Introduction to Hemorrhage and Shock Hemorrhage Abnormal internal

Introduction to Hemorrhage and Shock Hemorrhage – Abnormal internal or external loss of blood Homeostasis – Tendency of the body to maintain a steady and normal internal environment Shock – INADEQUATE TISSUE PERFUSION – Transition between homeostasis and death Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hemorrhage Circulatory System Hemorrhage Classification Clotting Factors Affecting Clotting Hemorrhage Control Stages of Hemorrhage Assessment Hemorrhage Management Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Heart Cardiac Cycle – The repetitive pumping action that produces pressure changes that circulate blood throughout the body Cardiac Output – The total amount of blood separately pumped by each ventricle per minute, usually expressed in liters per minute Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Cardiac Output Normal cardiac output = 5 to 6 liters per minute (LPM). Can increase up to 30 LPM in times of stress or exercise. Determined by multiplying the heart rate by the volume of blood ejected by each ventricle during each beat (stroke volume). CO is influenced by: – Strength of contraction – Rate of contraction – Amount of venous return available to the ventricle (preload) Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Circulatory System (1 of 4) Heart – Autonomic nervous system Parasympathetic nervous system Slows rate Mediated by vagus nerve Sympathetic nervous system Increases rate Cardiac plexus Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Circulatory System Key Terms Stroke Volume Preload Ventricular Filling Starling’s Law of the heart Afterload (End Diastolic Pressure or EDP) Cardiac Output – SV x HR – 5 liters/minute Fick Principle Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Circulation Systolic Pressure – Strength and volume of cardiac output Diastolic Pressure – More indicative of the state of constriction of the arterioles Mean Arterial Pressure – 1/3 pulse pressure added to the diastolic pressure – Tissue perfusion pressure Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Circulation (2 of 2) Vascular Control – Increased sympathetic tone results in increased vasoconstriction. Microcirculation – Blood flow in the arterioles, capillaries, and venules. – Sphincter functioning. Most organ tissue requires blood flow 5 to 20% of the time. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Cardiac Physiology (1 of 2) Oxygen Supply – The myocardium receives its blood/oxygen supply during the diastole phase of contraction. The blood flows from the aorta through the two coronaries into the relaxed myocardium. Oxygen Demand – 90% of the O 2 demand, or work, of the heart is performed during the isovolumetric phase of contraction. In this phase, NO blood flows from the heart into the aorta, until the pressure in the heart is greater than the end diastolic pressure (EDP). Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Cardiac Physiology (2 of 2) Releases a polypeptide called atrial natriuretic peptide (ANP) Works antagonistically to renin-angiotensin Four Effects – Promotes Na+ and water loss at the kidneys – Inhibits renin release and ADH, aldosterone secretion – Suppresses thirst – Blocks action of angiotensin II and norepinephrine Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Negative Feedback Important negative feedback mechanisms in maintaining tissue perfusion are the: – Baroreceptor reflexes – Central nervous system ischemia responses – Hormonal mechanisms – Reabsorption of tissue fluids Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Cardiovascular System Regulation (1 of 3) PNS and SNS always act in balance Baroreceptors: monitor BP Chemoreceptors Hormone regulation Reabsorption of tissue fluids Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Cardiovascular System Regulation (2 of 3) Parasympathetic Nervous System Decrease – Heart rate – Strength of contractions – Blood pressure Increase – Digestive system – Kidneys Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Cardiovascular System Regulation (3 of 3) Sympathetic Nervous System Increase – – Body activity Heart rate Strength of contractions Vascular constriction Bowel and digestive viscera Decreased urine production – Respirations – Bronchodilation Increases skeletal muscle perfusion Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Baroreceptor Reflexes (1 of 5) High in the neck, each carotid artery divides into external and internal carotid arteries. – At the bifurcation, the wall of the artery is thin and contains many vine-like nerve endings. The small portion of the artery is the carotid sinus. – Nerve endings in this area are sensitive to stretch or distortion. Serve as pressure receptors or baroreceptors. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Baroreceptor Reflexes (2 of 5) Similar area found in the arch of the aorta. – Serves as a second important baroreceptor Large arteries, large veins, and the wall of the myocardium also contain less important baroreceptors. Baroreceptor reflexes help maintain blood pressure by two negative feedback mechanisms: – By lowering blood pressure in response to increased arterial pressure – By increasing blood pressure in response to decreased arterial pressure Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Baroreceptor Reflexes (3 of 5) Normal blood pressure partially stretches the arterial walls so that baroreceptors produce a constant, low-frequency stimulation. Impulses from the baroreceptors inhibit the vasoconstrictor center of the medulla and excite the vagal center when blood pressure increases. – Results in vasodilation in the peripheral circulatory system and a decrease in the heart rate and force of contraction. Combined effect is a decrease in arterial pressure. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Baroreceptor Reflexes (5 of 5) When baroreceptor stimulation ceases due to a fall in arterial pressure, several cardiovascular responses are evoked: – Vagal stimulation is reduced and sympathetic response is increased. – The increase in sympathetic impulses results in increased peripheral resistance and an increase in heart rate and stroke volume. Sympathetic discharges also produce generalized arteriolar vasoconstriction, which decreases the container size. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Chemoreceptor Reflexes Chemoreceptors – Monitor level of CO 2 in CSF – Monitor level of O 2 in blood Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Chemoreceptor Physiology Low arterial pressure leads to hypoxemia and/or acidosis. Hypoxemia/acidosis stimulate peripheral chemoreceptor cells within the carotid and aortic bodies. – These bodies have an abundant blood supply. When oxygen or p. H decreases, these cells stimulate the vasomotor center of the medulla. – The rate and depth of ventilation are also increased to help eliminate excess carbon dioxide and maintain acid-base balance. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

