Bleeding, also called hemorrhage, is the name used to describe blood loss. It can refer to blood loss inside the body, called internal bleeding, or to blood loss outside of the body, called external bleeding. Blood loss can occur in almost any area of the body.

1. HAEMORRHAGE
PRESENTED BY
Sakuntala Giri
SUM Nursing College

2. Introduction
• Shock is a life threatening condition. lt is
characterized by inadequate tissue perfusion
that if untreated results in cell death. The
supply of oxygen to tissues is essential in the
maintenance of life and this can be ensured
when circulatory system is functioning
normally.
• In 1923 Walter and Canner first worked for all
conditions of shock.
SHOCK

3. SHOCK

4. CLASSIFICATIONOF SHOCK
• Hypovolemic shock.
• Cardiogenic shock.
• Circulatory shock or distributive shock
a. Septic shock.
b. Obstructive shock.
c. Neurogenic shock.
d. Anaphylactic shock.

5. Hypovolemic shock
• This is the most common type of shock, due to
insufficient circulatory volume
• This occurs when there is loss in the
intravascular fluid up to 15% to 25%.
• That is a loss of 750 to 1300 ml of blood in a
70 kg person

6. ETIOLOGY

7. PATHOPHYSLOLOGY
Decreased blood volume
Decreased venous return
Decreased cardiac output
Decreased tissue perfusion
Decreased cellular metabolism

8. CLINICAL MANIFESTATIONS
• Decreased cardiac output
• Hypotension
• Altered tissue perfusion
• Cool and clammy skin
• Cyanosis or PaIe skin color (pallor)
• A rapid, weak, thready pulse
• Thirst and dry mouth, due to fluid depletion
• Fatigue due to inadequate oxygenation
• Anxiety, restlessness, altered mental state

9. CARDIOGENIC SHOCK
It is caused by the failure of heart to pump
effectively.
 This is due damage of heart muscles, mostly
from myocardial infarction.

10. ETIOLOGY

12. •
Decreased cardiac contractility
Decreased stroke volume and cardiac output
Pulmonary congestion
decreased tissue perfusion
decreased coronary artery perfusion
volume

13. CLINICAL MANIFESTATIONS
• Pulmonary edema
• Increased central venous pressure
• Distended jugular veins due to increased jugular
venous pressure
• Weak or absent Pulse due to tachyarrhythmia
• Shortness of breath
• Chest pain

14. SEPTIC SHOCK
• It is secondary to infections by micro organisms.
• Septic shock is caused by an overwhelming systemic
infection and inflammation resulting in vasodilation
• Most common gram negative bacteria such as
Escherichia coli, Proteus species, Klebsiella
pneumoniae
• Which release an endotoxin and produce adverse
biochemical,immunological & neurological effects
which are harmful to the body.

15. SEPTIC SHOCK

16. Pathophysiology
Severe localize infection of gram –ve bacili
Bacterial invasion into bloodstream(septicemia)
Inflammatory response
Endotoxin release into circulation
Histamine & other chemical mediator release
vasodilation
Increased capillary permeability
Inadequate tissue perfusion to vital organ
Multiple organ failure
I

17. CLINICAL MANIFESTATION
• Pyrexia due to increased level of cytokines
• Systemic vasodilation resulting in hypotension
• Warm and sweaty skin due to vasodilation
• Reduced contractility of the heart
• Increased levels of neutrophils
• Increased heart rate
• Increased cardiac output

18. OBSTRUCTIVE SHOCK
ETIOLOGY

19. Clinical manifestations
• Tachycardia
• Tachypnea
• Hypotension
• Cyanosis
• Oliguria
• Altered mental status
• jugular veins may be distended
• Pulsus paradoxus in case of tamponade

20. Neurogenic shock
• This is a very uncommon type of shock.
• lt is most often seen in patients who have had
and extensive spinal cord injuries.
• The loss of autonomic and motor reflexes below
level of injury results in loss of sympathetic
control.
• This leads to relaxation of vessels and peripheral
dilation and hypotension.

