Bleeding
Bleeding
Bleeding
Shock is the medical condition that develops as a result of an imbalance between the delivery of
oxygen and the consumption of oxygen at the cellular level.
Perfusion is the movement of sufficient oxygenated blood to the cells. Inadequate perfusion or
hypoperfusion is the result of a problem in one of the three components of the system getting
oxygen-rich blood to cells:
• Heart: the pump of the system.
• Vessels: the pipes of the system.
• Blood: the liquid circulating in the system.
A continuous interaction between these three components maintains blood pressure, circulation,
perfusion and the delivery of oxygen to the body.
In the patrolling environment, generally:
• shock as a result of a traumatic event is most likely due to blood loss either internally or
externally;
• shock as a result of a non-traumatic event is most likely due to pump failure or compromise;
• shock as a result of sepsis is rarely seen in the field.
Treatment
Regardless of the cause or type of shock, the first responder treatment is the same.
• Stop external bleeding. Blood cannot be replaced in our environmental setting.
• Activate EMS and treat as a load and go.
• Administer oxygen at high flow rate.
• Keep the patient warm.
• Lay the patient down.
• Treat the patient gently.
• Give nothing by mouth.
• Closely monitor the patient. Record vital signs and history.
• Reassure the patient.
Make every effort to prevent the situation from deteriorating. All movement and
temperature regulation requires blood flow which is in short supply during shock. Keep the
patient quiet and ensure they are not too hot or too cold.
Types of Shock
1. Cardiogenic Shock:
- Affected System: Heart (the pump)
- Description: Cardiogenic shock occurs when the heart fails to pump blood effectively,
leading to decreased tissue perfusion.
2. Hypovolemic Shock:
- Affected System: Circulating volume of blood
- Description: Hypovolemic shock results from a significant decrease in intravascular
volume, often due to hemorrhage, severe dehydration, or fluid loss.
Cardiogenic Shock
Hypovolemic Shock
Failure to stop bleeding may lead to the progression of profound shock and eventually lead to
death.
External Bleeding
External bleeding refers to the loss of blood from the body through visible openings in the skin,
such as wounds or lacerations. It can occur due to various causes, including trauma, injuries,
surgical procedures, or medical conditions.
Arterial Bleeding: Arterial bleeding occurs when blood is expelled from an artery, which
carries oxygen-rich blood away from the heart and to the body's tissues. Arterial bleeding is
typically characterized by bright red, spurting blood that corresponds to the rhythmic beating of
the heart. It can be life-threatening and requires immediate medical attention.
Venous Bleeding: Venous bleeding involves blood flowing from a vein, which transports
oxygen-depleted blood back to the heart. Venous bleeding is often steady and dark red in color.
While it may not be as rapid as arterial bleeding, significant venous bleeding can still lead to
hypovolemic shock if left untreated.
Capillary Bleeding: Capillary bleeding occurs from the smallest blood vessels, called
capillaries, near the skin's surface. Capillary bleeding is typically slow and oozing, and it may
appear as a reddish discharge from minor cuts or abrasions.
Special Considerations: External bleeding may also present with special considerations, such
as bleeding from specific anatomical locations (e.g., head, neck, groin), wounds with embedded
foreign objects, or bleeding disorders that affect clotting function.
The general treatment for external bleeding can be easily remembered with the acronym
RED, which stands for:
Rest: The first step in managing external bleeding is to lay the injured person down and
encourage them to rest. Resting helps reduce physical activity, which can minimize blood flow
to the injured area and promote clot formation.
Elevate: If possible, elevate the bleeding part above the level of the heart. Elevating the injured
limb helps reduce blood flow to the area by utilizing gravity to assist in drainage. This can be
particularly effective for extremity injuries, such as cuts or lacerations on the arms or legs.
Direct: Apply direct pressure to the wound using a clean cloth, bandage, or sterile dressing.
Direct pressure helps control bleeding by promoting clot formation and reducing blood flow
from the injured blood vessels. Maintain pressure continuously until bleeding stops or medical
assistance arrives.
Remembering the RED approach can help individuals respond effectively to external bleeding
emergencies by taking immediate action to control bleeding and minimize complications.
Quickly Check for Foreign Objects: Before applying any pressure or dressing, quickly assess
the wound for any foreign objects such as glass, debris, or penetrating objects. If present, do not
remove them; instead, stabilize the object and seek medical help.
Apply Firm, Direct Pressure: Place your protected hand (using gloves or a clean cloth if
available) directly on top of the wound and apply firm pressure. Direct pressure helps to control
bleeding by promoting clot formation and reducing blood flow from the injured blood vessels.
Maintain pressure continuously until bleeding stops or medical assistance arrives.
Apply Sterile Dressing and Bandage: With as little movement as possible to avoid
aggravating the wound, apply a sterile dressing directly over the wound. Secure the dressing in
place with a bandage, such as a cravat or other form of compression bandage. Ensure that the
bandage is snug but not too tight to impede circulation.
Treat for Shock: For severe bleeding, it's important to anticipate and treat for shock, a life-
threatening condition that can occur due to significant blood loss. Do not wait for symptoms of
shock to appear; instead, initiate appropriate treatment immediately. Lay the injured person
down, elevate their legs if possible, and cover them with a blanket to maintain body warmth.
Monitor their vital signs and provide reassurance while awaiting medical help.
3. Maintain Pressure
- Tie the knot of the bandage directly over the wound site to maintain constant pressure and
promote clot formation.
Internal Bleeding
Internal bleeding refers to the loss of blood into compartments within the body, rather than
external bleeding that occurs outside the body. It can occur in various compartments depending
on the affected organs or structures. Unlike external bleeding, signs and symptoms of internal
bleeding may not always be evident, making it challenging to diagnose without medical
intervention.
