TOBY
● Physiologic compensation for hemorrhage (p. 1585)
Hemorrhage means bleeding
Arterial bleeding is bright red (high oxygen content)
■ More difficult to control bleeding
Venous bleeding is dark red (low oxygen content)
■ Tends to clot spontaneously
Significant vital sign changes occur after an adult loses 1L of blood or more
■ Increased heart rate, respiratory rate, and decreased BP
HEMOSTASIS: Platelets aggregate to the site, plugging the hole and sealing the
injured portions of the vessel; 3 steps
■ Step 1: vasoconstriction
■ Step 2: platelet aggregation
■ Step 3: fibrinogen weaving into the clot and forming fibrin to hold the clot
together
● Occlusive dressings (p. 1622)
Neck dressing: prevents pulmonary emboli
Truncal (chest) dressing: cover open wounds with an occlusive dressing and tape
on 3 sides
■ GSW, stabbing
■ hemo/pneumo-thorax
● S/s shock(1999)
● Compensated
○ Agitation, anxiety, restlessness
○ Sense of impending doom
○ Weak rapid (thready) pulse
○ Cool, moist skin (clammy)
○ Pallor with cyanotic lips
○ SOB
○ Nausea, vomiting
○ Delayed capillary refill in infants and children
○ Thirst
○ Normal BP
● Decompensated
○ Altered mental status (verbal to unresponsive)
○ Hypotension
○ Labored or irregular breathing
○ Thready or absent peripheral pulses
○ Ashen, mottled, or cyanotic skin
○ Dilated pupils
○ Diminished urine output (oliguria)
○ Impending cardiac arrest
● Irreversible
, ○ Treatment has no effect on pts ability to perfuse
○ No clear correlation between the amount of blood loss and reaching this point of
shock
● Disseminated intravascular coagulopathy (DIC) (p.1306-1307)
Pathophysiology
■ Can result from massive injury and hypotension due to trauma, sepsis
and obstetric complications as well
■ Progresses in 2 stages:
● Free thrombin and fibrin deposits in the blood increase, and
platelets begin to aggregate; defibrination (breakdown of fibrin
clots) occurs in this stage due to excessive bleeding
● Uncontrolled hemorrhage occurs due to severe lack of clotting
factors
Assessment
■ In cases involving severe trauma, patients may have episodes of
respiratory difficulty, signs of shock, and skin changes ranging from
clammy to palor to small black and blue marks (purpura) on the chest and
abdomen
Management
■ Pts with DIC from trauma have a poor survival rate; be honest about it
with family members if present
■ Treat signs of shock
● Fluids for hypotension
● Keep pt warm
● Control bleeding
■ Maintain airway
■ Administer oxygen
■ Pain medication administration
■ Possible cardiovascular treatment (comes last) if dysrhythmias are
present
● S/s of various shock states (p. 1589)
● CENTRAL SHOCKS:
○ Cardiogenic— (Pump Performance is decreased/Failing)
■ BP: Hypotensive
■ HR: Low, then becomes elevated
■ Skin: Pale, cool, moist
■ Lungs: Crackles
○ Obstructive— (Blockage [Embolism] in a vessel)
■ Two most common examples are tension pneumothorax and cardiac
tamponade.
● PERIPHERAL SHOCKS:
○ Hypovolemic— (Fluid Volume is decreasing)
■ BP: Hypotensive
, ■ HR: Elevated
■ Skin: Pale, cool, moist
■ Lungs: Clear
● DISTRIBUTIVE SHOCKS:
○ Septic— (Vessels/Container dilates; maldistribution of blood, Low peripheral
resistance)
■ BP: Decreased (Low)
■ HR: Elevated (Fast)
■ Skin: Flushed, hot or cool, moist
■ Lungs: Crackles if pulmonary origin
○ Neurogenic— (Vessels/Container dilates; maldistribution of blood, Low peripheral
resistance)
■ BP: Decreased (Low)
■ HR: Decreased (Slow)
■ Skin: Flushed, dry, warm
■ Lungs: Clear
○ Anaphylactic—(Vessels/Container dilates; maldistribution of blood, Low
peripheral resistance)
■ BP: Decreased (Low)
■ HR: Elevated (Fast)
■ Skin: Flushed warm, moist
■ Lungs: May have wheezes, may be diminished with no sounds
● Anaerobic metabolism or shocks
○ The anaerobic process ultimately leads to the death of the cell. If enough
cells die, organs start to fail, and the body starts to fail and, eventually,
death occurs.
● S/s of abdominal hemorrhage
○ Most commonly experienced symptom is pain. Significant internal hemorrhage
will cause swelling in the area of bleeding. There may be distinction and rigidity
(upon palpation).
○ Cullen Sign—appearance of bruising surrounding the umbilicus.
○ Grey Turner Sign—bruising in the flanks.
● Goals of fluid resuscitation
● Should be given at volumes that maintain a minimum blood pressure that allows clots to
form at sites of bleeding within the body, which will reduce ongoing blood loss.
○ Bleeding—administer warm isotonic crystalloids of normal saline in 250 mL
increments to maintain a patient’s systolic BP in the low normal range. BP 80 to
90 mm Hg is preferred for hemorrhagic shock.
