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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Chapter 26
Bleeding and Shock
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
U.S. DOT Objectives Directory
U.S. DOT Objectives are covered and/or supported by the PowerPoint™ Slide Program and Notes for Emergency Care, 11th Ed. Please see the Chapter 26 correlation below.
*KNOWLEDGE AND ATTITUDE
• 5-1.1 List the structure and function of the circulatory system. Slides 6-9
• 5-1.2 Differentiate between arterial, venous, and capillary bleeding. Slides 12, 14
• 5-1.3 State methods of emergency medical care of external bleeding. Slides 16-28
• 5-1.4 Establish the relationship between Standard Precautions (body substance isolation) and bleeding. Slides 11, 16, 51
• 5-1.5 Establish the relationship between airway management and the trauma patient. Slides 16, 28, 43, 51-52
• 5-1.6 Establish the relationship between mechanism of injury and internal bleeding. Slides 31-32
• 5-1.7 List the signs of internal bleeding. Slide 33
• 5-1.8 List the steps in the emergency medical care of the patient with signs and symptoms of internal bleeding. Slide 34
(cont.)
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
U.S. DOT Objectives Directory
*KNOWLEDGE AND ATTITUDE
• 5-1.9 List signs and symptoms of shock (hypoperfusion). Slides 42, 44-50
• 5-1.10 State the steps in the emergency medical care of the patient with signs
and symptoms of shock (hypoperfusion). Slides 43, 51-52
• 5-1.11 Explain the sense of urgency to transport patients that are bleeding and
show signs of shock (hypoperfusion). Slides 34, 43, 51-52
(cont.)
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
U.S. DOT Objectives Directory
*SKILLS
• 5-1.12 Demonstrate direct pressure as a method of emergency medical care of
external bleeding.
• 5-1.13 Demonstrate the use of diffuse pressure as a method of emergency
medical care of external bleeding.
• 5-1.14 Demonstrate the use of pressure points and tourniquets as a method of
emergency medical care of external bleeding.
• 5-1.15 Demonstrate the care of the patient exhibiting signs and symptoms of
internal bleeding.
• 5-1.16 Demonstrate the care of the patient exhibiting signs and symptoms of
shock (hypoperfusion).
• 5-1.17 Demonstrate completing a prehospital care report for patient with
bleeding and/or shock (hypoperfusion).
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Circulatory System
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Circulatory System
Cardiovascular System
Responsible for distribution of blood
Components
– Heart
– Blood
– Blood vesselsArteries
Veins
Capillaries
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Types of Blood Vessels
Arteries
– Carry oxygen-rich blood away from heart
– Thick muscular wall that constricts and dilates
Capillaries
– Microscopically small and carry oxygen-rich
blood to supply every cell
Veins
– Carry deoxygenated blood back to the heart
– Less pressure than blood in an artery
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Circulatory System
Perfusion
• Adequate circulation of blood throughout the body
Hypoperfusion
• Inadequate perfusion of the body’s tissues and organs
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Functions of the Blood
Transportation
– Oxygenated blood
– Deoxygenated
blood
Nutrition
– Nutrients from
intestines or
storage tissues
Excretion
– Waste products
Protection
– Antibodies
– White blood cells
Regulation
– Hormones
– Water, salt
– Enzymes
– Chemicals
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Bleeding
Classification– Internal
– External
Hemorrhage– Severe bleeding
– Major cause of shock
Most sensitive– Brain
– Spinal cord
– Kidneys
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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External Bleeding
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
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Classification
Arterial– Bright red
– Rich in oxygen
– High pressure
Venous– Dark red (low in oxygen)
– Maroon color
Capillary– Slow and oozing
– Low pressure
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
External Bleeding
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Types of Bleeding
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Patient Assessment—Bleeding
Estimate amount of external blood
loss
Triage (prioritize)
Predict potential shock
Control external bleeding
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Patient Care—External Bleeding
Control bleeding.
Ventilate if necessary.
Monitor respirations.
