Shock and haemorrhage final for UG students

1. SHOCK AND HAEMORRHAGE
DR.SAGAR A. SAVSANI
JUNIOR RESIDENT , DEPT. OF ORTHOPAEDICS ,
JSS MEDICAL COLLEGE ,
MYSURU

2. Objectives
• Understand the definition and major types of shock,
• Recognize signs and symptoms of shock,
• Recognize types of external bleeding (arterial, venous,
capillary),
• Recognize signs and symptoms of internal bleeding,
• Initiate treatment of shock by appropriately positioning
the patient and by stopping hemorrhage when
possible,
• Treat external hemorrhage
2

3. SHOCK
Shock is a syndrome that results from
a decrease in effective circulating
blood volume or fluid in the body as
a result of any injury or illness.
Shock is inadequate tissue perfusion
with oxygenated blood.

4. PRINCIPLE MECHANISMS
• Not enough blood volume in body
• Circulatory Pump failure
• Abnormalities of peripheral circulation (when
all small blood vessels dilate)
• Mechanical blockage of outflow from the
heart

5. TYPES OF SHOCK
Hypovolemic Shock
• Results from trauma in which there is blood
loss
• Decreased blood volume causes a decrease in
blood pressure
• Insufficient amounts of O2 is being
transported to body tissues and organs

6. TYPES OF SHOCK
Respiratory Shock
• Results when the lungs are unable to supply
enough O2 the circulating blood
• Trauma that may produce respiratory shock
include:
– Pneumothorax
– Injury to the respiratory control center

7. TYPES OF SHOCK
Neurogenic Shock
• Results due to the overall dilation of the blood
vessels within the cardiovascular system
• Decreased blood pressure
• Insufficient amounts of O2 is being
transported to body tissues and organs

8. TYPES OF SHOCK
Psychogenic Shock
• Commonly known as “fainting” (syncope)
• Results due to a temporary dilation of the
blood vessels in the body causing a decrease
in the blood flow to the brain

9. TYPES OF SHOCK
Cardiogenic Shock
• Results due to the inability of the heart to
pump enough blood to the body
• Decreased cardiac output
• Decreased blood pressure
• Insufficient amounts of O2 is being
transported to body tissues and organs

10. TYPES OF SHOCK
Septic Shock
• Results due to a severe infection
– Usually a bacterial infection
• Toxins released by the bacteria cause dilation
of the blood vessels within the cardiovascular
system
• Decreased blood pressure
• Insufficient amounts of O2 is being
transported to body tissues and organs

11. TYPES OF SHOCK
Anaphylactic Shock
• Results due to a severe allergic reaction
• Allergic reaction may be caused by:
–Foods
–Insect bites
–Drugs
–Inhaling dusts, pollens, etc…

12. TYPES OF SHOCK
Metabolic Shock
• Results due to a severe illness that goes
untreated
– For example, untreated diabetes
• Results due to an extreme loss of bodily fluid
– For example, excessive urination, diarrhea, or
vomiting

13. SIGN AND SYMPTOMS
• Anxiety, restlessness,
altered mental state
• Hypotension
• Rapid, weak, thready
pulse
• Cool, clammy skin
• Capillary refill > 3 seconds
• Rapid and deep
respirations
•Hypothermia
• Fatigue
• Cold and mottled skin
• Thirst and dry mouth
• Vasoconstriction
• Low urine output

15. SHOCK STAGES BY FINDINGS
• Compensated - Early
– Initial stage, body progressively compensated for
blood loss
• ↑ pulse, vasoconstriction
• Weak pulse, cool clammy skin, anxiety, thirst, weak
• Decompensated – Late
– Body’s compensatory mechanisms no longer
maintain system
• Loss of radial pulse, ↓ BP, loss of consciousness, ↓
respirations

16. CAUSES
• Internal
– Blunt force trauma
• Contusions, lacerations, shear, fractures
– Penetrating trauma
• Punctures
• External
– General trauma
• Contusions, abrasions, lacerations, incisions, avulsions,
amputation

