Shock and Bleeding in the Trauma Patient

April Morgenroth RN, MN

Shock: Hypoperfusion

Hypoperfusion: A state where the body’s organs are not sufficiently perfused with oxygenated blood.

Nursing Priorities

Establish “Rapid Dominance “ over states of hypoperfusion by:

Early recognitionAggressive treatment Prevention of progressive and

decompensated stages of shock

Recognizing Shock

Types of Shock:Distributive:

NeurogenicSepticAnaphylactic

Cardiogenic:MI, Cardiomyopathy, tamponade

Hypovolemic:Relative vs. Absolute

Key Points

Pressure = amount of stuff in a given space

Remember: Hypoperfusion= oxygenated blood not getting where it needs to goBlood is driven by pressures

Distributive Shock

Insult

Vasodilation

Same Stuff/ More Space

Hypotension

Causes of Distributive Shock

Neurogenic: Head injuries Spinal Cord injuries Pain and drugs

Septic: UTI SIRS Bacteremia

Anaphylactic Bee stings Drugs Foods

The Autonomic Nervous SystemThe autonomic nervous system controls the body’s involuntary

functions: digestion, heartbeat, respirations…Sympathetic Nervous System Parasympathetic Nervous

System

Fight or Flight

Regulate the body’s response to danger or threat: •Vasoconstriction•Rapid Heartbeat•Deep Respirations•Dilated Pupils

Rest and Digest

The body’s resting state allowing metabolism and energy conservation:•Vasodilation•Increased blood flow to the gut•Slower Heartbeat•Lower Blood Pressure

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Neurogenic ShockDamage to the brain and spinal cord

Loss of Sympathetic Tone:

Parasympathetic Nervous System is

Unopposed

Uncontrolled Vasodilation

Low Blood Pressure

Hypoperfusion: Shock

Septic Shock

Cytokines released in response to infection

Vasodilation and increase capillary permeability

Decreased SVR

Decreased Pressure

Decreased Perfusion

Anaphylactic Shock

Allergen

Massive Release of Mast Cells

Systemic Vasodilation

Increased Capillary Permeability

Edema

Hypotension

Hypovolemic Shock

Hypovolemic Shock= Decreased amount of fluid in the vascular space

Absolute: external fluid lossHemorrhageBurnsDieresis

Relative: Internal fluid shiftInternal bleedingBlood pooling

Hypovolemic Shock

Decreased fluid in circulation

Decreased preload in the heart

Decreased stroke volume

Decreased cardiac output

Hypovolemia: The Body’s Response

The Body will always strive to work toward a state of homeostasis, as steady state of balance.

Mechanism Response Clinical PictureDecreased fluid in circulation

Vasoconstriction Shunting of blood from the periphery, gut, kidneys, and liver to the vital organsThe body will release hormones to hold water

Cool, clammy, pale extremities, nausea, vomiting, decreased urine output. Prolonged hypoperfusion: Increase in BUN Creatinine Possible kidney failure .

Decreased preload in the heart

Increased heart rate Tachycardia Arrhythmias

Decreased Stoke Volume

Increased heart rate Cardiac output= stroke volume x heart rate

Narrowed pulse pressure: systolic and diastolic pressures begin to equalize

Decreased Cardiac Output

Increased heart rate Delayed capillary refill, hypoperfusion

Respiratory Response

Patient hyperventilates and blows off excessive carbon dioxide causing respiratory alkalosis

Bleeding =

Less red blood cells =

Less oxygen carrying capacity

Patient becomes short of breath and tachypnic

CO2

Compensated ShockIn compensated:Body’s compensatory

mechanisms temporarily maintain a steady state.

Vital organs perfused.Blood pressure stable.

Blood is shunted from the periphery.

Sympathetic nervous system is activated.

You may start to see the following early signs.

Blood pressure may be normal or somewhat low

Anxious

Tachycardia/rapid pulse

Tachypnea

Extremities may be cool and pale under the nail beds.

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Clinical Manifestations of Progressive Shock

Confusion, listlessness, apathy decreased response to painful stimuli

Tachycardia Beta blockers may blunt Weak or absent peripheral pulses

Hypotension (SBP < 90) & falling > 25% decrease in hypertensive pt May need to use doppler or Arterial line

Resp rapid & shallowLow urine output

ThirstSkin cool & clammy, dusky, slow capillary

refill

Decompensated Shock

Decompensated Shock:Body exhausts

reservesDamage is not

reversiblePatient will

eventually die.

Blood pressure continues to fall

Pulse pressure narrowsAltered level of consciousness

Slow deep respirations

Cyanosis

Cold extremities

arrhythmias

Metabolic Response

As the body continues to fight against the altered state it begins to go into anaerobic metabolismThis causes a build of lactic acid eventually leading to a metabolic acidosis

Metabolic acidosis and respiratory alkalosis can exist concurrently to some degree compensating for one another resulting in a relatively normal pH.

