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
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