17. SOURCES OF BLOOD LOSS
• Arterial bleeding
– Bright red in color, Rich in oxygen
– Often profuse and spurting
– Often hard to control - continuous direct pressure required
• Venous bleeding
– Dark red/maroon in color, does not contain much oxygen
– Usually easy to control because veins are under low pressure
– Venous bleeding in neck can draw in air and cause further
complications
• Capillary bleeding
– Usually slow, oozing, small size and low pressure
– Generally minor and easy to control

18. GRADES

19. MANAGEMENT
• STOP the bleeding
• Supportive care
measures
– Positioning of victim
– Ensuring A-B-C’s
– Maintenance of body
temp
• Definitive management

20. Every problem,
even the extreme,
can be worked
as an algorithmic
sequence of steps.

21. Apply direct pressure:
• with gloved hand,
• sterile dressing(s).
Bleeding stopped? YesNo
Elevate extremity:
• above victim’s heart,
continue direct pressure
Locate pressure point,
apply pressure:
• maintain direct pressure
over wound
Treat for shock:
• care for wound,
• seek definitive care
Bleeding stopped?
Bleeding stopped?
No
Bleeding from
extremity?
No
Apply tourniquet
(last resort)
Yes
No
Definitive therapy
21

22. Direct pressure
• Apply pressure directly to wound
site:
– Gloved hand, dressing
– If dressing soaks thru, add
more gauze on top and press
harder
22
Apply direct pressure:
• with gloved hand,
• sterile dressing(s).
Bleeding stopped? YesNo
Elevate extremity:
• above victim’s heart,
continue direct pressure
Locate pressure point,
apply pressure:
• maintain direct pressure
over wound
Treat for shock:
• care for wound,
• seek definitive care
Bleeding stopped?
Bleeding stopped?
No
Bleeding from
extremity?
No
Apply tourniquet
(last resort)
Yes
No
Definitive therapy

23. Elevate wound site
• If possible, raise wound site
above level of victim’s heart
23
Apply direct pressure:
• with gloved hand,
• sterile dressing(s).
Bleeding stopped? YesNo
Elevate extremity:
• above victim’s heart,
continue direct pressure
Locate pressure point,
apply pressure:
• maintain direct pressure
over wound
Treat for shock:
• care for wound,
• seek definitive care
Bleeding stopped?
Bleeding stopped?
No
Bleeding from
extremity?
No
Apply tourniquet
(last resort)
Yes
No
Definitive therapy

24. Pressure points
• Find proximal “pressure point”
and press on it
(radial, ulnar, brachial, axillary, femoral
arteries—not carotid)
• Apply direct pressure to site
24
Apply direct pressure:
• with gloved hand,
• sterile dressing(s).
Bleeding stopped? YesNo
Elevate extremity:
• above victim’s heart,
continue direct pressure
Locate pressure point,
apply pressure:
• maintain direct pressure
over wound
Treat for shock:
• care for wound,
• seek definitive care
Bleeding stopped?
Bleeding stopped?
No
Bleeding from
extremity?
No
Apply tourniquet
(last resort)
Yes
No
Definitive therapy

25. Tourniquet
• Apply band above injury site,
tighten to stop bleeding:
– Last resort—risky
– Note time of application
– Reassess frequently
25
Apply direct pressure:
• with gloved hand,
• sterile dressing(s).
Bleeding stopped? YesNo
Elevate extremity:
• above victim’s heart,
continue direct pressure
Locate pressure point,
apply pressure:
• maintain direct pressure
over wound
Treat for shock:
• care for wound,
• seek definitive care
Bleeding stopped?
Bleeding stopped?
No
Bleeding from
extremity?
No
Apply tourniquet
(last resort)
Yes
No
Definitive therapy

26. EMERGENCY DEPARTMENT CARE
• Three goals exist in the emergency department
treatment of the patient with hypovolemic shock as
follows:
(1) Maximize oxygen delivery - completed by
ensuring adequacy of ventilation, increasing oxygen
saturation of the blood, and restoring blood flow,
(2) Control further blood loss, and
(3) Fluid resuscitation.

