bleeding and volume replacement therapy j. málek
TRANSCRIPT
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Bleeding andVolume Replacement
TherapyJ. Málek
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Casualty treatment
• call for medical help
• vital functions
• control of major external bleeding
• general examination
• prevention of secondary injuries
• detailed examination
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Blood
• in adults 40-50 ml/kg, in children 50-60 ml/kg
• oxygen and CO2 transport
• water and mineral balance
• transport of metabolites
• transport of hormones
• immunity
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Blood
• red cells
• white cells
• thrombocytes
• plasma
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Bleeding
• arterial, venous, capillary, mixed
• minor, major
• localisation
• normal, abnormal
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Minor bleeding
• clean with water
• apply antiseptic around the wound
• apply sterile dressing
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Bleeding
• external
• internal
• from body orifices
• mixed
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Major external bleeding• lay the victim down to supine position• compress and elevate the bleeding site (if
possible)– pressure dressing– manual compression– pressure points– tourniquet
• do not try to clean a large wound (remove only obvious debris)
• never remove a foreign body
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Internal bleeding
• pain
• signs of injury
• signs of shock
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Internal bleeding
• positioning
• call for emergency
• nothing per os
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Bleeding from body orifices
• mouth
• nose
• ear
• haemoptoea
• vomiting of blood
• rectal bleeding/melaena
• vaginal bleeding
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Volume replacement therapy
• crystalloid solutions
• colloids solutions– volume substituents– volume expanders
• blood
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Crystalloid solutions
• advantages• no allergic reactions• easily available• low effect on blood
coagulation• easily mobilised
• disadvantages• move quickly from
blood vessels• no transport capacity
for oxygen
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Colloid solutions
• dextrans
• gelatine
• starch
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Colloid solutions
• advantages• stay longer in blood
vessels• rapid volume
replacement (molecular weight dependent)
• easily available
• disadvantages• allergic reaction
possible• various effect on blood
coagulation• difficulty in
mobilisation• no transport capacity
for oxygen
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Blood and blood products
• packed red cells
• fresh frozen plasma
• thrombocytes
• various factors
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Risks of blood transfusion
• incompatibility
• infection
• allergy
• fever
• overloading
• bleeding problems
• immunity
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Blood transfusion
• indication
• patient´s consent
• taking blood sample to transfusion dept.
• cross match in TD
• check documentation and transfusion bag
• security test
• biological test
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Blood groups
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Population O+
A+
B+
AB+
O−
A−
B−
AB−
Argentina[11] 53.8% 34.7% 8.8% 2.7% 8.4% 0.44% 0.21% 0.06%
Australia[12] 40% 31% 8% 2% 9% 7% 2% 1%
Belgium[13] 38.1% 34% 8.5% 4.1% 7% 6% 1.5% 0.8%
Canada[14] 39% 36% 7.6% 2.5% 7% 7% 1.4% 0.5%
Denmark[15] 35% 37% 8% 4% 6% 7% 2% 1%
Finland[16] 27% 38% 15% 7% 4% 6% 2% 1%
France[17] 36% 37% 9% 3% 6% 7% 1% 1%
Hong Kong, China[18]
40% 26% 27% 7% <0.3% <0.3% <0.3% <0.3%
Korea, South[19] 27.4% 34.4% 26.8% 11.2% 0.1% 0.1% 0.1% 0.05%
Netherlands[20] 39.5% 35% 6.7% 2.5% 7.5% 7% 1.3% 0.5%
Poland[21] 31% 32% 15% 7% 6% 6% 2% 1%
Sweden[22] 32% 37% 10% 5% 6% 7% 2% 1%
UK[23] 37% 35% 8% 3% 7% 6% 2% 1%
USA[24] 38% 34% 9% 3% 7% 6% 2% 1%
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Human red blood cells before (left) and after (right) adding serum containing anti-A antibodies. The agglutination reaction reveals the presence of the A antigen on the surface of the cells.
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Transfusion
• Colecting blood sample from the patient• Transfusion station
– Blood group– Crossmatching– Delivery
• Ward– Check delivery list– Safety test– Biological test– Monitoring – Save blood pack for 24 hours
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Indications for blood transfusions
• acute hemorrhage
• anemia
• bleeding disorders
• hematological diseases
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Acute bleeding
Blood loss Replacement
<750 ml crystalloid solutions
750 – 1500 ml crystalloid solutions (colloid solutions or blood)
>1500 ml crystalloid solutions (colloid solutions) + blood
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Shock
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Definition
Acute state in which tissue perfusion is inadequate to maintain the supply of oxygen and nutritients necessary for normal cell function, which results in widespread hypoxia.
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Reasons for inadequate tissue perfusion
• A decreased circulating blood volume – hypovolaemic shock
• A failure of the heart to pump effectively – cardiogenic shock and obstructive shock
• A massive increase in peripheral vasodilatation – neurogenic shock
• Combination – septic shock, anaphylactic shock
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Stages of shock
• Initial stage – anaerobic metabolism
• Compensatory stage – centralisation of circulation
• Progressive stage – increased acidosis, leakage of fluid from the capillaries and formation of microthrombes
• Refractory stage
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Classification of shock
• Hypovolaemic shock
• Cardiogenic shock
• Anaphylactic shock
• Septic shock
• Neurogenic shock
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Hypovolaemic shock
• Haemorrhage
• Plasma loss
• Extracelular fluid loss
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Symptoms of hypovolemia according to blood loss
Blood loss (ml) Symptoms
<750 none
-1 500 thirst, weakness, tachypnoea
-2 000 systolic pressure falls
>2 000 no pulse on periphery
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Estimated blood loss in trauma
Pelvis 3 000 mL
Femur 1 000 mL
Tibia 650 mL
Abdominal injury 2 000 – 4 000 mL
Thoracic injury 2 000 – 4 000 mL
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Signs of haemorrhagic shock
• Pale, cold, clammy skin, decreased capilary refill
• Rapid, weak and thready pulse
• Thirst
• Decreased urine production
• Increased respiratory rate
• Change in mental status – late sign
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First aid• Prevent further blood loss
• Antishock or autotransfusion position
• Activation of emergency service
• Prevention of hypothermia
• Prevention of positioning trauma
• Treatment of other injuries, immobilisation of fractures
• Nil by mouth, no oral or i.m. medication
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Medical treatment
• Intravenous access
• Surgery
• Fluid replacement
• Artificial ventilation
• Pharmacological support of shock organs
• Monitoring: BP, P, SaO2, CPV, urine output
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Cardiogenic shock
• Heart failure, cardiomyopathy
• Decreased cardiac output
• First vasoconstriction, next vasodilatation due to acidosis
• Pulmonary oedema
• Cold, clammy and cyanotic skin
• Mortality 80 per cent
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Anaphylactic shock
• Severe allergic reaction
• Degranulation of mast cells
• Vasodilatation, increased vascular permeability, oedema, bronchospasm
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Septic shock
• Bacteria or bacterial toxins
• Released histamine and other mediators of inflammation
• Oxygen demand – supply mismatch
• Vasodilatation
• Tachycardia, hypotension, fever of hypothermia
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Neurogenic (spinal) shock
• Loss of sympathetic nerve activity
• Massive vasodilatation