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Volume 4 Chapter 3: Hemorrhage and Shock
Introduction to Hemorrhage and Shock
Shock (1 of 2)• Shock is a state of inadequate tissue ____________________________________• Complicated transitional stage between normal life (homeostasis) and death• Ultimate ____________________________________ of all trauma and medical patients• Often presents with limited signs and symptoms
Shock (2 of 2)• Hemorrhage: blood loss• Hemorrhagic shock: inadequate perfusion (shock) resulting from
____________________________________ loss (internal or external) from vascular container• Frequent ____________________________________ of trauma• Common cause of shock and death in trauma patients
The Circulatory System3 Components of The Circulatory System:• The ____________________________________• The Vascular System (Blood Vessels)• The ____________________________________
The Heart (1 of 2)• Blood flow depends on functioning heart (pump)• ____________________________________ volume: volume of blood ejected from heart with each
beat• Stroke Volume is dependent on:
– ____________________________________–Cardiac contractility–Afterload
The Heart (2 of 2)• ____________________________________: blood flowing to heart
–Amount available to be pumped out• Cardiac contractility: strength of ____________________________________
– The more forceful the contraction, the greater the potential for increased output• ____________________________________ or peripheral vascular resistance: resistance to blood
flow out of heart
Figure 3-1 Factors Affecting Stroke Volume(Page 60)
The Vascular SystemThree types of vessels: • ____________________________________• Capillaries
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Capillaries• ____________________________________
Arteries (1 of 3)• Arteries distribute blood to various regions of body (pumped
____________________________________ from the heart)–All except the pulmonary artery carry oxygenated blood
• Contain about 13% of the blood volume• Smaller arteries (____________________________________) can vary lumen size and control blood
flow to organs.• Major determinants of peripheral vascular resistance.
Arteries (2 of 3)Mean Arterial Pressure:• The measurement of peripheral vascular ____________________________________• Formula:
–Diastolic BP + Diastolic BP + Systolic BP3
Arteries (3 of 3)Mean Arterial Pressure (cont’d):• Example: A patient has a BP of 90/60:
–MAP = 60 + 60 + 903
–MAP = 2103
–MAP = ____________mmHg
Capillaries• Capillaries are microscopic vessels large enough for red blood cells to pass through only in
____________________________________ file • Close proximity to all body cells• Contain about 7% of the vascular volume• Walls are ____________________________________ cell thick and allows for efficient gas and
metabolic movement in and out of vessels
Veins• ____________________________________ transport blood back to the heart
–With the exception of the pulmonary vein, veins carry unoxygenated blood• Contain 64% of blood volume (capacitance vessels)• Venous ____________________________________ effective in maintaining venous return (preload)
in early stages of hypovolemic (low volume) shock
The Blood (1 of 3)• The blood is a mixture of ____________________________________, cells, proteins, and suspended
elements• ____________________________________: fluid portion of blood
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____________________________________: fluid portion of blood–Accounts for about 55% of blood volume–Consists mostly of water, dissolved salts, proteins, and other necessary materials
The Blood (2 of 3)Red blood cells (____________________________________): • Responsible for oxygen transport• Accounts for about 45% of total blood volume• ____________________________________: the percentage of the total blood volume consisting of
RBCs• Erythrocytes contain hemoglobin responsible for oxygen transport from alveoli to cells.• Hemoglobin: iron-based compound that binds with oxygen for transport to body cells
The Blood (3 of 3)• Platelet: important for ____________________________________ and blood vessel repair
– If platelets are too plentiful, blood ____________________________________ can develop– If platelets are too decreased, significant bleeding can occur
Types of Hemorrhage (1 of 4)Capillary hemorrhage:• Blood ____________________________________ from wound• Caused by abrasion or ____________________________________ injury• Stops quickly• Blood bright red; well oxygenated
