Title: Hemorrhage
1Hemorrhage Shock
2Review of Hemorrhage
- Location
- Anatomical Type Timing
- Coagulation
- Fibrinolysis
- Assessment
- Management
3Review of Hemorrhage
- Location
- External
- Internal
- Traumatic
- Non-Traumatic
- Examples?
4Review of Hemorrhage
- Anatomical Type
- Arterial
- Venous
- Capillary
- Timing
- Acute
- Chronic
5Severity of Hemorrhage
Comparison of Adult vs Child
6Hematocrit
- of RBC in blood (hematocrit)
- Normal
- 37 - 47 (Female)
- 40 - 54 (Male)
7Thrombocytes
- Platelets
- Form platelet plugs
- contact collagen adhere to injured surface
- activate platelets
- aggregate to form platelet plug
8Coagulation
- Formation of blood clots
- Prothrombin activator
- Prothrombin ? Thrombin
- Fibrinogen ? Fibrin
- entrap platelets, blood cells plasma
- Clot retraction
9Fibrinolysis
- Breaking up the clot
- tissue plasminogen activator (tPA)
- plasminogen ? plasmin
10Assessing Hemorrhage
- Clues
- Bright red blood from wound, mouth, rectum or
other orifice - Hematemesis
- Coffee ground appearance of vomitus
- Hematochezia
- Melena
- Orthostatic hypotension
- Dizziness or syncope on sitting or standing
- Signs and symptoms of hypovolemic shock
11Management of Hemorrhage
- Airway and Ventilatory Support
- Circulatory Support
- From nose or ears after head trauma loose drsg
- Control bleeding
- direct pressure, elevation, pressure points
- tourniquet
- packing of large wounds
- splinting
- PASG
- transport to appropriate facility
12Shock
A rude unhinging of the machinery of life
A brief pause in the act of dying
13Shock
- Inadequate peripheral perfusion leading to
failure of tissue oxygenation - ? may lead to anaerobic metabolism
14Shock
- Homeostasis
- cellular state of balance
- perfusion of cells with oxygen is one of its
cornerstones
15Shock
- Adequate Cellular Oxygenation
- Red Cell Oxygenation
- Red Cell Delivery To Tissues
Fick Principle
16Fick Principle
- Airs gotta go in and out.
- Bloods gotta go round and round.
- Any variation of the above is not a good thing!
17Shock
- Red Cell Oxygenation
- Oxygen delivery to alveoli
- Adequate FiO2
- Patent airways
- Adequate ventilation
18Shock
- Red Cell Oxygenation
- Oxygen exchange with blood
- Adequate oxygen diffusion into blood
- Adequate RBC flow past alveoli
- Adequate RBC mass/Hgb levels
- Adequate RBC capacity to bind O2
- pH
- Temperature
19Shock
- Red Cell Delivery To Tissues
- Adequate perfusion
- Blood volume
- Cardiac output
- Heart rate
- Stroke volume (pre-load, contractility,
after-load) - Conductance
- Arterial resistance
- Venous capacitance
20Shock
- Red Cell Delivery To Tissues
- Adequate RBC mass
- Adequate Hgb levels
- Adequate RBC capacity to unbind O2
- pH
- Temperature
- Distance between capillaries and cells
21Shock
- Inadequate oxygenation or perfusion causes
- Inadequate cellular oxygenation
- Shift from aerobic to anaerobic metabolism
22AEROBIC METABOLISM
Glycolysis Inefficient source of energy
production 2 ATP for every glucose produces
pyruvic acid Oxidative phosphorylation Each
pyruvic acid is converted into 34 ATP
23ANAEROBIC METABOLISM
Glycolysis Inefficient source of energy
production 2 ATP for every glucose produces
pyruvic acid
24Anaerobic Metabolism
- Occurs without oxygen
- oxydative phosphorylation cant occur without
oxygen - glycolysis can occur without oxygen
- cellular death leads to tissue and organ death
- can occur even after return of perfusion
- ? organ or organism death
25Ultimate Effects of Anaerobic Metabolism
26Maintaining perfusion requires
- Volume
- Pump
- Vessels
- Failure of one or more of these causes shock
27Shock
- Hypovolemic Shock Low Volume
- Trauma
- Non-traumatic blood loss
- Vaginal
- GI
- GU
- Burns
- Diarrhea
- Vomiting
- Diuresis
- Sweating
- Third space losses
- Pancreatitis
- Peritonitis
- Bowel obstruction
28Shock
- Cardiogenic Shock Pump Failure
- Mechanical obstruction (distributive shock)
- Cardiac tamponade