CV System and Hormone Regulation (1 of 7) Catecholamines – Epinephrine – Norepinephrine – Actions Alpha 1 Alpha 2 Beta 1 Beta 2 Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

CV System and Hormone Regulation (2 of 7) Alpha 1 – Vasoconstriction – Increased peripheral vascular resistance – Increased preload Alpha 2 – Regulates release of NE Beta 1 – Positive inotropy – Positive chronotropy – Positive dromotropy Beta 2 – Bronchodilation – Smooth muscle dilation in bowel Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

CV System and Hormone Regulation (3 of 7) Antidiuretic Hormone (ADH) – AKA: Arginine Vasopressin (AVP) – Released Posterior pituitary Drop in BP or increase in serum osmolarity – Action Increase in peripheral vascular resistance Increase water retention by kidneys Decrease urine output Splenic vasoconstriction 200 m. L of free blood to circulation Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

CV System and Hormone Regulation (4 of 7) Angiotensin II – Released Primary chemical from kidneys Lowered BP and decreased perfusion – Action Converted from renin into angiotensin I Modified in lungs to angiotensin II 20 -minute process Potent systemic vasoconstrictor 1 -hour duration Causes release of ADH, aldosterone, and epinephrine Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

CV System and Hormone Regulation (5 of 7) Aldosterone – Release Adrenal cortex Stimulated by angiotensin II – Action Maintain kidney ion balance Retention of sodium and water Reduce insensible fluid loss Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

CV System and Hormone Regulation (6 of 7) Glucagon – Release Alpha cells of pancreas Triggered by epinephrine – Action Causes liver and skeletal muscles to convert glycogen into glucose Gluconeogenesis Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