Types of Hemorrhage (2 of 4)Venous hemorrhage:• Flows more ____________________________________• Tends to stop in few minutes • Hemorrhage ____________________________________; oxygen depleted after passage though
capillary beds• Can sometimes be extensive because of size and number of vessels involved
Types of Hemorrhage (3 of 4)Arterial hemorrhage:• Flows very ____________________________________, often spurting from wound• Blood ____________________________________ red; well oxygenated• Blood volume lost can be significant because of ____________________________________ and the
vessel size• Bleeds longer
Types of Hemorrhage (4 of 4)
Hemostasis (1 of 7)____________________________________: the body’s response to local hemorrhage that occurs in 3 phases• Vascular phase• ____________________________________ phase
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____________________________________ phase• Coagulation phase
Hemostasis (2 of 7)Vascular phase:• Smooth muscle within walls ____________________________________ causing vessel to withdraw
into wound, –Causes a ____________________________________ wall, reducing the size of the opened wound
Hemostasis (3 of 7)Platelet phase:• Platelets aggregate, or ____________________________________ and adhere; slowing hemorrhage
from capillaries and small vessels
Hemostasis (4 of 7)Coagulation phase:• ____________________________________ factors activated and released into bloodstream resulting
in a complex cascade of events• Triggers series of chemical reactions and the formation of strong protein fibers
(____________________________________) that strand forming strong protein mesh
Hemostasis (5 of 7)• Wound type affects hemostasis and clot formation• Systemic ____________________________________ beneficial in controlling serious internal
hemorrhage– Increased blood ____________________________________ can result in increased blood loss
Figure 3-5 The Type of Blood Vessel Injury Often Affects the Nature of the Hemorrhage (Page 63)
Hemostasis (6 of 7)Factors Affecting Hemostasis:• Immediate immobilization (____________________________________) wound site aids clotting
process• Aggressive fluid therapy may ____________________________________ affect hemostasis
– Fine line between maintaining perfusion and increasing blood loss• As body ____________________________________ falls below normal, hemostasis slower and less
effective
Hemostasis (7 of 7)Factors Affecting Hemostasis (cont’d):• ____________________________________ to prevent or limit heart attack or stroke, slow clot
formation and increase risk for hemorrhage.–Aspirin, NSAIDs, ____________________________________, Plavix, Lovenox, warfarin, Prodoxa.
Hemorrhage Control (1 of 12)External hemorrhage:• Look for severe and continuing external hemorrhage• Capillary and venous bleeding from small vessels can be controlled by firmly
____________________________________ dressing over wound
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____________________________________ dressing over wound• More severe bleeding controlled with direct ____________________________________ on dressing
and wound
Hemorrhage Control (2 of 12)Tourniquets:• Tourniquets can be used on ____________________________________ when other methods have
failed –Only for life threatening bleeding
• When TQ is released and blood flow resumes, ____________________________________ products of metabolism move into central circulation, potentially worsening patient's condition
Hemorrhage Control (3 of 12)Tourniquet (cont’d):• Allow tourniquet to ____________________________________ in place until patient in emergency
department• Use ____________________________________ tourniquet or wide cravat, belt, blood pressure cuff
Hemorrhage Control (4 of 12)Internal hemorrhage:• Can occur from all forms of serious ____________________________________ and penetrating
trauma• Can be capillary, venous, or arterial blood loss• Blood can accumulate in ____________________________________ spaces resulting in contusion• Forced between layers of tissue (fascia); will form pocket of blood (hematoma)
Hemorrhage Control (5 of 12)Internal Hemorrhage (cont’d): • Indicators: localized injury signs and symptoms; ____________________________________ signs
and symptoms of blood loss and shock• If significant ____________________________________ to chest, abdomen, pelvis, be alert for
significant, continuing, uncontrolled blood loss