- Tension pneumothorax
- Pulmonary embolism
- Acute M I
- CHF
- Bradyarrhythmias
- Tachyarrhythmias
29Shock
- Vasogenic Shock Low Resistance
- Spinal cord trauma
- neurogenic shock
- Depressant drug toxicity
- Simple fainting
30Shock
- Mixed Shock
- Septic Shock
- Overwhelming infection
- Inflammatory response occurs
- Blood vessels
- Dilate (loss of resistance)
- Leak (loss of volume)
31Shock
- Mixed Shock
- Septic Shock
- Fever
- Increased O2 demand
- Increased anaerobic metabolism
- Bacterial toxins
- Impaired tissue metabolism
32Shock
- Mixed Shock
- Anaphylactic Shock
- Severe allergic reaction
- Histamine is released
- Blood vessels
- Dilate (loss of resistance)
- Leak (loss of volume)
33Shock
- Mixed Shock
- Anaphylactic Shock
- Histamine release
- Extravascular smooth muscle spasm
- Laryngospasm
- Bronchospasm
34Shock
- Progressive syndrome
- Three phases
- Compensated
- Decompensated
- Irreversible
35Shock
- Signs and symptoms due to
- Hypoperfusion
- Compensatory responses
36Compensated Shock
- Baroreceptors detect fall in BP
- Usually 60-80 mm Hg (adult)
- Sympathetic nervous system activates
- What are the primary SNS Neurotransmitters
their effects?
37Compensated Shock
- Cardiac effects
- Increased force of contractions
- Increased rate
- Increased cardiac output
38Compensated Shock
- Peripheral effects
- Arteriolar constriction
- Pre-/post-capillary sphincter contraction
- Increased peripheral resistance
- Shunting of blood to core organs
39Compensated Shock
- Decreased renal blood flow
- Renin released from kidney arteriole
- Renin Angiotensinogen combine
- Converts to Angiotensin I
- Angiotensin I converts to Angiotensin II
- Peripheral vasoconstriction
- Increased aldosterone release (adrenal cortex)
- promotes reabsorption of sodium water
40Compensated Shock
- Decreased blood flow to hypothalamus
- Release of antidiuretic hormone (ADH or Arginine
Vasopressin) from posterior pituitary - Retention of salt, water
- Peripheral vasoconstriction
41Compensated Shock
- Insulin
- ? secretion caused by epinephrine
- contributes to hyperglycemia
- Glucagon
- ? release caused by epinephrine
- promotes liver glycogenolysis gluconeogenesis
- ACTH
- stimulates adrenal cortex release of cortisol
- ? glucose production
42Compensated Shock
- Peripheral capillaries contain minimal blood
- Stagnation
- Aerobic metabolism changes to anaerobic
- Extracellular potassium shifts begin
43Compensated Shock
- Presentation
- Restlessness, anxiety
- Earliest sign of shock
- Tachycardia
- ?Bradycardia in cardiogenic, neurogenic
44Compensated Shock
- Presentation
- Normal BP, narrow pulse pressure
- Falling BP late sign of shock
- Mild orthostatic hypotension (15 to 25 mm Hg)
- Possible delay in capillary refill
45Compensated Shock
- Presentation
- Pale, cool skin
- Cardiogenic
- Hypovolemic
- Flushed skin
- Anaphylactic
- Septic
- Neurogenic
46Compensated Shock
- Presentation
- Slight tachypnea
- Respiratory compensation for metabolic acidosis
47Compensated Shock
- Presentation
- Nausea, vomiting
- Thirst
- Decreased body temperature
- Feels cold
- Weakness
48Decreased Cardiac Output
Catecholamine Release
Aldosterone, ADH Release
Increased Blood Volume
Increased PVR
Increased Cardiac Output
Increased Myocardial Work, O2 Demand
Increased Volume Loss
Compensated Shock Leading to Decompensation
Myocardial Ischemia
49Decompensated Shock
- Presentation
- Cardiac Effects
- Decreased RBC oxygenation
- Decreased coronary blood flow
- Myocardial ischemia
- Decreased force of contraction
50Decompensated Shock
- Presentation
- Peripheral effects
- Relaxation of precapillary sphincters
- Continued contraction of postcapillary sphincters
- Peripheral pooling of blood
- Plasma leakage into interstitial spaces
51Decompensated Shock
- Presentation
- Peripheral effects
- Continued anaerobic metabolism
- Continued increase in extracellular potassium
- Rouleaux formations of RBCs
- pile up like coins