21. ETIOLOGY

22. Pathophysiology
Spinal cord injury
Inhibit the sympathetic nerve stimulation
Arterial & venous dilatation
Arterial / venous blood pooling
Hypotenson
Bradycardia, warm dry flushed skin
Decreased perfusion of vital organ
Multisystem organ failure

23. CLINICAL FEATURE
• Hypotension
• Altered mental status
• Bradycardia
• Skin that is warm and dry
• Tachycardia and tachypnea
• Cool and clammy skin
• Priapism due to Peripheral nervous system
stimulation

24. Anaphylactic shock
Anaphylactic shock is caused by severe
reaction to an allergen, antigen, drug or
foreign protein.
 When a patient who has already produced
antibodies to a foreign substance develops a
systemic antigen antibody reaction.
Antigen antibody provides mast cells to
release vasoactive substance such as
histamine or bradykinin that cause
vasodilatation

26. PATHOPHYSIOLOGY
• Due to antibody responses
• Release of histamine
• Vasodilatation
• Increased capillary permeability
• Severe broncho constriction
• Decreased oxygen supply and utilization
• Inadequate tissue perfusion.

27. CLINICAL FEATURE
• Skin eruptions and large bumps
• Localized edema, especially around the face
• Laryngeal edema
• Weak and rapid pulse
• Breathlessness and cough
• Tachycardia and tachypnea
• Hypotension
• Cyanosis
• Urticaria and pruritus
• Severe bronchospasm

28. DIAGNOSIS OF SHOCK
• Chest x-rays
• CVP Measurement
• Hemoglobin level measurement
• Arterial Blood Gases (ABG) analysis
• Urinalysis
• Complete blood count
• Blood, urine and sputum culture
• Blood chemistry including kidney function tests
• Cardiac catheterization and Coronary
angiography
• Echocardiogram and Electrocardiogram
• Cardiac enzymes (troponin, CKMB) test
• Computed tomography

29. MANAGEMENT OF SHOCK

30. MANAGEMENT
Management in all types of shock include the
following:
• Management of airway, breathing and
circulation
• Fluid replacement to restore intravascular
volume
• Vasoactive medications to restore vasomotor
tone and improve cardiac function
• Nutritional support to address metabolic
requirement

31. The ABCDE approach
A
B
CD
E
Disability due
to neurological
deterioration
Circulation &
shock
management
Breathing &
ventilation
Airway & oxygenation
Exposure &
examination

32. Airway
• See respiratory pattern
• Head tilt chin lift
• Jaw thrust
• Suction
• Oral airways
• Nasal airways
• Nebulised adrenaline for stridor
• Intubation
• Cricothyroidotomy
– Needle or surgical.
• O2 administer,if airway open

33. Breathing
Consider ventilation
with AMBU bag.
Position upright if
struggling to breath
Specific treatment
i.e.: β agonist for
wheeze, chest
drain for
pneumothorax

34. circulation
• Position supine with legs raised
– Left lateral tilt in pregnancy
• IV access
• Fluid challenge
– colloid or crystalloid?
• ECG Monitoring
• Specific treatment

35. Disability - assessment
• AVPU (or GCS)
– Alert, responds to Voice, responds to Pain,
Unresponsive
• Pupil size/response
• Posture
• BM
• Pain relief

36. Disability - interventions
• Optimise airway, breathing & circulation
• Treat underlying cause if drug induced
causes.
– i.e.: naloxone for opiate toxicity
• Treat  blood glucosei,e hypoglycemia
– 100ml of 10% dextrose (or 20ml of 50%
dextrose)
• Control seizures
• Seek expert help for CVA or ICP

37. Exposure & Examine
• Remove clothes and examine head to toe
front and back.
– Haemorrhage, rashes, swelling, sores,
catheter etc
• Keep warm
• Maintain dignity

44. Complications
• a. ARDS- (acute respiratory distress syndrome)
• b. Multiple Organ Failure

45. DEFINITION
• Hemorrhage or bleeding is termed as escape
or loss of blood from the circulatory system.
• It may be internally (from blood vessels) and
externally (through natural opening such as
mouth, anus or vagina). It may be termed as
exsanguination (complete loss of blood) and
desanguination (massive blood loss).