Hemorrhage Control (6 of 12)Internal Hemorrhage (cont’d): • Careful assessment; rapid transport to ____________________________________ center.• If in extremities, effective ____________________________________ can aid in bleeding control (if
time and manpower allow)
Hemorrhage Control (7 of 12)Internal Hemorrhage (cont’d): • The drug tranexamic acid (____________________________________) is beginning to be used in
EMS: –Anti-fibrinolytic – Inhibits ____________________________________ (the process that prevents blood clotting)
Hemorrhage Control (8 of 12)
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Internal Hemorrhage (cont’d): • Patients with significant trauma develop ____________________________________: condition in
which blood's ability to clot is impaired• TXA can reduce trauma mortality by ____________________________________ fibrinolysis
Hemorrhage Control (9 of 12)Internal Hemorrhage (cont’d): • Evidence may present at body ____________________________________• Nasal cavity: mild to moderate hemorrhage (____________________________________)• Blood evacuated shortly after ingestion will be bright red in color
Hemorrhage Control (10 of 12)Internal Hemorrhage (cont’d): • Blood in gastrointestinal tract for long time will result in emesis that resembles wet
____________________________________ grounds in color and consistency• Lower respiratory injuries can result in coughing up bright red blood
(____________________________________).• Upper digestive system injury may cause blood to accumulate in stomach resulting in
emesis containing blood (____________________________________)
Hemorrhage Control (11 of 12)Internal Hemorrhage (cont’d): • Small or large bowel can result in frank rectal bleeding, blood mixed with stool
(____________________________________)• Blood that remains in bowel for some time will appear as black and tarry stool
(____________________________________).• Rectal injuries can occur in conjunction with pelvic fractures or direct trauma and may
cause severe bright red rectal hemorrhage
Hemorrhage Control (12 of 12)Internal Hemorrhage (cont’d): • Vaginal: may be associated with ____________________________________ (rare)• Urethral hemorrhage is generally ____________________________________ and may reflect
damage to prostate or urethra• Blood in urine may indicate injury to genitourinary tract
Classes of Hemorrhage (1 of 14)• Fluid accounts for about ___________% of the body's weight distributed among intracellular,
interstitial, intravascular spaces.• Hemorrhage categorized into four classes that relate to blood
____________________________________ lost in acute hemorrhage and result in "classic" signs and symptoms of hemorrhage and shock.
Classes of Hemorrhage (2 of 14)Class I Hemorrhage:• Blood loss of up to 15% (750mL) of circulating blood volume• Healthy patient can easily ____________________________________ for such blood volume loss
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Healthy patient can easily ____________________________________ for such blood volume loss• Blood pressure remains ____________________________________, as do pulse pressure, respiratory
rate, and urine output
Classes of Hemorrhage (3 of 14)Class I Hemorrhage (cont’d):• Body may show signs of catecholamine (epinephrine and norepinephrine) release causing:
–Nervousness/____________________________________–Marginally cool skin with slight pallor– Slight pulse ____________________________________
Classes of Hemorrhage (4 of 14)Class II Hemorrhage:• 15 to 30% (750 to 1,500mL) of blood volume lost• First-line compensatory responses can no longer maintain
____________________________________• Secondary mechanisms employed:
– ____________________________________ occurs; pulse pressure narrows; pulse strength diminishes
Classes of Hemorrhage (5 of 14)Class II Hemorrhage (cont’d):• Strong ____________________________________ release results in increased peripheral vascular
resistance do to vasoconstriction–Aids in maintenance of BP
• Increased restlessness/anxiety and thirst• ____________________________________ output remains normal• Respiratory rate increases
Classes of Hemorrhage (6 of 14)Class III Hemorrhage:• Blood loss of 30 to 40% (1,500 to 2,000mL) of blood volume• Compensatory mechanisms ____________________________________ to cope with loss; classic
signs of shock• Tachycardia more ____________________________________ as blood pressure begins to fall• Pulse barely palpable
