Bleeding and Shock Chapter 21 PDF

CHAPTER 21 Bleeding and Shock Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. Introduction (1 of 2) ▪Recognizing bleeding and its effects on Copyright © 2021 by Jones & Bartlett Learni...

CHAPTER 21 Bleeding and Shock Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. Introduction (1 of 2) ▪Recognizing bleeding and its effects on Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com the body ▪Paradigm shift away from focus on managing the airway as most important skills of a paramedic; bleeding now recognized as one of most time-sensitive conditions paramedics face ▪Any kind of bleeding is potentially dangerous. ▪May eventually lead to shock ▪Shock Explained in 120 Seconds | Treatmen t, Symptoms, Causes | Video – YouTube Introduction (2 of 2) ▪Shock Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Bleeding is the most common cause. ▪State of collapse and failure of the cardiovascular system that causes inadequate tissue perfusion ▪Normal compensatory mechanism used by the body to maintain systolic blood pressure and brain perfusion during times of distress ▪If not treated promptly, shock will injure the body’s vital organs and ultimately lead to death. ▪https://www.youtube.com/watch?v=9a7N9AU1GiQ Anatomy and Physiology of the Cardiovascular System (1 of 3) ▪One crucial function: Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Keep blood flowing via the lungs to the peripheral tissues ▪In the lungs ▪Blood dumps gaseous waste products of metabolism. ▪Blood picks up life-sustaining oxygen. https://ed.ted.com/lessons/oxygen-s-surprisingly-complex-journey-through- your-body-enda-butler Anatomy and Physiology of the Cardiovascular System (2 of 3) ▪In peripheral tissues Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Blood unloads oxygen and picks up wastes. ▪If blood flow stops or slows significantly ▪Oxygen delivery would be disrupted. ▪Anaerobic metabolism: emergency metabolic system that does not require oxygen; produces even more acids and toxic wastes Anatomy and Physiology of the Cardiovascular System (3 of 3) ▪Three intact components: Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Heart ▪Blood and body fluids ▪Blood vessels ▪ All three must interact effectively to maintain life.  Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com © Jones & Bartlett Learning. The Circulatory System Structures of the Heart (1 of 2) ▪Muscular cone-shaped organ Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Function is to pump blood throughout the body ▪Located behind the sternum ▪About the size of a closed fist ▪Weighs 280 to 350 g in men and 225 to 280 g in women Structures of the Heart (2 of 2) ▪Four chambers Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Two atria and two ventricles ▪Each atrium receives blood that is returned to the heart from other parts of the body. ▪Each ventricle pumps blood out of the heart. ▪Atrioventricular valves ▪Semilunar valves Blood Flow Within the Heart (1 of 4) ▪Starts in the right atrium Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Superior vena cava and inferior vena cava return deoxygenated blood from the body to the right atrium. ▪From the right atrium, blood passes through the tricuspid valve into the right ventricle. ▪Right ventricle pumps blood through the pulmonic valve into the pulmonary artery and then to the lungs. Blood Flow Within the Heart (2 of 4) ▪In the lungs Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Oxygen is returned to the blood. ▪Carbon dioxide and other waste products are removed. ▪Freshly oxygenated blood returns to the left atrium through the pulmonary veins. Blood Flow Within the Heart (3 of 4) ▪After return Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Blood flows through the mitral valve into the left ventricle. ▪Left ventricle pumps the oxygenated blood through the aortic valve, into the aorta.  Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com Blood Flow Within the Heart (4 of 4) © Jones & Bartlett Learning. The Cardiac Cycle (1 of 4) https://ed.ted.com/lessons/how-the-heart-actually-pumps-blood-edmond- Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com hui ▪Repetitive pumping process ▪Begins with the onset of cardiac muscle contraction ▪Ends just before the beginning of the next contraction ▪Myocardial contraction ▪Afterload ▪Stroke volume The Cardiac Cycle (2 of 4) ▪Cardiac output Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Amount of blood pumped through the circulatory system in 1 minute ▪Expressed in litres per minute (L/min) ▪Equals pulse rate multiplied by the stroke volume ▪Factors that influence the pulse rate, the stroke volume, or both will affect cardiac output and, therefore, oxygen delivery to the tissues. The Cardiac Cycle (3 of 4) ▪Increased venous return Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Stretches the ventricles ▪Results in increased cardiac contractility ▪First described by Ernest Henry Starling ▪ British physiologist ▪ Known as the Starling law of the heart The Cardiac Cycle (4 of 4) ▪Ejection fraction Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪A normal heart continues to pump the same percentage of blood returned. ▪EF is the % of blood that the heart pumps per contraction* ▪Amount of blood returning to the right atrium varies. ▪If more blood returns to the heart, the stretched heart pumps harder. ▪Maintains normal cardiac function Blood and Its Components (1 of 4) ▪Blood Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Consists of plasma and formed elements, or cells that are suspended in the plasma ▪Red blood cells ▪White blood cells ▪Platelets ▪Purpose is to carry oxygen and nutrients to the tissues and cellular waste products away from the tissues ▪Formed elements serve as the mainstay of numerous other body functions, such as fighting infections and controlling bleeding. Blood and Its Components (2 of 4) ▪Plasma Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Watery, straw-coloured fluid ▪More than half of the total blood volume ▪Consists of 92% water and 8% dissolved substances ▪Water enters the plasma: ▪ From the digestive tract ▪ From fluids between cells ▪ As a by-product of metabolism Blood and Its Components (3 of 4) ▪Red blood cells (erythrocytes) Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Disc-shaped ▪Most numerous of the formed elements ▪Unable to move on their own ▪Contain hemoglobin ▪ Protein that gives them their largely red colour ▪ Binds oxygen absorbed in the lungs and transports it to the tissues* Blood and Its Components (4 of 4) ▪White blood cells (leukocytes) Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Several types exist ▪Primary function is to fight infection. ▪Platelets ▪Small cells in the blood ▪Essential for clot formation ▪The process is a complex series of events involving platelets, clotting proteins in the plasma, other proteins, and calcium. ▪Aggregate in a clump and form much of the foundation of a blood clot Blood Circulation and Perfusion (1 of 2) ▪Blood vessels Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Arteries ▪Veins ▪Arterioles and capillaries ▪ Diffusion ▪Venules ▪ Venules merge together Blood Circulation and Perfusion (2 of 2) ▪Perfusion Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Circulation of blood within an organ or tissue in adequate amounts to meet the cells’ current needs for oxygen, nutrients, and waste removal* ▪ Blood must pass through the system at a speed that is fast enough to maintain adequate circulation, yet slow enough to allow each cell time to exchange oxygen and nutrients for carbon dioxide and other waste products. ▪ Most tissues require circulating blood only intermittently. Autonomic Nervous System (1 of 2) ▪Monitors the body’s needs from Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com moment to moment ▪During emergencies: ▪ Automatically redirects blood away from other organs and toward the heart, brain, lungs, and kidneys ▪ Sometimes fails to provide sufficient circulation for every body part to perform its function Autonomic Nervous System (2 of 2) ▪Perfusion needs Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪The heart requires constant perfusion. ▪Brain and spinal cord cannot go for more than 4 to 6 minutes without perfusion. ▪Kidneys will be permanently damaged after 45 minutes of inadequate perfusion. ▪Skeletal muscles cannot tolerate more than 2 hours of inadequate perfusion. ▪The GI tract can exist with limited (but not absent) perfusion for several hours. ▪Times based on a normal body temperature of 37.0°C ▪An organ or a tissue that is considerably colder is better able to resist damage from hypoperfusion because of slowing metabolism.* ▪You are called to a shooting at a local gas station. The dispatcher alerts you that Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com police on the scene are requesting “a rush on the bus.” ▪A detective informs you, “There was a robbery; the clerk was shot and the perpetrator has left the scene.” You observe a 22-year-old man sitting on the floor holding his left upper quadrant with his bloody hand. The patient appears to weigh about 80 kg. Although he is conscious, alert, and in obvious pain, he tells you that the shooting occurred just as the clock struck 23:00. It is now 23:10, and you hit the elapsed time counter on your digital watch as you don your PPE. As you begin to talk to the patient, you reach down to palpate his radial pulse but cannot feel it. ▪Does the lack of significant visible bleeding and the fact that he is alert indicate that this patient is not bleeding seriously? ▪What is the significance of time in this type of incident? Pathophysiology of Hemorrhage ▪Hemorrhage Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Simply means bleeding ▪Can range from a “nick,” to a severely spurting artery, to a ruptured spleen ▪*External bleeding (visible hemorrhage) ▪*Internal bleeding External Hemorrhage (1 of 2) ▪External bleeding Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Occurs due to a break in the skin ▪Extent or severity is often a function of the type of wound and the types of blood vessels that have been injured. ▪Bleeding from a capillary usually oozes. ▪Bleeding from a vein flows. ▪Bleeding from an artery spurts. External Hemorrhage (2 of 2) ▪Injuries Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Do not always have serious hemorrhaging ▪Other injuries may cause more bleeding than expected. Internal Hemorrhage (1 of 3) ▪Internal bleeding Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪As a result of trauma ▪The smaller the space, the less the bleeding. ▪Nontraumatic usually occurs in cases of: ▪ GI bleeding from the upper or lower GI tract ▪ Ruptured ectopic pregnancies ▪ Ruptured aneurysms ▪ Other conditions Internal Hemorrhage (2 of 3) ▪Must be treated promptly Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Signs do not always develop quickly. ▪Rely on other signs and symptoms and an evaluation of the MOI to make this diagnosis. ▪Pay close attention to patient complaints of pain or tenderness, development of tachycardia, and pallor. ▪Be alert for the development of shock. Internal Hemorrhage (3 of 3) ▪Management Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Focuses on: ▪ Treatment of shock ▪ Minimizing movement of the injured or bleeding part or region ▪ Rapid transport ▪Patient will need a surgical procedure to stop the bleeding. Controlled Versus Uncontrolled Hemorrhage (1 of 3) ▪Serious emergency Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Initial assessment of the patient always includes a search for life-threatening bleeding. ▪If found, the hemorrhage must be controlled. ▪If the hemorrhage cannot be controlled in the prehospital environment: ▪ Concentrate on attempting to control the bleeding as you rapidly transport the patient. Controlled Versus Uncontrolled Hemorrhage (2 of 3) ▪External bleeding Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Most can be managed with direct pressure ▪Arterial bleeding may take 5 or more minutes of direct pressure to form a clot. ▪Military experience has shown that the use of pressure points is not as effective as previously thought. ▪Use of a tourniquet for external bleeding of an extremity that cannot be controlled with direct pressure and a pressure bandage Controlled Versus Uncontrolled Hemorrhage (3 of 3) ▪Internal bleeding Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Most cases are rarely fully controlled in the prehospital setting. ▪Rapid transport needed ▪External circumferential pressure of a pelvic binder may help control the massive bleeding that accompanies a pelvic fracture. The Significance of Bleeding (1 of 5) ▪Blood loss Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Often difficult to determine ▪Looks different on different surfaces ▪Patient’s presentation and your assessment direct your care and treatment plan. The Significance of Bleeding (2 of 5) ▪Averages Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Human adult male bodies contain approximately 70 mL of blood per kilogram of body weight. ▪Adult female bodies contain approximately 65 mL/kg. ▪Body cannot tolerate an acute loss of more than 20% of this total blood volume. © Jones & Bartlett Learning. The Significance of Bleeding (3 of 5) ▪Averages (continued) Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪If a typical adult loses more than 1 litre of blood: ▪ Significant changes in vital signs will occur. ▪ Increasing heart and respiratory rates ▪ Decreasing blood pressure ▪Infants and children have less blood volume. ▪ May experience the same effect with smaller amounts of blood loss. The Significance of Bleeding (4 of 5) ▪Compensation Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Depends on the rate of bleeding ▪A healthy adult can donate one unit (500 mL) of blood in a period of 15 to 20 minutes without having ill effects. ▪If a similar blood loss occurs in a much shorter period, hypovolemic shock may rapidly develop. The Significance of Bleeding (5 of 5) ▪Serious if any of the following Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com conditions are present: ▪*A significant MOI ▪Poor general appearance of the patient ▪Signs and symptoms of shock ▪Significant amount of blood loss ▪Blood loss causing hemodynamic instability ▪Uncontrollable bleeding Physiologic Response to Hemorrhage (1 of 5) ▪https://ed.ted.com/lessons/how-blood-pressure-works-wilfred-manzano Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Bleeding from an artery ▪Bright red ▪Spurts in time with the pulse ▪Difficult to control ▪As the amount of blood circulating in the body drops, so does the patient’s BP, and eventually the arterial spurting diminishes. ▪Bleeding from an open vein ▪Much darker ▪Flows steadily ▪Easier to manage Physiologic Response to Hemorrhage (2 of 5) ▪Bleeding from damaged capillary Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com vessels ▪Dark red ▪Oozes slowly ▪Venous and capillary bleeding are more likely to clot spontaneously than arterial bleeding. ▪On its own ▪Bleeding tends to stop rather quickly (within about 10 minutes). ▪Response to internal clotting mechanisms and exposure to air Physiologic Response to Hemorrhage (3 of 5) ▪On its own (continued) Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪When vessels are lacerated, blood flows rapidly. ▪Open ends of the vessel begin to narrow. ▪Platelets aggregate at the site, plugging the hole and sealing the injured portions of the vessel (hemostasis). ▪Bleeding will not stop if a clot does not form. ▪Direct contact with body tissues and fluids or the external environment commonly triggers the blood’s clotting factors. Physiologic Response to Hemorrhage (4 of 5) ▪The hemostatic system may fail in Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com certain situations. ▪*Medications - anticoagulants (aspirin and prescription blood thinners) interfere with normal clotting.* ▪*Severe injury ▪*Only part of the vessel wall is cut ▪Acute blood loss may result in death before vasoconstriction and clotting can help. Physiologic Response to Hemorrhage (5 of 5) ▪Trauma triad of death Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Combination of hypothermia, coagulopathy (poor blood clotting), and acidosis that significantly increases mortality in trauma patients ▪Important to: ▪Aggressively control bleeding. ▪Keep patients warm. as low body temperature hinders the clotting process. ▪Minimize volume of acidic IV fluid administered. ▪If possible, monitor end-tidal carbon dioxide and ventilations to prevent respiratory acidosis. ▪Consider administering tranexamic acid to help control internal bleeding. Assessment of a Bleeding Patient (1 of 5) ▪Scene assessment Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Begins assessment of any patient ▪General impression and initial assessment once the scene is deemed safe to enter ▪PPE entails: ▪ Gloves ▪ Mask ▪ Eyeshield ▪ Gown © AndaPhoto/Shutterstock. Assessment of a Bleeding Patient (2 of 5) ▪Initial assessment Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Determine the patient’s mental status. ▪Locate and manage immediate life threats involving the airway, breathing, and circulation. ▪Ensure that the patient has a patent airway. ▪If the patient has minor external bleeding, note it and move on. ▪If major external bleeding is present, deal with it immediately. ▪If internal bleeding is suspected, keep patient warm and administer supplemental oxygen, but remember rapid transport to hospital is necessary. Assessment of a Bleeding Patient (3 of 5) ▪MOI Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Trauma patients ▪May be best indicator of internal injury or bleeding Assessment of a Bleeding Patient (4 of 5) ▪Focused history Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Elaborate on the patient’s chief complaint using the OPQRST mnemonic. ▪Obtain a history of the present illness using SAMPLE. ▪Look for signs of shock. ▪Ask the patient about medications and about any history of clotting insufficiency.  Assessment of a Bleeding Patient (5 of 5) ▪Physical examination Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Note the colour of bleeding. ▪Try to determine its source. ▪Bright red blood from a wound or the mouth, rectum, or other orifice indicates fresh arterial bleeding. ▪*Coffee-ground emesis * ▪*Melena* ▪*Hematochezia* - passage of stool with bright red blood* ▪*Hematuria ▪*Nonmenstrual vaginal bleeding Treatment of a Bleeding Patient (1 of 3) ▪Managing external hemorrhage Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Steps to control hemorrhaging ▪ Apply direct pressure over the wound. ▪ Elevate the injury above the level of the heart if no fracture is suspected. ▪ Apply a pressure dressing. ▪ A tourniquet is generally a last resort. Treatment of a Bleeding Patient (2 of 3) ▪Bleeding from the nose, ears, and mouth Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Epistaxis (non-traumatic) Standard pg 85 ▪ https://www.health.gov.on.ca/en/pro/programs/emergency_health/edu/docs/ bls_pcs_v3.4.pdf ▪ May indicate a skull fracture ▪ Cover the bleeding site loosely with sterile gauze pad. ▪ May contain cerebrospinal fluid  Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com To control nosebleed, have the patient sit leaning forward Pinch the fleshy part of the patient’s nostrils firmly for at least 5 minutes (non trauma) or 10 min (traumatic) Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com Treatment of a Bleeding Patient (3 of 3) ▪Bleeding from other areas Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Control bleeding through use of direct pressure and elevation. ▪ Apply pressure dressings. ▪ Use splints as necessary. ▪ Pack large, gaping wounds with sterile dressings. ▪ Keep the patient warm and in the appropriate position. Special Management Techniques (1 of 6) ▪Fractures Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Most bleeding occurs because the sharp ends lacerate vessels, muscles, and other tissues. ▪As long as the fracture remains unstable, the bone end will move and continue to damage tissues and vessels. ▪Immobilizing is a priority in the prompt control of bleeding. Special Management Techniques (2 of 6) ▪Air splints Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Can control the bleeding associated with severe soft-tissue injuries or fractures ▪Stabilize fractures ▪Act like a pressure dressing applied to an entire extremity rather than to a small, local area ▪Monitor circulation ▪Not appropriate for use on arterial bleeding © Jones & Bartlett Learning. Special Management Techniques (3 of 6) ▪Rigid splints Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Can stabilize fractures ▪Reduce pain ▪Prevent further soft-tissue injury © Jones & Bartlett Learning. Special Management Techniques (4 of 6) ▪Traction splints Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Particularly useful in stabilizing femur fractures ▪Reduces thigh muscle spasms ▪Prevents one end of fracture from impacting or overriding the other © Jones & Bartlett Learning.  