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1
Bleeding and Shock
Pipes, pump, and fluid…really, it’s that simple!
2
The Second Rule of EMS….
…eventually the bleeding will stop!
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Cardiovascular System
Heart
Arteries
Veins
Capillaries
Blood
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Cardiovascular System
• Transports O2 and fuel to the cells, tissues, and organs.
• Removes CO2 and wastes from the cells for elimination from the body.
• Must be able to maintain sufficient flow through the capillary beds to meet the cell’s
O2 and fuel needs
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Bleeding
Internal External
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Internal BleedingTrauma
Clotting disordersRupture of blood vessels
Fractures (injury to nearby vessels)Can result in rapid progression to
hypovolemic shock & death!
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Internal Bleeding S/S Think about MOI or NOI!
Anxiety, restlessness, irritability
Pale, diaphoretic skin
Sustained tachycardia
Hypotension
Unstable vitals signs (postural changes)
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Internal Bleeding S/SVomiting bright red blood or coffee ground
materialBleeding form any body orifice
Dark, tarry stools (melena)Tender, rigid, or distended abdomen
Pain, discoloration, swelling, tenderness at injury site
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Managing Internal Bleeding
ABC’sHigh concentration oxygen
Assist ventilationsControl external bleeding
Stabilize fracturesRICE
Transport rapidly to appropriate facility
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External Bleeding
• Arterial Bleed – Bright red, spurting
• Venous Bleed– Dark red, steady flow
• Capillary Bleed– Dark red, oozing
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Control of External Bleeding
Direct Pressure:Gloved hand
OrDressing and bandage
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Control of External Bleeding
Elevation: Raise extremity
above the level of the heart
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Control of External Bleeding
Pressure Dressing:Use bandage to
secure dressing in place
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Arterial Pressure Points
• Upper extremity:
– Brachial
– Radial
• Lower extremity:
– Femoral
– Popliteal
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Tourniquets
Final resort when all else fails
Used for amputations
3-4” wide (blood pressure cuffs)
Write “TK” and time of application on forehead of patient
Notify other personnel
Once applied, DO NOT REMOVE
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Epistaxis (Nosebleed)
• Causes– Fractured skull– Facial injuries– Sinusitis, other
URIs– High BP– Clotting disorders– Digital insertion
(nose picking)
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Management of Epistaxis
Sit up, lean forward
Pinch nostrils together
Keep in sitting position
Keep quiet
Apply ice over nose (15 min)
Can result in life-threatening blood loss!
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SHOCKInadequate perfusion(blood flow)
leading to inadequate oxygen delivery to tissues
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Physiology
• Cell is the basic unit of life
• Cells get energy needed to stay alive by reacting oxygen with fuel (usually glucose)
• No oxygen, no energy
• No energy, no life
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Perfusion Failure
Pump Failure (heart)
Pipe Failure (vessels)
Loss of Volume (blood)
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Stages of Shock
Compensated Shock
Decompensated Shock
Irreversible Shock
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Compensated Shock
• Body still compensates for blood loss
• Pulse rate increases
• Pulse strength decreases
• Pale, diaphoretic skin
• Anxiety, restlessness, combativeness
• Thirst, weakness, eventual air hunger
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Decompensated Shock
• Body compensatory mechanisms fail
• Unpalpable pulse
• Precipitous drop in blood pressure
• Patient becomes unconscious
• Respirations slow or cease
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Irreversible Shock
• Lack of circulation causes:
– Cellular death
– Tissue dysfunction
– Organ dysfunction
– Patient death
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Shock: Etiology
