Chapter 26 Bleeding and Shock - Triton College · PDF fileChapter 26 Bleeding and Shock. ... distribution of blood Components ... Controls life-threatening bleeding Commonly used in

Limmer et al., Emergency Care, 11th Edition

© 2009 by Pearson Education, Inc., Upper Saddle River, NJ

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Chapter 26

Bleeding 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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*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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*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 vesselsArteries

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

– Carry deoxygenated blood back to the heart

– Less pressure than blood in an artery



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Circulatory System

Perfusion

• Adequate circulation of blood throughout the body

Hypoperfusion

• Inadequate perfusion of the body’s tissues and organs



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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 Assessment—Bleeding

Estimate amount of external blood

loss

Triage (prioritize)

Predict potential shock

Control external bleeding



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Patient Care—External Bleeding

Control bleeding.

Ventilate if necessary.

Monitor respirations.

Open airway.

Standard precautions.



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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

Don’t remove

dressing



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Elevation

Used at the same time as

direct pressure

Above the level of the

heart

Gravity helps

Slows bleeding

Do not use with 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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Tourniquet—Use

Extremity injuries only

Once applied, do not remove or loosen.

Material

– 4 inches wide

– 6–8 layers thick

– Cravats frequently used

– Never use narrow material

Commercial tourniquets are available.



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Tourniquet—Application

Contact Medical Direction

B/P cuff may be used

Attach notation to patient

Tighten tourniquet

Select site

BP cuff may be used



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Tourniquet—Effectiveness

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 points—brachial

Pressure points—femoral



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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 in lower extremities

Never inflate just abdominal section

Follow local protocol



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Special Situations

Head injuries– Fracture skull

– Bleeding or loss of CSF from ears or nose

– Do not attempt to stop bleeding

Nose bleed– Epistaxis

– Direct trauma

– Increased blood pressure

– Patients at risk



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Controlling Nosebleeds

Position patient on side if unconscious

Do not let patient lean back

Keep patient quiet and calm

Apply or instruct patient to apply direct pressure

Have patient sit down and lean forward



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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 Care—Internal Bleeding

Prompt transport

Control external bleeding

Administer high flow oxygen via NRB

Maintain ABCs

Administer high-concentration oxygen via NRB



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Shock (Hypoperfusion)

Inadequate perfusion of cells with oxygen and

nutrients

Inadequate removal of

metabolic waste products



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The Effects of Shock

Click here to view an animation on the effects of shock.

media/10shockS_revised.htm



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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

Early

• The body shunts blood away from areas of lesser need to areas of greater need

Late

• Reduced perfusion results in malfunction of cells and organs

• Not recognized nor treated, death may result

• Reduced perfusion

results in malfunction

of cells and organs

• If not recognized or

treated, death may

result

• The body shunts

blood away from

areas of lesser need

to areas of greater

need



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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

Every minute between the time of injury and the patient getting to an operating suite is, in fact, like gold to the patient

Transport (intervention).

Oxygenation.

Maintain airway.



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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

Fingernails 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 patient’s condition

Unstable—vital signs taken every 5

minutes



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Normal, Shock, or Excited?

On -Scene

Pulse

96 Weak/regular

Respirations 8

Shallow

Skin Cool/moist

BP 90/60

5 Minutes

Pulse

100 Weak/regular

Respirations 10

Shallow

Skin Cool/moist

B/P 82/56

10 Minutes

Pulse

112 Weak/regular

Respirations 6

Shallow

Skin Cool/moist

B/P 74/50

(cont.)



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On-Scene

Pulse

68 Strong/regular

Respirations 12

B/P 110/62

Skin

Warm/dry

5 Minutes

Pulse

62

Strong/regular

Respirations

10

B/P 108/60

Skin

Warm/dry

10 Minutes

Pulse

62

Strong/regular

Respirations

12

B/P 118/60

Skin

Warm/dry

(cont.)



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On-Scene

Pules

124 Strong/regular

Respirations 24

BP 144/84

Skin

Cool/dry

5 Minutes

Pulse

120 Strong/regular

Respirations 22

B/P 122/82

Skin

Warm/dry

10 Minutes

Pulse

92 Strong/regular

Respirations 16

B/P 136/78

Skin

Warm/dry

(cont.)



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On Scene

Pulse

66 Strong/regular

Respirations

12

B/P 142/86

Skin Cool/dry

5 Minutes

Pulse

78 Strong/regular

Respirations

12

B/P 132/78

Skin Cool/dry

10 Minutes

Pulse

92

Regular

Respirations

18

B/P 120/70

Skin Cool/moist



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Patient Care

Reassure patient.

Transport.

Prevent heat loss.

Splint bone injuries or joints.

Elevate legs 8-12 inches (no spine injury).

Apply and inflate PASG.

Control external bleeding.

Maintain open airway & assess respiratory rate.

Standard Precautions.



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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

4. List the signs and symptoms of

shock. Which would you expect to

see early? Which are late signs?

Explain what causes each of them.

5. List the three major types of shock

and what causes each one.

(cont.)



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Review Questions

6. List the emergency care steps for

treating a patient in shock.

7. 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

Documents

Chapter 26 Bleeding and Shock - Triton College · PDF fileChapter 26 Bleeding and Shock. ... distribution of blood Components ... Controls life-threatening bleeding Commonly used in