med surg

HAEMORRHAGE AND SHOCK

INTRODUCTION TO HAEMORRHAGE

  • Definition: Haemorrhage refers to the escape or loss of blood from the circulatory system due to rupture or damage to blood vessels.

  • Occurrence: It can be internal (within the body) or external (through a visible wound).

  • Significance: Haemorrhage is potentially life-threatening if not promptly managed.

DEFINITION OF HAEMORRHAGE

  • Hemorrhage: Defined as the loss of fresh blood from an artery, a vein, or a capillary; or simply bleeding. This can be evident (visible) or not seen (concealed).

  • Note: Haemorrhage is loss of blood from blood vessels through natural openings, injuries, or pathological conditions.

CAUSES OF HAEMORRHAGE

  • Trauma or injury: Includes accidents and cuts.

  • Surgical procedures: Can lead to unwanted bleeding.

  • Obstetric complications: Examples include postpartum haemorrhage.

  • Ruptured blood vessels: Pathological issues that cause vessel rupture.

  • Coagulation disorders: Conditions that impair normal blood clotting.

  • Diseases: Such as ulcers or cancers that can cause bleeding.

CLASSIFICATION OF HAEMORRHAGE
By Source

  • Arterial Haemorrhage: Characterized by bright red blood that spurts with each heartbeat.

  • Venous Haemorrhage: Dark red blood that flows steadily.

  • Capillary Haemorrhage: Slow, oozing blood from small vessels.

By Location

  • External Haemorrhage: Visible blood loss outside the body.

  • Internal Haemorrhage: Blood collects within body cavities (e.g., abdomen, chest).

  • Concealed Haemorrhage: Blood is not visible and accumulates within tissues.

By Timing (especially in obstetrics)

  • Primary Haemorrhage: Occurs immediately after injury or delivery.

  • Reactionary Haemorrhage: Occurs within the first 24 hours post-injury or delivery.

  • Secondary Haemorrhage: Occurs after the first 24 hours, lasting days or weeks.

Types/Classifications of Haemorrhage

  • Primary Haemorrhage: Bleeding within the first 24 hours of an operation or injury.

  • Secondary Haemorrhage: Occurs 24 hours after an operation due to unsecured tying, infection, or erosion by a drainage tube.

  • Reactionary Haemorrhage: Occurs during the first few hours post-operation due to normal fluctuation in blood pressure.

CLINICAL MANIFESTATION OF HAEMORRHAGE

  • Responses to Damaged Blood Vessels: The body attempts to control bleeding through:
      - Vasoconstriction: Narrowing of blood vessels.
      - Platelet Plug Formation: Initial hemostatic response.
      - Coagulation: Clotting cascade activated to form a stable clot.

  • Potential Outcomes: If bleeding is severe, may lead to hypovolemic shock, reduced tissue perfusion, and organ failure.

CLINICAL FEATURES OF HAEMORRHAGE

  • Depend on the amount of blood lost and the rate of escape:
      - Patient may appear apprehensive and restless.
      - Thirstiness, cold skin with a pale appearance.
      - Rapid pulse, falling temperature, rapid and deep (gasping) respirations.
      - If untreated, cardiac output declines, arterial and venous pressure drops, hemoglobin levels fall quickly; lips and conjunctiva become pale.

SIGNS AND SYMPTOMS OF HAEMORRHAGE

  • Visible bleeding: External sources of blood loss.

  • Internal Signs: Swelling or bruising.

  • Decreased Vitality: Weakness, dizziness, rapid pulse (tachycardia), and low blood pressure (hypotension).

  • Physical Indicators: Pale, cold, clammy skin, restlessness, or confusion.

MANAGEMENT OF HAEMORRHAGE

  • General Principles of Management:
      - Control bleeding through pressure, bandaging, or surgery if required.
      - Replace lost fluids (IV fluids, blood transfusion).
      - Treat the underlying cause and monitor vital signs closely.

