1. Hamburg High School EMT Program
4/22/2017
Shock and Bleeding
Hamburg High School
EMT Program
Temple College EMSP

5. Circulatory System Anatomy Heart Arteries Capillary Veins
Muscular organ, size of your fist, located in the center of the thoracic cavity
Arteries
Carry blood rich in oxygen – all arteries carry blood away from the heart
Capillary
Place where exchange of oxygen and carbon dioxide take place
Veins
Carry blood high in carbon dioxide – all veins carry blood back to the heart

6. Function of the Blood Transportation of Gases Nutrition Excretion
Carries oxygen from lungs to body cells, carries carbon dioxide back to lungs to be exhaled
Nutrition
Circulates nutrients from tissue to other body cells
Excretion
Carries waste products from cells to organs, such as the kidneys

7. Function of the Blood Protection Regulation
Carries antibodies and WBC’s, which help fight disease and infection
Regulation
Blood carries substances that control the functions of the body, such as hormones, water, salt, enzymes, and chemicals
Blood also helps regulate body temperature by carrying body heat to the lungs and skin

8. The average amount of blood found in a:
Male: 5 – 6 Liters
Female: 4 – 5 Liters

9. Composition of Blood Plasma Red Blood Cells
Water, salty fluid that makes up over half the volume of the blood. (56% of the bloods volume)
Red & white blood cells and platelets are carried in plasma
Red Blood Cells
RBC’s, erythrocytes, or red corpuscles.
Carry oxygen to tissues and carbon dioxide away.
Gives blood its red color

10. Composition of Blood White Blood Cells Platelets WBC’s or leukocytes
Involved in destroying micro-organisms (germs) and produce antibodies that help the body resist infection
Platelets
Helps the blood to clot; when fragments are activated they release chemical factors
Solid part of blood

11. Perfusion Circulation of blood through an organ
Perfusion supplies oxygen and other nutrients to the cells of all organ systems and the removal of waste products

12. Hypoperfusion (SHOCK)
Inadequate circulation of blood through an organ

13. Types of Bleeding Arterial Bleed Venous Bleed Capillary Bleed
Bright red
Spurting
Venous Bleed
Dark red/maroon
Steady flow
Easier to control
Capillary Bleed
Dark red
Oozing
Often clots spontaneously

14. Severity of Bleeding Considered severe when loss equals:
One liter (1000 cc) in an adult
½ liter (500 cc) in a child
cc in an infant
Uncontrolled bleeding or significant blood loss leads to shock (hypoperfusion) and possibly death

15. Severity of Blood Loss Determined by:
General impression of the amount of blood loss
Signs or symptoms of hypoperfusion
If the patient exhibits signs and symptoms of shock (hypoperfusion), the bleeding is to be considered serious

16. Control of External Bleeding
PPE for BSI
Maintain Airway
Administer Oxygen
1. Direct Pressure
gloved hand
dressing/bandage
2. Elevation
3. Tourniquet
CONSIDER:
Arterial pressure points
Upper extremity: Brachial
Lower extremity: Femoral

17. Other Methods to Control Bleeding
Splints
Air splints

18. Tourniquet
Application can cause permanent damage to nerves, muscle, and blood vessels resulting in loss of the extremity
Used for amputations
3-4” wide & 6-8 layers deep
Wrap around extremity twice at a point above bleeding as close to the wound as possible
Tie one knot in the bandage and place a stick or rod on top of the knot and tie it
Twist the stick until the bleeding stops
Once the bleeding has stopped secure in place

19. Tourniquet
Blood pressure cuff may be used as a tourniquet until bleeding stops
Write “TK” and time of application on forehead of patient
Notify other personnel
Do not loosen or remove until definitive care is available
Do not use wire, rope, or any material that may cut into the skin
Do not cover with sheets, blankets, etc.
Do not apply over a joint, but as close to the injury as possible

20. Bleeding from the Nose, Ears, and Mouth
Possible causes
Skull fracture
Simple nose bleed – epistaxis
Facial trauma

21. Skull Fracture
May cause loss of blood or clear fluid (cerebrospinal fluid) from the nose and ears.
Check for Halo Effect
Do not stop the flow of fluid – collect in a loose dressing

22. Epistaxis Causes Fractured skull Facial injuries Sinusitis, other URIs
High BP
Clotting disorders
Digital trauma (nose picking)

23. Epistaxis Nosebleed Management Sit up, lean forward
Pinch the fleshy portion of the nostrils together
Keep in sitting position
Keep patient calm and quiet
Apply ice over nose
15 min adequate

24. Epistaxis can result in life-threatening blood loss

25. Internal Bleeding
1. Can result in severe blood loss which can lead to shock and subsequent death
2. Injured or damaged internal organs are a common cause of extensive bleeding that is concealed
3. Painful, swollen, deformed extremities (fractures) may lead to serious internal blood loss
4. Suspicion and severity of internal bleeding should be based on mechanism of injury and clinical signs and symptoms

26. Internal Bleeding Mechanism of Injury Blunt trauma Falls
4/22/2017
Internal Bleeding
Mechanism of Injury
Blunt trauma
Falls
Motorcycle Crashes
Pedestrian Impacts
Automobile Collision
Blast Injuries
Look for evidence of contusions, abrasions, deformities, impact marks and swelling
Temple College EMSP

27. Internal Bleeding Mechanism of Injury Penetrating Trauma
Pain, tenderness, swelling or discoloration at site of injury
Bleeding from mouth, rectum, vagina or other orifice
Vomiting of bright red blood or dark coffee-ground-colored emesis
Dark, tarry stools or stools with bright red blood
Tender, rigid abdomen
S/S of shock