Special Management Techniques (5 of 6) ▪Hemostatic agents Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Work by causing enhanced clot formation at wound site ▪Wound packing ▪Has been successfully used by military for many years, now moving into civilian EMS ▪Particularly helpful for bleeding in junctional areas (such as groin). ▪Involves pushing gauze into wound to completely and tightly pack the wound cavity ▪Goal is to contact the source of bleeding and fill the cavity if possible. ▪https://www.youtube.com/watch?v=RSxl2K65YVs Courtesy of SAM Medical. Special Management Techniques (6 of 6) ▪Tourniquets Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Used with partial or complete amputation or when other methods of bleeding control have proved ineffective ▪Can cause permanent damage to nerves, muscles, and blood vessels ▪Do not apply directly over a joint. ▪Use the widest bandage possible. ▪Never use wire, rope, a belt, or any other narrow material. ▪Use wide padding under the tourniquet. ▪Never cover with a bandage. ▪Do not loosen the tourniquet after you have applied it.  Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com (1 of 2) Skill Drill 21-1: Managing External Hemorrhage Step 2 Step 1 © Jones & Bartlett Learning.  Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com (2 of 2) Skill Drill 21-1: Managing External Hemorrhage Step 4 Step 3 © Jones & Bartlett Learning. Pelvic Trauma (1 of 4) ▪Use a pelvic binder to reduce a pelvic fracture and provide mechanical Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com stability. ▪Reduces blood loss and helps maintain BP ▪Indications for application of pelvic binder include trauma patients with: ▪Signs of pelvic fracture, including pain in pelvis, hip, groin, or lower back ▪Signs of hypovolemic shock ▪Suspicious mechanism of injury, even if currently hemodynamically stable  Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com © Jones & Bartlett Learning. Pelvic Trauma (2 of 4) Pelvic Trauma (3 of 4) ▪Applying pelvic sheeting Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪https://www.youtube.com/watch?v=Om g79Ced6s0 ▪Step 1: Align—bring legs together and remove outer clothing. Place narrow folded sheet on stretcher. ▪Step 2: Place padding between the knees and ankles, and secure the legs together. ▪Step 3: Scoop patient onto folded sheet on stretcher. ▪Step 4: The top of the sheet should be at the level of the iliac crest. Pelvic Trauma (4 of 4) ▪Applying pelvic sheeting (continued) Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Step 5: Apply tension, by holding one side of the sheet while passing the other to your partner on the other side and pulling tight. Sheeting is ineffective if loose. ▪Step 6: Clamp sheet to prevent loss of tension. Position the clamps laterally to avoid obstructing X-ray views. ▪Step 7: Reassess tension and clamps periodically. Managing Internal Hemorrhage (1 of 2) ▪Definitive management Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Occurs in the hospital ▪Prehospital management involves treating for shock and splinting injured extremities: ▪Keep the patient supine. ▪Open the airway. ▪Check breathing and pulse. ▪Administer high-flow supplemental oxygen. ▪Assist ventilation if needed. Managing Internal Hemorrhage (2 of 2) ▪Prehospital management (continued) Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Splint broken bones or joint injuries ▪If a pelvic fracture is suspected, apply a pelvic binder. ▪Keep the patient warm. ▪While en route to the ED, insert a large-bore IV catheter, and administer a fluid challenge of 250 mL of a crystalloid if evidence of hypoperfusion is present. ▪ Insert an IV line at the scene only if transport is delayed (such as if the patient is entrapped). ▪ Whenever possible, use warm IV fluids to maintain the patient temperature. ▪Consider giving pain medication. ▪Monitor the serial vital signs.  Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com Step 3 Skill Drill 21-2: Managing Internal Hemorrhage Step 2 Step 1 © Jones & Bartlett Learning. Transportation of Patients With Hemorrhage (1 of 2) ▪In case of hemorrhage Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪The issue is not whether the patient will be transported. ▪Depends on: ▪ How fast the decision should be made ▪ Where the patient should be taken Transportation of Patients With Hemorrhage (2 of 2) ▪In case of hemorrhage (continued) Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Exceptions: minor wounds ▪Consideration for the priority of the patient and the availability of a regional trauma centre ▪Severe internal or external bleeding will be candidates for surgical interventions and should be transported to a facility with those capabilities. ▪May be appropriate for helicopter transport  (continued ) ▪Your partner has brought in the stretcher and is beginning to administer supplemental Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com oxygen via a nonrebreathing mask at 15 L/min. Police inform you that the robber’s weapon may have been a “sawed-off shotgun” that was fired at a fairly close range. ▪You give the patient some gauze and tell him to hold it firmly against the wound. When you complete your initial assessment, you decide to perform the rapid physical examination in the back of the ambulance and the SAMPLE history as you have time, given the higher priorities and need for rapid transport. ▪ On the basis of the information you have so far, and remembering that the patient weighs approximately 80 kg, how much blood did he have before the incident? How much could he have lost so far? ▪ What phase or stage of shock is this patient in? ▪ Which BLS (basic life support) and ALS (advanced life support) interventions would be most appropriate for this patient