- Cold, gray, waxy skin
52Decompensated Shock
- Presentation
- Listlessness, confusion, apathy, slow speech
- Tachycardia weak, thready pulse
- Decreased blood pressure
- Moderate to severe orthostatic hypotension
- Decreased body temperature
- Tachypnea
53Irreversible Shock
- Post-capillary sphincter relaxation
- Loss of peripheral vascular resistance
54Irreversible Shock
- Washout of accumulated products
- Hydrogen ion
- Potassium
- Rouleaux formations
- Carbon dioxide
- Rouleaux formations microembolize in lungs
- Systemic metabolic acidosis occurs
- Cardiac Output decreases further
55Irreversible Shock
- Presentation
- Confusion, slurred speech, unconscious
- Slow, irregular, thready pulse
- Falling BP diastolic goes to zero
- Cold, clammy, cyanotic skin
- Slow, shallow, irregular respirations
- Dilated, sluggish pupils
- Severely decreased body temperature
56Irreversible Shock
- Irreversible shock leads to
- Renal failure
- Hepatic failure
- Disseminated intravascular coagulation (DIC)
- Multiple organ systems failure
- Adult respiratory distress syndrome (ARDS)
- Death
57Disseminated Intravascular Coagulation (DIC)
- Decreased perfusion causes tissue damage/necrosis
- Tissue necrosis triggers diffuse clotting
- Diffuse clotting consumes clotting factors
- Fibrinolysis begins
- Severe, uncontrolled systemic hemorrhage occurs
58Adult Respiratory Distress Syndrome (ARDS)
- AKA Shock Lung, Da Nang Lung
- Decreased perfusion damages alveolar and
capillary walls - Surfactant production decreases
- Fluid leaks into interstitial spaces and alveoli
- Gas exchange impaired
- Work of breathing increases
59Shock Classifications
- Hypovolemic
- Cardiogenic
- Vasogenic (Distributive)
- Neurogenic
60Shock Classifications
- Hypovolemic Causes
- Hemorrhage
- Plasma
- Fluid Electrolytes
- Endocrine
61Shock Classifications
- Cardiogenic Causes
- Contractility
- Rate
- Obstructive (Preload/Afterload)
- Tension pneumothorax
- Pericardial tamponade
- Pulmonary embolism
- Severe Hypertension
62Shock Classifications
- Vasogenic (distributive)
- Increased venous capacitance
- low resistance, vasodilation
- anaphylaxis
- sepsis
63Shock Classifications
- Neurogenic (spinal shock)
- loss of spinal cord function below site of injury
- loss of sympathetic tone
- cutaneous vasodilation
- relative bradycardia
64Key Issues In Shock
- Tissue ischemic sensitivity
- Heart, brain, lung 4 to 6 minutes
- GI tract, liver, kidney 45 to 60 minutes
- Muscle, skin 2 to 3 hours
Resuscitate Critical Tissues First!
65Key Issues In Shock
- Recognize Treat during compensatory phase
Restlessness, anxiety, combativeness Earliest
signs of shock
Best indicator of resuscitation effectiveness
Level of Consciousness
66Key Issues In Shock
- Falling BP LATE sign of shock
- BP is NOT same thing as perfusion
- Pallor, tachycardia, slow capillary refill
Shock, until proven otherwise
67Key Issues In Shock
- Isolated head trauma does NOT cause shock
- (possible in peds)
68General Shock Management
- Airway
- Open, Clear, Maintained
- Consider Intubation
69General Shock Management
- High concentration oxygen
- Oxygen Most Important Drug in Shock
- Assist ventilation as needed
- When in Doubt, Ventilate
- BVM
- Decompress Tension Pneumothorax
70General Shock Management
- Establish venous access
- Replace fluid
- Give drugs, as appropriate
- Dont delay definitive therapy
- Maintain body temperature
- Cover patient with blanket if needed
- Avoid cold IV fluids
71General Shock Management
- Monitor
- Mental Status
- Pulse
- Respirations
- Blood Pressure
- ECG
72Hypovolemic Shock
- Control severe external bleeding
- Elevate lower extremities
- Avoid Trendelenburg
- Pneumatic anti-shock garment
73Hypovolemic Shock
- Two large bore IV lines
- Infuse Lactated Ringers solution
- Titrate BP to 90-100 mm Hg
74Hypovolemic Shock
- Do NOT delay transport
- Start IVs enroute to hospital
Where does stabilization of critical trauma occur?
