Bleeding and Shock
Pipes, pump, and fluid…really,
it’s that simple!
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The Second Rule of EMS….
…eventually the bleeding
will stop!
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Cardiovascular System
Heart
Arteries
Veins
Capillaries
Blood
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Cardiovascular System
• Transports O2 and fuel to the cells, tissues,
and organs.
• Removes CO2 and wastes from the cells for
elimination from the body.
• Must be able to maintain sufficient flow
through the capillary beds to meet the cell’s
O2 and fuel needs
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Bleeding
Internal
External
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Internal Bleeding
Trauma
Clotting disorders
Rupture of blood vessels
Fractures (injury to nearby vessels)
Can result in rapid progression to
hypovolemic shock & death!
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Internal Bleeding S/S
Think about MOI or NOI!
Anxiety, restlessness, irritability
Pale, diaphoretic skin
Sustained tachycardia
Hypotension
Unstable vitals signs (postural changes)
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Internal Bleeding S/S
Vomiting bright red blood or coffee ground
material
Bleeding form any body orifice
Dark, tarry stools (melena)
Tender, rigid, or distended abdomen
Pain, discoloration, swelling, tenderness at
injury site
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Managing Internal Bleeding
ABC’s
High concentration oxygen
Assist ventilations
Control external bleeding
Stabilize fractures
RICE
Transport rapidly to appropriate facility
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External Bleeding
• Arterial Bleed
– Bright red, spurting
• Venous Bleed
– Dark red, steady flow
• Capillary Bleed
– Dark red, oozing
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Control of External Bleeding
Direct Pressure:
Gloved hand
Or
Dressing and bandage
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Control of External Bleeding
Elevation:
Raise extremity
above the level of the
heart
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Control of External Bleeding
Pressure Dressing:
Use bandage to
secure dressing in
place
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Arterial Pressure Points
• Upper extremity:
– Brachial
– Radial
• Lower extremity:
– Femoral
– Popliteal
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Tourniquets
Final resort when all else fails
Used for amputations
3-4” wide (blood pressure cuffs)
Write “TK” and time of application on
forehead of patient
Notify other personnel
Once applied, DO NOT REMOVE
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Epistaxis (Nosebleed)
• Causes
– Fractured skull
– Facial injuries
– Sinusitis, other
URIs
– High BP
– Clotting disorders
– Digital insertion
(nose picking)
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Management of Epistaxis
Sit up, lean forward
Pinch nostrils together
Keep in sitting position
Keep quiet
Apply ice over nose (15 min)
Can result in life-threatening blood loss!
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SHOCK
Inadequate perfusion(blood flow)
leading to inadequate oxygen delivery
to tissues
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Physiology
• Cell is the basic unit of life
• Cells get energy needed to stay alive by
reacting oxygen with fuel (usually glucose)
• No oxygen, no energy
• No energy, no life
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Perfusion Failure
Pump Failure (heart)
Pipe Failure (vessels)
Loss of Volume
(blood)
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Stages of Shock
Compensated Shock
Decompensated Shock
Irreversible Shock
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Compensated Shock
• Body still compensates for blood loss
• Pulse rate increases
• Pulse strength decreases
• Pale, diaphoretic skin
• Anxiety, restlessness, combativeness
• Thirst, weakness, eventual air hunger
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Decompensated Shock
• Body compensatory mechanisms fail
• Unpalpable pulse
• Precipitous drop in blood pressure
• Patient becomes unconscious
• Respirations slow or cease
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Irreversible Shock
• Lack of circulation causes:
– Cellular death
– Tissue dysfunction
– Organ dysfunction
– Patient death
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Shock:
Etiology
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• Psychogenic
• Hypovolemic
• Distributive
• Obstructive
• Cardiogenic
• Respiratory
• Neurogenic
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Psychogenic Shock
• Simple fainting (syncope)