O2

Assessment for Shock

Recent history of event putting pt at riskAssess for clinical manifestations

General appearance & skin LOC & orientation Vitals Urine output

Foley if at risk, or evidence of shock Bleeding (external or internal) or fluid loss Signs of cardiac dysfunction Hemodynamic parameters ABGs & oxygen saturation

Aggressive Treatment

Always begin with ABCs: airway, breathing, circulation

Airway: establish and maintain the airwayBreathing: be prepared to support breathing with supplemental O2, manual ventilation may be neededCirculation: be prepared for massive fluid resuscitation and make plans for circulatory support

Basic TreatmentIntervention Rational

Raise the feet Dumps blood to vital organs of the body by gravity

Supplemental Oxygen

Maximizes oxygenation of red blood cells

Indentify and remove cause (if possible)Stop the bleeding, treat the infection etc…

Removing the mechanism prevents worsening of symptoms and is vital in recovering the patient.

Two large bore IVs Provide access for medication administration and fluid replacement therapy

Check Electrolytes and Hematocrit

Loss of body fluids plus the body’s altered state can cause dangerous electrolyte imbalances. A patients hematocrit can drop quickly in the presence of heavy bleeding.

Protect from hypothermia In an altered state, thermoregulation is affected

Fluid ResuscitationMore Stuff in the Space

Three liters of normal saline replaces 1 liter of blood lost for intravascular volume to come out even.

Fluid shifts and much of it is displaced into the surrounding tissues

=BLOOD

LOST

Fluid Effect Drawbacks

Hypertonic Solutions: higher salt concentrations

Remain in the intravascular spaceRapid fluid volume expansion(salt sucks)

Watch for hypernutremia (seizures and confusion)

Blood Products Replace fluid volumeIncrease oxygen carrying capacitysevere bleeding may require blood

Availability, possibility for transfusion reaction

ColloidsAlbumin

Large molecules remain in inctravascular spaceIncrease osmotic pressure (protein sucks)

Availability and expense

Lactated Ringers Replacement of fluid volume and some electrolytes

Compromised liver can’t metabolize lactic acid into bicarbonate and lactic acid may build up

Normal Saline Replaces fluid volume Generally more available

Caution in patients who have high sodium

Fluid Resuscitation

Obtain I.V. access

Choose the most appropriate I.V. fluid for the situation

Two Large Bore I.V.s 18 gauge or

largerChoose a large vein

LR

Fluid ResuscitationInfusion Rates

Normalize

In severe cases of hypovolemic shock, fluids may initially need to be run wide open as fast as possible.Assess the patient frequently and document their response to interventions

Heart rateBlood

PressureRespiratory RateSkin Temperature

Once the patient becomes more stable the infusion rate may be slowed.

Fluid Volume Overload

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Fluid volume overload can result from rapid aggressive fluid resuscitation.

If you see signs and symptoms of fluid overload you may need to slow infusion rate and/or stop fluids if the patient is stable enough. The patient may need careful dieresis once stable.

Keep Track of : Vital signsIntake and

OutputWeight gain

or loss

Look for:Pitting edemaIncreased respiratory rateOrthopneaWet sounding lungsPink frothy sputum Massive weight gain

Circulatory Support Space/Vasoconstriction

Medications: Vasopressors:

DopamineNorepinepherine/ LevophedVasopressin

Considerations: Use of these meds requires intense monitoring and titration.Monitor: EKG, BP, HR, RR, O2, hemodynamics, peripheral

pulses.Prolonged use at higher doses can cause peripheral tissue

damage related to ischemia.

Aggressive Care

Constant Assessment:Indentify the cause!Notice signs and symptoms early

Aggressive Treatment: Treat the cause effectivelySupport the body systems

Hemorrhage Control

Direct Pressure

Application of direct pressure to a open wound helps to control bleeding and can help to speed the body’s natural process of clot formation.

Use sterile or clean dressing to apply direct pressure over the bleeding wound.

Be careful with wounds to the chest and neck, too much pressure can impair breathing.

Pressure Dressings

• Place sterile dressing directly over the wound.

• Stack bulky dressings on top.

• Wrap a gauze dressing snuggly around the wound.

• Tie the rolled gauze with the knot directly over padding previously placed over the wound.

• If gauze becomes soaked add more on top.

Reassess: • Sensory, motor, circulatory

function distal to the wound

Use of the Tourniquet

• Attempt to control bleeding with direct pressure, and pressure dressing before using a tourniquet.

• Wrap the wound snuggly

• Pile dressings over the wrap

Wrap wound again leaving two long ends.

• Wrap the ends around a stick • Use the stick to twist the

tourniquet tighter until bleeding is controlled

Tournquets should only be used with other method of hemorrhage control have failed.

Use of the Tourniquet

Tie a knot to secure the stick in placeBe sure to label with date and time of

applicationReassess the patient frequently and document

your findings

.

Inappropriate use of a tourniquet can be very dangerous!

Internal BleedingInternal bleeding: bleeding out of vessels into tissue.

• Early Recognition + Early Intervention = Better Outcome

Mechanism of injury: crushing injury, impact, blows to the head, chest, abdomen, car vs. pedestrian accident

Signs:• Hematoma• Edema• Area under the skin may be firm• Pain• Signs of shock• Vomiting or coughing up blood • Pain directly over an organ

Emergency: Pt may need surgery, call doctor immediatelyPatients with internal bleeding can die very quickly if they are not

treated immediately!