  • Specific Management Steps Include:
      - Positioning patient in a shock position, administration of sedatives or analgesics as needed.
      - Inspect and manage visible wounds with sterile gauze and bandage.
      - Administer blood transfusions and IV fluids, particularly plasma expanders.
      - Restoration of blood supply and medications to support low blood pressure, possibly using mechanical aids for critical cases.

COMPLICATIONS OF HAEMORRHAGE

  • Consequences:
      - Hypovolemic shock
      - Anemia
      - Organ failure

INTRODUCTION TO SHOCK

Definition of Shock

  • Basic Definition: A life-threatening medical emergency characterized by inadequate tissue perfusion, insufficient delivery of oxygen and nutrients to the body's cells.

  • Consequences: Untreated shock can lead to organ failure and death.

CLASSIFICATIONS OF SHOCK
Haemorrhagic/Haematogenous/Oligaemic Shock

  • Description: Resulting from the loss of plasma or whole blood, can be external or internal.

  • Loss of more than 10% of blood volume leads to hypovolemia. Haemorrhage equates to a loss of circulating whole blood.

Bactraemic/Septic/Toxic Shock

  • Causes: Result from changes in the capillary endothelium leading to plasma loss into surrounding tissues through extravasation, without fluid volume loss from the body.

  • Examples include infections by E. coli or gas gangrene pathogens resulting in vasodilatation and BP drop.

Cardiogenic Shock

  • Mechanism: Occurs when there is inadequate heart pumping due to conditions like myocardial infarction or cardiac tamponade, leading to poor circulation.

Other Types of Shock

  • Burns Shock: Caused by rapid plasma loss from damaged tissues.

  • Dehydration/Diarrhoea/Vomiting Shock: Resulting from fluid loss outside the vascular system.

  • Pleural/Retroperitoneal/Mediastinal Shock: Due to sudden leakage of blood or secretions into these cavities.

  • Anaphylactic Shock: Follows allergic reactions, causing vasodilatation from histamine release leading to low blood pressure and systemic failure.

ALTERED PHYSIOLOGY OF SHOCK (PATHOPHYSIOLOGY)

  • Mechanism: Shock involves loss of blood from the vascular system, causing decreased cardiac output and low blood pressure, reducing tissue oxygenation.

  • Initial Response: Vasoconstriction aims to maintain blood pressure and oxygenation.
      - This may be reversible if treated on time (Reversible Shock), failing which tissue death occurs (Irreversible Shock).

CLINICAL MANIFESTATION OF SHOCK

  • Pallor: Due to circulatory blood loss leading to poor perfusion and stress-induced reactions.

  • Hyperventilation: Stress response causing breathing alkalosis followed by acidosis leading to discomfort.

  • Hormonal Changes: (Pituitary)
      - ACTH Release: Stimulates adrenal cortex, causing glycosuria or hyperglycaemia.
      - ADH Release: Encourages kidney water retention, leading to oliguria.
      - Aldosterone Release: Promotes retention of sodium leading to edema.

  • Physiological Responses:
      - Release of adrenaline/noradrenalin facilitates vital organ blood flow, reducing peripheral circulation, leading to cold, clammy skin.
      - Result of acidosis can lead to tachypnoea as the body tries to correct oxyenation issues.
      - Increased heart rate with decreased systolic blood pressure leading to further complications including cardiac arrest.

  • Secondary Symptoms:
      - Weak pulse, subnormal temperature, cyanosis of lips, dry mucous membranes, apprehension leading to lethargy.

PRINCIPLES OF MANAGEMENT OF SHOCK

  1. Identify and remove the cause of shock.

  2. Replace blood/fluids, specifically:
       - If due to hemorrhage, use blood products.
       - If due to burns, replace plasma, use dextran, and hemacell.

  3. Positioning: Elevate lower limbs at about 20°, keep knees and trunk horizontal, and head slightly elevated. Avoid overheating.