CV System and Hormone Regulation (7 of 7) Insulin – Release Beta cells of pancreas – Action Facilitates transport of glucose across cell membrane Erythropoietin – Release Kidneys Hypoperfusion or hypoxia – Action Increases production and maturation of RBCs in the bone marrow Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Reabsorption of Tissue Fluids (1 of 2) Arterial hypotension, arteriolar constriction, and reduced venous pressure during hypovolemia lower the blood pressure in the capillaries (hydrostatic pressure). The decrease promotes reabsorption of interstitial fluid into the vascular compartment. – Considerable quantities of fluid may be drawn into the circulation during hemorrhage. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Reabsorption of Tissue Fluids (2 of 2) Approximately 0. 25 m. L/min/kg of body weight (1 L/hr in the adult male) can be autotransfused from the interstitial spaces after acute blood loss. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Vasculature Lined with smooth muscle. All vessels larger than capillaries have layers of tissues (tunicae). Maintains blood flow by changes in pressure and peripheral vascular resistance. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Peripheral Vascular Resistance (Afterload) The total resistance against which blood must be pumped. It is essentially a measure of friction between the vessel walls and fluid, and between the molecules within the fluid itself (viscosity). – Both oppose flow. When resistance to flow increases, blood pressure must increase for the flow to remain constant. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Starling’s Law of the Heart When the rate at which blood flows into the heart from the veins (venous return) changes, the heart automatically adjusts its output to match inflow. The more blood the heart receives the more it pumps… Increased end diastolic volume increases contractility. Increases stroke volume. – Increases cardiac output. Starling curves at any end-diastolic volume. Increased sympathetic input increases stroke volume. Decreased sympathetic input decreases stroke volume. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Resistance to Blood Flow Increases with… Increased fluid viscosity Increased vessel length Decreased vessel diameter Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Blood Flow Resistance (2 of 2) Arterioles have a much smaller diameter and offer the major resistance to blood flow. – Smooth muscles in the arteriole walls can relax or contract. – Can change the diameter of the vessel as much as fivefold. – Arterial blood pressure is regulated primarily by the vasoconstriction or vasodilation of these vessels. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Microcirculation (2 of 3) Venules and veins serve as collecting channels and storage vessels (capacitance). Normally contain 70% of the blood volume. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Microcirculation (3 of 3) Bledsoe et al. , Paramedic Care Principles & Practice Volume

Mechanisms That Control Blood Flow Local control of blood flow by the tissues Nervous control of blood flow Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Local Control Blood usually flows through capillaries intermittently due to: – The pulsatile manner of blood flow resulting from cardiac pumping action and vasomotion – The intermittent constriction and dilation of arterioles and precapillary sphincters Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Vasomotion (1 of 3) Regulated primarily by the concentration of oxygen in the tissues. When oxygen concentration is low, the cells lining and adjacent to the closed capillaries secrete histamine, which is thought to be responsible for arteriolar smooth muscle vasodilation, causing the capillary to open. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Vasomotion (2 of 3) Histamine is quickly destroyed in the blood and does not enter the general circulation. As cells become reoxygenated they stop the histamine secretion, and the capillary closes. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Vasomotion (3 of 3) A decrease in oxygen concentration leads to a local release of vasodilating substances, which allows blood flow to increase. – This in turn increases the delivery of oxygen and restores aerobic metabolism. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

CNS Ischemia Response CNS ischemia response is activated when blood flow to the vasomotor center of the medulla is decreased. – In the presence of ischemia, the neurons within the medulla stimulate the sympathetic nervous system. Sympathetic vasoconstriction can elevate arterial pressure for as long as 10 minutes. The cerebral ischemia response functions only in emergency situations. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Blood Components (2 of 2) Bledsoe et al. , Paramedic Care Principles & Practice

Clotting (1 of 2) Three-Step Process – Vascular phase Vasoconstriction – Platelet phase Tunica intima damaged Turbulent blood flow Frictional damage to platelets Agglutination and aggregation – Coagulation Release of enzymes Extrinsic – nearby tissue Intrinsic – damaged platelets Fibrin release Normal coagulation in 7– 10 minutes Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Clotting (2 of 2) Bledsoe et al. , Paramedic Care Principles & Practice Volume

Factors Affecting Clotting (1 of 2) Movement of the wound site Aggressive fluid therapy – Increased BP and displaced clots – Dilution of clotting factors Low body temperature – Ineffective clot formation Medications – ASA, heparin, Ticlid, warfarin (Coumadin) Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Factors Affecting Clotting (2 of 2) Nature of the wound – Transverse (clean tear) Vessels constrict and draw inward Reduction of the lumen Reduction of blood loss – Longitudinal (crush injury) Constriction of the smooth muscle Enlarges the wound Increases blood loss Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Stages of Shock Cellular Level Bledsoe et al. , Paramedic Care Principles & Practice

Four Stages Stage 1: Vasoconstriction Stage 2: Capillary and venule opening Stage 3: Disseminated intravascular coagulation Stage 4: Multiple organ failure Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Shock and Hemorrhage Bledsoe et al. , Paramedic Care Principles & Practice Volume 4:

