Bleeding andVolume Replacement

TherapyJ. Málek

Casualty treatment

• call for medical help

• vital functions

• control of major external bleeding

• general examination

• prevention of secondary injuries

• detailed examination

Blood

• in adults 40-50 ml/kg, in children 50-60 ml/kg

• oxygen and CO2 transport

• water and mineral balance

• transport of metabolites

• transport of hormones

• immunity

Blood

• red cells

• white cells

• thrombocytes

• plasma

Bleeding

• arterial, venous, capillary, mixed

• minor, major

• localisation

• normal, abnormal

Minor bleeding

• clean with water

• apply antiseptic around the wound

• apply sterile dressing

Bleeding

• external

• internal

• from body orifices

• mixed

Major external bleeding• lay the victim down to supine position• compress and elevate the bleeding site (if

possible)– pressure dressing– manual compression– pressure points– tourniquet

• do not try to clean a large wound (remove only obvious debris)

• never remove a foreign body

Internal bleeding

• pain

• signs of injury

• signs of shock

Internal bleeding

• positioning

• call for emergency

• nothing per os

Bleeding from body orifices

• mouth

• nose

• ear

• haemoptoea

• vomiting of blood

• rectal bleeding/melaena

• vaginal bleeding

Volume replacement therapy

• crystalloid solutions

• colloids solutions– volume substituents– volume expanders

• blood

Crystalloid solutions

• advantages• no allergic reactions• easily available• low effect on blood

coagulation• easily mobilised

• disadvantages• move quickly from

blood vessels• no transport capacity

for oxygen

Colloid solutions

• dextrans

• gelatine

• starch

Colloid solutions

• advantages• stay longer in blood

vessels• rapid volume

replacement (molecular weight dependent)

• easily available

• disadvantages• allergic reaction

possible• various effect on blood

coagulation• difficulty in

mobilisation• no transport capacity

for oxygen

Blood and blood products

• packed red cells

• fresh frozen plasma

• thrombocytes

• various factors

Risks of blood transfusion

• incompatibility

• infection

• allergy

• fever

• overloading

• bleeding problems

• immunity

Blood transfusion

• indication

• patient´s consent

• taking blood sample to transfusion dept.

• cross match in TD

• check documentation and transfusion bag

• security test

• biological test

Blood groups

Population     O+      

A+      

B+      

AB+      

O−      

A−      

B−      

AB−      

Argentina[11] 53.8% 34.7% 8.8% 2.7% 8.4% 0.44% 0.21% 0.06%

Australia[12] 40% 31% 8% 2% 9% 7% 2% 1%

Belgium[13] 38.1% 34% 8.5% 4.1% 7% 6% 1.5% 0.8%

Canada[14] 39% 36% 7.6% 2.5% 7% 7% 1.4% 0.5%

Denmark[15] 35% 37% 8% 4% 6% 7% 2% 1%

Finland[16] 27% 38% 15% 7% 4% 6% 2% 1%

France[17] 36% 37% 9% 3% 6% 7% 1% 1%

Hong Kong, China[18]

40% 26% 27% 7% <0.3% <0.3% <0.3% <0.3%

Korea, South[19] 27.4% 34.4% 26.8% 11.2% 0.1% 0.1% 0.1% 0.05%

Netherlands[20] 39.5% 35% 6.7% 2.5% 7.5% 7% 1.3% 0.5%

Poland[21] 31% 32% 15% 7% 6% 6% 2% 1%

Sweden[22] 32% 37% 10% 5% 6% 7% 2% 1%

UK[23] 37% 35% 8% 3% 7% 6% 2% 1%

USA[24] 38% 34% 9% 3% 7% 6% 2% 1%

Human red blood cells before (left) and after (right) adding serum containing anti-A antibodies. The agglutination reaction reveals the presence of the A antigen on the surface of the cells.

                                                                            

Transfusion

• Colecting blood sample from the patient• Transfusion station

– Blood group– Crossmatching– Delivery

• Ward– Check delivery list– Safety test– Biological test– Monitoring – Save blood pack for 24 hours

Indications for blood transfusions

• acute hemorrhage

• anemia

• bleeding disorders

• hematological diseases

Acute bleeding

Blood loss Replacement

<750 ml crystalloid solutions

750 – 1500 ml crystalloid solutions (colloid solutions or blood)

>1500 ml crystalloid solutions (colloid solutions) + blood

Shock

Definition

Acute state in which tissue perfusion is inadequate to maintain the supply of oxygen and nutritients necessary for normal cell function, which results in widespread hypoxia.

Reasons for inadequate tissue perfusion

• A decreased circulating blood volume – hypovolaemic shock

• A failure of the heart to pump effectively – cardiogenic shock and obstructive shock

• A massive increase in peripheral vasodilatation – neurogenic shock

• Combination – septic shock, anaphylactic shock

Stages of shock

• Initial stage – anaerobic metabolism

• Compensatory stage – centralisation of circulation

• Progressive stage – increased acidosis, leakage of fluid from the capillaries and formation of microthrombes

• Refractory stage

Classification of shock

• Hypovolaemic shock

• Cardiogenic shock

• Anaphylactic shock

• Septic shock

• Neurogenic shock

Hypovolaemic shock

• Haemorrhage

• Plasma loss

• Extracelular fluid loss

Symptoms of hypovolemia according to blood loss

Blood loss (ml) Symptoms

<750 none

-1 500 thirst, weakness, tachypnoea

-2 000 systolic pressure falls

>2 000 no pulse on periphery

Estimated blood loss in trauma

Pelvis 3 000 mL

Femur 1 000 mL

Tibia 650 mL

Abdominal injury 2 000 – 4 000 mL

Thoracic injury 2 000 – 4 000 mL

Signs of haemorrhagic shock

• Pale, cold, clammy skin, decreased capilary refill

• Rapid, weak and thready pulse

• Thirst

• Decreased urine production

• Increased respiratory rate

• Change in mental status – late sign

First aid• Prevent further blood loss

• Antishock or autotransfusion position

• Activation of emergency service

• Prevention of hypothermia

• Prevention of positioning trauma

• Treatment of other injuries, immobilisation of fractures

• Nil by mouth, no oral or i.m. medication

Medical treatment

• Intravenous access

• Surgery

• Fluid replacement

• Artificial ventilation

• Pharmacological support of shock organs

• Monitoring: BP, P, SaO2, CPV, urine output

Cardiogenic shock

• Heart failure, cardiomyopathy

• Decreased cardiac output

• First vasoconstriction, next vasodilatation due to acidosis

• Pulmonary oedema

• Cold, clammy and cyanotic skin

• Mortality 80 per cent

Anaphylactic shock

• Severe allergic reaction

• Degranulation of mast cells

• Vasodilatation, increased vascular permeability, oedema, bronchospasm

Septic shock

• Bacteria or bacterial toxins

• Released histamine and other mediators of inflammation

• Oxygen demand – supply mismatch

• Vasodilatation

• Tachycardia, hypotension, fever of hypothermia

Neurogenic (spinal) shock

• Loss of sympathetic nerve activity

• Massive vasodilatation