4. Introduction;
A
Hemorrhagic shock occurs when the body begins to
shut down due to heavy blood loss. People
suffering injuries that cause heavy bleeding may go
into hemorrhagic shock if the bleeding isn't stopped
immediately.
5. Definition;
B
Hemorrhagic shock is a condition of reduced
tissue perfusion, resulting in the inadequate
delivery of oxygen and nutrients that are
necessary for cellular function. Whenever
cellular oxygen demand out weighs supply,
both the cell and the organism are in a state
of shock.
6. Cont....
On a multi-cellular level, the definition of shock becomes
more difficult because not all tissues and organs will
experience the same amount of oxygen imbalance for a
given clinical disturbance. Clinicians struggle daily to
adequately define and monitor oxygen utilization on the
cellular level and to correlate this physiology to useful
clinical parameters and diagnostic tests.
10. Cont;
Hemorrhagic shock is caused by the loss of both
circulating blood volume and oxygen-carrying
capacity. The most common clinical etiologies are
penetrating and blunt trauma, gastrointestinal
bleeding, and obstetrical bleeding.
12. Cont;
At the site of hemorrhage, clotting cascade and
platelets form a hemostatic plug whereas remote
from the site fibrinolytic activity increases,
presumably to prevent microvascular thrombosis.
However excess plasmin activity and
autoheparinization can lead to pathologic
hyperfibrinolysis and coagulopathy.
13. Cont;
There is transition to anaerobic metabolism
which generates lactic acid, inorganic
phosphates and oxygen radicals.
Release of Damage Associated Molecular
Patterns (DAMP) incites a systemic
inflammatory response.
As ATP levels deplete, cellular homeostasis
fails and cell death ensues
14. Cont; External Hemorrhage
• Results from soft tissue injury.
• Most soft tissue trauma is accompanied by mild
hemorrhage and is not life threatening.
–Can carry significant risks of patient morbidity and
disfigurement
• The seriousness of the injury is dependent on:
– Anatomical source of the hemorrhage (arterial,
venous, capillary)
– Degree of vascular disruption
– Amount of blood loss that can be tolerated by the patient
15. Cont; Internal Hemorrhage
• Can result from:
–Blunt or penetrating trauma
–Acute or chronic medical illnesses
• Internal bleeding that can cause hemodynamic instability
usually occurs in one of four body cavities:
–Chest
–Abdomen
–Pelvis
–Retroperitoneum
16. Compensated Shock;
• 0-20% of blood loss
• Blood pressure is
maintained via
increased vascular
tone and increased
blood flow to vital
organs
24. Cont...,
• Initial Assessment
–General Impression
–Obvious bleeding
–Mental Status
–Interventions
• Manage as you go
–O2
–Bleeding control
–Shock
–BLS before ALS!
25. Cont...,
• Focused History & Physical examination
– Rapid Trauma Assessment
• Full head to toe
• Consider air medical if stage 2+ blood loss
– Focused Physical Exam
• Guided by c/c
– Vitals, SAMPLE,
– Additional Assessment
• Orthostatic hypotension
• Tilt test: 20
– ↓BP or ↑P from supine tositting
26. Cont...,
• Fractures and Blood Loss
• Pelvic fracture →
• Femur fracture
• Tibia/fibula fracture →
• Hematomas and
contusions →
2,000 mL
1,500 mL
500–750 mL
500 mL
27. Cont...,
• Ongoing Assessment;
– Reassess vitals and mental status:
• Q 5 min: UNSTABLE patients
• Q 15 min: STABLE patients
– Reassess interventions:
• Oxygen
• ET
• IV
• Medication actions
– Trending: improvement vs. deterioration
• Pulse oximetry
• End-tidal CO2 levels
28. Management of Shock;
Management of ABC Fluid replacement
Vasoactive medications
G
Shock required immediate intervention to preserve life. Re-
establishing perfusion to the organs is the primary goal through restoring
and maintaining the blod circulating volume ensuring oxygenation and
blood pressure are adequate, achieving and maintaining effective cardiac
function and preventing complications.
Nutritional support
29. 1. Management of ABC;
A - Airway
B - Breathing
C - Circulation
Secure the airway, breathing and
circulation, by performing cardio
pulmonary resuscitation (or) life support
measurements
Provide oxygen supplements through nasal
cannula, mask (or) endotrachial intubation
(or) mechanical ventilator.
30. 2.Fluid replacement to restore intravascular;
Stop further bleeding- Recent studies indicates that
tourniquet application proximal to the site of
hemorrhage in the extremities saves lives without
risking amputation or extremity dysfunction, if the
patient can be quickly transported to the hospital.
Isotonic crystalloid resuscitation has been used for
decades in early management of bleeding. However
they only transiently expand the intravascular
volume & have no intrinsic therapeutic benefit.
Overzealous resuscitation with crystalloid dilutes the
oxygen carrying capacity and clotting factors.
Limiting crystalloid infusion to 3L in 1st 6 hours is
recommended as a part of bundle of care for
patients with acute bleeding & trauma.
31. Cont....
Blood Transfusion;
• Blood products transfusion provide a greater survival benefit
as compared to colloids/crystalloids
TYPES-
• Red blood cells
• Plasma
• Platelets
• Cryoprecipitate
• Prospective studies show that 1:1:1 ratio of plasma to
platelets to RBC’s is safe
• However all these contain citrate which can lead to
hypocalcemia &
progressive coagulopathy.
• Thus empirical dosing of calcium & frequent measurement of
electrolytes is recommended.
32. Cont....
Vasopressor therapy initially to target a mean
arterial pressure (MAP) of 65 mm Hg
Norepinephrine as the first choice vasopressor
Epinephrine (added to and potentially
substituted for norepinephrine) when an
additional agent is needed to maintain
adequate blood pressure
Vasopressin 0.03 units/minute can be added to
norepinephrine (NE) with intent of either raising
MAP or decreasing NE dosage
33. Cont- Emergency care & First aid;
Rapid evaluation
Damage control resuscitation
CXR, Pelvis X-Ray,ICD Insertion
Permissive hypotension
Control hemorrhage
Prevent contamination
Avoid further injuries
Initial homeostasis and packing.
34. Cont- Emergency care & First aid;
Reverse the sequel of hypotension
Physiological and biochemical restoration
Adequate Oxygen delivery
Agressive core rewarming
Correction of coagulopathy
Definitive surgery
35. Decrease cardiac output related to
• Alteration in heart rate & rhythm
• Decreased ventricular filling
• Fluid volume loss of 30% (or) more
• Late uncompensated shock
Difficult fluid volume, decreased intravascular,
interstitial and intracellular fluid may related to
• Active fluid volume loss
• Internal fluid shifts
• Regulatory mechanism failure
NURSING MANAGEMENT;
Nursing diagnosis;