Classes of Hemorrhage (7 of 14)Class III Hemorrhage (cont’d):• Patient may display dyspnea and ____________________________________• Anxiety, restlessness, thirst more pronounced• ____________________________________ status may be altered• Pale, cool, ____________________________________• Urinary output declines• Process rapidly becoming more difficult for body to sustain
Classes of Hemorrhage (8 of 14)
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Class IV Hemorrhage:• Blood loss greater than 40% (2,000mL) of total blood supply• Pulse barely ____________________________________ in central arteries• ____________________________________ very rapid, shallow, and ineffective
Classes of Hemorrhage (9 of 14)Class IV Hemorrhage (cont’d):• Skin very cool, pale and diaphoretic • Urinary output ____________________________________• Very lethargic and ____________________________________ moving rapidly to unresponsiveness• Even with fluid resuscitation and blood transfusion, ____________________________________ is
unlikely
Table 3-1 Patient Signs Associated with Stages of Hemorrhage (Page 66)
Classes of Hemorrhage (10 of 14)• Preexisting conditions can affect volume of blood loss
– ____________________________________ status, medication, diseases, etc.• Blood loss ____________________________________ has profound effect on how quickly patient
moves from class I to class IV
Classes of Hemorrhage (11 of 14)Certain patient categories react differently to blood loss:• Pregnant women: have ____________________________________ blood volume
– Progress more slowly through the classes• Athlete: may have greater cardiac ____________________________________
– Progress more slowly through the classes• Obese patients: have a ____________________________________ volume close to 7% of their ideal
body weight, not actual weight– Progress more rapidly through the classes
Classes of Hemorrhage (12 of 14)Certain patient categories react differently to blood loss (cont’d):• Infants and young children: have ____________________________________ blood volume (in
percentage)– ____________________________________ the initial S/S of shock– But causes rapid ____________________________________
• Alcohol: vasodilation and slows the compensatory mechanisms– Progress more rapidly through the classes
Classes of Hemorrhage (13 of 14)Certain patient categories react differently to blood loss (cont’d):• Elderly: have ____________________________________ reserve volume
–May also be on ____________________________________ that inhibit compensatory mechanisms
–May progress more rapidly through the classes
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May progress more rapidly through the classes–More prone to hypothermia
Classes of Hemorrhage (14 of 14)• Hemorrhage (internal or external) can lead to ____________________________________• ____________________________________ shock: subclass of hypovolemic shock and is associated
with trauma
Stages of Shock• Stages of shock are based on body's ability to ____________________________________ and the
presenting signs and symptoms• Phases are progressive in severity• 3 Phases are:
–Compensated– ____________________________________– Irreversible
Compensated Shock (1 of 2)• Initial stage of shock in which body progressively compensates for continuing blood loss• ____________________________________
–May be attributed to pain or the trauma• Pulse rate increases
–May not be reliable as an increased pulse rate is a common reaction to pain and trauma• Narrowing pulse ____________________________________ often is the first reliable sign
Compensated Shock (2 of 2)• Pulse strength ____________________________________• Skin becomes cool and clammy and capillary refill time may increase• Progressing anxiety, restlessness, combativeness• ____________________________________ and weakness• Stage ends with a precipitous ____________________________________ in blood pressure
Decompensated Shock (1 of 2)• Begins when body's compensatory mechanisms can no longer maintain
____________________________________ resulting in inability to maintain BP• Extreme ____________________________________ with inadequate cardiac output
– Pulse becomes unpalpable• Blood pressure drops precipitously with vital organs becoming hypoperfused
Decompensated Shock (2 of 2)• Brain is ____________________________________ and patient becomes unconscious• ____________________________________ slow or cease• Body takes on a deathlike appearance
