Bleeding and Shock

The Circulatory SystemFunction/Components

• Function• Transport system of the body• Delivers O2 and nutrients to cells• Returns waste to liver/kidneys/lungs• Transports specialized cells to fight infection.

• Components• Blood• Blood vessels

• 60,000 – 100,000 miles• Heart

The Circulatory SystemThe heart

• Location• Just left of midline• Posterior to sternum• Anterior to T-spine

• Function• Pump for driving of blood

flow

The Circulatory SystemChambers of the Heart

• 4 Chambers• Divided by a septum• 2 Atria

• Receiving chambers• Contract together• Superior to ventricles

• 2 Ventricles • Pumping Chambers• Contract together• Inferior to atria

The Circulatory SystemValves of The Heart

• Function• Prevents backflow of blood• Create heart sounds

• Atrioventricular Valvues• Between each atria and its ventricle

• Tricuspid Valve• Between Right Atria/Ventricle

• Bicuspid/Mitral Valve• Between Left Atria/Ventricle

• Semilunar Valves• Between each ventricle and its artery

• Pulmonic Valve• Right Ventricle and Pulmonary Artery

• Aortic Valve• Left Ventricle and Aorta

The Circulatory SystemTypes of Circulation

• Separate Systems• Pulmonary

• Right ventricle• Blood to the lungs

• Oxygenation

• Systemic• Left ventricle• Blood to the body

• Perfusion

The Circulatory SystemConductive System

• Automaticity• Ability to create own

electrical signal• Pacemaker Sites

• Sinoatrail Node (SA)• 60-100 bpm

• Atrioventricular Node (AV)• 40-60 bpm

• Bundle of HIS• 40-60 bpm

• Purkinje Fibers• 20-40 bpm

The Circulatory SystemBlood Vessels

• Arteries Arterioles Capillaries

Venules Veins

The Circulatory SystemArteries

• Function• Conduct blood away from

heart• High pressure

• Structure• Endothelial lining• Connective tissue • THICK Smooth muscle• Connective tissue

• Allows for great expansion of vessels

The Circulatory SystemMajor Arteries

• Coronary• Supply heart with blood

• Aorta• Major artery from the heart to the

body• 1” diameter

• Pulmonary• Carries O2 poor blood to lungs

• Umbilical • Carries O2 poor blood to lungs

• Carotid• Major artery of the neck• Supplies the head with blood

• Femoral• Major artery of the thigh• Supplies lower extremities with

blood• Bifurcation of aorta at navel

• Radial• Major artery of the lower arm

• Brachial• Artery of the upper arm

• Posterior tibial• Artery running posterior to ankle

• Dorsalis pedis• Artery of the foot• Anterior

The Circulatory SystemArterioles

• Smallest branch of an artery• Leads to a capillary

• Structure• Thin smooth muscle wall (1-

2 layers)• Function

• Main site of vascular resistance

• Important in blood pressure

The Circulatory SystemCapillaries

• Structure• Tiny blood vessel

• 5-10 μm diameter• 1 endothelial cell thick

• Function• Connect arterioles to venules• Exchange of gases, nutrients,

etc.• Decrease pressure• Usually carries no more than

50% of the volume it could

The Circulatory SystemVenule

• Smallest branch of a vein leading from a capillary

• Structure• A vein on small scale• Internal valves

• Function • Conducts deoxygenated

blood out of capillaries into veins

The Circulatory SystemVeins

• Function• Return blood to the heart• Low pressure system

• Structure• Endothelial lining• Connective tissue • Thinner Smooth muscle• Connective tissue• Internal Valves

The Circulatory SystemMajor Veins

• Pulmonary• Carries O2 rich blood from lungs to left atrium

• Umbilical• Carries O2 rich blood from lungs to left atrium

• Vena Cava• Superior

• Drains head/upper extremities

• Inferior• Drains trunk/lower extremities

The Circulatory SystemBlood

• 5-6 Liters• Components• Plasma

• Fluid that carries blood cells/nutrients• 55%

• Formed Elements • 40%• Red Blood Cells

• Carry O2 to organs & CO2 away• Give blood its color• Hemoglobin• 45%, 4.2-6.1 million/mL