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• Psychogenic
• Hypovolemic
• Distributive
• Obstructive
• Cardiogenic
• Respiratory
• Neurogenic
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Psychogenic Shock
• Simple fainting (syncope)
• Caused by stress, fright, pain
• Heart rate slows, vessels dilate
• Brain becomes hypo-perfused
• Loss of consciousness occurs
• Patient usually recovers by self
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Psychogenic Shock S/S
• Anxiety, restlessness, irritability
• Rapid pulse
• Normal or low blood pressure
• Hyperventialtion
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Hypovolemic Shock
• Loss of volume• Causes:
– Blood loss from trauma– Plasma loss from burns
– Fluid/electrolyte loss from vomiting, diarrhea, sweating, increased urine
output, increase respiratory loss– “Third space” fluid shifts
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Hypovolemic Shock S/S
• Anxiety, restlessness, irritability
• Rapid, weak pulse
• Change in mental status
• Signs of inadequate perfussion (diaphoresis, cyanosis, pale/clammy skin)
• Increased respiratory rate
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Distributive Shock: Septic
• Results from body’s response to bacteria in bloodstream
• Vessels dilate, become “leaky”
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Distributive Shock: Septic S/S
• Anxiety, restlessness, irritability
• Febrile, warm skin
• Hypotension
• Tachycardia
• Increased respiratory rate
• Change in mental status
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Distributive Shock: Anaphylactic
• Results from severe allergic reactions
• Body responds to allergen by releasing histamine
• Histamine release causes vessels to dilates and become “leaky
34
Distributive Shock:Anaphylactic S/S
• Sudden onset• Mild itching, rash, uticaria, hives
• Burning sensation (skin)• Hypotension
• Generalized edema• Angiodema, airway compromise
• Respiratory distress• Coma, rapid death
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Obstructive Shock
• Interference with blood flow through the cardiovascular system
• Tension pneumothorax
• Cardiac tamponade
• Pulmonary embolism
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Obstructive Shock S/S
• Anxiety, irritability, restlessness
• Weak, irregular pulse
• Chest pain, shortness of breath
• Hypotension
• Pale, cool, clammy skin
• JVD, discoloration above nipple line
37
Cardiogenic Shock
• Pump failure
• Heart’s output depends on
– How often it beats (heart rate)
– How hard it beats (contractility)
• Rate or contractility problems cause pump failure
38
Cardiogenic Shock S/S• Causes
– Acute myocardial infarction– Very low heart rates (bradycardias)– Very high heart rates (tachycardias)
Why would a high heart rate caused decreased output?
Hint: Think about when the heart fills.
39
Cardiogenic Shock S/S
• Chest pain
• Weak, irregular pulse
• Hypotension (HTN with CHF)
• Cyanosis, signs of inadequate perfusion
• Cool, clammy skin
• Anxiety
40
Respiratory Shock
• Failure of respiratory system to supply oxygen to or remove CO2 from the alveoli
• Airway obstruction
• Flail chest, SCW
• Pneumothorax
• Respiratory muscle paralysis
41
Respiratory Shock S/S
• Anxiety, restlessness, irritability
• Rapid, weak pulse
• Hypotension
• Change in mental status
• Signs of inadequate perfussion
• Increased respiratory rate
• Bronchoconstrcition (wheezes)
42
Neurogenic Shock
• Spinal cord injuries that result in the interruption of communication
pathways between CNS and rest of body
• Vessels below the injury site dilate leading to decreased vascular
resistance
43
Neurogenic Shock S/S
• Anxiety, restlessness, irritability
• Bradycardia
• Hypotension
• Skin above injury site: pale, cool, clammy
• Skin below injury site: warm, pink, dry
• Signs of spinal injury
44
Treatment• ABC’s
• Apply O2, assist ventilations as needed• Keep patient in position of comfort• Control bleeding, stabilize fractures
• Prevent loss of body heat• Assist with medications
• Nothing by mouth• Calm and reassure
45
Treatment
• Elevate lower extremities 8 to 12 inches in hypovolemic shock
• Do NOT elevate the lower extremities in cardiogenic shock
Why the difference in management?
46
Shock is NOT the same as low pressure
A falling blood pressure is a LATE sign of shock!
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