Chapter 11

Bleeding

Shock

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

Bleeding

External / Internal

External Bleeding– Use Body Substance Isolation (BSI)

precautions– Always wash hands following contact

Waterless cleans

Signs & Symptoms

Arterial– Rapid, spurting, profuse, bright red (under

pressure)– Clot formation is difficult– Difficult to control– As blood pressure drops, spurting will also

drop

Signs & Symptoms

Venous– Usually steady flow (under lower pressure),

can be heavy– Dark red– Debris and air can be sucked into

wound– Clotting rate is dependent on size of area

or vessels involved

Signs & Symptoms

Capillary– Slow (oozing)– Red but not as bright as arterial bleeding– Good chance of infection– Clots easily

Blood Volumes & Serious Losses

Age Group

Average Blood Volume

Serious Volume Loss

Adult 5 - 6 liters 1 liter

Adolescent 2 – 3 ½ liters ¾ liter

Child 1 ½ - 2 liters ½ liter

Infant 500-600 ml 50-100 cc

Blood Loss

Severe or uncontrolled blood loss will lead to Shock (Hypoperfusion)

Most Bleeding will stop by itself within 6-10 minutes (dependent on area of involvement and vessels involved)

Care (Control) of External Bleeding

External bleeding usually easy to control Complete the initial assessment including

the ABC’s before focusing on bleeding Follow BSI precautions Cover wound with a clean dressing to

reduce risk of infection Follow basic steps for controlling bleeding

– If bleeding or CSF from ears do not stop flow

Care (Control) of External Bleeding

Direct pressure– Controls most bleeding

Elevate injured area (if no fractures are present)

Pressure Bandage Arterial pressure points (Femoral/Brachial)

– Summon EMS if bleeding cannot be controlled or if pressure points must be used

External BleedingNosebleeds (Epistaxis)

Care for a Nosebleed– Sitting position leaning slightly forward– Apply direct pressure (may take 15 min.)

Pinching nose or rolled gauze under noseCold compresses

– Do notPack noseBlow nose orTilt head back

Internal Bleeding

May not be obvious, may take time for signs & symptoms to appear

Leading causes– Blunt trauma– Penetrating injuries

Suspect internal bleeding in any serious injury

Signs & Symptoms

Bruising (Contusion)– contusions over abdomen or chest the size

of your fist - assume a 10% blood volume loss

Painful, swollen, deformed extremities Swollen, painful, tender or rigid abdomen

– rebound tenderness Bleeding from mouth, ears, nose

Signs Symptoms

Vomiting coffee grounds vomitus or bright red blood

Dark tarry stools or passing bright red blood in stools

Abnormal rectal or vaginal bleeding Anxiety & restlessness Increased respiratory rate

Signs & Symptoms

Cool, moist skin Pale or ashen skin leading to cyanosis Excessive thirst Decreasing level of consciousness Any additional signs or symptoms of

shock

Care of Internal Bleeding

Care depends on the severity and site of the injury

For minor internal bleeding (bruising)– Apply cold compresses

If internal bleeding appears to be serious– Activate EMS– Complete initial assessment including the

ABC’s– Treat for shock

Shock (Hypoperfusion)

Shock– Life-threatening potential– Inevitable result of any serious injury

(illness)– Results from the body’s inability to

maintain adequate perfusion– Signs & symptoms may be present

immediately, become evident during the physical exam or an ongoing assessment

Shock

Conditions required for normal flow of oxygenated blood to the tissues– Heart functioning properly– Adequate blood volume– Intact functional vessels

Classifications

Cardiogenic Shock - pump failure Hypovolemic -

– Hemorrhagic– Non-hemorrhagic

MetabolicSeptic

Neurogenic Psychogenic Anaphylaxic

Signs (In order of appearance)

Altered Mental Status– Anxiety, restlessness, combativeness

Pale, Cool, Clammy Skin– Develops into cyanosis (lips & nailbeds)– Infants & children may begin to exhibit

capillary refill times greater than 2 seconds Nausea & Vomiting

Signs(In order of appearance)

Vital Sign Changes– Pulse

Increases, becomes weak & thready

– RespirationsIncrease becoming more shallow & labored

– Blood PressureOne of last signs to change

– Dilated pupils

Care for Shock

Perform initial assessment– If no immediate life-threatening problems

perform a physical exam and SAMPLE history

Activate EMS when necessary Control any external bleeding

Care for Shock

Position patient– Supine with legs elevated unless– Respiratory difficulty - upright– Chest pain - upright or semi-recumbent

Maintain body temperature Nothing by Mouth (food or drink) Administer oxygen if available