Defining Shock (1 of 2) Shock is best defined as inadequate tissue perfusion. – Can result from a variety of disease states and injuries. – Can affect the entire organism, or it can occur at a tissue or cellular level. “The rude unhinging of the machinery of Life” Gross, 1877 Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Defining Shock (2 of 2) Shock is not adequately defined by: – – – Pulse rate Blood pressure Cardiac function Hypovolemia Loss of systemic vascular resistance Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hemorrhage Classification Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma

External Hemorrhage Results from soft tissue injury. Accounts for nearly 10 million emergency department visits in the United States each year. Most soft tissue trauma is accompanied by mild hemorrhage and is not life threatening. – Can carry significant risks of patient morbidity and disfigurement The seriousness of the injury is dependent on: – – – Anatomical source of the hemorrhage (arterial, venous, capillary) Degree of vascular disruption Amount of blood loss that can be tolerated by the patient Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Internal Hemorrhage (1 of 2) Can result from: – Blunt or penetrating trauma – Acute or chronic medical illnesses Internal bleeding that can cause hemodynamic instability usually occurs in one of four body cavities: – – Chest Abdomen Pelvis Retroperitoneum Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Internal Hemorrhage (2 of 2) Signs and symptoms that may suggest significant internal hemorrhage include: – Bright red blood from mouth, rectum, or other orifice – Coffee-ground appearance of vomitus – Melena (black, tarry stools) – Dizziness or syncope on sitting or standing – Orthostatic hypotension Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Physiological Response to Hemorrhage The body’s initial response to hemorrhage is to stop bleeding by chemical means (hemostasis). – This vascular reaction involves: Local vasoconstriction Formation of a platelet plug Coagulation Growth of tissue into the blood clot that permanently closes and seals the injured vessel Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hemorrhage Control External Hemorrhage – Direct pressure and pressure dressing – General Management Direct pressure Elevation Ice Pressure points Constricting band Tourniquet May use a BP cuff by inflating the cuff 20– 30 mm. Hg above the SBP Release may send toxins to heart Lactic acid and electrolytes Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Tourniquets are ONLY used as a last resort! OR ARE THEY? Bledsoe et al.

Internal Hemorrhage Control Hematoma – Epistaxis: Nose Bleed Causes: trauma, hypertension Treatment: lean forward, pinch nostrils – Pocket of blood between muscle and fascia UNEXPLAINED SHOCK is BEST attributed to abdominal trauma General Management – Immobilization, stabilization, elevation – – – Hemoptysis Esophageal Varices Melena Diverticulosis Chronic Hemorrhage Anemia Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Stages of Hemorrhage 60% of body weight is fluid. – 7% circulating blood volume (CBV) in men 5 L (10 units) – 6. 5% CBV in women 4. 6 L (9– 10 units) Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Stages of Hemorrhage Stage 1 15% loss of CBV – 70 kg pt = 500– 750 m. L Compensation – – Vasoconstriction Normal BP, pulse pressure, respirations Slight elevation of pulse Release of catecholamines Epinephrine Norepinephrine Anxiety, slightly pale and clammy skin Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Stages of Hemorrhage Stage 2 (1 of 2) 15– 25% loss of CBV – 750– 1250 m. L Early decompensation – Unable to maintain BP – Tachycardia and tachypnea Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Stages of Hemorrhage Stage 2 (2 of 2) Decreased pulse strength Narrowing pulse pressure Significant catecholamine release – – Increase PVR Cool, clammy skin and thirst Increased anxiety and agitation Normal renal output Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Stages of Hemorrhage Stage 3 (1 of 2) 25– 35% loss of CBV – 1250– 1750 m. L Late decompensation (early irreversible) – Compensatory mechanisms unable to cope with loss of blood volume Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Stages of Hemorrhage Stage 3 (2 of 2) Classic Shock – Weak, thready, rapid pulse Narrowing pulse pressure – – Tachypnea Anxiety, restlessness Decreased LOC and AMS Pale, cool, and clammy skin Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Stages of Hemorrhage Stage 4 >35% CBV loss – >1750 m. L Irreversible – – – Pulse: Barely palpable Respiration: Rapid, shallow, and ineffective LOC: Lethargic, confused, unresponsive GU: Ceases Skin: Cool, clammy, and very pale Unlikely survival Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Stages of Hemorrhage Concomitant Factors (1 of 2) Pre-existing condition Rate of blood loss Patient Types – Pregnant >50% greater blood volume than normal Fetal circulation impaired when mother compensating – Athletes Greater fluid and cardiac capacity – Obese CBV is based on IDEAL weight (less CBV) Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Stages of Hemorrhage Concomitant Factors (2 of 2) Children – CBV 8– 9% of body weight – Poor compensatory mechanisms – TREAT AGGRESIVELY! Elderly – Decreased CBV – Medications BP Anticoagulants Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hemorrhage Assessment (1 of 5) Scene Size-up – Is it safe? BSI Blood loss? Estimate? Law enforcement – Mechanism of Injury/Nature of Illness Should only be used in conjunction with vital signs and other clinical signs of injury to determine the probability of injury – Number of Patients – Need for Additional Resources Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hemorrhage Assessment (2 of 5) Initial Assessment – General Impression Obvious Bleeding – Mental Status – CABC – Interventions Manage as you go O 2 Bleeding control Shock BLS before ALS! Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

