Understand the definition and major types of shock,Recognize signs and symptoms of shock,Recognize types of external bleeding (arterial,

venous, capillary),Recognize signs and symptoms of internal bleeding,Initiate treatment of shock by appropriately

positioning the patient and by stopping hemorrhage when possible,

Treat external hemorrhage appropriately by direct pressure, elevation, pressure points, and/or tourniquet, and

Apply a dressing and bandage.

2

Shock is inadequate tissue perfusion with

oxygenated blood

3

Not enough blood volume Pump failureAbnormalities of peripheral circulation (when

all small blood vessels dilate) Mechanical blockage of outflow from the

heart

4

Most common type of shockInsufficient circulating volume

Primary cause = loss of blood or body fluids from an internal or external source

Hemorrhage, severe burns, severe dehydration

5Scalp laceration 3rd degree/full thickness burn

Failure of the heart to pump effectively1. Due to damage to the heart muscle2. Large myocardial infarction3. Arrhythmias (too fast or too slow)4. Cardiomyopathy5. Congestive heart failure (CHF)6. Cardiac valve problems

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Mechanical block to heart’s outflow Pulmonary embolusCardiac tamponadeTension pneumothorax

7Pulmonary embolus Cardiac tamponade

Similar to hypovolemic shock - insufficient intravascular volume of blood or “relative" hypovolemia result of dilation of all blood vessels so the

“tank” is much larger

8Urticaria/anaphylaxis Meningococcic sepsis

Septic shockOverwhelming infection leading to profound

systemic vasodilation Anaphylactic shock

Severe reaction to an allergen, antigen, drug or foreign protein, releasing histamine causing widespread vasodilation, hypotension and increased capillary permeability

Neurogenic shockRarest form of shock. Trauma to spinal cord resulting in loss of

autonomic and motor reflexes below injury level. Vessel walls relax uncontrolled, decreasing peripheral vascular resistance, result = vasodilation and hypotension

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If shock is “inadequate tissue perfusion with oxygenated

blood,” then . . .

. . . look at the tissues!

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Cardiovascular

Respiratory

Skin

CNS

Renal

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Global signs and symptoms:

• Anxiety, restlessness, altered mental state • Hypotension • Rapid, weak, thready pulse • Cool, clammy skin• Capillary refill > 3 seconds• Rapid and deep respirations• Hypothermia • Fatigue• Cold and mottled skin• Thirst and dry mouth• Vasoconstriction• Low urine output

Compensated - earlyInitial stage, body progressively compensated for

blood loss↑ pulse, vasoconstrictionWeak pulse, cool clammy skin, anxiety, thirst, weak

Decompensated – lateBody’s compensatory mechanisms no longer

maintain systemLoss of radial pulse, ↓ BP, loss of consciousness, ↓

respirations

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“All bleeding stops eventually”

Rapid, simple interventions are highly advantageous to the patient

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InternalBlunt force trauma

Contusions, lacerations, shear, fracturesPenetrating trauma

Punctures

ExternalGeneral trauma

Contusions, abrasions, lacerations, incisions, avulsions, amputation

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Arterial bleeding Usually bright red in color, rich in oxygen Often profuse and spurting Often hard to control - continuous direct pressure

required

Venous bleeding Usually dark red/maroon in color, does not contain much

oxygen Usually easy to control because veins are under low

pressure Venous bleeding in neck can draw in air and cause

further complications

Capillary bleeding Usually slow, oozing, small size and low pressure Generally minor and easy to control

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STOP the bleedingSupportive care measures

Positioning of victimEnsuring A-B-C’sMaintenance of body temp

Definitive management

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Apply direct pressure:• with gloved hand,• sterile dressing(s).

Bleeding stopped? YesNo

Elevate extremity:• above victim’s heart,continue direct pressure

Locate pressure point,apply pressure:• maintain direct pressureover wound

Treat for shock:• care for wound,• seek definitive care

Bleeding stopped?

Bleeding stopped?

No

Bleeding fromextremity?

No

Apply tourniquet(last resort)

Yes

No

Definitive therapy18

Apply pressure directly to wound site:Gloved hand, dressingIf dressing soaks thru, add

more gauze on top and press harder

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Apply direct pressure:• with gloved hand,• sterile dressing(s).

Bleeding stopped? YesNo

Elevate extremity:• above victim’s heart,continue direct pressure

Locate pressure point,apply pressure:• maintain direct pressureover wound

Treat for shock:• care for wound,• seek definitive care

Bleeding stopped?

Bleeding stopped?

No

Bleeding fromextremity?

No

Apply tourniquet(last resort)

Yes

No

Definitive therapy

If possible, raise wound site above level of victim’s heart

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Apply direct pressure:• with gloved hand,• sterile dressing(s).

Bleeding stopped? YesNo

Elevate extremity:• above victim’s heart,continue direct pressure

Locate pressure point,apply pressure:• maintain direct pressureover wound

Treat for shock:• care for wound,• seek definitive care

Bleeding stopped?

Bleeding stopped?

No

Bleeding fromextremity?

No

Apply tourniquet(last resort)

Yes

No

Definitive therapy

Find proximal “pressure point” and press on it (radial, ulnar, brachial, axillary, femoral arteries—not carotid)

Apply direct pressure to site

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Apply direct pressure:• with gloved hand,• sterile dressing(s).

Bleeding stopped? YesNo

Elevate extremity:• above victim’s heart,continue direct pressure

Locate pressure point,apply pressure:• maintain direct pressureover wound

Treat for shock:• care for wound,• seek definitive care

Bleeding stopped?

Bleeding stopped?

No

Bleeding fromextremity?

No

Apply tourniquet(last resort)

Yes

No

Definitive therapy

Apply band above injury site, tighten to stop bleeding:Last resort—riskyNote time of applicationReassess frequently

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Apply direct pressure:• with gloved hand,• sterile dressing(s).

Bleeding stopped? YesNo

Elevate extremity:• above victim’s heart,continue direct pressure

Locate pressure point,apply pressure:• maintain direct pressureover wound

Treat for shock:• care for wound,• seek definitive care

Bleeding stopped?

Bleeding stopped?

No

Bleeding fromextremity?

No

Apply tourniquet(last resort)

Yes

No

Definitive therapy

Goal: improve perfusion of brain and heartPosition patient: Have patient lie down and

elevate legs (moves blood into chest and head)

Keep warm if blanket availableGive nothing by mouth if any possibility of

internal injuries (may need emergency surgery)

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Administer supplemental oxygenObtain vascular access

Administer fluid/blood to “fill up the tank”Wound closure/managementImmobilizationSpecial situations

Release cardiac tamponadeTension pneumothorax

Find hidden sources of bleeding

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BP 90, P < 120O2 saturation > 92%Warm, moist skin, < 2 sec capillary refillConsciousness, no agitationUrine output 0.5 cc/kg/hr

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Shock = inadequate tissue perfusion

Find shock by looking at tissue perfusion

Categories of shockHypovolemicObstructiveDistributiveCardiogenic

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Most common source of shock = hemorrhage

Management of hemorrhagic shockStop the bleedingVascular accessVolumeReassess

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“Chance favors the prepared mind.”Louis Pasteur