Symptoms of internal bleeding can vary depending on the location and severity of the bleed. In
cases of abdominal bleeding, free blood in the abdominal cavity can irritate nerves, resulting in
pain, guarding (tensing of muscles to protect the area), and rigidity of the abdominal wall.
Additionally, internal bleeding may lead to referred pain, where the perception of pain occurs in
locations remote from the site of injury. For example:
Left shoulder tip pain may indicate possible rupture of the spleen.
Right shoulder tip pain may suggest injury to the liver or gall bladder.
Shoulder tip pain in the presence of abdominal bleeding is known as Kehr's Sign.
Internal bleeding can present with various signs and symptoms depending on the location and
severity of the bleed. Recognizing these signs is crucial for timely diagnosis and appropriate
medical intervention. Here are some evident signs and symptoms associated with internal
bleeding:
It's important to note that injuries to the bowels (small or large), stomach, or bladder may often
result in free air in the abdomen rather than internal bleeding. This can be detected through
medical imaging tests such as X-rays or CT scans.
Internal bleeding resulting from trauma, particularly crushing injuries or blows to the abdominal
region, can be insidious and challenging to detect. Here are some non-evident signs and
symptoms associated with internal bleeding:
1. Tenderness
- Increasing sensitivity to touch or pressure over the abdomen. Patients may report discomfort
or pain when pressure is applied to the affected area.
2. Rigidity
- The abdomen may feel rigid or tense, resembling a wooden or boardlike texture upon
palpation. This rigidity can indicate internal bleeding and is often associated with intra-
abdominal inflammation or irritation.
3. Guarding
- Guarding refers to the involuntary tightening of the abdominal muscles in response to pain
or discomfort. Patients may instinctively tense their muscles to protect the injured or sensitive
area.
When signs and symptoms of internal bleeding become evident, prompt action is crucial to
optimize patient outcomes. Here's what to do as a first aid provider:
Distributive Shock
The underlying causes of distributive shock may vary and can include conditions such as:
1. Septic Shock Caused by a severe systemic infection leading to widespread inflammation and
vasodilation.
3. Neurogenic Shock Occurs due to dysfunction of the autonomic nervous system, leading to
widespread vasodilation following spinal cord injury or neurological disorders.
Vasovagal syncope, also known as vasovagal fainting, is a common cause of fainting episodes
triggered by various physical or emotional stressors. It occurs due to a sudden dilation of
peripheral blood vessels, leading to a drop in blood pressure and temporary deprivation of
oxygen to the brain, resulting in loss of consciousness.
Mechanism:
- Stressful stimuli, such as pain, fear, anxiety, or standing for long periods, can stimulate the
vagus nerve, which regulates heart rate and blood vessel dilation.
- Activation of the vagus nerve leads to excessive dilation of peripheral blood vessels and a
decrease in heart rate, resulting in reduced blood flow to the brain.
- The insufficient blood supply to the brain causes temporary loss of consciousness, resulting in
fainting.
Characteristics:
- Vasovagal syncope typically presents with prodromal symptoms such as lightheadedness,
nausea, sweating, and feeling warm or clammy.
- Loss of consciousness is brief and self-limiting, usually lasting only a few seconds to minutes.
- Patients often recover spontaneously when lying down horizontally, as normal blood flow to
the brain is restored.
Management:
1. Ensure Patient Safety: Check for any injuries resulting from the fainting episode. Provide a
safe environment and prevent further harm.
2. Positioning: Lay the patient flat on their back with their legs elevated slightly, which helps
improve blood flow to the brain and facilitates recovery.
3. Monitor Vital Signs: Assess the patient's vital signs, including heart rate and blood pressure,
to ensure stability and rule out any underlying medical conditions.
4. Reassurance: Offer reassurance to the patient and provide emotional support. Explain the
benign nature of vasovagal syncope and the expected resolution of symptoms.
5. Preventive Measures: Encourage the patient to avoid triggers known to precipitate vasovagal
episodes, such as prolonged standing, dehydration, or extreme emotional stress.
Obstructive Shock
Obstructive shock occurs due to the obstruction of blood flow outside of the heart. Various
conditions can lead to this type of shock, each affecting blood flow in different ways:
1. Tension Pneumothorax:
- Tension pneumothorax occurs when air accumulates in the pleural space, leading to
increased pressure within the chest cavity. This increased pressure compresses the blood
vessels, impeding blood return to the heart and reducing cardiac output. The collapsed lung
further exacerbates the obstruction of blood flow, leading to decreased oxygenation and
perfusion.
2. Cardiac Tamponade:
- Cardiac tamponade occurs when fluid (usually blood) accumulates in the pericardial sac
surrounding the heart, exerting pressure on the heart chambers and restricting their ability to fill
with blood. This impairs cardiac function and reduces cardiac output, leading to decreased
tissue perfusion and shock. Cardiac tamponade is commonly associated with penetrating chest
injuries.
4. Aortic Stenosis:
- Aortic stenosis refers to the narrowing of the aortic valve, obstructing the outflow of blood
from the heart to the systemic circulation. This obstruction increases the workload of the heart
and reduces cardiac output, leading to decreased tissue perfusion and shock.
Obstructive shock requires prompt recognition and management to relieve the obstruction and
restore normal blood flow. Treatment may involve interventions such as chest decompression
for tension pneumothorax, pericardiocentesis for cardiac tamponade, thrombolytic therapy or
embolectomy for embolic events, and valve replacement or repair for aortic stenosis.