$Hemorrhage Assessment (4 of 5) Fractures and Blood Loss Pelvic fracture: Femur fracture: Tibia/fibula$

Hemorrhage Assessment (4 of 5) Fractures and Blood Loss Pelvic fracture: Femur fracture: Tibia/fibula fracture: Hematomas and contusions: 2, 000 m. L 1, 500 m. L 500– 750 m. L 500 m. L Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Shock Management Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma

Specific Wound Considerations (1 of 2) Head Wounds Neck Wounds – Presentation Severe bleeding Skull fracture – Management Gentle direct pressure Fluid drainage from ears and nose Large vessel can entrap air – Management Consider direct digital pressure Occlusive dressing DO NOT pack Cover and bandage loosely Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Specific Wound Considerations (2 of 2) Gaping Wounds – Presentation Multiple sites Gaping prevents uniform pressure – Management Bulky dressing Trauma dressing Sterile, nonadherent surface to wound Compression dressing Crush Injury – Presentation Difficult to locate source of bleeding Normal hemorrhage control mechanism non-functional – Management Consider an airsplint and pressure dressing Consider tourniquet Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Transport Considerations Consider rapid transport: – Suspected serious blood loss – Suspected serious internal bleeding – Decompensating shock AMS, pulse, narrowing pulse pressure – WHEN IN DOUBT, TRANSPORT. Other Considerations – Sympathetic response – Anxiety Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Shock Management (1 of 2) Airway and Breathing – – – NRB PPV (overdrive respiration) ET CPAP PEEP Hemorrhage Control Fluid Resuscitation – – – Any injury to the head or torso is ALSO considered an injury to the spine. Catheter size and length Large bore 20 m. L/kg of NS or LR Polyhemoglobins STABILIZE VITALS to SBP of 80 mm. Hg or 90 mm. Hg in head injuries. Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Shock Management (2 of 2) Temperature Control – Conserve core temperature – Warm IV fluids PASG – Action Increase PVR Reduce vascular volume Increase central CBV Immobilize lower extremities – Assess Pulmonary edema Pregnancy Vital signs Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Shock Management Permissive Hypotension – Traditional-establishing large-bore IVs (preferably bilaterally) and then rapidly infuse crystalloids. – Formula-use the systolic blood pressure (SBP), heart rate (HR) or both. Abnormal , use IV crystalloids, bring measurement back to an expected number. – The question should be: What is the best resuscitation strategy to keep the victim alive until hemostasis can be achieved? – SBP measurement – Two Studies JAMA-MAP of 50 Hypo. RESUS-Systolic of 70 with 250 bolus Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Shock Management TXA – – – Tranexamic Acid Anti-Clot buster CRASH 2 (piggyback)/ MATTERs (SIVP) Caution Class I recommendation in the U. S. military’s Tactical Combat Casualty Care guidelines Bledsoe et al. , Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