Chapter 26 Bleeding and Shock

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Chapter 26Bleeding and Shock
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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.)
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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.)
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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).

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Circulatory System
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Circulatory System

• Cardiovascular System
• Responsible for distribution of blood
• Components
• Heart
• Blood
• Blood vessels
• Arteries
• Veins
• Capillaries

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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
• Carries deoxygenated blood back to the heart
• Less pressure than blood in an artery

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Circulatory System
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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

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Bleeding

• Classification
• Internal
• External
• Hemorrhage
• Severe bleeding
• Major cause of shock
• Most sensitive
• Brain
• Spinal cord
• Kidneys

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External Bleeding
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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

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External Bleeding
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Types of Bleeding
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Patient AssessmentBleeding

• Estimate amount of external blood loss
• Triage (prioritize)
• Predict potential shock
• Control external bleeding

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Patient CareExternal Bleeding
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Controlling External Bleeding

• Direct pressure
• Elevation
• Tourniquet

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Direct Pressure

• Apply pressure to wound
• Hold pressure firmly
• Bandage
• Dont remove dressing

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Elevation

• Used the same time as direct pressure
• Above the level of the heart
• Gravity helps
• Slows bleeding
• Do not use impaled objects or spinal injury

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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.

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TourniquetUse

• Extremity injuries only
• Once applied, do not remove or loosen.
• Material
• 4 inches wide
• 68 layers thick
• Cravats frequently used
• Never use narrow material
• Commercial tourniquets are available.

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TourniquetApplication
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TourniquetEffectiveness

• 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.

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Alternative Bleeding-Control Methods

• Pressure pointsbrachial

Pressure pointsfemoral
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Alternative Bleeding-Control Methods Splinting

• Used to control bleeding
• Stabilization
• Various types
• Not effective for arterial bleeds
• Maintains pressure

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Alternative Bleeding-Control Methods Pneumatic
Anti-shock Garment

• Bleeding lower extremities
• Never inflate abdominal section
• Not used when shock present
• Follow local protocol

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Special Situations

• Head injuries
• Fracture skull
• Bleeding or loss of CSF
• Do not attempt to stop bleeding
• Nose bleed
• Epistaxis
• Direct trauma
• Increased blood pressure
• Patients at risk

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Controlling Nosebleeds
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Internal Bleeding
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Internal Bleeding

• Damage to internal organs and large blood vessels
• Blood loss cannot be seen.

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Mechanisms of Blunt Trauma

• Falls
• Motor-vehicle or motorcycle crashes
• Auto-pedestrian collisions
• Blast injuries

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Penetrating Trauma

• Gunshot wounds
• Stab wounds
• Impaled objects

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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

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Patient CareInternal Bleeding
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Shock (Hypoperfusion)
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The Effects of Shock
Click here to view an animation on the effects of
shock.
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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

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Development of Shock

• Heart fails as a pump.
• Blood volume is lost.
• Blood vessels dilate.

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Severity of Shock
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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

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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

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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

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Emergency Care for Shock
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Pediatric Notes

• Efficient compensating mechanism
• Blood pressure drop serious
• Consider shock and treat early.

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Cultural Considerations

• Skin color
• Finger nails and lips
• Mouth
• Eyelids
• Palms of hands
• Soles of feet
• Ask the family.

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Trending Vital Signs

• Elevated pulse
• Elevated respiratory rates
• Identifies patients condition
• Unstablevital signs taken every 5 minutes

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Normal, Shock, or Excited?
(cont.)
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Normal, Shock, or Excited?
(cont.)
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Normal, Shock, or Excited?
(cont.)
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Normal, Shock, or Excited?
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Patient Care
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Treatment of Shock
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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.)
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Review Questions

1. List the signs and symptoms of shock. Which would
   you expect to see early? Which are late signs?
   Explain what causes each of them.
2. List the three major types of shock and what
   causes each one.

(cont.)
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Review Questions

1. List the emergency care steps for treating a
   patient in shock.
2. In gauging the optimal time between injury and
   definitive care, when does the clock start
   running and when does the clock stop running?

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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.)
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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?

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Sample Documentation