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					Bleeding & Shock
           DOT Lesson 5-1

Phoenix College EMT/Fire Science Dept
                                        Perfusion
                Circulation of blood to meet cellular
                metabolic needs
                       Oxygen & nutrient delivery
                       CO2 & waste removal
                Requires perfusion triad (circulatory system)
                       Heart (Pump)
                       Vessel (Pipes)
                       Fluid (blood)
                Triad changes with metabolic need
                       Heart pumps faster/slower
                       Vessels change size to redirect blood flow

DOT Objective: 5-1.1
                          Heart (Pump) Review
                       Right Side Pump




                                         Left Side Pump




DOT Objective: 5-1.1
                             Vessel (Pipes) Review
                  Arteries
                       Elastic
                       High volume
                  Arterioles
                       Smooth muscle
                       Local supply
                  Capillaries
                       Sphincters direct flow
                       Cellular respiration
                  Venules
                       Low pressure
                  Veins
                       One way valves

DOT Objective: 5-1.1
                              Blood (Fluid) Review
                  Erythrocyte
                       RBC
                       Hemoglobin
                       Oxygen
                  Leukocyte
                       WBC
                       Immune System
                  Platelets
                       Clotting factor
                  Plasma
                       Water
                       Protein
                       Blood products

DOT Objective: 5-1.1
                                        Shock
                Inadequate cellular perfusion resulting
                in organ system failure
                Disruption of the perfusion triad
                       Heart (pump) failure
                       Vessel (pipe/container) failure
                       Blood (fluid/contents) failure
                       Hypoxia



DOT Objective: 5-1.9
        Progression of Shock
Compensated shock
  Body adapting to early shock
    Autonomic nervous system stimulation
    Heart rate increases
    Respiration increases
    Peripheral vasoconstriction reroutes blood
Decompensated shock
  Adaptive mechanisms break down
    Loss of vasculature tone
    Capillary sphincters relax
    BLOOD PRESSURE DROPS
Irreversible shock
  Death at cellular level
  Capillary blood flow blocked by clots
                        Shock Signs & Symptoms
                Mental                         Other
                       Restlessness            signs/symptoms
                       Anxiety                   Nausea/vomiting
                       Altered mental status     Thirsty
                       Feeling of doom           Air hungry/SOB
                Vital signs                    Late
                       Increased pulse rate    signs/symptoms
                       Weak pulses               Labored/irregular
                       Increased respiration     breathing
                       Pale/cool/clammy          Ashen/mottled
                       Delayed cap refill        Dilated pupils
                                                 BP DROPS
DOT Objective: 5-1.9
                                   Shock Treatment
                 BSI
                 Airway
                 Insure adequate oxygen/ventilation
                 Stop the bleeding
                 Elevate legs 8 – 12 inches
                         Trauma: lift foot end of backboard, keep pt supine
                 Splint bone/joint injuries
                 Prevent body heat loss
                 Rapid transport


DOT Objective: 5-1.10, 5-1.16
            Pediatric Note
Infant/children maintain blood pressure
until over half of blood is lost
Perfusion gauge
  Level of consciousness
  Capillary refill
  Skin color
Infants/children have less blood
  150-200cc loss out of 800cc is serious
      Fluid/Content Failure
Bleeding
 Hypovolemic (hemorrhagic) shock
 20% blood loss causes problems
 5 – 6 liters of blood in an adult
   1 liter loss can trigger decompensated shock
 Rapid blood loss overcomes the bodies
 adaptive mechanisms
 Internal or external
                                Internal Bleeding
                Not always apparent
                Suspicion based upon history/physical
                Significant Mechanism of Injury
                       Fall
                       High speed car/motorcycle accident
                       Car vs. pedestrian/bike
                       Penetrating injuries
                Nature of illness
                       GI Bleeding
                       Aortic aneurism
DOT Objective: 5-1.6
                                 Internal Bleeding
                Abdominal organs
                       Liver
                       Spleen
                       Kidney
                Bones
                       Femur
                       Multiple fractures
                Chest
                       Torn great vessels
                       Hemothorax

DOT Objective: 5-1.6
                               Internal Bleeding S/S
                 Trauma                    Medical
                          Pain               Vomiting blood
                          Tenderness         Melena
                          Bruising           Rectal bleeding
                          Guarding
                                             Coughing blood
                          Abd firmness
                                             Vaginal bleeding
                          Abd distension
                          Crepitus
                          Deformity        Med/Trauma
                          Absent breath      Signs/symptoms of
                          sounds on-side     shock

