precautions
Eye Protection, Gloves, Gown, Mask
Always wash hands following contact
Waterless cleans

8. Types of Bleeding Arterial
Bright red (oxygen rich), spurting, rapid, profuse
Clot formation is difficult
Most difficult to control
As blood pressure drops, spurting will also drop

9. Types of Bleeding Venous
Usually steady flow (under lower pressure), can be profuse
Dark red oxygen poor
Debris and air can be sucked into wound
Clotting rate is dependent on size of area or vessels involved
Bleeding easier to control

10. Types of Bleeding Capillary Slow (oozing) Dark red
Good chance of infection
Clots easily

11. Blood Loss Severity Signs & symptoms of hypoperfusion
General impression of amount of loss
Severe or uncontrolled blood loss will lead to Shock (Hypoperfusion) and possibly death
Most Bleeding will stop by itself within 6-10 minutes (dependent on area of involvement and vessels involved, vasoconstriction & clotting)

12. External Severity

13. Care for External Bleeding
Body Substance Isolation Precautions
Maintain airway
Cover wound with a clean dressing to reduce risk of infection
Follow basic steps for controlling bleeding

14. Bleeding Control Direct Pressure Elevation Pressure Bandage
Pressure Points
Absolute last resort - Tourniquet

15. Pressure Points Arterial pressure points Brachial Femoral
Summon EMS if bleeding cannot be controlled or if pressure points must be used

16. Supplemental Methods of Controlling Bleeding
Splints
Pressure splints (air splints)

17. Supplemental Methods of Controlling Bleeding
Tourniquet Precautions
Wide versus narrow bandage
Do Not remove or loosen
Leave it in open view
Do not apply over a joint

18. External Bleeding Special Areas Bleeding from the nose, ears or mouth
Potential causes
Skull fractures
Facial fractures
Sinusitis (& other URT infections)
Hypertension
Coagulation Disorders
If bleeding or CSF is coming from the ears do not stop flow
If CSF is coming from the nose DO NOT stop flow

19. External Bleeding Care for a Nosebleed
If bleeding from a head wound that resulted from a fracture DO NOT apply direct pressure, do not attempt to stop bleeding, cover with a bulky dressing
Care for a Nosebleed
Sitting position leaning slightly forward
Apply direct pressure (may take 15 min.)
Pinching nose or rolled gauze under nose
Cold compresses
Do not
Pack nose
Blow nose or
Tilt head back

20. Dressings & Bandages Dressings (should be sterile)
Placed directly on wound
Absorbs blood and other fluids
Reduces risk of infection
Types
2 X 2, 4 X 4
Compress
Universal
Occlusive

21. Dressings and Bandages
Holds dressings in place
Helps protect wound from infection
Provides support to injury
Types
Tape
Roller bandages (widths: 1 to 6 inches)
(Elastic not usually used for bleeding injuries)
Triangular bandage

22. Internal Bleeding Severity Based On Mechanism of Injury
Clinical Signs and Symptoms

23. Internal Bleeding Relationship to Mechanism of Injury (MOI)
May not be obvious, may take time for signs & symptoms to appear
Blunt Trauma
Falls
Motorcycle crashes
Pedestrian impacts
Blast injuries
Look for contusions, abrasions, deformity. Impact marks, & swelling
Suspect internal bleeding in any serious injury

24. Internal Bleeding Signs and Symptoms Significant MOI
Bruising (Contusion)
contusions over abdomen or chest the size of your fist - assume a 10% blood volume loss
Painful, swollen, deformed extremities
Anxiety & restlessness
Bleeding from mouth, ears, nose, rectum, vagina, or other orifice

25. Internal Bleeding Signs & Symptoms
Tender, rigid and/or distended abdomen
Rebound tenderness
Vomiting Blood
Bright Red
Coffee-ground color or consistency
Blood in stool
Bright red
Dark, tarry

26. Internal Bleeding Nausea and vomiting
Combativeness, clearly altered mental status
Weakness, faintness, dizziness
Excessive thirst
Cool, clammy skin
Pale or ashen skin leading to cyanosis
Shallow rapid breathing

27. Internal Bleeding Weak rapid pulse Delayed capillary refill
Dilated sluggish pupils (late sign)
Dropping blood pressure (late sign)

28. Internal Bleeding Care Body Substance Isolation Airway care and oxygen
Immediate transport to an appropriate facility
Apply direct pressure if injured area is on an extremity
Splint extremity

