Haemorrhage

Bleeding, also called hemorrhage, is the name used to describe blood loss. It can refer to blood loss inside the body, called internal bleeding, or to blood loss outside of the body, called external bleeding. Blood loss can occur in almost any area of the body.

1. HAEMORRHAGE PRESENTED BY Sakuntala Giri SUM Nursing College

2. I ntroduction Shock is a life threatening condition. lt is characterized by inadequate tissue perfusion that if untreated results in cell death. The supply of oxygen to tissues is essential in the maintenance of life and this can be ensured when circulatory system is functioning normally. In 1923 Walter and Canner first worked for all conditions of shock. SHOCK

3. SHOCK

4. CLASSIFICATION OF SHOCK Hypovolemic shock. Cardiogenic shock. Circulatory shock or distributive shock a. Septic shock. b. Obstructive shock. c. Neurogenic shock. d. Anaphylactic shock.

5. Hypovolemic shock This is the most common type of shock, due to insufficient circulatory volume This occurs when there is loss in the intravascular fluid up to 15% to 25%. That is a loss of 750 to 1300 ml of blood in a 70 kg person

6. ETIOLOGY

7. PATHOPHYSLOLOGY Decreased blood volume Decreased venous return Decreased cardiac output Decreased tissue perfusion Decreased cellular metabolism

8. CLINICAL MANIFESTATIONS Decreased cardiac output Hypotension Altered tissue perfusion Cool and clammy skin Cyanosis or PaIe skin color (pallor) A rapid, weak, thready pulse Thirst and dry mouth, due to fluid depletion Fatigue due to inadequate oxygenation Anxiety, restlessness, altered mental state

9. CARDIOGENIC SHOCK It is caused by the failure of heart to pump effectively. This is due damage of heart muscles, mostly from myocardial infarction.

10. ETIOLOGY

11. PATHOPHYSIOLOGY

12. Decreased cardiac contractility Decreased stroke volume and cardiac output Pulmonary congestion decreased tissue perfusion decreased coronary artery perfusion volume

13. CLINICAL MANIFESTATIONS Pulmonary edema Increased central venous pressure Distended jugular veins due to increased jugular venous pressure Weak or absent Pulse due to tachyarrhythmia Shortness of breath Chest pain

14. SEPTIC SHOCK It is secondary to infections by micro organisms. Septic shock is caused by an overwhelming systemic infection and inflammation resulting in vasodilation Most common gram negative bacteria such as Escherichia coli, Proteus species, Klebsiella pneumoniae Which release an endotoxin and produce adverse biochemical,immunological & neurological effects which are harmful to the body.

15. SEPTIC SHOCK

16. Pathophysiology Severe localize infection of gram – ve bacili Bacterial invasion into bloodstream(septicemia) Inflammatory response Endotoxin release into circulation Histamine & other chemical mediator release vasodilation Increased capillary permeability Inadequate tissue perfusion to vital organ Multiple organ failure I

17. CLINICAL MANIFESTATION Pyrexia due to increased level of cytokines Systemic vasodilation resulting in hypotension Warm and sweaty skin due to vasodilation Reduced contractility of the heart Increased levels of neutrophils Increased heart rate Increased cardiac output

18. OBSTRUCTIVE SHOCK ETIOLOGY

19. Clinical manifestations Tachycardia Tachypnea Hypotension Cyanosis Oliguria Altered mental status jugular veins may be distended Pulsus paradoxus in case of tamponade

20. Neurogenic shock This is a very uncommon type of shock. lt is most often seen in patients who have had and extensive spinal cord injuries. The loss of autonomic and motor reflexes below level of injury results in loss of sympathetic control. This leads to relaxation of vessels and peripheral dilation and hypotension.

21. ETIOLOGY

22. Pathophysiology Spinal cord injury Inhibit the sympathetic nerve stimulation Arterial & venous dilatation Arterial / venous blood pooling Hypotenson Bradycardia , warm dry flushed skin Decreased perfusion of vital organ Multisystem organ failure

23. CLINICAL FEATURE Hypotension Altered mental status Bradycardia Skin that is warm and dry Tachycardia and tachypnea Cool and clammy skin Priapism due to Peripheral nervous system stimulation

24. Anaphylactic shock Anaphylactic shock is caused by severe reaction to an allergen, antigen, drug or foreign protein. When a patient who has already produced antibodies to a foreign substance develops a systemic antigen antibody reaction. Antigen antibody provides mast cells to release vasoactive substance such as histamine or bradykinin that cause vasodilatation

25. PATHOPHYSIOLOGY Due to antibody responses Release of histamine Vasodilatation Increased capillary permeability Severe broncho constriction Decreased oxygen supply and utilization Inadequate tissue perfusion.

26. CLINICAL FEATURE Skin eruptions and large bumps Localized edema, especially around the face Laryngeal edema Weak and rapid pulse Breathlessness and cough Tachycardia and tachypnea Hypotension Cyanosis Urticaria and pruritus Severe bronchospasm

27. DIAGNOSIS OF SHOCK Chest x-rays CVP Measurement Hemoglobin level measurement Arterial Blood Gases (ABG) analysis Urinalysis Complete blood count Blood, urine and sputum culture Blood chemistry including kidney function tests Cardiac catheterization and Coronary angiography Echocardiogram and Electrocardiogram Cardiac enzymes ( troponin , CKMB) test Computed tomography

28. MANAGEMENT OF SHOCK

29. MANAGEMENT   Management in all types of shock include the following: Management of airway, breathing and circulation Fluid replacement to restore intravascular volume Vasoactive medications to restore vasomotor tone and improve cardiac function Nutritional support to address metabolic requirement

30. The ABCDE approach E D C A B Disability due to neurological deterioration Circulation & shock management Breathing & ventilation Airway & oxygenation Exposure & examination

31. Airway See respiratory pattern Head tilt chin lift Jaw thrust Suction Oral airways Nasal airways Nebulised adrenaline for stridor Intubation Cricothyroidotomy Needle or surgical. O2 administer,if airway open A

32. Breathing Consider ventilation with AMBU bag. Position upright if struggling to breath Specific treatment i.e.: β agonist for wheeze, chest drain for pneumothorax B

33. circulation Position supine with legs raised Left lateral tilt in pregnancy IV access Fluid challenge colloid or crystalloid? ECG Monitoring Specific treatment C

34. Disability - assessment AVPU (or GCS) A lert, responds to V oice, responds to P ain, U nresponsive Pupil size/response Posture BM Pain relief D

35. Disability - interventions Optimise airway, breathing & circulation Treat underlying cause if drug induced causes. i.e.: naloxone for opiate toxicity Treat  blood glucosei,e hypoglycemia 100ml of 10% dextrose (or 20ml of 50% dextrose) Control seizures Seek expert help for CVA or ICP

36. Exposure & Examine Remove clothes and examine head to toe front and back. Haemorrhage, rashes, swelling, sores, catheter etc Keep warm Maintain dignity E

37. Complications a. ARDS- (acute respiratory distress syndrome) b. Multiple Organ Failure

38. DEFINITION Hemorrhage or bleeding is termed as escape or loss of blood from the circulatory system. It may be internally (from blood vessels) and externally (through natural opening such as mouth, anus or vagina). It may be termed as exsanguination (complete loss of blood) and desanguination (massive blood loss).