DOT Objective: 5-1.6, 5-1.7
                               Treating Internal Bleeding
                 BSI
                 Airway
                 Insure adequate oxygen/ventilation
                 Splint fractures
                 Elevate legs 8 – 12 inches
                         Trauma: lift foot end of backboard, keep pt supine
                 Prevent body heat loss
                 Rapid transport
                         Only surgeon can stop internal bleeding
                         60 minutes injury to OR

DOT Objective: 5-1.8, 5-1.15
                                External Bleeding
                Arterial
                       Bright red
                       High pressure spurting
                       Harder to control
                Venous
                       Darker red
                       Flows as steady stream
                       Easier to control due to lower pressure
                Capillary
                       Oozing of darker blood
                       Clots spontaneously

DOT Objective: 5-1.2
                                       Bleeding Control
                 BSI
                 Airway/oxygen/ventilation
                 Control bleeding
                          Finger tip pressure to point of bleeding
                          Elevate extremity while applying pressure
                          Pack large gaping wounds with sterile gauze and
                          apply pressure with hand
                          Wrap in pressure dressing and continue manual
                          pressure is needed
                          Use pressure points
                              Point where pulse can be felt
DOT Objective: 5-1.3, 5-1.4
                                               Bleeding Control




     Direct pressure with                        Wrapping of pressure   Continued elevation
     gloved hand and                             bandage around         of extremity
     dressing.                                   dressing
                                                                        Pressure point used
     Elevation of                                Pulse/Cap Refill       to slow down blood
     extremity                                   should be present      flow allowing clotting
                                                 after pressure
                                                                        Additional pressure
                                                 bandage applied
                                                                        bandage used if
                                                                        bleeding continues
DOT Objective: 5-1.3, 5-1.12, 5-1.13, 5-1.14
                              Additional Methods
                Splints
                       Reducing bone movement reduces bleeding from
                       fractures and damaged vessels
                       Pressure/air splint applies direct pressure to
                       external bleeding
                Tourniquet
                       Last resort for amputated/mutilated extremity
                       Can cause permanent nerve, vessel, and muscle
                       damage resulting in loss of extremity



DOT Objective: 5-1.3
             Tourniquet Use
4 inch wide bandage 6 layers deep
Wrap bandage around extremity
  2 times around
  Proximal to bleeding, as distal as possible
  Never directly over a joint
Tie knot in bandage/place stick on top
Tie knot over stick holding it in place
Twist stick until bleeding stops
Secure stick in place & note time applied
Leave tourniquet visible
Never remove a tourniquet
           Ears, Nose, Mouth
Causes:
  Basil skull fracture
  Facial trauma
  Digital insertion trauma
  Sinusitis
  Coagulation disorder
  Hypertension (high bp)
Don’t stop ear/nose bleeding if associated
with head trauma
Collect/cover with loose dressing
Protect airway & suction as needed
                          Epistaxis




Have patient sit,      Additional pressure    Ice may help in
leaning forward        maybe applied by       control of bleeding in
                       placing rolled gauze   addition to pressure
Direct pressure by
                       in upper lip and
pinching nose closed                          Watch for shock and
                       pushing up
                                              vomiting
      Fluid/Content Failure
Dehydration hypovolemic shock
 Loss of water fluid
   Heat related emergency
   Burns
 ABC
 Shock position
 Rapid transport
        Vessel (Pipe) Failure
Neurogenic shock
  Loss of vascular tone with spinal cord damage
  ABC with spinal precautions
  Keep patient warm
  Rapid transport
Psychogenic shock
  Syncope caused by dilation of blood vessels as
  result of mental stress
  Rule out other causes of syncope
    Irregular pulse, aneurysm, stroke
    Vessel & Content Failure
Septic shock
 Bacterial infection releases toxins
 Causes vessel to relax and leak
 Fluid levels vessel and enters tissues
 ABC with ventilation if needed & transport
Anaphylactic shock
 Allergic reaction causes vessel dilation
 and leakage of fluid into tissues
 ABC & Epinephrine
 Rapid transport
       Heart (Pump) Failure
Cardiogenic shock
 Inability of heart to pump blood to meet
 metabolic needs of the body
 Right side failure causes blood to pool in
 legs and JVD
 Left side failure causes lungs to fill with
 fluid
 ABC with assisted ventilations & suction if
 needed
 Keep patient in sitting position if possible
                 Hypoxia
Cells need oxygen to function
Perfusion triad provides blood
  Respiratory system provides oxygen
  Ensure adequate airway and ventilations
  Administer high flow oxygen for all serious
  patients

				
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