at this time? Should you insert an intravenous (IV) line at the scene? Pathophysiology of Shock (1 of 3) ▪Hypoperfusion Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Occurs when the level of tissue perfusion decreases below normal ▪Early decreased tissue perfusion may result in subtle changes before a patient’s vital signs appear abnormal. Pathophysiology of Shock (2 of 3) ▪Shock Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ State of collapse and failure of the cardiovascular system ▪ Creates inadequate circulation and tissue perfusion ▪ Cannot be seen ▪ Not a specific disease or injury ▪ Inadequate flow of blood to the body’s cells and failure to rid the body of metabolic wastes Pathophysiology of Shock (3 of 3) ▪Diagnosing shock Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Evaluation of a patient’s level of organ perfusion is important. ▪Severity of the disease or injury overwhelms the normal compensatory mechanisms, leading to progressive deterioration in the patient’s condition. ▪If conditions causing shock are not promptly addressed, the patient will rapidly deteriorate. Mechanisms of Shock (1 of 6) ▪Normal tissue perfusion Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Requires three intact mechanisms: ▪ Heart ▪ Blood and body fluids ▪ Blood vessels ▪If any one of those mechanisms is damaged, tissue perfusion may be disrupted, and shock will ensue. ▪Mechanisms of shock ▪https://www.youtube.com/watch?v=WueGqL58tlo Mechanisms of Shock (2 of 6) ▪Cardiogenic shock Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Arises because of failure of the heart’s ability to pump effectively due to muscle dysfunction ▪Cardiac arrest is the most drastic form. ▪May occur secondary to: ▪ Myocardial infarction ▪ Cardiac arrhythmias ▪ Pulmonary embolism ▪ Severe acidosis ▪ A variety of other conditions ▪https://ed.ted.com/lessons/how-does-heart-transplant-surgery-work-roni-shanoada Mechanisms of Shock (3 of 6) ▪Hypovolemic shock Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Occurs because of a loss of fluid volume ▪Lost as blood (hemorrhagic shock), plasma, or electrolyte solution ▪Suspect in any patient with unexplained shock. ▪Treat the patient for hypovolemia first. Mechanisms of Shock (4 of 6) ▪Neurogenic shock Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Failure of vasoconstriction ▪Sympathetic nervous system ordinarily controls the dilation and constriction of blood vessels. ▪In a healthy person, the calibre of the blood vessels constantly changes in response to signals from the nervous system, allowing the body to adapt to changes in position, fluid volume, and so forth. ▪In certain situations, nervous system control over the calibre of blood vessels becomes deranged (spinal cord injury). Mechanisms of Shock (5 of 6) ▪More than one cause Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪More than one component of the circulatory system may be affected in case of shock. ▪Some types of shock always result from combined deficits from both fluid leakage into the interstitial space and vasodilation. Mechanisms of Shock (6 of 6) ▪High risk Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Certain categories of patients are at a high risk to develop shock: ▪ Patients known to have had trauma or bleeding ▪ Older people ▪ Patients with massive myocardial infarction ▪ Pregnant women ▪ Patients with a possible source for septic shock (patients with burns, diabetes, or cancer) Compensation for Decreased Perfusion (1 of 6) ▪Maintaining blood pressure Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Central homeostatic mechanism for regulating cardiovascular dynamics ▪*Baroreceptors ▪Stimulation typically occurs when the systolic pressure is between 60 and 80 mm Hg in adults (lower in children). ▪The drop in arterial pressure decreases the stretching of the arterial walls, thereby decreasing baroreceptor firing, stimulating the vasoconstrictor centre of the medulla. ▪Sympathetic nervous system is also stimulated as the body recognizes a potential catastrophic event.  Compensation for Decreased Perfusion (2 of 6) ▪In response to hypoperfusion Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Renin–angiotensin–aldosterone system is activated and antidiuretic hormone is released from the pituitary gland. ▪ Triggers salt and water retention and peripheral vasoconstriction ▪Increase in blood pressure and cardiac output ▪Spleen releases RBCs that are normally sequestered. ▪The overall response of the initial compensatory mechanisms is to increase the preload, stroke volume, and pulse rate, which usually results in an increase in cardiac output.  Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com 📂🖲📫85 Renin-Angiotensin-Aldosterone Mechanism*  Renin-Angiotensin-Aldosterone System* ▪Renin Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Aldosterone ▪Angiotensin II ▪Angiotensin I ▪Angiotensinogen ▪JGA ▪Angiotensin Converting Enzyme ▪ADH (vasopressin) ▪Liver ▪Lungs ▪Vasoconstriction ▪Thirst ▪Adrenal cortex Compensation for Decreased Perfusion (3 of 6) ▪The body’s own “medicines” Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Epinephrine and norepinephrine released by adrenal glands in response to hypoperfusion ▪Released by the body as part of the global compensatory state ▪Administered by caregivers in cases of anaphylaxis, severe airway disease, and cardiac arrest Compensation for Decreased Perfusion (4 of 6) ▪The body’s “medicines” (continued) Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Release of epinephrine improves cardiac output by increasing the pulse rate and strength. ▪Alpha-1 response to release of epinephrine includes: ▪ Vasoconstriction ▪ Increased peripheral vascular resistance ▪ Increased afterload from the arteriolar constriction Compensation for Decreased Perfusion (5 of 6) ▪The body’s “medicines” (continued) Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Alpha-2 effects ensure a regulated release of alpha-1. ▪Effects of norepinephrine are primarily alpha-1 and alpha-2: ▪ Centre on vasoconstriction and increasing PVR * ▪**“Golden hour of trauma” Compensation for Decreased Perfusion (6 of 6) ▪As hypoperfusion persists Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Myocardial oxygen demand continues to increase. ▪*Compensatory mechanisms fail. ▪Myocardial function worsens. ▪**Tissue perfusion decreases. ▪***Fluid may leak from the blood vessels. Types of Shock (1 of 4) ▪Impairment of cellular metabolism Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Inadequate oxygen and nutrient delivery to the metabolic apparatus of the cell ▪Results in the inability to properly use oxygen and glucose at the cellular level Types of Shock (2 of 4) ▪Impairment of cellular metabolism Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com (continued) ▪Cell converts to anaerobic metabolism. ▪ Increased lactic acid production and metabolic acidosis ▪ Decreased oxygen affinity for hemoglobin ▪ Decreased adenosine triphosphate production ▪ Changes in cellular electrolytes ▪ Cellular edema ▪ Release of lysosomal enzymes ▪Elevated blood glucose level due to release of catecholamines and cortisol ▪Fat breakdown (lipolysis) with ketone formation may occur.  Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com Aerobic MetabolismAerobic Metabolism HEAT (417 H2O ATP 36 6 kcal) CO2 6 METABOLI SM GLUCO O2 SE 6  Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com HEAT (32 2 LACTIC ATP ACID kcal) 2 METABOLI Anaerobic Metabolism SM GLUCO SE Types of Shock (3 of 4) ▪Weil-Shubin classification Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Shock from a mechanistic point of view ▪Central shock ▪ Cardiogenic shock ▪ Obstructive shock ▪Peripheral shock ▪ Hypovolemic shock ▪ Distributive shock Types of Shock (4 of 4) ▪Regardless of type Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Characterized by: ▪ Reduced cardiac output ▪ Circulatory insufficiency ▪ Tachycardia ▪Most types also include pallor. ▪Patient’s mental status may be altered. ▪Low blood pressure is a late sign, especially in children. Cardiogenic Shock (1 of 2) ▪Cardiogenic shock Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Heart is unable to circulate sufficient blood to maintain adequate peripheral oxygen delivery ▪*Circulation requires constant pumping of the heart. ▪Many diseases can cause the heart to stop pumping adequately. ▪If too much muscular damage occurs, the heart no longer functions effectively. ▪Filling is impaired because of a lack of pressure to return blood to the heart. ▪Outflow is reduced by a lack of pumping function. Cardiogenic Shock (2 of 2) ▪Most common causes Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Extensive infarction of the left ventricle ▪Diffuse ischemia ▪Decompensated heart failure resulting in primary pump failure ▪May be due to a single massive event or from cumulative damage ▪Patients have a poor prognosis when more than 40% of the left ventricle does not function. ▪Mortality rates range as high as 80%, even with appropriate therapy ▪LVAD video ▪.https://www.youtube.com/watch?v=Fh7E2G4-Rlk Obstructive Shock ▪Blood flow in the heart or great vessels Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com becomes blocked. ▪Pericardial tamponade ▪Obstruction of the superior or inferior vena cava ▪Large pulmonary embolus or tension pneumothorax Hypovolemic Shock (1 of 6) ▪Circulating blood volume is not Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com sufficient to maintain adequate perfusion ▪Exogenous or endogenous, depending on where fluid loss occurs ▪Most common cause of exogenous is external bleeding due to: ▪ Blunt or penetrating injuries ▪ Long bone or pelvic fractures ▪ Major vascular injuries ▪ Multisystem injury Hypovolemic Shock (2 of 6) ▪Organs and organ systems with a high Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com incidence of exsanguination from penetrating injuries include: ▪ Heart ▪ Liver ▪ Spleen ▪ Thoracic vascular system ▪ Abdominal vascular system ▪ Venous system Hypovolemic Shock (3 of 6) ▪Endogenous occurs when the fluid loss is Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com contained within the body. ▪ Dehydration ▪ Burn injury ▪ Crush injury ▪ Anaphylaxis Hypovolemic Shock (4 of 6) ▪Abnormal losses of fluids and electrolytes Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ *GI losses ▪ Fever, hyperventilation, or high environmental temperatures ▪ Increased sweating ▪ Internal losses ▪ Plasma losses Hypovolemic Shock (5 of 6) ▪Other causes include ascites, diabetes Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com insipidus, acute renal failure, and osmotic diuresis secondary to hyperosmolar states ▪*Fluid loss ▪ Therapy aims to restore deficient chemicals. ▪Symptoms of dehydration ▪ Loss of appetite ▪ Nausea ▪ Vomiting ▪ Fainting when standing up Hypovolemic Shock (6 of 6) ▪Physical examination reveals: Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Poor skin turgor ▪ Shrunken, furrowed tongue ▪ Sunken eyes ▪Pulse will be weak and rapid. ▪Dehydrated patients need replacement of fluid and electrolytes; IV infusion of normal saline or lactated Ringer solution at a rate of 100 to 200 mL/h for an adult. Distributive Shock (1 of 5) ▪Distributive shock Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Widespread dilation of the resistance vessels, the capacitance vessels, or both. ▪Circulating blood volume pools in the expanded vascular beds and tissue perfusion decreases ▪Three most common types: ▪ Septic ▪ Neurogenic ▪ Anaphylactic Distributive Shock (2 of 5) ▪Septic shock Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Presence of sepsis syndrome and a systolic blood pressure of less than 90 mm Hg or a decrease from the baseline blood pressure of more than 40 mm Hg ▪ Sepsis: result of widespread infection ▪ Complex interactions between pathogen and body’s defence systems ▪ Uncontrolled and unregulated inflammatory-immune response ▪ Result: hypoperfusion to cells, tissue destruction, organ death ▪ Left untreated: multiple-organ dysfunction syndrome and, often, death. ▪ Complex problem: insufficient volume of fluid; fluid that leaks out often collects in the respiratory system; larger-than-normal vascular bed is asked to contain the smaller-than-normal volume of intravascular fluid Distributive Shock (3 of 5) ▪Neurogenic shock Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Usually results from spinal cord injury ▪Loss of normal sympathetic nervous system tone and vasodilation ▪Muscles in the walls of the blood vessels ▪All vessels below the level of spinal injury dilate widely. ▪Perfusion becomes inadequate. ▪Relative hypovolemia leading to hypotension ▪Skin is pink, warm, and dry. ▪No release of epinephrine and norepinephrine ▪Absence of sweating below the level of injury Distributive Shock (4 of 5) ▪Spinal shock Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪*Local neurologic condition after a spinal injury produces motor and sensory losses ▪Characterized by flaccid paralysis, flaccid sphincters, and absent reflexes ▪Absence of all pain, temperature, touch, proprioception, and pressure below the level of the lesion ▪Absent or impaired thermoregulation ▪Absent somatic and visceral sensations below the lesion ▪Bowel distension ▪Loss of peristalsis Distributive Shock (5 of 5) ▪Anaphylactic shock Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Severe reaction to a foreign substance ▪Patient