29. Internal Bleeding Care For minor internal bleeding (bruising)
Apply cold compresses, reduce movement

30. Shock (Hypoperfusion)
Signs of Shock appear LATE
Waiting for signs to appear before
recognizing and treating may result
in the DEATH of your patient

31. Shock (Hypoperfusion)
Results from the body’s
inability to maintain adequate perfusion
inadequate removal of metabolic waste products
May develop from internal or external blood loss
Peripheral perfusion is reduced due to the reduction in circulating blood volume

32. Shock (Hypoperfusion)
Reduced perfusion results in malfunction of cells and organs
Shock that is not recognized and treated may result in death
Body tries to compensate by shunting blood away from areas of lesser need to greater needs
Explains order of signs and symptoms

33. Shock (Hypoperfusion)
Signs & symptoms may be present immediately, become evident during the physical exam or an ongoing assessment

34. Shock Signs and Symptoms Restlessness, changes in mental status
Pale, cool, clammy skin
Nausea and vomiting
Increased pulse rate
Increased respiratory rate
Decreasing blood pressure is a LATE sign

35. Shock Dilated pupils Thirst Cyanosis Delayed capillary refill time
Infants and Children
Maintain blood pressure with up to 40% blood volume loss
By the time their pressure drops they are near DEATH

36. Care for Shock Body Substance Isolation Activate EMS
Ensure patent airway, administer oxygen
Stabilize spine
Control any external bleeding
Elevate lower extremities 8-12 inches (when indicated)
Prevent loss of body heat
NPO (food nor drink)

37. Care for Shock Position patient
Supine with legs elevated 8-12 inches unless
Anaphylactic shock - upright
Cardiogenic shock - upright or semi-recumbent
Neurogenic shock - supine
Lower extremity or pelvic injuries - supine

38. Specifics of Shock Classifications Hypovolemic - volume loss
Hemorrhagic - most common
Non-hemorrhagic – vomiting, diarrhea, etc.
Cardiogenic Shock
Ineffective pump

39. Specifics of Shock Obstructive Distributive
Tension pneumothorax, pulmonary contusion, cardiac tamponade, pulmonary embolus
Distributive
Loss of vascular tone due to sepsis, spinal injury, anaphylaxis

40. Classic Presentation 24 y/o male with GSW to RUQ
Decreased cerebral perfusion
Vasoconstriction
Volume loss
Hypoxemia, Acidosis
24 y/o male with GSW to RUQ
Anxious
Pale, Cool, Moist skin
BP 88/50
P – 140, Thready
R – 24, Shallow

41. Presentation of Classic Shock
At a Blood Loss of 10% - 15%
Compensatory Effect
Veins contract
Signs and Symptoms
None to transient

42. Presentation of Classic Shock
At a Blood Loss of up to 30%
Compensatory Effect
Epinephrine response
Arteries constrict to maintain BP
Reduced blood flow to skin, gut & muscle
Increased heart rate
Signs and Symptoms
Anxiety
Rapid, pulse becoming more thready with increased volume loss

43. Presentation of Classic Shock
At a Blood Loss of up to 30%
Signs and Symptoms con’t.
Cool, pale, clammy skin
Thirst
Weakness, faintness or dizziness
Rapid, shallow breathing
Delayed capillary refill
Normal BP

44. Presentation of Classic Shock
At a Blood Loss of 30% to 45%
Compensatory Effect
Decompensation
Cardiac output falls to half of normal
Signs and Symptoms
Hypotension
Deteriorated mental status
Combativeness, restlessness
Rapid, shallow, (air-hungry) respirations

45. Presentation of Classic Shock
At a Blood Loss Greater Than 45%
Signs and Symptoms
Fall in BP
Total circulatory collapse
Cardiac arrest
Infants and Children
Maintain blood pressure until blood volume loss is more than 40%
Decompensate rapidly

46. Atypical Presentation
Caused by
Pathogenesis of Specific Type of Shock
Some Medications
Previous Medical History

47. Non-hemorrhagic Hypovolemic Shock
Loss of fluid other than blood
Diarrhea, vomiting, dehydration
Atypical Signs & Symptoms
Warm – low grade 101oF, (often febrile), dry skin
Vital signs may be normal (if supine); orthostatic hypotension
Respirations may vary due to acidosis
Vomiting – tend to become alkaline – respirations will be more shallow
Diarrhea – loss of carbs – tend to become acidic – respirations tend to be deeper

48. Cardiogenic Shock Cardiogenic Shock Classic Presentation
Heart damage (AMI)
Chest pain
Pulmonary edema
Slow to normal heart rate