• White Blood Cells• Defense • 4,3000-10,800 WBC/mL

• Platelets • Clotting • 150,000 - 350,000/mL

The Circulatory System Physiology

Perfusion

• Perfusion• In an organ system:

• Delivery of O2/nutrients • Removal of waste products

Cardiac Output

• Stroke Volume • Amount of blood ejected in one contraction of heart• Approx 70 ml

• Cardiac Output• Heart Rate X Stroke Volume

• i.e. (70 beats/min)X(70 ml/beat) = 4900 ml =5 L/min• Decrease Stoke Volume= Decreases Cardiac

Output• Leads to Hypoperfusion/Shock!!!!!

Bleeding and ShockFactors Affecting BP

• Cardiac Output• Volume of blood circulating• Increase = Raise BP• Decrease = Lowe BP

• Vascular Space• Size of total space within circulatory system:

• Arteries• Veins• Capillaries

• Increase (vasodilation/hemorrhage)• Lowers BP

• Decrease( vasoconstriction)• Raises BP

Severity of blood loss

• Serious• Adult = 1 liter (1000 ml)• Child = ½ liter (500 ml)• Infant = 100-200 ml

• Based on• S/S• General impression of volume lost• S/S of shock

• Compensation• Vasoconstriction• Clotting

• Pathophysiology• Uncontrolled bleeding =

Hypoperfusion = Shock

Effects of blood loss

• Loss of blood cells• Less able to perfuse

tissues with less hemoglobin

• Loss of blood volume• Less volume = less

pressure • Circulatory collapse

Sources of Bleeding

• Arterial• Spurting • Bright red (O2 rich)• Most difficult to control due to pressure• As BP drops so does amount of spurting

• Venous• Steady flow• Dark red (O2 poor) • Can be profuse• Generally easier to control

• Capillary• Oozes• Dark red • Often clots spontaneously

External Bleeding: BSI

• BSI• Eye protection• Gloves• Gown• Mask• Hand washing

Bleeding Control

• BSI• Maintain airway control• Direct pressure

• Gloved Hand• Pressure Dressing

• Elevate area• Raise area above level of pt heart

• Packing• Large gaping wounds may require sterile dressing packing• If this fails, remove and apply direct pressure to bleeding site

• Pressure points• Place pressure on the artery proximal to bleeding site• Brachial artery – Compress with fingers• Femoral artery – Compress with heel of hand• Etc…

Direct pressure

Direct pressure with dressing

Pressure Dressing

ElevationPre

ssure

Point

Bleeding Control cont’d

• If direct pressure fails…• Splints

• Reduced motion of bone ends

• Reduces aggravation of damage and blood loss

• Pressure Splints• Helps control soft tissue

injuries and bleeding assoc with broken bones

• Pneumatic Anti shock garments can be used to sever bleeding due to MASSIVE soft tissue injuries

• Lower extremities = Leg compartments only

• Pelvic injury = ALL compartments

Tourniquet

• Use as a LAST resort to control bleeding in an amputated extremity when ALL other methods have failed…

• Can result in PERMENANT damage to nerves, muscle and blood vessels

• Loss of extremity…

Tourniquet Precautions

• Use a wide bandage and secure it• NEVER use wire, rope, belts or anything else that may cut

into the skin and underlying tissue• Do not remove/loosen it once in place unless told by

medical control• Leave the tourniquet in open view• Do not apply a tourniquet over a joint• Apply it as close to the injury as possible

Application of a Tourniquet

• Bandage : 4 “ wide and 6-8 layers deep• Wrap around extremity X 2 at a location proximal to bleeding but distal

on the extremity as possible• Tie 1 knot in the bandage• Place a rod/stick over knot and tie square knot over stick/rod• Twist stick until bleeding has stopped• Secure the stick/rod in place• Let other providers know that a tourniquet has been applied• DOCUMENT the time!!!• A continuously inflated BP cuff can be used as a tourniquet until

bleeding stops.

