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Shock and Bleeding in the Trauma Patient
April Morgenroth RN, MN
Shock: Hypoperfusion
Hypoperfusion: A state where the body’s organs are not sufficiently perfused with oxygenated blood.
Nursing Priorities
Establish “Rapid Dominance “ over states of hypoperfusion by:
Early recognitionAggressive treatment Prevention of progressive and
decompensated stages of shock
Recognizing Shock
Types of Shock:Distributive:
NeurogenicSepticAnaphylactic
Cardiogenic:MI, Cardiomyopathy, tamponade
Hypovolemic:Relative vs. Absolute
Key Points
Pressure = amount of stuff in a given space
Remember: Hypoperfusion= oxygenated blood not getting where it needs to goBlood is driven by pressures
Distributive Shock
Insult
Vasodilation
Same Stuff/ More Space
Hypotension
Causes of Distributive Shock
Neurogenic: Head injuries Spinal Cord injuries Pain and drugs
Septic: UTI SIRS Bacteremia
Anaphylactic Bee stings Drugs Foods
The Autonomic Nervous SystemThe autonomic nervous system controls the body’s involuntary
functions: digestion, heartbeat, respirations…Sympathetic Nervous System Parasympathetic Nervous
System
Fight or Flight
Regulate the body’s response to danger or threat: •Vasoconstriction•Rapid Heartbeat•Deep Respirations•Dilated Pupils
Rest and Digest
The body’s resting state allowing metabolism and energy conservation:•Vasodilation•Increased blood flow to the gut•Slower Heartbeat•Lower Blood Pressure
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Neurogenic Shock
Damage to the brain and spinal cord
Loss of Sympathetic Tone:
Parasympathetic Nervous System is
Unopposed
Uncontrolled Vasodilation
Low Blood Pressure
Hypoperfusion: Shock
Septic Shock
Cytokines released in response to infection
Vasodilation and increase capillary permeability
Decreased SVR
Decreased Pressure
Decreased Perfusion
Anaphylactic Shock
Allergen
Massive Release of Mast Cells
Systemic Vasodilation
Increased Capillary Permeability
Edema
Hypotension
Hypovolemic Shock
Hypovolemic Shock= Decreased amount of fluid in the vascular space
Absolute: external fluid lossHemorrhageBurnsDieresis
Relative: Internal fluid shiftInternal bleedingBlood pooling
Hypovolemic Shock
Decreased fluid in circulation
Decreased preload in the heart
Decreased stroke volume
Decreased cardiac output
Hypovolemia: The Body’s Response
The Body will always strive to work toward a state of homeostasis, as steady state of balance.
Mechanism Response Clinical Picture
Decreased fluid in circulation
Vasoconstriction Shunting of blood from the periphery, gut, kidneys, and liver to the vital organsThe body will release hormones to hold water
Cool, clammy, pale extremities, nausea, vomiting, decreased urine output. Prolonged hypoperfusion: Increase in BUN Creatinine Possible kidney failure .
Decreased preload in the heart
Increased heart rate Tachycardia Arrhythmias
Decreased Stoke Volume
Increased heart rate Cardiac output= stroke volume x heart rate
Narrowed pulse pressure: systolic and diastolic pressures begin to equalize
Decreased Cardiac Output
Increased heart rate Delayed capillary refill, hypoperfusion
Respiratory Response
Patient hyperventilates and blows off excessive carbon dioxide causing respiratory alkalosis
Bleeding =
Less red blood cells =
Less oxygen carrying capacity
Patient becomes short of breath and tachypnic
CO2
Compensated Shock
In compensated:Body’s compensatory
mechanisms temporarily maintain a steady state.
Vital organs perfused.Blood pressure stable.
Blood is shunted from the periphery.
Sympathetic nervous system is activated.
You may start to see the following early signs.
Blood pressure may be normal or somewhat low
Anxious
Tachycardia/rapid pulse
Tachypnea
Extremities may be cool and pale under the nail beds.
http://www.ronjones.org/Health&Fitness/FunctionalTraining/anatomicalposition.htm
Clinical Manifestations of Progressive Shock
Confusion, listlessness, apathy decreased response to painful stimuli
Tachycardia Beta blockers may blunt Weak or absent peripheral pulses
Hypotension (SBP < 90) & falling > 25% decrease in hypertensive pt May need to use doppler or Arterial line
Resp rapid & shallowLow urine output
ThirstSkin cool & clammy, dusky, slow capillary
refill
Decompensated Shock
Decompensated Shock:Body exhausts
reservesDamage is not
reversiblePatient will
eventually die.
Blood pressure continues to fall
Pulse pressure narrows
Altered level of consciousness
Slow deep respirations
Cyanosis
Cold extremities
arrhythmias
Metabolic Response
As the body continues to fight against the altered state it begins to go into anaerobic metabolismThis causes a build of lactic acid eventually leading to a metabolic acidosis
Metabolic acidosis and respiratory alkalosis can exist concurrently to some degree compensating for one another resulting in a relatively normal pH.