Irreversible Shock• Shortly after patient enters decompensated shock, lack of circulation begins to have
profound effects on body cells• As they are irreversibly damaged, the cells ____________________________________, tissues
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As they are irreversibly damaged, the cells ____________________________________, tissues dysfunction, organs dysfunction, and patient dies
• The transition between decompensated shock and irreversible shock is a ____________________________________ one and impossible to differentiate based on S/S
Table 3-2 The Stages of Shock (Page 79)
Types of Shock5 Types of Shock are:• ____________________________________• Cardiogenic• ____________________________________• ____________________________________• Septic
Hypovolemic Shock• Significant reduction in ____________________________________ of cardiovascular system• ____________________________________ common cause; fluid loss from other pathologies can
occur– If from fluid loss it is commonly referred to as non-hemorrhagic hypovolemic shock
• Hemorrhagic shock specific subset of hypovolemia caused by blood loss
Cardiogenic Shock• Results from ____________________________________ insufficiency• Any cardiac pathology profound impact on circulation• May present with signs and symptoms of myocardial infarction or pulmonary edema and
with classic signs and symptoms of shock• Cardiac ____________________________________ may be present• Prognosis very poor; 80 percent mortality rate
Neurogenic Shock (1 of 2)• Results from ____________________________________ in communication pathway between central
nervous system and the body • Most commonly caused by a spinal or head injury• Results in ____________________________________• Tachycardia and rising diastolic blood pressure expected with other shock states may
____________________________________ occur
Neurogenic Shock (2 of 2)• Skin below nervous system injury warm, ____________________________________ and pink• Skin ____________________________________ it displays pallor, coolness, clamminess• Commonly characterized by normal or ____________________________________ heart rate with
low BP
Anaphylactic Shock• Introduction of ____________________________________ substance into body causes massive
histamine release• Over exaggerated response due to a ____________________________________ threat
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Over exaggerated response due to a ____________________________________ threat• Causes general vasodilation, leaking blood vessels, and edema
Septic Shock• Results from massive ____________________________________ releasing toxins that adversely
affect vascular system's ability to control blood vessels and distribute blood• Blood vessels ____________________________________ and leak• Results in multiple organ death
Assessment of the Patient with Hemorrhage and Shock
Scene Size Up• BSI• Scene ____________________________________• Evaluate mechanism of injury (MOI) considering for potential of external and internal
hemorrhage• Determine time elapsed between injury and assessment• Maintain ____________________________________ oversight
Primary Assessment (1 of 5)• Assess initial mental status; determine alertness, orientation, responsiveness• ____________________________________
–Administer oxygen if S/S of shock present• Look at patient's ____________________________________ condition• Control significant breathing
Primary Assessment (2 of 5)• Patient priorities, using C U P S acronym
– (C) ____________________________________– (U) Unstable– (P) ____________________________________ unstable– (S) Stable
• Consider rapid trauma assessment
Secondary Assessment (1 of 6)• Critical trauma patients should ____________________________________ receive a secondary
assessment on scene– For these patients, perform a rapid trauma assessment managing life threats and begin
rapid ____________________________________• Stable trauma patients should receive a focused trauma assessment
Secondary Assessment (2 of 6)Rapid Trauma Assessment:• Quickly palpate the body from head to toe looking for life
____________________________________• Often guided by the ____________________________________• Correct life threats
– Sucking neck wound, tension pneumothorax, sucking chest wound,
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Sucking neck wound, tension pneumothorax, sucking chest wound, ____________________________________ chest, serious bleeding, etc.