27. GENERAL TREATMENT FOR SHOCK
• Goal: improve perfusion of brain and heart
• Position patient: Have patient lie down and
elevate legs (moves blood into chest and
head)
• Keep warm if blanket available
• Give nothing by mouth if any possibility of
internal injuries (may need emergency
surgery)

28. POSITIONING OF PATIENT
•Maintain normal body temperature
•In most cases, elevate the feet and legs above the level
of the heart

29. IN CASE OF HEAD INJURIES

30. THE HEAD MAY NOT BE ELEVATED
IN CASE OF IF THERE IN CASE OF
MUCUS IN THROAT

32. WATCH FOR :-
Vital Signs
• Pulse
• Respiration
• Blood pressure
• Temperature
• Skin color
• Pupils
• Level of
consciousness
• Movement
• Abnormal nerve
response

34. DEFINITIVE CARE
• Administer supplemental oxygen
• Obtain vascular access
– Administer fluid/blood to “fill up the tank”
• Wound closure/management
• Immobilization
• Special situations
– Release cardiac tamponade
– Tension pneumothorax
• Find hidden sources of bleeding

35. AIRWAY
• The patient's airway should be assessed
immediately upon arrival and stabilized if necessary.
• The depth and rate of respirations, as well as
breath sounds, should be assessed.
• High-flow supplemental oxygen should be
administered to all patients, and ventilatory support
should be given, if needed.
• Excessive positive-pressure ventilation can be
detrimental for a patient suffering hypovolemic
shock and should be avoided.

36. FLUID MANAGEMENT
• Two large bore IV line access
• Blood products and fluids via the intravenous
route.
• This is to replenish what is lost and to significantly
improve the circulation of blood in the body.
• Fluids are given to restore what was lost.
• Medications are given to strengthen and improve
the condition of the heart and other vital organs in
the body.

37. Following fluids and medications should be
given:
• Intravenous crystalloids/colloids
• Whole blood transfusion
• Blood plasma transfusion
• Red blood cell / Platelet transfusion
• Dopamine
• Epinephrine
• Dobutamine
• Norepinephrine
• Antibiotics to prevent infection and septic shock

38. • Initial fluid resuscitation is performed with an
isotonic crystalloid, such as Ringer lactate solution
or Normal Saline.
• An initial bolus of 1-2 L is given in an adult (20
mL/kg in a pediatric patient), and the patient's
response is assessed.
• 3% and 7.5% Hypertonic Saline Solutions
• Fresh frozen plasma, Hetastarch and Dextran 40/70.
• Type O Rh-negative blood / Cross matched blood
• IV Antibiotics – In case of Open Wounds

39. MONITORING
• SBP 90, PR < 120
• O2 saturation > 92%
• Warm, Moist skin, CRT <3 sec
• Consciousness, Alert, No agitation
• Urine output 0.5 cc/kg/hr

40. HYPOVOLEMIC SHOCK IN CHILDREN
• In children, hypovolemic shock is the leading cause
of morbidity and mortality.
• Thorough physical examination, vital signs
monitoring, and gathering of important laboratory
data.
• Severe dehydration, injury, and blood disorders are
the leading causes of hypovolemic shock in
children.

41. HYPOVOLEMIC SHOCK IN OLDER ADULTS
• Hypovolemic shock is very dangerous in older
adults.
• They have a higher mortality rate than the younger
ones.
• Older adults have less tolerance for shock.
• Hence, Older patients should be treated right away
to prevent further complications.

42. RECOVERY TIME
• Depends on the patient’s age, degree of shock, and
medical condition.
• Patient with mild degree of shock tend to recover more
easily than those with severe shock.
• Patients with severe organ damage may take some time
to fully recover.
• A course of extensive medications should be given to
help the patient recover from the shock.
• In fact, there are instances wherein the organ damage
is irreversible.
• Severe hypovolemic shock could lead to death,
especially in the case of older adults.

43. COMPLICATIONS
• Heart attack
• Gangrene of the arms or legs due to lack of
blood supply
• Damage to vital organs of the body like the
brain and kidney
• Death

44. SUMMARY
• Determine the type of shock
• Immediate management of shock is universal
• Provide reassurance and comfort
• Maintain normal body temperature
• In most cases, elevate the feet and legs above
the level of the heart
• Control Bleeding
• Fluid Resucsitation
• Monitoring

45. THANK YOU