emt basic hemorrhage and shock
TRANSCRIPT
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Bleeding and Shock
Bleedin’ Like a Mug
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Three main parts
Pump
Container
Fluid
= The Heart
= The Vessels
= The Blood
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HeartPump
Moves blood through the system
Role in blood pressure maintenance (CO = HR X SV)
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VesselsContainer
Carry blood to peripheral tissues and back to the heart
Gas exchange
Role in blood pressure maintenance (PVR)
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Blood
Fluid
Transportation of gases
Regulation of pH
Restriction of blood loss
Defense agent against toxins and pathogens
Stabilization of body temperature
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Remember!COCO = HR X SV
BPBP = CO X PVR
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Blood Volumes
Adult – 70 ml/kg
Child – 80 ml/kg
Infant – 80 ml/kg
Related to blood loss severity15% loss is considered to be significant and can
lead to shock
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Blood Volumes
What is significant?Adult weighing 154 lbs (70 kg)
70kg * 70 ml = 4900 ml
4900ml * 0.15 = 735 ml blood loss
Infant weighing 22 lbs (10 kg)
10 kg * 80ml = 800 ml
800 ml * 0.15 = 120 ml blood loss800 ml * 0.15 = 120 ml blood loss
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Hemorrhage
Hemorrhage occurs when there is a
disruption, or "leak," in the vascular system
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TERMS
Shock (hypoperfusion)The insufficient supply of oxygen and other nutrients
to some of the body’s cells that result in inadequate circulation of blood
EpistaxisBleeding from the nose resulting from injury,
disease, or the environment; a nose bleed
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TERMS
PerfusionThe delivery of oxygen and other nutrients to the
cells of all organ systems, which results from the constant adequate circulation of blood through the capillaries.
HemorrhageThe escape of blood from the vessels; bleeding
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HemorrhageBlunt trauma to the chest or abdomen
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Hemorrhage
Penetrating trauma to the chest or abdomen
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Hemorrhage
Pelvic or Femur fractures
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Hemorrhage
•GI Bleeds
•Ectopic pregnancy
•AAA (abdominal aortic aneurysm)
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Hemorrhage
Any other significant mechanism of injury when multi-system
trauma is suspected
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Hemorrhage
Externalseriousness depends
– anatomical source of the hemorrhage
– degree of vascular disruption
– amount of blood loss tolerated
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Hemorrhage
Internal• occurs in abdomen, chest, or retroperitoneum
• can be caused by chronic medical problems
• associated with higher morbidity and mortality
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The Injury Occurs....Initial Response
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The Body’s Initial ResponseWhen bleeding starts the body
tries to stop it through,
Hemostasis
hemo -Blood,
Stasis - stop, slow down
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The Body’s Initial Response
Local vasoconstriction at the bleeding site
Formation of a platelet plug
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The Body’s Initial Response
Coagulation
Growth of fibrous tissue into the blood clot
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The Body’s Initial ResponseIf the bleeding is
severe, these mechanisms fail
resulting in shock.
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Shock
““Rude unhinging of the Rude unhinging of the machinery of life”machinery of life”
“Momentary pause in the act of death”
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Inadequate Capillary Perfusion
Very complex group of physiological
abnormalities…is not adequately defined by
pulse rate, b/p, or cardiac function
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Progression of Shock
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Stage 1 - VasoconstrictionStage 1 - Vasoconstriction
Blood volume decreases by 15%
Oxygen delivery to the cells decreases
Anaerobic metabolism begins
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Stage 1 - VasoconstrictionCapillaries begin to
leak
Skin becomes pale and sweaty
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Stage 1 - VasoconstrictionStage 1 - Vasoconstriction
Respiratory rate, BP, heart rate, and renal
output remains normal early on
Late in stage 1, pulse becomes weak and thready (sympathetic stimulation)
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Stage 1 - Vasoconstriction
Stage 1 is reversible if the hemorrhage is
controlled
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Stage 2 - Capillary/Venule Opening
15 - 25% blood loss
Pre-capillary sphincters relax, post capillary
sphincters resist relaxation
Blood pools in the capillaries
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Stage 2 - Capillary/Venule Opening
Soon blood flow bypasses the capillaries altogether (into venules),
capillary refill time increases
Capillaries and venules continue to dilate while
larger arterioles continue to constrict
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Stage 2 - Capillary/Venule Opening
Capillary/venule capacity can become great
enough to reduce blood return to heart
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Stage 2 - Stage 2 - Capillary/Venule OpeningCapillary/Venule Opening
Heart rate increases in an attempt to maintain
cardiac output but near the end of this stage, output begins to fall.
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Stage 2 - Stage 2 - Capillary/Venule OpeningCapillary/Venule Opening Blood pressure may be
normal to the end of stage 2, but pulse
pressure begins to fall !