Special Areas

• Bleeding from the:• Nose• Mouth• Ears

• Possible causes • Injured skull• Facial injury• Digital trauma (nose picking)• Sinusitis• Other upper resp tract

infections• Hypertension• Coagulation disorders

Special Areas Treatment

• Nose/Ears• If bleeding is a result of trauma

do not attempt to stop blood flow

• Collect blood with loose dressing

• May be result of skull fracture• Epistaxis (Nosebleed)

• Place pt in seated post• Lean pt forward• Apply direct pressure

• Pinch the fleshy part of the nostrils together

• Keep pt calm and quiet

Bleeding Control/Treatment

• BSI• Maintain airway• Administer O2• Control bleeding

• Direct pressure• Pressure dressing• Elevation• Pressure point• Splinting• Tourniquet• Etc…

• IMMEDIATE transport!!!• ALS

Internal Bleeding

• Can result is SEVERE blood loss• Shock/hypoperfusion results• Injured organs

• Extensive concealed bleeding

• Swollen, deformed, painful extremities may also lead to bleeding

• Suspicion and severity are base on MOI and S/S

Causes

• Trauma• Blunt

• Falls• MVA• Motorcycles• Pedestrian impacts • Blast injuries • DCAP-BTLS

• Penetrating • Stabbing• GSW

• Fractures • Medical conditions

• Ulcers (stomach/duodenal)• Aortic aneurysm • Ruptured ectopic pregnancy

Abdominal Aortic Aneurysm

Shock/Hypoperfusion Syndrome

• Shock/Hypoperfusion • Failure of the circulatory system to adequately perfuse and oxygenate the

tissues of the body • Problems with either:

• The Heart - Pump• The Blood Volume - Fluid• The Vascular System - Pipes

• Pathophysiology• Inadequate perfusion of cells with O2 and nutrients• Inadequate removal of waste products

• Consequences • Peripheral perfusion is drastically reduced• Reduction in circulating blood volume• Death

The Circulatory System Pathology

Shock

• Signs/Symptoms• Pale, cool, cyanotic, clammy skin• Rapid/shallow breathing• Restlessness/anxiety• Nausea/vomiting • Weak pulse• Low blood pressure/volume

Compensation Mechanisms Effects of Epinephrine

• Cardiac Output increases• Heart rate• Force of contractions

• Blood flow to brain is increased• Alertness• Apprehension/Anxiety

• Pupils dilate• Blood flow is redistributed

• Blood is shunted away from less vital organs

• Blood is sent to brain, heart, and muscles on priority basis

• Pale, cool, clammy, sweaty skin• Nausea

• Resp. rate increased• Rate• Depth

S/S

• Anxiety• Restlessness• AMS• Combativeness• Weakness, faintness, dizziness• Thirst• Shallow, rapid breathing• Pale, cool, clammy skin• Capillary refill greater than 2 seconds (infant/child)• Dropping BP• Raising pulse rate• Rapid, weak pulse – late • Elevated BP – early compensation • Dilated sluggish pupils• Nausea and vomiting

Shock/Hypoperfusion Children

• Can loose up to half their blood volume and maintain BP

• The infant/child in shock has less reserve

• By the time their BP drops they are close to death

Treatment

• BSI• Maintain airway/ventilation• Admin O2• Control external bleeding• Apply pneumatic anti shock garment

• S/S of shock• Abd tender• Pelvic injury suspected• No evidence of chest injury• Medical direction approval

• Elevate feet 8-12”• If pt atraumatic

• Splint suspected bone/joint injuries• Cover pt with blanket to prevent heat loss• IMMEDIATE transport

Applying Pneumatic Anti Shock Garment (PASG)

• Examine pt abd and legs for injury• They will be covered and

inaccessible one PASG is applied

• Remove pt clothing if possible• Lay PASG on stretcher• Lay pt on PASG with log roll • Top of abd section of the PASG

should like below the ribs• Fasten the Velcro straps

• At least ¾ of Velcro surface should be covered

• Connect the foot pump to the PASG• Open the stopcock valves• Inflate legs and (if not

contraindicated) abdominal sections• Check for S/S of response

• Improved vitals• Cap refill, Skin color, Mental

status

Remember Direct pressure!!! Prevent shock…