O2
Assessment for Shock
Recent history of event putting pt at riskAssess for clinical manifestations
General appearance & skin LOC & orientation Vitals Urine output
Foley if at risk, or evidence of shock Bleeding (external or internal) or fluid loss Signs of cardiac dysfunction Hemodynamic parameters ABGs & oxygen saturation
Aggressive Treatment
Always begin with ABCs: airway, breathing, circulation
Airway: establish and maintain the airwayBreathing: be prepared to support breathing with supplemental O2, manual ventilation may be needed
Circulation: be prepared for massive fluid resuscitation and make plans for circulatory support
Basic TreatmentIntervention Rational
Raise the feet Dumps blood to vital organs of the body by gravity
Supplemental Oxygen
Maximizes oxygenation of red blood cells
Indentify and remove cause (if possible)Stop the bleeding, treat the infection etc…
Removing the mechanism prevents worsening of symptoms and is vital in recovering the patient.
Two large bore IVs Provide access for medication administration and fluid replacement therapy
Check Electrolytes and Hematocrit
Loss of body fluids plus the body’s altered state can cause dangerous electrolyte imbalances. A patients hematocrit can drop quickly in the presence of heavy bleeding.
Protect from hypothermia In an altered state, thermoregulation is affected
Fluid ResuscitationMore Stuff in the Space
Three liters of normal saline replaces 1 liter of blood lost for intravascular volume to come out even.
Fluid shifts and much of it is displaced into the surrounding tissues
=BLOOD
LOST
Fluid Effect Drawbacks
Hypertonic Solutions: higher salt concentrations
Remain in the intravascular spaceRapid fluid volume expansion(salt sucks)
Watch for hypernutremia (seizures and confusion)
Blood Products Replace fluid volumeIncrease oxygen carrying capacitysevere bleeding may require blood
Availability, possibility for transfusion reaction
ColloidsAlbumin
Large molecules remain in inctravascular spaceIncrease osmotic pressure (protein sucks)
Availability and expense
Lactated Ringers Replacement of fluid volume and some electrolytes
Compromised liver can’t metabolize lactic acid into bicarbonate and lactic acid may build up
Normal Saline Replaces fluid volume Generally more available
Caution in patients who have high sodium
Fluid Resuscitation
Obtain I.V. access
Choose the most appropriate I.V. fluid for the situation
Two Large Bore I.V.s 18 gauge or
largerChoose a large vein
LR
Fluid ResuscitationInfusion Rates
Normalize
In severe cases of hypovolemic shock, fluids may initially need to be run wide open as fast as possible.
Assess the patient frequently and document their response to interventions
Heart rateBlood
PressureRespiratory RateSkin Temperature
Once the patient becomes more stable the infusion rate may be slowed.
Fluid Volume Overload
seejanenurse.files.wordpress.com/2007/07/lung
Fluid volume overload can result from rapid aggressive fluid resuscitation.
If you see signs and symptoms of fluid overload you may need to slow infusion rate and/or stop fluids if the patient is stable enough. The patient may need careful dieresis once stable.
Keep Track of : Vital signsIntake and
OutputWeight gain
or loss
Look for:Pitting edemaIncreased respiratory rateOrthopneaWet sounding lungsPink frothy sputum Massive weight gain
Circulatory Support Space/Vasoconstriction
Medications: Vasopressors:
DopamineNorepinepherine/ LevophedVasopressin
Considerations: Use of these meds requires intense monitoring and titration.Monitor: EKG, BP, HR, RR, O2, hemodynamics, peripheral
pulses.Prolonged use at higher doses can cause peripheral tissue
damage related to ischemia.
Aggressive Care
Constant Assessment:Indentify the cause!Notice signs and symptoms early
Aggressive Treatment: Treat the cause effectivelySupport the body systems
Hemorrhage Control
Direct Pressure
Application of direct pressure to a open wound helps to control bleeding and can help to speed the body’s natural process of clot formation.
Use sterile or clean dressing to apply direct pressure over the bleeding wound.
Be careful with wounds to the chest and neck, too much pressure can impair breathing.
Pressure Dressings
• Place sterile dressing directly over the wound.
• Stack bulky dressings on top.
• Wrap a gauze dressing snuggly around the wound.
• Tie the rolled gauze with the knot directly over padding previously placed over the wound.
• If gauze becomes soaked add more on top.
Reassess: • Sensory, motor, circulatory
function distal to the wound
Use of the Tourniquet
• Attempt to control bleeding with direct pressure, and pressure dressing before using a tourniquet.
• Wrap the wound snuggly
• Pile dressings over the wrap
Wrap wound again leaving two long ends.
• Wrap the ends around a stick • Use the stick to twist the
tourniquet tighter until bleeding is controlled
Tournquets should only be used with other method of hemorrhage control have failed.
Use of the Tourniquet
Tie a knot to secure the stick in placeBe sure to label with date and time of
applicationReassess the patient frequently and document
your findings
.
Inappropriate use of a tourniquet can be very dangerous!
Internal BleedingInternal bleeding: bleeding out of vessels into tissue.
• Early Recognition + Early Intervention = Better Outcome
Mechanism of injury: crushing injury, impact, blows to the head, chest, abdomen, car vs. pedestrian accident
Signs:• Hematoma• Edema• Area under the skin may be firm• Pain• Signs of shock• Vomiting or coughing up blood • Pain directly over an organ
Emergency: Pt may need surgery, call doctor immediatelyPatients with internal bleeding can die very quickly if they are not
treated immediately!