experiences widespread vascular dilation*, resulting in relative hypovolemia. ▪Immune system chemicals are released, causing severe bronchoconstriction. ▪Fluid leaks out of the blood vessels and into the interstitial spaces. ▪Swelling may occlude the upper airway. ▪Angioedema*  (continued ) ▪You decide that the patient does not have spinal involvement. He reports that he was not Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com blown to the ground, but rather felt dizzy and sat down on his own. You and your partner decide to quickly pick the patient up and load him onto the stretcher, rather than spending the time for spinal immobilization to a backboard. You also decide to insert the IV line en route to the regional trauma centre. ▪The patient is starting to become confused as you place him into Trendelenburg position and head out the door. He states that he is nauseated and thirsty and asks your partner, “Am I going to die?” When closing the back of the ambulance, you note on your watch that 7 minutes have elapsed on the scene. Your plan for the next few minutes is to redo the initial assessment, get IV fluids running, do the rapid trauma assessment and SAMPLE history, and notify the ED. ▪ For this patient, is the SpO2 a helpful indicator? ▪ Why were the baseline vital signs not taken on the scene? Shock-Related Events (1 of 4) ▪At the capillary and microcirculatory Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com levels ▪As perfusion decreases ▪ Cellular ischemia occurs. ▪ Minimal blood flow passes through the capillaries. ▪ Cells switch from aerobic metabolism to anaerobic metabolism. Shock-Related Events (2 of 4) ▪Anaerobic metabolism Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Body can tolerate for only a limited time ▪Much less efficient ▪Systemic acidosis and depletion of the body’s high energy reserves ▪Accumulation of pyruvic acid ▪Increased carbon dioxide production* ▪Sodium Shock-Related Events (3 of 4) ▪Intracellular enzymes Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Digest and neutralize bacteria ▪Bound in a relatively impermeable membrane ▪Cellular flooding damages the membrane and releases these enzymes. ▪Autodigest the cell ▪If enough cells are destroyed in this way, organ failure will become evident. ▪Opens the floodgates for the onset of the last phase of shock Shock-Related Events (4 of 4) ▪Accumulating acids and waste products Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Act as potent vasodilators ▪Decrease venous return and diminish blood flow to the vital organs and tissues ▪*When aortic pressures fall below a MAP of 60 mm Hg, the coronary arteries no longer fill, the heart is weakened, and the cardiac output falls. ▪**Cessation of sympathetic nervous system activity ▪***Metabolic wastes are released. ▪Accumulated hydrogen, potassium, carbon dioxide, and thrombosed RBCs wash out into the venous circulation. ▪Ischemia and necrosis ultimately lead to multiple-organ dysfunction syndrome. Systemic Inflammatory Response Syndrome (1 of 10) ▪SIRS - https://www.youtube.com/watch?v=90LnNDOSjjA Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Systemic inflammatory response to a variety of severe clinical insults ▪Does not confirm a diagnosis of infection or sepsis because the features in SIRS can be seen in many other conditions, including trauma, burns, and pancreatitis. ▪SIRS + infection = sepsis ▪Not a diagnosis itself, nor a good indicator of outcome ▪Definition proposed in 1991 by the American College of Chest Physicians and the Society of Critical Care Systemic Inflammatory Response Syndrome (2 of 10) ▪Manifested by two or more of the Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com following conditions: ▪Temperature greater than 38°C or less than 36°C ▪Heart rate greater than 90 beats/min ▪Respiratory rate greater than 20 breaths/min or PCO2 less than 32 mm Hg ▪White blood cell count greater than 12 × 109 cells/L or less than 4 × 109 cells/L Systemic Inflammatory Response Syndrome (3 of 10) ▪Release of cytokines in severe sepsis Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com and injury ▪Central to the development of SIRS ▪Central mediator is activated and released Systemic Inflammatory Response Syndrome (4 of 10) ▪Specific organs and organ systems Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Cardiovascular ▪ Tachycardia and hypotension ▪ Myocardial depression and ischemia ▪ Peripheral pulses are weak or absent ▪ Extremities become cyanotic and cold Systemic Inflammatory Response Syndrome (5 of 10) ▪Respiratory Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Tachypnea and increased minute ventilation ▪ Impaired gas exchange* ▪ Alveolar cells become ischemic ▪ Respiratory failure, severe hypoxemia, and respiratory acidosis Systemic Inflammatory Response Syndrome (6 of 10) ▪Central nervous system Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Decreased cerebral perfusion pressure and cerebral blood flow result in confusion, reduced responses to verbal and painful stimuli, and unresponsiveness. Systemic Inflammatory Response Syndrome (7 of 10) ▪Renal system Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Reduction in renal blood flow produces acute tubular necrosis leading to oliguria. ▪ Toxic waste products cannot be excreted. ▪ Metabolic acidosis worsens. Systemic Inflammatory Response Syndrome (8 of 10) ▪Liver and gastrointestinal tract Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Hypoperfusion results in ischemic gut. ▪ Failure to metabolize waste products ▪ Cell death evidenced by an increase in enzyme levels. Systemic Inflammatory Response Syndrome (9 of 10) ▪Metabolic Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Respiratory alkalosis is the first acid–base abnormality. ▪ Shock progresses with metabolic acidosis. Systemic Inflammatory Response Syndrome (10 of 10) ▪Uncontrolled SIRS Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Can lead to hypotension, inadequate perfusion, death ▪SIRS and sepsis can progress to multiple- organ dysfunction syndrome (MODS).  Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com Phases of Shock (1 of 5) ▪Three successive phases ▪Decompensated ▪Compensated ▪Irreversible*  Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com I D Blood Pressure Changes* C Diastolic Children Systolic  Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com © Jones & Bartlett Learning. Phases of Shock (2 of 5) Phases of Shock (3 of 5) ▪Compensated phase of shock Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Earliest stage ▪Body can still compensate for blood loss. ▪Level of responsiveness is best indicator of tissue perfusion (better than the other signs). ▪Blood pressure is maintained. Phases of Shock (4 of 5) ▪Compensated phase of shock Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com (continued) ▪Blood loss in hemorrhagic shock can be estimated at 15% to 30%. ▪*Narrowing of the pulse pressure occurs. ▪Positive orthostatic tilt test result ▪Treatment will typically result in recovery.  