  4. Pain Relief: Administer prescribed medications (morphine/pethidine).

  5. Administer Vasoconstrictors: Early application is crucial to prevent organ damage.
       - Common drugs used include Methidine (15mg), Noradrenalin (4ml in normal saline), and Hydrocortisone (100mg intravenously).

OXYGEN THERAPY IN SHOCK

  • Usage: Oxygen therapy can be beneficial; conditions such as chest injuries, severe haemorrhage, gas gangrene, carbon monoxide poisoning, morphine intoxication, pulmonary edema, pneumonia, fat embolism, myocardial infarction, and pneumothorax may require treatment.

  • Delivery Method: Optimal delivery is through facemasks; flow rates of 4-6 liters/min are typical.

NURSING MANAGEMENT OF SHOCK

  1. Maintain airway patency; remove oral/tracheal secretions and implement resuscitation measures.

  2. Control Hemorrhage: If applicable, ensure appropriate positioning to promote physiological recovery:
       - While elevating head (with a pillow), ensure trunk is horizontal, elevate lower extremities.

  3. Avoid Trendelenburg Position: This may result in decreased brain blood supply due to compensatory mechanisms, causing respiratory difficulties.

  4. Consult medical officers for advanced venous return methods as needed.

FLUID AND ELECTROLYTE IMBALANCE

  • Fluid Shifts: Loss through hemorrhage and third-spacing results in significant fluid imbalances. Third-spacing refers to fluid accumulating in areas such as the bowel lumen, subcutaneous tissues, and peritoneal cavity, leading to pressure on organs and reduced cardiac output.

  • Surgical Patient Considerations: Patients may be volume-depleted before surgery due to conditions like pancreatitis or cholecystitis. Post-operative care usually requires careful fluid management to avoid resuscitation feedback loops.

FLUID AND ELECTROLYTE REPLACEMENT

  • Resuscitation Phase: This initiates rapid fluid replacement to stabilize hemodynamics and replenish intravascular volume, crucial in trauma, shock, and burns management.

  • Types of Fluids:
      - Crystalloids: Fluids with high distribution volumes mainly containing water and electrolytes.
      - Colloids: Specialized fluids used in fluid resuscitation.

ANAPHYLACTIC SHOCK

  • Mechanism: Excessive immune response to allergens leading to multi-organ effects due to compromised blood supply and oxygenation.

  • Common Causes: Allergic reactions to foods, antibiotics, insect stings, etc.

SYMPTOMS OF SHOCK

  • Vital Signs: Initially, the body compensates by redistributing fluids, evidenced by tachycardia and increased heart rate.

  • As compensation fails, breathing rates and pulse worsen, with significant hypotension, indicating critical state issues.

BODY FUNCTION IMPACTED BY SHOCK

  • Oxygen Deprivation: Affects all organ functions leading to confusion, chest pain, kidney failure, and overall organ distress. Skin can become clammy and pale.

MEDICAL TREATMENT OF SHOCK

  • Initial Assessment: Focus on Airway, Breathing, and Circulation (the ABCs).

  • Control Obvious Bleeding: Direct pressure to manage bleeding effectively.

  • Emergency Treatment: Diagnosis and intervention concurrency with oxygen supplementation and IV fluid-drug administration to bolster blood pressure and circulatory response.

FOLLOW-UP CARE FOR SHOCK

  • Critical Care Admission: Intensive care is necessary for patients in shock, involving multi-disciplinary teams (nurses, respiratory therapists, pharmacists).

  • Infection Risk Management: Vigilance is crucial in preventing nosocomial infections during prolonged hospital stays.

  • The extent of organ damage often correlates with shock duration, impacting recovery.

POTENTIAL LONG-TERM EFFECTS

  • Organ Damage: May include irreversible impacts leading to brain injuries, heart and lung complications, and potential renal failure necessitating dialysis.

CONCLUSION

  • Extended rehabilitation may be needed for full recovery from shock, with specialists involved in the patient's ongoing care as they recover and regain function across affected organ systems.

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