Hemorrhagic shock Seminar

Advance Nursing

1. A dvanced N ursing P ractice P radeep MK M.Sc. Nursing I year

2. H emorrhagic S hock Seminar Presentation

3. CONTENTS Introduction A Definition B Causes C Pathophysiology D Signs & Symptoms E Diagnostic Evaluation F G Management

4. Introduction; A Hemorrhagic shock occurs when the body begins to shut down due to heavy blood loss. People suffering injuries that cause heavy bleeding may go into hemorrhagic shock if the bleeding isn't stopped immediately.

5. Definition; B Hemorrhagic shock is a condition of reduced tissue perfusion, resulting in the inadequate delivery of oxygen and nutrients that are necessary for cellular function. Whenever cellular oxygen demand out weighs supply, both the cell and the organism are in a state of shock.

6. Cont.... On a multi-cellular level, the definition of shock becomes more difficult because not a ll tissues and organs will experience the same amount of oxygen imbalance for a given clinica l disturbance. Clinicians struggle daily to adequately define and monitor oxygen utilizatio n on the cellular level and to correlate this physiology to useful clinical parameters and diagnosti c tests.

7. Hypovolemic Septic Cardiogenic (Obstructive) Neurogenic Four Classes of Shock;

8. Causes of Hemorrhagic Shock; Deep Cuts 1 Gunshot Wounds 2 Trauma 3 Blunt Injury 4 5 6 Severe Burns Amputations C

9. Cont;

10. Cont; Hemorrhagic shock is caused by the loss of both circulating blood volume and oxygen-carrying capacity. The most common clinical etiologies are penetrating and blunt trauma, gastrointestinal bleeding, and obstetrical bleeding.

11. Pathophysiology, D

12. Cont; At the site of hemorrhage, clotting cascade and platelets form a hemostatic plug whereas remote from the site fibrinolytic activity increases, presumably to prevent microvascular thrombosis. However excess plasmin activity and autoheparinization can lead to pathologic hyperfibrinolysis and coagulopathy.

13. Cont; There is transition to anaerobic metabolism which generates lactic acid, inorganic phosphates and oxygen radicals. Release of Damage Associated Molecular Patterns (DAMP) incites a systemic inflammatory response. As ATP levels deplete, cellular homeostasis fails and cell death ensues

14. Cont; External Hemorrhage Results from soft tissue injury. Most soft tissue trauma is accompanied by mild hemorrhage and is not life threatening. Can carry significant risks of patient morbidity and disfigurement The seriousness of the injury is dependent on: Anatomical source of the hemorrhage (arterial, venous, capillary) Degree of vascular disruption Amount of blood loss that can be tolerated by the patient

15. Cont; Internal Hemorrhage Can result from: Blunt or penetrating trauma Acute or chronic medical illnesses Internal bleeding that can cause hemodynamic instability usually occurs in one of four body cavities: Chest Abdomen Pelvis Retroperitoneum

16. Compensated Shock; 0-20% of blood loss Blood pressure is maintained via increased vascular tone and increased blood flow to vital organs

17. Cont....

18. Signs & Symptoms; Blue lips & fingernails 1 Low (or) no urine output 2 Profuse sweating 3 Dizziness 4 5 6 Anxiety Shallow Breathing E

19. Cont.... Chest pain 7 Loss of consciousness 8 Low blood pressure 9 Weak pulse 10 11 12 Confusion Rapid heart rate

20. Cont.... Blood in the stool 13 Blood in the urine 14 Vaginal bleeding 15 Chest pain 16 17 18 Abdominal pain/swelling Blood vomiting

21. Cont..., The organs who win - Brain Heart Kidney Liver The organs who lose – Skin GI tract Muscles

22. Diagnostic Evaluation; Physical Examination 01 Chest radiographs 3 CT Scan 5 Imaging studies 2 Abdominal radiographs 4 F

23. Cont.... Esophago Gastro duodenoscopy 6 Ultrasounds 8 Nuclear medicine scanning 1 Colonoscopy 7 Angiography 9

24. Cont..., Initial Assessment General Impression Obvious bleeding Mental Status Interventions Manage as you go O 2 Bleeding control Shock BLS before ALS!

