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Shock and Bleeding

Hamburg High SchoolEMT Program

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Circulatory System

Anatomy• Heart

• 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

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Function of the Blood

Transportation of Gases• 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

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Function of the Blood

Protection• 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

The average amount of blood found in a:

Male: 5 – 6 Liters Female: 4 – 5 Liters

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Composition of Blood

Plasma• 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

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Composition of Blood

White Blood Cells• 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

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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

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Hypoperfusion (SHOCK)•Inadequate circulation of blood through an organ

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Types of Bleeding

Arterial Bleed • Bright red• Spurting

Venous Bleed• Dark red/maroon• Steady flow• Easier to control

Capillary Bleed• Dark red• Oozing • Often clots spontaneously

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Severity of Bleeding

Considered severe when loss equals:• One liter (1000 cc) in an adult• ½ liter (500 cc) in a child• 100-200 cc in an infant

Uncontrolled bleeding or significant blood loss leads to shock (hypoperfusion) and possibly death

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Severity of Blood LossDetermined 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

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Control of External Bleeding

PPE for BSI Maintain Airway Administer Oxygen1. Direct Pressure

• gloved hand• dressing/bandage

2. Elevation3. Tourniquet

CONSIDER:Arterial pressure points

Upper extremity: BrachialLower extremity: Femoral

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Other Methods to Control Bleeding

Splints Air splints

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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

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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

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Bleeding from the Nose, Ears, and Mouth

Possible causes• Skull fracture• Simple nose bleed – epistaxis• Facial trauma

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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

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Epistaxis

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

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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

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Epistaxis

Epistaxis can result in life-threatening blood loss

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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

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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

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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

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Internal Bleeding

Management• BSI• Open airway• High concentration oxygen• Assist ventilations• Control external bleeding with direct

pressure• Stabilize fractures• Transport rapidly to appropriate facility

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Abdominal Evisceration

Penetrating Trauma

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SHOCK

Inadequate perfusion (blood flow) of cells leading to

inadequate oxygen delivery to tissues

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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

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How can perfusion fail, thus causing shock?

Heart fails as a pump Blood vessels dilate Loss of Volume

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3 Types of Shock and Their Causes

1. Hypovolemic Shock2. Cardiogenic Shock3. Distributive Shock

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1. Hypovolemic Shock

A type of shock that is the result of low blood volume

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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

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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

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

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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

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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)

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2. Cardiogenic Shock

Signs and Symptoms• Those symptoms commonly seen

during a heart attack Emergency care

• CPR with AED

3. Distributive Shock

Blood vessels suddenly dilate causing the blood pressure to fall

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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

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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

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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

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Psychogenic Shock

Simple fainting (syncope) Caused by stress, pain, fright Heart rate slows, vessels

dilate Brain becomes hypoperfused Loss of consciousness occurs

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Shock:Signs and Symptoms

1. Anxiety, restlessness, combativeness, or altered mental status

2. Weakness, faintness or dizziness3. Thirst4. Shallow rapid breathing5. Rapid, weak pulse6. Pale, cool, clammy skin

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Shock:Signs and Symptoms

7. Capillary refill >2 seconds (infants and children ONLY)

8. Dropping blood pressure (late sign)9. Dilated pupils that are sluggish to

respond10. Nausea & vomiting

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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!

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Severity of Shock

Compensated shock (Early)• 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)

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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

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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

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Treatment

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

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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

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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

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Indications

1. Systolic B/P of 50 mmhg with signs of shock

2. Systolic B/P of 90 mmhg with a pelvic injury

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S/S of Shock

Restlessness Cool clammy skin Tachycardia Delayed capillary refill

(children & infants)

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Absolute Contra-Indications

Pulmonary Edema Penetrating Chest Wound

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Partial Contra-Indications

Pregnancy (legs only) Abdominal injury (evisceration) or

impaled object (legs only) Impaled object in leg (abdominal

and one leg only)

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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 establishedIVs established• Surgical team readySurgical team ready• Abdomen then one leg at a time SLOWLYAbdomen then one leg at a time SLOWLY

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Never deflate entire suit at onceNever deflate entire suit at once

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Flow = Perfusion

Adequate Flow = Adequate Perfusion

Inadequate Flow = Inadequate Perfusion

(Hypoperfusion)

Hypoperfusion = Shock