Open airway.
Standard precautions.
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Controlling External Bleeding
Direct pressure
Elevation
Tourniquet
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Direct Pressure
Apply pressure to
wound
Hold pressure firmly
Bandage
Don’t remove
dressing
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Elevation
Used at the same time as
direct pressure
Above the level of the
heart
Gravity helps
Slows bleeding
Do not use with impaled
objects or spinal injury
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Tourniquet
Device that closes off blood flow
to and from an extremity
Controls life-threatening bleeding
Commonly used in military and
tactical settings
Direct pressure and elevation are
usually successful.
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Tourniquet—Use
Extremity injuries only
Once applied, do not remove or loosen.
Material
– 4 inches wide
– 6–8 layers thick
– Cravats frequently used
– Never use narrow material
Commercial tourniquets are available.
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Tourniquet—Application
Contact Medical Direction
B/P cuff may be used
Attach notation to patient
Tighten tourniquet
Select site
BP cuff may be used
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Tourniquet—Effectiveness
Research has shown that
tourniquets are highly effective
and pose less risk than originally
thought. Many current protocols
recommend using tourniquets
when direct pressure does not
stop bleeding.
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Alternative Bleeding-Control
Methods
Pressure points—brachial
Pressure points—femoral
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Alternative Bleeding-Control
Methods: Splinting
Used to control bleeding
Stabilization
Various types
Not effective for arterial bleeds
Maintains pressure
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Alternative Bleeding-Control Methods:
Pneumatic Anti-shock Garment
Bleeding in lower extremities
Never inflate just abdominal section
Follow local protocol
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Special Situations
Head injuries– Fracture skull
– Bleeding or loss of CSF from ears or nose
– Do not attempt to stop bleeding
Nose bleed– Epistaxis
– Direct trauma
– Increased blood pressure
– Patients at risk
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Controlling Nosebleeds
Position patient on side if unconscious
Do not let patient lean back
Keep patient quiet and calm
Apply or instruct patient to apply direct pressure
Have patient sit down and lean forward
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Internal Bleeding
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Internal Bleeding
Damage to internal organs and large
blood vessels
Blood loss cannot be seen.
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Mechanisms of Blunt Trauma
Falls
Motor-vehicle or
motorcycle
crashes
Auto-pedestrian
collisions
Blast injuries
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Penetrating Trauma
Gunshot wounds
Stab wounds
Impaled objects
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Signs of Internal Bleeding
Injuries to surface of body
Bruising
Painful, swollen, or deformed extremities
Bleeding from mouth, rectum, vagina, etc.
Tender, rigid, or distended abdomen
Vomiting
Dark, tarry stools or bright red blood
Signs and symptoms of shock
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Patient Care—Internal Bleeding
Prompt transport
Control external bleeding
Administer high flow oxygen via NRB
Maintain ABCs
Administer high-concentration oxygen via NRB
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Shock (Hypoperfusion)
Inadequate perfusion of cells with oxygen and
nutrients
Inadequate removal of
metabolic waste products
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
The Effects of Shock
Click here to view an animation on the effects of shock.
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Causes of Shock
Inability of heart to pump
Decreased supply of blood
Lack of integrity in blood vessels
Failure of vessels to dilate and
constrict
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Development of Shock
Heart fails as a pump.
Blood volume is lost.
Blood vessels dilate.
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Severity of Shock
Early
• The body shunts blood away from areas of lesser need to areas of greater need
Late
• Reduced perfusion results in malfunction of cells and organs
• Not recognized nor treated, death may result
• Reduced perfusion
results in malfunction
of cells and organs
• If not recognized or
treated, death may
result
• The body shunts
blood away from
areas of lesser need
to areas of greater
need
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Classification of Shock
Compensated
– Increased heart rate and respirations
– Constriction of periphery
Decompensated
– Blood pressure falls
Irreversible
– Unable to maintain perfusion of vital organs
– Cell damage occurs
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Types of Shock
Hypovolemic
– Uncontrolled bleeding or hemorrhage
– Internal, external, or a combination
Cardiogenic
– Myocardial infarction or heart attack
– Inadequate pumping of blood
– Electrical system malfunctioning
Neurogenic
– Uncontrolled dilation of blood vessels
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Signs and Symptoms
Restlessness, changes in mental
status
Pale, cool, and clammy skin
Nausea and vomiting
Vital sign changes
– Pulse and respirations increase.