• Caused by stress, fright, pain
• Heart rate slows, vessels dilate
• Brain becomes hypo-perfused
• Loss of consciousness occurs
• Patient usually recovers by self
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Psychogenic Shock S/S
• Anxiety, restlessness, irritability
• Rapid pulse
• Normal or low blood pressure
• Hyperventialtion
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Hypovolemic Shock
• Loss of volume
• Causes:
– Blood loss from trauma
– Plasma loss from burns
– Fluid/electrolyte loss from vomiting,
diarrhea, sweating, increased urine
output, increase respiratory loss
– “Third space” fluid shifts
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Hypovolemic Shock S/S
• Anxiety, restlessness, irritability
• Rapid, weak pulse
• Change in mental status
• Signs of inadequate perfussion (diaphoresis,
cyanosis, pale/clammy skin)
• Increased respiratory rate
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Distributive Shock: Septic
• Results from body’s response to bacteria in
bloodstream
• Vessels dilate, become “leaky”
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Distributive Shock: Septic S/S
• Anxiety, restlessness, irritability
• Febrile, warm skin
• Hypotension
• Tachycardia
• Increased respiratory rate
• Change in mental status
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Distributive Shock:
Anaphylactic
• Results from severe allergic reactions
• Body responds to allergen by releasing
histamine
• Histamine release causes vessels to dilates
and become “leaky
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Distributive Shock:
Anaphylactic S/S
• Sudden onset
• Mild itching, rash, uticaria, hives
• Burning sensation (skin)
• Hypotension
• Generalized edema
• Angiodema, airway compromise
• Respiratory distress
• Coma, rapid death
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Obstructive Shock
• Interference with blood flow through the
cardiovascular system
• Tension pneumothorax
• Cardiac tamponade
• Pulmonary embolism
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Obstructive Shock S/S
• Anxiety, irritability, restlessness
• Weak, irregular pulse
• Chest pain, shortness of breath
• Hypotension
• Pale, cool, clammy skin
• JVD, discoloration above nipple line
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Cardiogenic Shock
• Pump failure
• Heart’s output depends on
– How often it beats (heart rate)
– How hard it beats (contractility)
• Rate or contractility problems cause pump
failure
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Cardiogenic Shock S/S
• Causes
– Acute myocardial infarction
– Very low heart rates (bradycardias)
– Very high heart rates (tachycardias)
Why would a high heart rate caused decreased output?
Hint: Think about when the heart fills.
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Cardiogenic Shock S/S
• Chest pain
• Weak, irregular pulse
• Hypotension (HTN with CHF)
• Cyanosis, signs of inadequate perfusion
• Cool, clammy skin
• Anxiety
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Respiratory Shock
• Failure of respiratory system to supply
oxygen to or remove CO2 from the alveoli
• Airway obstruction
• Flail chest, SCW
• Pneumothorax
• Respiratory muscle paralysis
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Respiratory Shock S/S
• Anxiety, restlessness, irritability
• Rapid, weak pulse
• Hypotension
• Change in mental status
• Signs of inadequate perfussion
• Increased respiratory rate
• Bronchoconstrcition (wheezes)
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Neurogenic Shock
• Spinal cord injuries that result in the
interruption of communication
pathways between CNS and rest of
body
• Vessels below the injury site dilate
leading to decreased vascular
resistance
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Neurogenic Shock S/S
• Anxiety, restlessness, irritability
• Bradycardia
• Hypotension
• Skin above injury site: pale, cool, clammy
• Skin below injury site: warm, pink, dry
• Signs of spinal injury
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Treatment
• ABC’s
• Apply O2, assist ventilations as needed
• Keep patient in position of comfort
• Control bleeding, stabilize fractures
• Prevent loss of body heat
• Assist with medications
• Nothing by mouth
• Calm and reassure
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Treatment
• Elevate lower extremities 8 to 12 inches in
hypovolemic shock
• Do NOT elevate the lower extremities in
cardiogenic shock
Why the difference in
management?
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Shock is NOT the same as low
pressure
A falling blood pressure is a
LATE sign of shock!
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