Bleeding Control and Shock Management

Hemorrhage

- External or internal loss of a large amount of blood in a short period

- Do not become distracted by ugly but non-life threatening bleeding

Bleeding Control

- MOI of the bleed, don't get hurt

- BSI gloves at minimum (eye protection, face shield, gown)

- Signs and symptoms of shock

Arterial Bleeding

- Bright red

- Spurting, pulsating

Venous Bleeding

- Darker red

- Flowing blood

Capillary Bleeding

- Medium red

- Oozing

Severity of Bleeding

- Volume loss and rate of bleeding (>15% leads to shock)

- Patient's state of health

- Age and size (Adult: 70ml/kg, Peds: 80ml/kg)

Determining Blood Loss

Assess mental status of patient (pulse, skin vitals, respiration, BP)

Control of External Hemorrhage

- Direct pressure (with gloved hand or sterile material)

- Elevate above the heart (preferably with pressure)

- If suspected fracture, don't elevate until splinted

Tourniquets

- Devices used to stop bleeding in an emergency

- Can be left on for 8-10 hours

Bleeding from Nose or Mouth

- Check airway patency - suction needed?

- If nose bleed: do not tip head back - aspiration/throw up blood

- Be in lateral recumbent, sit up/lean over to drain

Bleeding from Ear

- May be due to basilar skull fracture (CSF present)

- Use loose dressing, do not put pressure or block drainage - avoids brain bleed

- May have CSF

Bull's Eye Test

Drop of blood on gauze and see if yellow ring forms, if so basilar skull fracture - CSF travels faster than blood

Internal Bleeding

- MOI determines suspicion - think anatomy damages

- Observe for pain, tenderness, bruising, distended abdomen (enlarging belly), bleeding from GI or genitourinary, shock

- Initiate transport quickly if suspected

Signs of Shock

- Decreased blood pressure

- Rapid, weak pulse

- Mottled to gray, clammy, cold skin

- Change in mental status

Decreasing Clotting and Increasing Bleeding

- Coagulopathy

- Movement or removal of dressing

- Decrease in body temperature

Coagulopathy

Impaired clotting leading to continued bleeding

Body Temperature and Bleeding

- Normal body temp is 98.6

- Drop 1 degree below and clotting slows

- If patient is wet, increase losing heat due to evaporation

Ambulance on Scene for Cold Patient

- Close doors when patient is in trunk

- Turn on heat, if your not sweating patient is cold and bleeding

Non-Steroidal Anti-Inflammatory Drugs

- Provide mild pain relief

- Aspirin

- Ibuprofen

- Naproxen

Anti-Coagulant

Breaks up formation

Anti-Platelet

Stops clot formation

Most Common Anti-Platelet

Plavix (Clopidogrel)

Most Common Anti-Coagulants

- Coumadin (Warfarin)

- Heparin (Heparin)

- Eliquis (Apixaban)

- Xarelto (Rivaroxaban)

Hypovolemic Shock Hemorrhagic

- Shock resulting from external or internal bleeding

- Plasma/whole blood loss (RBC, platelets, plasma)

Hypovolemic Shock Non-hemorrhagic (Fluid Deplition)

- Vomiting, diarrhea, dehydration, burns

- Plasma lost but other components intact

- Losing fluids causes fluid to come out of vessels but leaves RBC/WBC

Cardiogenic Shock

- Shock caused by inadequate function of the heart, or pump failure

- Loss of cardiac contractility, reduced cardiac output

- Heart attack, disease, trauma, age, dysrhythmias

- Too fast: chambers can't fill; Too slow: can't maintain pressure

Disruptive Shock

- Septic shock, Neurogenic shock, Anaphylactic shock

- Loss of peripheral vascular resistance

- Blood volume/heart function remains

- Blood vessels dilate and become leaky

Neurogenic Shock

- Hypoperfusion due to nerve paralysis

- Spinal cord injuries resulting in the dilation of blood vessels

- Increases the volume of the circulatory system beyond the point where it can be filled (warm skin rather than cold)

Anaphylactic Shock

- Severe shock caused by an allergic reaction

- Decrease in venous return, poor distribution of blood

Septic Shock

- Shock caused by severe infection, usually a bacterial infection

- Decrease in venous return, poor distribution of blood

Phases of Shock

-Compensated

-Decompensated

-Irreversible

Compensated Shock

- Early stage of shock

- Body's mechanisms attempting to maintain perfusion (BP)

- Normotension despite other vital sign changes

- Stop bleeding, O2, give fluids, keep warm

Compensated Shock Signs

- Normotension despite other vital sign changes

- Increased cardiac output (increased heart rate/stroke volume

- Shift blood to vital areas (away from skin/muscles)

- EMT: Stop bleeding, O2, give fluids, keep warm

Sympathetic Nervous Stimulation in Shock

- Body goes into hyperdrive cranking out adrenaline hormones

- Epinephrine and Norepinephrine

Alpha Receptors

- EPI: Smooth muscle contraction

- NE: Smooth muscle contraction

- Vasoconstriction, inability to defecate/urinate

Beta Receptors

- NE: Heart and lungs

- Increase cardiac output

Antidiuretic Hormone

- Released during compensated shock

- Inhibits urine output

- Thirsty but not peeing

Glucagon

- Released during compensated shock

- Converts glycogen to glucose

- Need insulin to use

Decompensated Shock

- Compensatory mechanism no longer effective

- Ischemia (higher need for O2 than what body is bringing) of organs leading to decrease function

- Unresponsiveness

- Cadriovascular collapse

- No more glycogen, fluid too low, BP falls

Fall in Blood Pressure

Increase clotting

Irreversible Shock

- Organ failure

- Final stage of shock

- Wide spread formation of microemboli blocking capillaries throughout body

SAMPLE of Shock: History

- Trauma: immediate or past few days

- Medical: allergic reaction, fever, infection, vomiting/diarrhea

- Increased thirst

- Decrease urine output (apple juice color)

- Medication: Anti-Hypertensives or Diuretics

SAMPLE of Shock: Physical Exam

- Increase pulse but weak or loss in peripheral

- Altered mental status

- Cool, pale, moist, sweaty skin

- LAST CHANGE: decreasing BP - indicator of decompensation

Treating Shock

- High flow O2

- Assess ABC

- Maintain body heat

- Elevate legs to help with venous return, never above shoulders

- Do not give food or drink

- Request AEMT/Medic and notify hospital