– Blood pressure drops.
– Inaccurate pulse oximetry
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Emergency Care for Shock
Every minute between the time of injury and the patient getting to an operating suite is, in fact, like gold to the patient
Transport (intervention).
Oxygenation.
Maintain airway.
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Pediatric Notes
Efficient compensating mechanism
Blood pressure drop = serious
Consider shock and treat early.
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Cultural Considerations
Skin color
Fingernails and lips
Mouth
Eyelids
Palms of hands
Soles of feet
Ask the family.
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Trending Vital Signs
Elevated pulse
Elevated respiratory rates
Identifies patient’s condition
Unstable—vital signs taken every 5
minutes
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Normal, Shock, or Excited?
On -Scene
Pulse
96 Weak/regular
Respirations 8
Shallow
Skin Cool/moist
BP 90/60
5 Minutes
Pulse
100 Weak/regular
Respirations 10
Shallow
Skin Cool/moist
B/P 82/56
10 Minutes
Pulse
112 Weak/regular
Respirations 6
Shallow
Skin Cool/moist
B/P 74/50
(cont.)
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Normal, Shock, or Excited?
On-Scene
Pulse
68 Strong/regular
Respirations 12
B/P 110/62
Skin
Warm/dry
5 Minutes
Pulse
62
Strong/regular
Respirations
10
B/P 108/60
Skin
Warm/dry
10 Minutes
Pulse
62
Strong/regular
Respirations
12
B/P 118/60
Skin
Warm/dry
(cont.)
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Normal, Shock, or Excited?
On-Scene
Pules
124 Strong/regular
Respirations 24
BP 144/84
Skin
Cool/dry
5 Minutes
Pulse
120 Strong/regular
Respirations 22
B/P 122/82
Skin
Warm/dry
10 Minutes
Pulse
92 Strong/regular
Respirations 16
B/P 136/78
Skin
Warm/dry
(cont.)
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
Directory
Normal, Shock, or Excited?
On Scene
Pulse
66 Strong/regular
Respirations
12
B/P 142/86
Skin Cool/dry
5 Minutes
Pulse
78 Strong/regular
Respirations
12
B/P 132/78
Skin Cool/dry
10 Minutes
Pulse
92
Regular
Respirations
18
B/P 120/70
Skin Cool/moist
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Patient Care
Reassure patient.
Transport.
Prevent heat loss.
Splint bone injuries or joints.
Elevate legs 8-12 inches (no spine injury).
Apply and inflate PASG.
Control external bleeding.
Maintain open airway & assess respiratory rate.
Standard Precautions.
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Treatment of Shock
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Review Questions
1. Name the three main types of blood
vessels, and describe the type of
bleeding you would expect to see
from each one.
2. List the patient care steps for
external bleeding control.
3. Define perfusion and
hypoperfusion.
(cont.)
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Review Questions
4. List the signs and symptoms of
shock. Which would you expect to
see early? Which are late signs?
Explain what causes each of them.
5. List the three major types of shock
and what causes each one.
(cont.)
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Review Questions
6. List the emergency care steps for
treating a patient in shock.
7. In gauging the optimal time
between injury and definitive care,
when does the clock start running
and when does the clock stop
running?
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Street Scenes
What is the priority for this patient? Does
an initial assessment still need to be
done?
What assessment information do you
want to receive from Squad 31?
Is the mechanism of injury important
information for this patient?(cont.)
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
DOT
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Street Scenes
What is the treatment priority for this
patient?
How often should you get a new set
of vital signs?