• Stabilized fractures of the pelvis or femur
Secondary Assessment (3 of 6)Rapid Trauma Assessment (cont’d):• Key is to find and treat ____________________________________ life threats and to minimize scene
time• Blood pressure and history taken ____________________________________
____________________________________• Treatments such as IVs, intubation, splinting of injuries (other than spine, pelvic and femur)
etc. performed en route–Unless there are extenuating circumstances such as entrapment or inability to control
the airway with BLS procedures
Secondary Assessment (4 of 6)Focused trauma assessment:• Patients ____________________________________ signs or symptoms of serious injury or blood
loss• Focus exam on ____________________________________ area• Obtain baseline vital signs, patient history, prepare and transport• Scene ____________________________________ is generally not a significant concern
Secondary Assessment (5 of 6)Additional assessment considerations:• Watch for signs of orthostatic hypotension
– Perform “____________________________________ test”– Tilt test is considered positive if:
▪ SBP ____________________________________ more than 15 to 20mmHg, and/or▪ Pulse rate ____________________________________ by more than 20bpm, and/or▪ Patient experiences light-headedness
Secondary Assessment (6 of 6)Additional assessment considerations (cont’d):• Do ____________________________________ perform tilt test is patient is already showing S/S of
____________________________________• Do not perform tilt test is patient is immobilized on a LSB
Patient Medical History• Question patient regarding chief complaint and past medical history• Pay attention to complaints of weakness, ____________________________________, or nausea that
may be signs of shock• Pay attention to preexisting medical problems, ____________________________________, last oral
intake, other medical information• Try to determine cause of incident• ____________________________________
Detailed Physical Exam
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• Performed only ____________________________________ all priorities addressed and the patient is en route to a trauma center
• Assess from head to toe looking for ____________________________________ signs of injury–As it pertains to patient’s condition and MOI
Reassessment (1 of 2)• At least every 5 minutes with critical, unstable, potentially unstable patients• Every 15 minutes with stable ones• Reevaluate general ____________________________________• Reassess mental status, airway, breathing, circulation• Check for ____________________________________ in patient’s condition and trends
Reassessment (2 of 2)• Additional set of vital signs, Glasgow Coma Scale score, oximetry and capnography
readings• Compare each finding with earlier ones to detect changes and
____________________________________• Attention to pulse rate and ____________________________________ pressure• Check adequacy and effectiveness of interventions performed• Check ____________________________________ and treatments
Management of the Patient with Hemorrhage and Shock
Hemorrhage Management (1 of 2)• Ensure ____________________________________ patent• Breathing adequate or establish and maintain airway• Provide ventilatory support; administer supplemental ____________________________________• Use pulse-oximetry, capnography, patient's signs and symptoms
Hemorrhage Management (2 of 2)• Treat serious (arterial and heavy venous) hemorrhage ____________________________________• Quickly apply dressings• If IV initiation will result in delayed transport, provide during
____________________________________• Care for injuries in established priority order previously established
Direct Pressure (1 of 2)• Controls all but most ____________________________________ hemorrhage• When blood loss control ____________________________________, direct pressure has not been
applied to hemorrhage source• Head wound with open fracture and brain injury: do not place pressure directly on
fractured skull or brain
Direct Pressure (2 of 2)• If serious bleeding from eye orbits, avoid placing pressure directly on
____________________________________ of eye• Avoid pressure on ____________________________________, larynx, airway structures
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Avoid pressure on ____________________________________, larynx, airway structures–May lead to airway constriction and hypoxia
• Limb splinting and ____________________________________ splints can aid in bleeding control on extremities
• Dressings held in place with pressure bandage
Elevation and Pressure Points• If direct pressure does not halt minor-to-moderate extremity hemorrhage, consider
elevation–Only if isolated bleeding and movement will not aggravate injury–Consult protocols
• If bleeding persists, find arterial pulse point proximal to wound; apply firm pressure– Pressure must be maintained
Topical Hemostatic Agents (1 of 2)• Approved by FDA• Can be used when direct pressure is ineffective and/or on an area where a tourniquet
____________________________________ be applied. • Support blood ____________________________________; help control further blood loss• Apply directly or indirectly to active hemorrhage• May not be effective on ____________________________________ bleeds due to the pressures
Topical Hemostatic Agents (2 of 2)• Comes in two forms:
–As a ____________________________________ impregnated with the hemostatic agent–A ____________________________________ that is poured directly into the wound
▪ Not recommended for EMS• After application, direct pressure for at least 3 minutes is required
Topical Hemostatic Agents Such as Quikclot Can be Used with Pressure Dressings to Control Bleeding
Tourniquets (1 of 2)• ____________________________________ resort when hemorrhage prolonged and persistent or
when multiple patients are present or when patient has other significant injuries also requiring immediate interventions and manpower is limited
• Used ONLY on ____________________________________• Apply commercial tourniquet proximal to hemorrhage site; firmly secure
Tourniquets (2 of 2)• Apply just ____________________________________ to the injury• Do not apply over a ____________________________________• Ensure bleeding does not continue after you apply tourniquet
Figure 3-11 Use a Tourniquet as a Last Resort When Hemorrhage is Prolonged and Persistent
Specific Wound Characteristics (1 of 7)Head Injuries:
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Head Injuries: • ____________________________________ is rich in blood vessels and can bleed profusely• Skull fracture may result in bleeding or fluids leaking from ears and nose; • Facial injuries threatening ____________________________________• Direct pressure on a skull fracture can damage brain
Specific Wound Characteristics (2 of 7)Head Injuries (cont’d):• Fluid drainage from ears and nose may be secondary to ____________________________________
fracture.• Cover area with soft, porous dressing, bandage ____________________________________ in place,
permit some blood to flow from wound.