28. Internal Bleeding Management BSI Open airway High concentration oxygen
4/22/2017
Internal Bleeding
Management
BSI
Open airway
High concentration oxygen
Assist ventilations
Control external bleeding with direct pressure
Stabilize fractures
Transport rapidly to appropriate facility
Temple College EMSP

29. Abdominal Evisceration
Penetrating Trauma

30. SHOCK
Inadequate perfusion (blood flow) of cells leading to inadequate oxygen delivery to tissues

31. 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

32. How can perfusion fail, thus causing shock?
Heart fails as a pump
Blood vessels dilate
Loss of Volume

33. 3 Types of Shock and Their Causes
Hypovolemic Shock
Cardiogenic Shock
Distributive Shock

35. 1. Hypovolemic Shock
A type of shock that is the result of low blood volume

36. A. Hemorrhagic Shock Shock most often seen by EMT’s
The natural response to bleeding is blood vessel constriction and clotting. Uncontrolled or significant bleeding can lead to shock and possibly death
Loss of volume

37. A. Hemorrhagic Shock Signs and Symptoms AMS, restlessness, anxiety
Increased respiratory rate
Weak, rapid pulse
Pale, moist/clammy, cool skin
Nausea, vomiting
Thirst
Falling blood pressure (LATE SIGN)
Infants and children maintain their blood pressure until their blood volume is more than half gone, so by the time their blood pressure drops they are close to death

38. B. Metabolic Shock
Form of Hypovolemic shock that is the result of electrolyte or plasma loss and does not involve the loss of whole blood. It can occur due to dehydration or from burns

39. B. Metabolic Shock Signs and Symptoms Sunken eyes
Poor skin turgor or tenting of the skin
Recent episodes of vomiting and diarrhea
Presence of burns

40. 2. Cardiogenic Shock Result of a massive myocardial infarction
Heart is unable to pump effectively and as a result blood begins to back up in the system
Heart’s output depends on
How often it beats (heart rate)
How hard it beats (contractibility)

41. 2. Cardiogenic Shock Signs and Symptoms Emergency care
Those symptoms commonly seen during a heart attack
Emergency care
CPR with AED

42. 3. Distributive Shock
Blood vessels suddenly dilate causing the blood pressure to fall

43. A. Anaphylactic Shock
Form of shock caused by a violent systemic reaction to an allergen/toxin
Signs and Symptoms
Those seen with a severe allergic reaction

44. B. Neurogenic Shock Spinal cord severed
Uncontrolled dilation of the blood vessels and drop in blood pressure
Compensatory mechanisms are not activated because nerve impulses cannot be conducted through the spinal cord

45. C. Septic Shock Caused by a severe bacterial infection
Toxins (poisons) released into the bloodstream
Vessels dilate and there is a drop in blood pressure
Increase in fluid seeping into the tissues from the capillaries
Urinary tract infection is a common cause
Seldom seen in the field

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

47. Shock: Signs and Symptoms
Anxiety, restlessness, combativeness, or altered mental status
Weakness, faintness or dizziness
Thirst
Shallow rapid breathing
Rapid, weak pulse
Pale, cool, clammy skin

48. Shock: Signs and Symptoms
Capillary refill >2 seconds (infants and children ONLY)
Dropping blood pressure (late sign)
Dilated pupils that are sluggish to respond
Nausea & vomiting

49. 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!

50. Severity of Shock Compensated shock (Early) Decompensated shock (Late)
Body senses a decrease in perfusion and attempts to compensate
Increased heart rate & respirations to increase flow of blood and oxygen
Decompensated shock (Late)
Body can no longer compensate for low blood volume (late sign is falling B/P)

51. Severity of Shock Irreversible shock
Body has lost the battle to maintain perfusion
Cell damage occurs in liver & kidneys.
Even if vital signs can be restored patient may die

52. Emergency Care for Shock
Golden Hour
From the time the injury occurs, until the patient is in the operating room
Platinum Ten Minutes
Goal for on-scene time when caring for a trauma patient

53. Treatment Secure, maintain airway Apply high concentration oxygen
Control bleeding (MAST if needed)
Splint fractures
Prevent loss of body heat

54. Treatment
Elevate lower extremities 8 to 12 inches in hypovolemic shock if no fractures
Do NOT elevate the lower extremities in cardiogenic shock
Administer nothing by mouth, even if the patient complains of thirst

55. Anti-Shock Garment MAST – military anti-shock trousers
PASG – pneumatic anti-shock garment
Purpose: to create artificial vasoconstriction in the lower extremities and the lower abdomen

56. Indications Systolic B/P of 50 mmhg with signs of shock
Systolic B/P of 90 mmhg with a pelvic injury

57. S/S of Shock Restlessness Cool clammy skin Tachycardia
Delayed capillary refill (children & infants)

58. Absolute Contra-Indications
Pulmonary Edema
Penetrating Chest Wound

59. Partial Contra-Indications
Pregnancy (legs only)
Abdominal injury (evisceration) or impaled object (legs only)
Impaled object in leg (abdominal and one leg only)

60. MAST Use
You must remove all undergarments before putting MAST in place
Inflate all 3 compartments at one time to 100 to 106 mmhg
MAST can only be deflated under Medical Control
IVs established
Surgical team ready
Abdomen then one leg at a time SLOWLY

61. Never deflate entire suit at once

62. Adequate Flow = Adequate Perfusion
Flow = Perfusion
Adequate Flow = Adequate Perfusion
Inadequate Flow = Inadequate Perfusion (Hypoperfusion)
Hypoperfusion = Shock