○ Burns—patients with burns covering more than 20% of the TBSA will need fluid
depending on age and other conditions. Formula for fluid in burn victims is:
(2-4mL) x (kg) x (percent of body surface burned). First 24 hours is the end
● Physiologic compensation for hemorrhage (p. 1585)
Hemorrhage means bleeding
Arterial bleeding is bright red (high oxygen content)
■ More difficult to control bleeding
Venous bleeding is dark red (low oxygen content)
■ Tends to clot spontaneously
Significant vital sign changes occur after an adult loses 1L of blood or more
■ Increased heart rate, respiratory rate, and decreased BP
HEMOSTASIS: Platelets aggregate to the site, plugging the hole and sealing the
injured portions of the vessel; 3 steps
■ Step 1: vasoconstriction
■ Step 2: platelet aggregation
■ Step 3: fibrinogen weaving into the clot and forming fibrin to hold the clot
together
● Occlusive dressings (p. 1622)
Neck dressing: prevents pulmonary emboli
Truncal (chest) dressing: cover open wounds with an occlusive dressing and tape
on 3 sides
■ GSW, stabbing
■ hemo/pneumo-thorax
● S/s shock(1999)
● Compensated
○ Agitation, anxiety, restlessness
○ Sense of impending doom
○ Weak rapid (thready) pulse
○ Cool, moist skin (clammy)
○ Pallor with cyanotic lips
○ SOB
○ Nausea, vomiting
○ Delayed capillary refill in infants and children
○ Thirst
○ Normal BP
● Decompensated
○ Altered mental status (verbal to unresponsive)
○ Hypotension
○ Labored or irregular breathing
○ Thready or absent peripheral pulses
○ Ashen, mottled, or cyanotic skin
○ Dilated pupils
○ Diminished urine output (oliguria)
○ Impending cardiac arrest
● Irreversible
, ○ Treatment has no effect on pts ability to perfuse
○ No clear correlation between the amount of blood loss and reaching this point of
shock
● Disseminated intravascular coagulopathy (DIC) (p.1306-1307)
Pathophysiology
■ Can result from massive injury and hypotension due to trauma, sepsis
and obstetric complications as well
■ Progresses in 2 stages:
● Free thrombin and fibrin deposits in the blood increase, and
platelets begin to aggregate; defibrination (breakdown of fibrin
clots) occurs in this stage due to excessive bleeding
● Uncontrolled hemorrhage occurs due to severe lack of clotting
factors
Assessment
■ In cases involving severe trauma, patients may have episodes of
respiratory difficulty, signs of shock, and skin changes ranging from
clammy to palor to small black and blue marks (purpura) on the chest and
abdomen
Management
■ Pts with DIC from trauma have a poor survival rate; be honest about it
with family members if present
■ Treat signs of shock
● Fluids for hypotension
● Keep pt warm
● Control bleeding
■ Maintain airway
■ Administer oxygen
■ Pain medication administration
■ Possible cardiovascular treatment (comes last) if dysrhythmias are
present
● S/s of various shock states (p. 1589)
● CENTRAL SHOCKS:
○ Cardiogenic— (Pump Performance is decreased/Failing)
■ BP: Hypotensive
■ HR: Low, then becomes elevated
■ Skin: Pale, cool, moist
■ Lungs: Crackles
○ Obstructive— (Blockage [Embolism] in a vessel)
■ Two most common examples are tension pneumothorax and cardiac
tamponade.
● PERIPHERAL SHOCKS:
○ Hypovolemic— (Fluid Volume is decreasing)
■ BP: Hypotensive
, ■ HR: Elevated
■ Skin: Pale, cool, moist
■ Lungs: Clear
● DISTRIBUTIVE SHOCKS:
○ Septic— (Vessels/Container dilates; maldistribution of blood, Low peripheral
resistance)
■ BP: Decreased (Low)
■ HR: Elevated (Fast)
■ Skin: Flushed, hot or cool, moist
■ Lungs: Crackles if pulmonary origin
○ Neurogenic— (Vessels/Container dilates; maldistribution of blood, Low peripheral
resistance)
■ BP: Decreased (Low)
■ HR: Decreased (Slow)
■ Skin: Flushed, dry, warm
■ Lungs: Clear
○ Anaphylactic—(Vessels/Container dilates; maldistribution of blood, Low
peripheral resistance)
■ BP: Decreased (Low)
■ HR: Elevated (Fast)
■ Skin: Flushed warm, moist
■ Lungs: May have wheezes, may be diminished with no sounds
● Anaerobic metabolism or shocks
○ The anaerobic process ultimately leads to the death of the cell. If enough
cells die, organs start to fail, and the body starts to fail and, eventually,
death occurs.
● S/s of abdominal hemorrhage
○ Most commonly experienced symptom is pain. Significant internal hemorrhage
will cause swelling in the area of bleeding. There may be distinction and rigidity
(upon palpation).
○ Cullen Sign—appearance of bruising surrounding the umbilicus.
○ Grey Turner Sign—bruising in the flanks.
● Goals of fluid resuscitation
● Should be given at volumes that maintain a minimum blood pressure that allows clots to
form at sites of bleeding within the body, which will reduce ongoing blood loss.
○ Bleeding—administer warm isotonic crystalloids of normal saline in 250 mL
increments to maintain a patient’s systolic BP in the low normal range. BP 80 to
90 mm Hg is preferred for hemorrhagic shock.
○ Burns—patients with burns covering more than 20% of the TBSA will need fluid
depending on age and other conditions. Formula for fluid in burn victims is:
(2-4mL) x (kg) x (percent of body surface burned). First 24 hours is the end