Specific Wound Characteristics (3 of 7)Eye Injuries:• Avoid ____________________________________ eye globe.• If ruptured, globe can lose irreplaceable ____________________________________ contents• Apply pressure only to intact and stable bony orbital rim
Specific Wound Characteristics (4 of 7)Neck Wounds:• Open neck wound run a risk of ____________________________________ drawn into venous
circulation, with life-threatening consequences• Cover with ____________________________________ dressing• Do not employ circumferential bandages to create direct pressure
Specific Wound Characteristics (5 of 7)Neck Wounds (cont’d):• ____________________________________ pressure controls most, if not all, neck bleeding.• ____________________________________ compressing trachea, larynx, other structures that may
cause airway compromise.
Specific Wound Characteristics (6 of 7)Gaping Wounds: • Often present bleeding control problems• Create a ____________________________________ of dressing materials based on volume and
shape of wound• Bandage dressing ____________________________________ in place• Consider hemostatic agent
Specific Wound Characteristics (7 of 7)Crush Injuries: • Bleeding source may be ____________________________________ to locate• Vessel damage may prevent clotting mechanisms from being effective• Place dressing around and over crushed area and use a ____________________________________
splint (if available) to hold in place. If not, secure with a pressure bandage• Consider ____________________________________ agent
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Consider ____________________________________ agent• Consider tourniquet if on extremity
Transport Considerations• Rapid transport all serious external hemorrhage that cannot control and all suspected
serious internal hemorrhage• When in doubt, ____________________________________• Serious hemorrhage has significant psychological impact on patients
– ____________________________________ and reassure patient
Shock Management (1 of 16)Airway and Breathing Management:• Ensure secure and patent airway• Good ventilations with supplemental oxygen; maintain saturation of at least 95-96%• ____________________________________ airway as needed• Endotracheal intubations, ____________________________________ should be used• Rapid sequence intubation (RSI) considered
Shock Management (2 of 16)Airway and Breathing Management (cont’d):• If moving air ineffectively (rate < ___________/minute or inadequate volume), provide
positive-pressure ventilations• Improve oxygen saturation: consider positive end-expiratory pressure (PEEP) or continuous
positive airway pressure (____________________________________)• Diagnose and treat tension pneumothorax with a pleural decompression
Shock Management (3 of 16)Airway and Breathing Management (cont’d):• Ensure unconscious and unresponsive patient has palpable
____________________________________ pulse• If not, initiate CPR, attach monitor-defibrillator (or AED), employ advanced life support
measures
Shock Management (4 of 16)Hemorrhage Control:• Rapid control of significant ____________________________________ hemorrhage• Use technique or combination of techniques previously discussed
Shock Management (5 of 16)Fluid Resuscitation:• Field treatment of choice for significant blood loss in trauma is whole
____________________________________–Not practical in most EMS services
• Practical fluid for prehospital administration is an isotonic crystalloid–Normal saline (NS) or Lactated Ringers (LR)–Replaces ____________________________________ but has no oxygen carrying
Shock Management (6 of 16)
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Fluid Resuscitation (cont’d):• ____________________________________ and synthetic solutions may have some applications• Synthetic agents that can carry oxygen being tested• ____________________________________ fluid administration: classic signs and symptoms of
shock; controlled isolated external hemorrhage