25. Cont..., Focused History & Physical examination Rapid Trauma Assessment Full head to toe Consider air medical if stage 2+ blood loss Focused Physical Exam Guided by c/c Vitals, SAMPLE, Additional Assessment Orthostatic hypotension Tilt test: 20 – ↓ BP or ↑ P from supine to sitting

26. Cont..., Fractures and Blood Loss Pelvic fracture → Femur fracture Tibia/fibula fracture → Hematomas and contusions → 2,000 mL 1,500 mL 500–750 mL 500 mL

27. Cont..., Ongoing Assessment ; Reassess vitals and mental status: Q 5 min: UNSTABLE patients Q 15 min: STABLE patients Reassess interventions: Oxygen ET IV Medication actions Trending: improvement vs. deterioration Pulse oximetry End-tidal CO 2 levels

28. Management of Shock; Management of ABC Fluid replacement Vasoactive medications G Shock required immediate intervention to preserve life. Re-establishing perfusion to the organs is the primary goal through restoring and maintaining the blod circulating volume ensuring oxygenation and blood pressure are adequate, achieving and maintaining effective cardiac function and preventing complications. Nutritional support

29. 1. Management of ABC; A - Airway B - Breathing C - Circulation Secure the airway, breathing and circulation, by performing cardio pulmonary resuscitation (or) life support measurements Provide oxygen supplements through nasal cannula, mask (or) endotrachial intubation (or) mechanical ventilator.

30. 2.Fluid replacement to restore intravascular; Stop further bleeding- Recent studies indicates that tourniquet application proximal to the site of hemorrhage in the extremities saves lives without risking amputation or extremity dysfunction, if the patient can be quickly transported to the hospital. Isotonic crystalloid resuscitation has been used for decades in early management of bleeding. However they only transiently expand the intravascular volume & have no intrinsic therapeutic benefit. Overzealous resuscitation with crystalloid dilutes the oxygen carrying capacity and clotting factors. Limiting crystalloid infusion to 3L in 1 st 6 hours is recommended as a part of bundle of care for patients with acute bleeding & trauma.

31. Cont.... Blood Transfusion; Blood products transfusion provide a greater survival benefit as compared to colloids/crystalloids TYPES- Red blood cells Plasma Platelets Cryoprecipitate Prospective studies show that 1:1:1 ratio of plasma to platelets to RBC’s is safe However all these contain citrate which can lead to hypocalcemia & progressive coagulopathy. Thus emp i rical dosing of calcium & frequent measurement of electrolytes is recommended.

32. Cont.... Vasopressor therapy initially to target a mean arterial pressure (MAP) of 65 mm Hg Norepinephrine as the first choice vasopressor Epinephrine (added to and potentially substituted for norepinephrine) when an additional agent is needed to maintain adequate blood pressure Vasopressin 0.03 units/minute can be added to norepinephrine (NE) with intent of either raising MAP or decreasing NE dosage

33. Cont- Emergency care & First aid; Rapid evaluation Damage control resuscitation CXR, Pelvis X-Ray,ICD Insertion Permissive hypotension Control hemorrhage Prevent contamination Avoid further injuries Initial homeostasis and packing .

34. Cont- Emergency care & First aid; Reverse the sequel of hypotension Physiological and biochemical restoration Adequate Oxygen delivery Agressive core rewarming Correction of coagulopathy Definitive surgery

35. Decrease cardiac output related to Alteration in heart rate & rhythm Decreased ventricular filling Fluid volume loss of 30% (or) more Late uncompensated shock Difficult fluid volume, decreased intravascular, interstitial and intracellular fluid may related to Active fluid volume loss Internal fluid shifts Regulatory mechanism failure NURSING MANAGEMENT; Nursing diagnosis;

36. Complications; Multiple organ failure 01 Kidney damage 02 Gangrene develops 03 Death 4

37. Summary

38. T H ANK Y OU