49. Cardiogenic Shock Cardiogenic Shock Atypical Presentation? Chest pain
Normal to rapid heart rate
No pulmonary edema
Normal to low blood pressure
Jugular vein distention

50. Obstructive Shock Tension pneumothorax Look for JVD Pulmonary embolus
Cardiac Tamponade
Medication effects
Anti-hypertensives
Beta blockers
May block beta 1 (sympathetic response) and mask signs of shock

51. Obstructive Shock Medical History Hypertension
BP may be normal, but what’s normal
Pregnancy
Increased circulating volume of 50%
Early signs of shock are late signs of shock
Spleen removed
Don’t compensate as well
Won’t see general decline, will crash quickly

52. Distributive Shock Septic Anaphylactic Neurogenic
Atypical Signs & Symptoms
Pink, Warm, Dry skin
Rapid Capillary refill <1/2 – 1 sec.
Respirations vary

53. Distributive Shock Septic Shock Result of infection
Common causes - UTI / Pneumonia
Exotoxins cause vasodilation
Altered mental status, may be sudden
Rapid capillary refill, warm, dry skin
Normal BP with widened pulse pressure (120/50) or hypotension
Bounding pulse

54. Distributive Shock Septic Shock Dehydration may alter presentation
Mechanism may be rapid respirations, fever, or decreased fluid intake
No rhonchi with pneumonia

55. Distributive Shock Neurogenic Shock Easily missed Pathogenesis unique
Damage to medulla or spinal cord
Can also be caused by spinal anesthesia

56. Distributive Shock Sympathetic vs. Parasympathetic
Thoracolumbar vs. Cervicosacral
Injury location determines signs & symptoms
May lose entire sympathetic system
Can result in bizarre presentation

57. Distributive Shock Assessment of Neurogenic Shock
Pink, warm, dry skin below injury
Bradycardia or normal heart rate
Constricted pupils ( non-reactive)
Diaphragmatic or absent breathing
Severe hypotension
Diarrhea
Paralysis

58. Distributive Shock Anaphylaxis
Life threatening allergic reaction that causes shock and airway swelling
Common Causes

59. Distributive Shock Anaphylactic Shock Common Signs & Symptoms Itching
Hives
Flushing
Warm tingling feeling
Swelling (Especially face, neck, hand, feet, tongue

60. Distributive Shock Anaphylactic Shock Tightness in throat / chest
Cough
Rapid, labored, noisy breathing
Hoarseness
Stridor and wheezing
Increased heart rate
Low blood pressure (late sign)

61. Distributive Shock Anaphylactic Shock Generalized Findings
Itchy, watery eyes and runny nose
Headache
Sense of impending doom

62. Patient Assessment Anaphylactic Shock Initial assessment
Focused history and physical exam
Baseline vitals and SAMPLE history
Apply high flow oxygen

63. Patient Assessment & Care
Determine patient need for epinephrine and use
Epinephrine is needed if the patient
has had a similar reaction to the same substance in the past
shows S & S of shock
complains of respiratory distress
has a prescribed epinephrine auto-injector

64. Patient Assessment Anaphylactic Shock What is patient allergic to?
What was patient exposed to?
How was the patient exposed?
What signs and symptoms (S & S) does the patient have?
How have the S & S progressed?
What interventions has the patient received?

65. Anaphylactic Shock Relationship to Airway Management
The patient may need aggressive airway management immediately because of swelling in the airway or respiratory compromise.
The patient’s condition may be stable initially but deteriorate to the point where he/she needs aggressive airway management
Progressive airway swelling
Respiratory compromise

66. When Shock Doesn’t Look Like Shock
“Classic” Shock presentation is limited
Multiple factors may alter presentation
If the person shows signs of altered perfusion, treat for shock
Resuscitate perfusion not blood pressure
Don’t forget that Medical History and Medications can alter presentation

67. Review Questions Describe the following types of bleeding Arterial
Venous
Capillary
Describe the care for external bleeding
List the signs and symptoms of internal bleeding
Describe the care for internal bleeding

68. Review Questions Define Shock (hypoperfusion)
List the signs and symptoms of shock in the order in which they are likely to appear (in a classic presentation)
Describe the care for shock
Define an allergic reaction and anaphylactic shock
List some common causes of allergic reactions

69. Review Questions
List the signs and symptoms of anaphylactic reaction associated with the skin, respiratory system, and cardiovascular system
Tell how to determine whether the patient needs epinephrine