5-1 Bleeding and Shock

Signs and symptoms

• Bright red, spurting blood = arterial bleed.
• Dark red, flowing blood = venous bleed.
• Slow, oozing blood = capillary bleed.
• Bleeding from the nose, ears, or mouth may be due to head injury.
• Internal bleeding signs
  • Hematoma.
  • Abdominal bruising.
  • Discoloration.
  • Tenderness.
  • Rigidity.
  • Distended abdomen.
  • Bleeding from mouth, rectum and other body orifice.
  • Vomiting blood (a red or dark color).
  • Stools with blood.
• Shock signs
  • Anxiety.
  • Altered mental status.
  • Tachycardia.
  • Rapid, thready pulse.
  • Decreased (or normal if in the compensatory stage) blood pressure.
  • Rapid, shallow respiratory rate.
  • Pale, cool clammy skin.
  • Poor cap refill.
  • Narrow pulse pressure (low systolic, high diastolic) due to vasoconstriction.
  • Altered mental status.
  • Dilated pupils that are slow to respond to light.
  • Thirst.

Treatment

• Direct pressure: immediately press down with the finger tips of your gloved hand. Apply pressure over a dressing when it becomes available.
• Elevate extremity: if bone fracture or joint injury occurred, splint before elevating extremity.
• Pressure points: brachial artery for the upper extremity and femoral artery for the lower extremity.
• Oxygen.
• PPV if needed.
• Splinting: provides immobilization that prevents further injury.
  • Traction splint: for femur fractures.
  • Air splint: a splint that also applies pressure to control bleeding.
  • PASG (pneumatic antishock garment): control severe bleeding in the pelvis and lower extremities.
• Cold application to local area: ice packs wrapped with a soft covering, applied to the site of injury can help clotting, vasoconstriction and may reduce swelling.
• Tourniquet as a last resort, as close to the injury site as possible, and follow medical direction.
• For nose bleeds, have the patient sit and lean forward, pinch the nostrils together and apply ice pack to the bridge of the nose.
• Do not give medications that are anticoagulants such as aspirin to patients with bleeding.
• Patients with signs of shock should be placed in a Trendelenburg position to help maintain blood pressure.
• Keep shock patients warm so their core body temperature is maintained. Wrap patient in blankets.
• ALS intercept can better stabilize shock patients by transfusion of saline solution.

Trauma conditions and mechanisms

• Femur fracture: up to 1500 mL of blood can be lost around each femur. The traction splint pulls on the leg and decrease the amount of blood that can bleed into it.
• 3000 mL of blood can be lost in the thorax.
• Tibia, fibula and humerus can lose up to 500 - 750 mL of blood.
• Bleeding in the nasopharynx can fall into the stomach, which results in vomiting of blood.
• In response to loss of blood, the body responds by increasing heart rate, strength of contraction, and vasoconstriction. Also, the adrenal glands will secrete epinephrine and norepinephrine, which stimulate vasoconstriction and sweating. All this serves to maintain blood pressure and gives the patient the characteristic shock signs of pale, cool and clammy skin.
• Hemophilia: clotting disorder where bleeding can not stop.
• Shock is hypoperfusion due to a variety of factors:
  • Fluid loss: from bleeding, fluid loss, or dehydration. The body's response is vasoconstriction to maintain blood pressure.
  • Pump failure: inadequate heart function.
  • Vasodilation: blood pressure drops when vessels dilate.
  • Hypoxia: inadequate oxygen.
• Types of shock:
  • Hypovolemic shock: decreased blood volume. A type of hypovolemic shock is hemorrhagic shock, which results from blood loss.
  • Obstructive shock: something blocks perfusion to the heart. For example, pulmonary embolism, tension pneumothorax, or cardiac tamponade.
  • Distributive shock: abnormal blood distribution that leads to inadequate blood reaching the heart.
    • Vasogenic or neurogenic shock: nervous system injury leading to vasodilation in the periphery. This causes inadequate perfusion to the vital organs.
    • Anaphylactic shock: severe allergic reaction that leads to vasodilation and bronchoconstriction.
    • Cadiogenic shock: inadequate pumping of the heart. Can be due to heart disease or heart attack.
• Stages of shock:
  • Compensatory shock: the body is able to maintain blood pressure by vasoconstriction and also maintain perfusion by increasing the pulse and respiratory rate. Perfusion to the periphery decreases as blood is shunted to maintain perfusion to the vital organs. Thus the patients exhibits normal blood pressure but has a high diastolic blood pressure (vasoconstriction), increased pulse and respiratory rate, pale and cool skin (blood shunting to the vital organs) and anxiety (epinephrine effect).
  • Decompensated (progressive) shock: the body can no longer maintain adequate perfusion to the vital organs. Blood pressure drops even though the heart attempts to beat even faster (tachycardia) and stronger. This leads to a very weak pulse. Vasoconstriction increases so much that it begins to shut off perfusion to vital organs - kidney failure. Metabolic waste from poor perfusion builds up. More epinephrine is released and the skin becomes pale, cool and clammy. Thirst develops. As the brain experiences hypoxia, the patient experiences anxiety and eventually altered mental status.
  • Irreversible shock: The body fails at this stage, and the effects can not be reversed. Blood pressure drops so much that even the carotid and femoral pulses are barely palpable. The heart begins to slow and eventually stop. Breathing is ineffective (rapid, shallow). The skin mottles. Bleeding may occur from every orifice. Patient is unresponsive.

Terms

• Epistaxis: nosebleed.
• Hematoma: a contained collection of blood.