Chapter 19: Hemorrhage & Shock

Hemorrhage- an abnormal internal or external discharge of blood. Shock- a state of inadequate tissue perfusion. Homeostasis- the natural tendency of the body to maintain a steady and normal internal environment. Types of Hemorrhage Capillary Venous Arterial Clotting- the bodys 3-step response to stop the loss of blood. 1. Vascular phase- step in the clotting process in which smooth blood vessel muscle contracts, reducing the vessel muscle contracts, reducing the vessel lumen and the flow of blood through it. 2. Platelet phase- second step in the clotting process in which platelets adhere to blood vessel walls and to blood vessel walls and to each other. Aggregate- to cluster or come together. 3. Coagulation- the third step in the clotting process, which involves the formation of a protein called fibrin that forms a network around a wound to stop bleeding, ward off infection, and lay a foundation for healing and repair of the wound. Fibrin- protein fibers that trap red blood cells as part of the clotting process. Factors Hindering the Clotting Process Movement of the wound site Aggressive fluid therapy Low body temperature Medications such as aspirin, heparin, or Coumadin Types of Blood Vessel injury Lateral (Transverse) cut- permits the vessel to retract and thicken its walls (flexion of Vessel sphincters) and control blood loss. Longitudinal cut- a cut that is along the length of a vessel that causes the vessel to open and allows for uncontrolled bleeding. Hemorrhage Control External Hemorrhage 1. Direct Pressure 2. Elevation 3. Pressure Points 4. Tourniquet Internal Hemorrhage o Blood loss due to Fractures Large Contusion = 500mL Humerus & Tibia/Fibula = 750mL Femur = 1,500mL

 Pelvis = 2,000mL o Area of Internal Hemorrhage Hematoma- collection of blood beneath the skin or trapped within a body compartment. Epistaxis- nose bleed; due to injury, disease, or environmental factors. Esophageal Varicies- enlarged and tortuous esophageal veins. Hematochezia- passage of stools containing red blood (Melena). Melena- black, tar-like feces due to gastrointestinal bleeding. Anemia- a reduction in the hemoglobin content in the blood to a point below that required to meet the O2 requirements of the body. Stages of Hemorrhage Stage 1- blood loss of up to 15%; Pt. may display some nervousness and marginally cool skin w/slight pallor. Catecholamine- (sympathetic) a hormone, such as epinephrine or norepinephrine, that strongly affects the nervous and cardiovascular systems, metabolic rate, temperature, and smooth muscle. Catecholamines responses begin to be noted in this stage. Stage 2- blood loss of 15-25%; Pt. displays thirst, anxiety, restlessness, cool, clammy skin, increased respiratory rate. Pulse Pressure- difference between the systolic and diastolic blood pressures. The Pulse Pressure is noticeably narrowed in this stage. Stage 3- blood loss of 25-35%; Pt. experiences air hunger, Dyspnea, severe thirst, anxiety, restlessness; survival unlikely w/out rapid intervention. Stage 4- blood loss >35%; pulse barely palpable, respirations ineffective; Pt. lethargic, confused, moving toward unresponsiveness; survival unlikely. Blood Volume Fluid accounts for about 60% of the bodys weight. Body fluid components: o Intracellular fluid 75% of TBW (Total Body Water) o Extra cellular fluid 25% of TBW - Interstitial fluid 17.5% + Intravascular fluid 7.5% = 25% of Extra cellular fluid Fluid in the Intravascular space accounts for 5L of blood volume in an adult. The blood volume of a in late pregnancy is 50% greater than normal. In infants and young children, blood volumes approximate 8-9% of body weight, volumes that are proportionally about 20% greater than those of adults. Orthostatic Hypotension- the state of having a decrease in blood pressure that occurs when a person moves from a supine or sitting to an upright position. Tilt Test- to test for Orthostatic Hypotension; drop in the systolic blood pressure of 20mmHg or an increase in the pulse rate of 20 beats per minute when a patient is moved form a supine to a sitting position; a finding suggestive of a relative Hypovolemia.

During the initial assessment, care for serious hemorrhage only after any airway and breathing problems is corrected. W/head injury patients, do not attempt to stop the flow of blood or fluid from the nose or ear canal, but cover the area w/ porous dressing to collect the material and bandage loosely. Cover any open neck wound w/an occlusive dressing held firmly in place. Consider rapid transport for any Pt. who experiences serious external hemorrhage that you cannot control and for any Pt. w/suspected serious internal hemorrhage. SHOCK- a state of inadequate tissue perfusion Metabolism- the total changes that take place in an organism during physiological processes. Ischemia- a blockage in the delivery of oxygenated blood to the cells. Hydrostatic pressure- the pressure of liquids in equilibrium; the pressure exerted by or within liquids. Rouleaux- group of red blood cells that are stuck together. Washout- release of accumulated lactic acid, CO2 (carbonic acid), potassium, and Rouleaux into the venous circulation. Stages of SHOCK 1. Compensated Shock- hemodynamic insult to the body in which the body responds effectively. In compensated shock, the body reduces venous capacity (decrease size of the container) in response to blood loss. 2. Decompensated Shock- continuing hemodynamic insult to the body in which the compensatory mechanisms break down. Entry into Decompensated shock is indicated by a drop in Systolic B/P. 3. Irreversible Shock- final stage of shock in which organs and cells are so damaged that recovery is impossible. In caring for SHOCK attempt to provide adequate tissue perfusion; by oxygenating the patient and allowing for CO2 off-loading. Provide this by supplementing high-flow O2 or PPV (Positive Pressure Ventilation). Overdrive respiration- PPV supplied to a breathing patient. The ideal catheter for the shock patient is relatively short, 1 or shorter. PASG/MAST (Pneumatic Anti-Shock Garment)- garment designed to produce uniform pressure on the lower extremities and abdomen; used w/shock and hemorrhage patients in some EMS systems. PASG is responsible for a return of about 250mL of blood to the central circulation and probably reduces the venous capacitance by the same volume.