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Bleeding and Shock

Pipes, pump, and fluid…really, it’s that simple!

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The Second Rule of EMS….

…eventually the bleeding will stop!

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Cardiovascular System

Heart

Arteries

Veins

Capillaries

Blood

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Cardiovascular System

• Transports O2 and fuel to the cells, tissues, and organs.

• Removes CO2 and wastes from the cells for elimination from the body.

• Must be able to maintain sufficient flow through the capillary beds to meet the cell’s

O2 and fuel needs

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Bleeding

Internal External

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Internal BleedingTrauma

Clotting disordersRupture of blood vessels

Fractures (injury to nearby vessels)Can result in rapid progression to

hypovolemic shock & death!

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Internal Bleeding S/S Think about MOI or NOI!

Anxiety, restlessness, irritability

Pale, diaphoretic skin

Sustained tachycardia

Hypotension

Unstable vitals signs (postural changes)

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Internal Bleeding S/SVomiting bright red blood or coffee ground

materialBleeding form any body orifice

Dark, tarry stools (melena)Tender, rigid, or distended abdomen

Pain, discoloration, swelling, tenderness at injury site

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Managing Internal Bleeding

ABC’sHigh concentration oxygen

Assist ventilationsControl external bleeding

Stabilize fracturesRICE

Transport rapidly to appropriate facility

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External Bleeding

• Arterial Bleed – Bright red, spurting

• Venous Bleed– Dark red, steady flow

• Capillary Bleed– Dark red, oozing

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Control of External Bleeding

Direct Pressure:Gloved hand

OrDressing and bandage

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Control of External Bleeding

Elevation: Raise extremity

above the level of the heart

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Control of External Bleeding

Pressure Dressing:Use bandage to

secure dressing in place

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Arterial Pressure Points

• Upper extremity:

– Brachial

– Radial

• Lower extremity:

– Femoral

– Popliteal

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Tourniquets

Final resort when all else fails

Used for amputations

3-4” wide (blood pressure cuffs)

Write “TK” and time of application on forehead of patient

Notify other personnel

Once applied, DO NOT REMOVE

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Epistaxis (Nosebleed)

• Causes– Fractured skull– Facial injuries– Sinusitis, other

URIs– High BP– Clotting disorders– Digital insertion

(nose picking)

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Management of Epistaxis

Sit up, lean forward

Pinch nostrils together

Keep in sitting position

Keep quiet

Apply ice over nose (15 min)

Can result in life-threatening blood loss!

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SHOCKInadequate perfusion(blood flow)

leading to inadequate oxygen delivery to tissues

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Physiology

• Cell is the basic unit of life

• Cells get energy needed to stay alive by reacting oxygen with fuel (usually glucose)

• No oxygen, no energy

• No energy, no life

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Perfusion Failure

Pump Failure (heart)

Pipe Failure (vessels)

Loss of Volume (blood)

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Stages of Shock

Compensated Shock

Decompensated Shock

Irreversible Shock

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Compensated Shock

• Body still compensates for blood loss

• Pulse rate increases

• Pulse strength decreases

• Pale, diaphoretic skin

• Anxiety, restlessness, combativeness

• Thirst, weakness, eventual air hunger

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Decompensated Shock

• Body compensatory mechanisms fail

• Unpalpable pulse

• Precipitous drop in blood pressure

• Patient becomes unconscious

• Respirations slow or cease

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Irreversible Shock

• Lack of circulation causes:

– Cellular death

– Tissue dysfunction

– Organ dysfunction

– Patient death

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Shock: Etiology

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• Psychogenic

• Hypovolemic

• Distributive

• Obstructive

• Cardiogenic

• Respiratory

• Neurogenic

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Psychogenic Shock

• Simple fainting (syncope)

• Caused by stress, fright, pain

• Heart rate slows, vessels dilate

• Brain becomes hypo-perfused

• Loss of consciousness occurs

• Patient usually recovers by self

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Psychogenic Shock S/S

• Anxiety, restlessness, irritability

• Rapid pulse

• Normal or low blood pressure

• Hyperventialtion

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Hypovolemic Shock

• Loss of volume• Causes:

– Blood loss from trauma– Plasma loss from burns

– Fluid/electrolyte loss from vomiting, diarrhea, sweating, increased urine

output, increase respiratory loss– “Third space” fluid shifts

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Hypovolemic Shock S/S

• Anxiety, restlessness, irritability

• Rapid, weak pulse

• Change in mental status

• Signs of inadequate perfussion (diaphoresis, cyanosis, pale/clammy skin)

• Increased respiratory rate

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Distributive Shock: Septic

• Results from body’s response to bacteria in bloodstream

• Vessels dilate, become “leaky”

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Distributive Shock: Septic S/S

• Anxiety, restlessness, irritability

• Febrile, warm skin

• Hypotension

• Tachycardia

• Increased respiratory rate

• Change in mental status

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Distributive Shock: Anaphylactic

• Results from severe allergic reactions

• Body responds to allergen by releasing histamine

• Histamine release causes vessels to dilates and become “leaky

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Distributive Shock:Anaphylactic S/S

• Sudden onset• Mild itching, rash, uticaria, hives

• Burning sensation (skin)• Hypotension

• Generalized edema• Angiodema, airway compromise

• Respiratory distress• Coma, rapid death

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Obstructive Shock

• Interference with blood flow through the cardiovascular system

• Tension pneumothorax

• Cardiac tamponade

• Pulmonary embolism

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Obstructive Shock S/S

• Anxiety, irritability, restlessness

• Weak, irregular pulse

• Chest pain, shortness of breath

• Hypotension

• Pale, cool, clammy skin

• JVD, discoloration above nipple line

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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

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Cardiogenic Shock S/S• Causes

– Acute myocardial infarction– Very low heart rates (bradycardias)– Very high heart rates (tachycardias)

Why would a high heart rate caused decreased output?

Hint: Think about when the heart fills.

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Cardiogenic Shock S/S

• Chest pain

• Weak, irregular pulse

• Hypotension (HTN with CHF)

• Cyanosis, signs of inadequate perfusion

• Cool, clammy skin

• Anxiety

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Respiratory Shock

• Failure of respiratory system to supply oxygen to or remove CO2 from the alveoli

• Airway obstruction

• Flail chest, SCW

• Pneumothorax

• Respiratory muscle paralysis

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Respiratory Shock S/S

• Anxiety, restlessness, irritability

• Rapid, weak pulse

• Hypotension

• Change in mental status

• Signs of inadequate perfussion

• Increased respiratory rate

• Bronchoconstrcition (wheezes)

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Neurogenic Shock

• Spinal cord injuries that result in the interruption of communication

pathways between CNS and rest of body

• Vessels below the injury site dilate leading to decreased vascular

resistance

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Neurogenic Shock S/S

• Anxiety, restlessness, irritability

• Bradycardia

• Hypotension

• Skin above injury site: pale, cool, clammy

• Skin below injury site: warm, pink, dry

• Signs of spinal injury

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Treatment• ABC’s

• Apply O2, assist ventilations as needed• Keep patient in position of comfort• Control bleeding, stabilize fractures

• Prevent loss of body heat• Assist with medications

• Nothing by mouth• Calm and reassure

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Treatment

• Elevate lower extremities 8 to 12 inches in hypovolemic shock

• Do NOT elevate the lower extremities in cardiogenic shock

Why the difference in management?

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Shock is NOT the same as low pressure

A falling blood pressure is a LATE sign of shock!