75Cardiogenic Shock
- Supine, or head and shoulders slightly elevated
- Do NOT elevate lower extremities
76Cardiogenic Shock
- Keep open line, micro-drip set
- Fluid challenge based on cardiovascular mechanism
and history - Titrate to BP 90 mm Hg
77Cardiogenic Shock
- Treat the underlying cause if possible
- Treat rate, then rhythm, then BP
- Correct bradycardia or tachycardia
- Correct irregular rhythms
- Treat BP
- Cardiac contractility
- Dobutamine, Dopamine
- Peripheral resistance
- Dopamine, Norepinephrine
78Cardiogenic Shock
- Obstructive Shock
- Treat the underlying cause
- Tension Pneumothorax
- Pericardial Tamponade
- Isotonic fluids titrated to BP w/o pulmonary
edema - Control airway
- Intubation
79Shock Management
- Avoid vasopressors until hypovolemia ruled out,
or corrected
80Shock Management
Squeezing partially empty tank can cause
ischemia, necrosis of kidney and bowel
81Vasogenic Shock
- Consider need to assist ventilations
- Patient supine lower extremities elevated
- Avoid Trendelenburg
82Vasogenic Shock
- Infuse isotonic crystalloid
- Top off tank
- Consider PASG
- Consider possible hypovolemia
- Consider vasopressors
83Vasogenic Shock
- Maintain body temperature
- Hypothermia may occur
84Vasogenic Shock
- Anaphylaxis
- Suppress inflammatory response
- Antihistamines
- Corticosteroids
- Oppose histamine response
- Epinephrine
- bronchospasm vasodilation
- Replace intravascular fluid
- Isotonic fluid titrated to BP 90 mm
85Pneumatic AntiShock Garment (PASG)
- Function
- Primary effect is increased PVR
- Hemorrhage control through
- Direct pressure
- Fracture stabilization
- Increased intra-abdominal pressure
- Little effect from autotransfusion
86Pneumatic AntiShock Garment
- Indications
- Multiple lower extremity fractures
- Pelvic fractures
- Abdominal injuries
- Abdominal aortic aneurysm
- Refractory decompensated shock
87Pneumatic Antishock Garment
- Contraindications
- Absolute
- Pulmonary edema
88Pneumatic Antishock Garment
- Contraindications
- Relative
- Closed head injury
- Thoracic hemorrhage
- Impaled object (abdomen, chest?)
- Pregnancy (abdominal section)
- Evisceration
- Ruptured diaphragm
- Cardiogenic shock
89Shock in Children
- Small blood volume
- Increased hypovolemia risk
- Very efficient compensatory mechanisms
- Failure may cause sudden shock
- Pallor, altered LOC, cool skin shock UPO
90Shock in Children
- Avoid massive fluid infusion
- Use 20 cc/kg boluses
- High surface to volume ratio
- Increased hypothermia risk
91Shock in the Elderly
- Poor cardiovascular condition
- Rapid decompensation
- Sepsis more likely
- Hypoperfusion can cause
- CVA
- AMI
- Seizures
- Bowel Infarctions
- Renal failure
92Shock in the Elderly
- Assessment more difficult
- Peripheral vascular disease
- Weak pulses
- Altered sensorium
- Hypertension masking hypoperfusion
- Beta-blockers masking hypoperfusion
- Fluid infusion may produce volume overload/CHF
93Shock in OB Patients
- Pulse increases 10 to 15 bpm
- BP lower than in non-pregnant patient
- Blood volume increased by 45
- Slower onset of shock signs/ symptoms
- Fluid resuscitation requires greater volume
94Shock in OB Patients
- Oxygen requirement increased 10 to 20
- Pregnant uterus may compress vena cava,
decreasing venous return to heart - Place women in late-term pregnancy on left-side
- Fetus can be in trouble even though mother looks
well-perfused
95Transport Considerations
- Indications for Rapid Transport
- Indications for Trauma Center Transport
- Considerations for Air Medical Transport