Phases of Shock (5 of 5) ▪Decompensated phase of shock Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Blood pressure is falling. ▪Blood volume drops by more than 30%. ▪Compensatory measures begin to fail. ▪Signs and symptoms are more obvious - ie the skin becomes mottled and pupils dilate.* ▪Cardiac output falls dramatically.* ▪Treatment will sometimes result in recovery.** ▪IV and fluid therapy medical directive pg 183 ▪https://www.health.gov.on.ca/en/pro/programs/emergency_health/docs/ advanced_life_support_patientcare_v5_2_en.pdf The Clinical Picture of Hypovolemic Shock (1 of 5) ▪Typical signs and symptoms Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪*Inadequate tissue oxygenation and the attempt to compensate ▪Earliest signs of shock are restlessness and anxiety…pt looks scared ▪Decline in tissue perfusion sets off alarms all over the body. The Clinical Picture of Hypovolemic Shock (2 of 5) ▪Typical signs and symptoms Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com (continued) ▪If conscious, the patient may complain of thirst and feel nauseated. ▪Skin becomes pale, cool, and clammy. ▪Heart speeds up to circulate the remaining RBCs more rapidly. The Clinical Picture of Hypovolemic Shock (3 of 5) ▪While arteries constrict and heart Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com speeds up ▪Brain signals the respiratory muscles to speed up their activity. ▪As bleeding continues ▪*The blood pressure falls. ▪Falling blood pressure is a late sign in shock. The Clinical Picture of Hypovolemic Shock (4 of 5) ▪Treatment goal Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Save the brain and kidneys.* ▪Best indication of brain perfusion is the state of consciousness. ▪ If the patient is conscious and alert, the brain is being perfused adequately. ▪ If the patient is confused, disoriented, or unconscious, perfusion of the brain is likely inadequate. The Clinical Picture of Hypovolemic Shock (5 of 5) ▪Treatment goal (continued) Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Kidney perfusion can be gauged by urine output. ▪ *Adequately perfused kidneys ▪ Poorly perfused kidneys shut down. ▪ Test for kidney perfusion in the prehospital setting with capillary refill.**  (continued ) ▪ You and your partner can focus on the patient for the entire 15-minute trip to the hospital. You Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com insert a large-bore IV catheter and give normal saline. You have just enough time to repeat the initial assessment before you call the ED to report the patient’s condition. The physician advises you to insert a second IV line. Meanwhile, your partner prepares to begin ventilatory assistance with a bag-mask device. The patient’s mental status has diminished, signaling he is truly fighting for his life. ▪ When you return to the ED about 4 hours later, the patient is still holding on after a few hours of intensive surgery. He had major internal bleeding and damage to his stomach and spleen and major vessel damage from a bullet fragment. The ED physician states that in this case, the patient’s best chance was the operating room. Because of your quick judgment about how to save time on the scene and your willingness to call ahead so the ED was ready, the patient made it to the operating room about 35 minutes after the shooting. ▪ Without interventions in the prehospital setting, how long would this patient have lived? ▪ What is the benefit of calling ahead and focusing on the time factor? General Assessment of a Patient With Suspected Shock (1 of 6) ▪Assessment plan Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Scene assessment for hazards ▪Standard precautions ▪Address the need for additional help ▪Initial assessment ▪Scene assessment ▪Also includes a quick assessment of the MOI ▪For a patient with suspected shock, this information can give you clues about the cause and the extent of any bleeding. General Assessment of a Patient With Suspected Shock (2 of 6) ▪Initial assessment Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Form an initial diagnosis. ▪Assess mental status. ▪Manage life threats to airway, breathing, and circulation. ▪In conscious patients, assess the pulse at the radius. ▪In unconscious patients, assess the carotid pulse in the neck. ▪Radial pulse* General Assessment of a Patient With Suspected Shock (3 of 6) ▪Priority Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Patients with shock will usually be prioritized as “high.” ▪*If the shock originates from a medical problem ▪*If the shock originates from trauma General Assessment of a Patient With Suspected Shock (4 of 6) ▪SAMPLE history and baseline vital signs Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Can be done en route to the ED ▪Time is of the essence in shock cases. ▪Keep the on-scene care to essential items. ▪Delay inserting IV lines until en route. ▪Considered hypovolemic or hemorrhagic until ruled out  Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com General Assessment of a Patient With Suspected Shock (5 of 6) © Jones & Bartlett Learning.  Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com General Assessment of a Patient With Suspected Shock (6 of 6) © Jones & Bartlett Learning. Treatment of a Patient With Suspected Shock (1 of 4) ▪Airway and ventilation support Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪Take top priority as with any patient. ▪Maintain an open airway, and suction as needed. ▪Give high-flow supplemental oxygen. ▪Consider early definitive management in patients who are unable to maintain their own airway. ▪Control any external hemorrhage. ▪Try to estimate the amount of blood loss. ▪Look for signs of internal hemorrhage. Treatment of a Patient With Suspected Shock (2 of 4) ▪IV fluid therapy Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com ▪ Two large-bore catheters ▪ Administer IV fluid to maintain perfusion.* ▪ Solutions of dextrose in water are not effective. ▪ Presence of radial pulses equates to systolic blood pressure of 80 to 90 mm Hg. ▪ Growing evidence suggests titration of systolic blood pressure to 80 to 90 mm Hg is preferred for hemorrhagic shock. ▪ This low pressure (permis­sive hypotension) may allow the body to clot better and not dis­- lodge clots already formed. ▪ Consider the entire patient before using permissive hypotension.** ▪ Even a single episode of hypotension (systolic blood pressure