Shock Management (7 of 16)Fluid Resuscitation (cont’d):• Hemodynamically stable patient may have ____________________________________, tachypnea,
decreased urine output and still be in shock• Hemodynamically normal patients do not have signs of ____________________________________
tissue perfusion
Shock Management (8 of 16)Isotonic Fluid Administration:• Indicated for the patient with the classic S/S of shock and isolated but controlled external
hemorrhage• Use aggressive fluid therapy using ___________ or ___________ via one line• Goal is to restore organ perfusion; not blood pressure
Shock Management (9 of 16)Isotonic Fluid Administration (cont’d):• Risks of continued infusion of large volumes of isotonic fluids:
–Dilution of the ____________________________________ factors–Decreases the hematocrit– Increases ____________________________________ due to increased BP– ____________________________________ the patient outcomes
Shock Management (10 of 16)Isotonic Fluid Administration (cont’d):• Generally, adults require 1 to 2 liters of fluid• Given in boluses of ___________ mL to 1 Liter at a time
– Fluid run wide open W/O–With close observation of ____________________________________ sounds between boluses– Bolus ____________________________________ only if needed
• Children are given boluses at ___________mL/kg repeated as needed
Shock Management (11 of 16)Isotonic Fluid Administration (cont’d):• Patients in hypovolemic shock respond to intravenous fluids in one of three ways:
–Rapid response: stabilize ____________________________________ after 1st bolus–____________________________________ response: respond favorably initially and then
deteriorate again–Minimal or no response: fluid achieves no change
Table 3-3 Response to Initial Fluid Resuscitation (2 L of Isotonic Crystollids in Adults; 20 mL/Kg in Children) (Page 79)
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20 mL/Kg in Children) (Page 79)
Shock Management (12 of 16)Isotonic Fluid Administration (cont’d):• Use as ____________________________________ of a bore possible IV catheter connected to
trauma (10 drop set) or blood tubing to ensure unimpeded flow and non–flow-restrictive saline lock if system so requires
• Objective in field is not return of normal vital signs, but ____________________________________ of vital signs until patient reaches trauma center
• Monitor fluid volume
Shock Management (13 of 16)Temperature Control:• In trauma, patients lose heat more rapidly than normal and heat
____________________________________ is low• Heat-generating reflexes (____________________________________) ineffective and
counterproductive to shock care process• Hypothermia reduces effectiveness of clotting mechanism which can worsen and prolong
hemorrhage
Shock Management (14 of 16)Temperature Control (cont’d):• Cover patient with ____________________________________• Keep ambulance very ____________________________________• If you infuse fluids, ensure they are not cold
– Ideally at body temperature but no more than 104 degrees
Shock Management (15 of 16)Pharmacological Intervention:• The use of ____________________________________ for shock management is limited, especially in
hypovolemic patients• Hypovolemic shock: blood replacement should be used ____________________________________
to vasopressors• Cardiogenic shock: fluid challenge, vasopressors, cardiac drugs indicated
Shock Management (16 of 16)Pharmacological Intervention (cont’d):• Spinal and obstructive shock: ____________________________________ fluids• Distributive shock: consider IV fluids or ____________________________________
Conclusion• Significant hemorrhage and its serious consequence, shock, are genuine threats to trauma
patient's life.• Signs of these threats are often subtle or hidden, especially if bleeding is internal• A thorough patient assessment is required• Treatment of shock requires rapid transport with most treatments performed en route
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