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Stage 2 - Stage 2 - Capillary/Venule OpeningCapillary/Venule Opening
As the blood pools in the capillaries, the tissues continue to extract all
available oxygen and lactic acid builds
Respiratory system attempts to compensate
by increasing respirations
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Stage 2 - Capillary/Venule Opening
Stage 2 is still reversible Stage 2 is still reversible with proper fluid with proper fluid
resuscitationresuscitation
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Stage 3 - Disseminated Intravascular Coagulation
25 -35% blood loss
Acidosis increases, pH continues to fall, red blood cells begin
to cluster together
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Stage 3 - Disseminated Stage 3 - Disseminated Intravascular CoagulationIntravascular Coagulation
These clusters occlude capillaries and prevent
distribution of oxygen or removal of metabolic
wastes
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Stage 3 - Disseminated Stage 3 - Disseminated Intravascular CoagulationIntravascular Coagulation
Distal tissues have now fully switched to
anaerobic metabolism and lactic acid
production increases
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Stage 3 - Disseminated Stage 3 - Disseminated Intravascular CoagulationIntravascular Coagulation
Cells can no longer produce the energy to
maintain their membranes
Water and sodium leak into the cell and
potassium leaks out
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Stage 3 - Disseminated Stage 3 - Disseminated Intravascular CoagulationIntravascular Coagulation
Cells begin to swell and die.
Capillaries in the pulmonary vascular
leak fluid into the alveoli (eventually causes respiratory failure)
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Stage 3 - Disseminated Intravascular Coagulation
Altered mental status occurs because of the
hypoxia
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Stage 3 - Disseminated Stage 3 - Disseminated Intravascular CoagulationIntravascular Coagulation
All the classic signs of hypovolemic shock are present:
Tachycardia
Tachypnea
Decreased systolic pressure (first time pt shows this)
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Stage 3 - Disseminated Stage 3 - Disseminated Intravascular CoagulationIntravascular Coagulation
Diaphoresis continues with cool, pale skin
Still reversible (mortality high)
Cannot be reversed without the
administration of blood
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Stage 4 - Multiple Organ Failure
Greater than 35% blood loss
Blood pressure falls dramatically; patient is diaphoretic, cool, and
extremely pale
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Stage 4 - Multiple Organ FailureStage 4 - Multiple Organ FailureIf the given area of capillary occlusion
persists for more than 1 to 2 hours, changes occur
that are irreversible
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Stage 4 - Multiple Organ FailureThose changes create conditions that make it impossible for the cells that have survived this long to obtain enough energy to continue to
survive
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Stage 4 - Multiple Organ FailureStage 4 - Multiple Organ FailureIf enough cells within an organ die, that organ will
fail
The first two to go are usually the liverliver and the
kidneykidney
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Stage 4 - Multiple Organ Failure
The mental status continues to decrease
Clotting red blood cells produce pulmonary
hemorrhages leading to a decreasing respiratory
rate, then failure.
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Stage 4 - Multiple Organ FailureStage 4 - Multiple Organ FailureCapillary blockage and
hypoxia causes a decreasing heart rate
then heart failure
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The Body’s Response to Shock
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Compensated Shock
Some decreased tissue perfusion, but body's compensatory
responses are sufficient to overcome
the decrease
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Compensated Shock
Increase in catecholamine
production maintains cardiac output and a normal systolic blood
pressure
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Uncompensated Shock
Uncompensated shock occurs when the body
is no longer able to maintain systemic
blood pressure
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Uncompensated Shock
As the body's compensatory
mechanisms begin to fail, both systolic and
diastolic pressure drop and cerebral blood flow
decreases
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Irreversible Shock
Patients with irreversible shock as a result of massive cellular damage do not survive
Cells and the vital organs begin to die from the lack of energy
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Compensated Uncompensated Irreversible
Heart Rate Mild Tachycardia
Moderate tachycardia
Bradycardia, severe
dysrhythmia
Level of Consciousness
Lethargy, confusion,
combativeness Confusion Coma
Skin Delayed
capillary refill, cool skin
Delayed capillary refill, cold
extremities, cyanosis
Pale, cold, clammy skin
Blood Pressure Normal or slightly elevated
Decreased systolic and diastolic
Frank hypotension
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Assessment and Management
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Primary Assessment
Airway - opened and patency maintained
Breathing - insure adequate oxygenation and ventilation
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Primary Assessment
Circulation - assess for and correct uncontrolled bleeding
–Direct pressure–Elevation–Pressure points–Tourniquet–Splinting–PASG
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Primary AssessmentDisability - evaluation of the patient's level of consciousness
Expose and Examine - visual inspection can reveal life-threatening conditions hidden by clothing
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Secondary AssessmentSecondary Assessment
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Secondary AssessmentSecondary Assessment
Any abnormality that interferes with adequate ventilation
should be corrected
After controlling blood loss, volume replacement can begin
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Assessment of Internal HemorrhageAssessment of Internal Hemorrhage
Bright red blood
Coffee ground emesisMelena - (black, tarry stools)
Hematochezia - (passage of red blood through the rectum)
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Pneumatic Antishock Garment
PASG
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Physiologic Changes with PASG
•Artificially increases peripheral vascular resistance
Arrests hemorrhage
•Stabilize pelvic and lower-
extremity fractures
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Indications
•Hypoperfusion with an unstable
pelvis•Conditions of decreased SVR
not corrected by other means•As approved locally by medical
direction
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Contraindications
No abdominal section with advanced pregnancy, impaled object in abdomen, or evisceration
Ruptured diaphragm
Chest trauma
Pulmonary edema
Cardiogenic shock
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Management of Hemorrhage
1. ABCs, Oxygen 100% NRB
2. Control obvious bleeding
3. Restrict movement of the patient
4. Begin transport ASAP
5.5. Keep patient warmKeep patient warm
6. Consider Trendelenberg position
7. PASG
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QUESTIONS ?