Transcript Ambulance Background - San Joaquin County California

Shock and Bleeding
Shock and Bleeding
By Kevin O’Loughlin, MICP
This Course Has Been Approved for 2.5
Hour of Continuing Education for:
•First Responders
•EMT-I
•Paramedics
Continuing Education
•To receive continuing education for this
course you must complete the post test
and evaluation available on the EMS
Agency website San Joaquin County
EMS- Training / Continuing Education.
•Submit the completed test and evaluation
to the EMS Agency and a CE certificate
will be mailed to you.
•There is no charge for this course.
LEARNING OBJECTIVES
Upon completion of this course, you will be able to:
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Define shock and identify the different types
of shock.
Discuss the signs, symptoms and treatment
for shock.
Describe the three types of external
bleeding.
Discuss the four ways to control bleeding.
Properly control bleeding and dress a wound
utilizing the Emergency Bandage.
Stop bleeding with the SOF Tactical
Tourniquet.
Instructor Contact Information
If you have questions regarding this
course, please contact Kevin
O’Loughlin, MICP, EMS Specialist.
Phone (209) 468-6818. Email:
[email protected]. A response
will be provided within 48 hours.
Routine Medical Care
 Routine Medical Care is provided to all
patients regardless of presenting complaint.
 Standard precautions:
Application of body substance isolation
precautions including the use of
appropriate personal protective equipment
(PPE) shall apply to all patients receiving
care, regardless of their diagnosis or
presumed infectious status
Routine Medical Care
 Body substance isolation precautions apply to:
 Blood;
 All bodily fluids, secretions, and excretions except
sweat, regardless of whether or not they contain
visible blood;
 Non intact skin; and
 Mucous membranes. Standard precautions are
designed to reduce the risk of transmission of
microorganisms from both recognized and
unrecognized sources of infection in the prehospital
setting.
Routine Medical Care

Patient Assessment:
 Primary Survey – which includes scene survey
and ABC’s
 Secondary Survey – which includes, history,
medications, allergies and a head-to-toe
survey.
 Initiation of appropriate basic life support (BLS)
treatment including, when appropriate:

Monitoring of vital signs:
 Initial set.
 Repeated every 5 – 10 minutes.
Routine Medical Care
 Initiation of spinal precautions.
 Administration of oxygen.
 Hemorrhage control.
 Ensuring ALS transport response.
 Initiation of specific treatments in accordance
with San Joaquin County EMS Agency
Policies and Procedures.
Shock
Defined as inadequate
perfusion (blood flow) leading
to inadequate oxygen delivery
to tissues.
Physiology
Basic unit of life = cell
Cells get energy needed to stay alive
by reacting oxygen with fuel (usually
glucose)
No oxygen, no energy
No energy, no life
Cardiovascular System
• Transports oxygen, fuel to cells
• Removes carbon dioxide, waste
products for elimination from body
Cardiovascular system must be
able to maintain sufficient flow
through capillary beds to meet
cell’s oxygen and fuel needs
What is needed to maintain
perfusion?
• Pump = Heart
• Pipes = Blood Vessels
• Fluid = Blood
How can Perfusion Fail?
Loss of Volume
Pump Failure
Pipe Failure
Types of Shock and Causes
Cardiogenic Shock
• Pump failure
• Heart’s output depends on
– How often it beats (heart rate)
– How hard it beats (contractility)
• Rate or contractility problems cause
pump failure
Cardiogenic Shock
• Causes
– Acute myocardial infarction
– Very low heart rates (bradycardias)
– Very high heart rates (tachycardias)
Neurogenic Shock
• Spinal cord injured
• Loss of peripheral resistance
• Vessels below injury dilate
Hypovolemic Shock
• Loss of volume
• Causes
– Blood loss: trauma
– Plasma loss: burns
– Water loss: Vomiting, diarrhea,
sweating, increased urine, increased
respiratory loss
Psychogenic Shock
•
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•
Simple fainting (syncope)
Caused by stress, pain, fright
Heart rate slows, vessels dilate
Brain becomes hypoperfused
Loss of consciousness occurs
Septic Shock
• Results from body’s response to
bacteria in bloodstream
• Vessels dilate, become “leaky”
Anaphylactic Shock
• Results from severe allergic
reaction
• Body responds to allergen by
releasing histamine
• Histamine causes vessels to
dilate and become “leaky”
Shock:
Signs and Symptoms
• Restlessness,
anxiety
• Increased pulse rate
• Decreasing level of
consciousness
• Rapid, shallow
respirations
• Nausea, vomiting
• Thirst
• Diminished urine
output
• Dull eyes
Shock:
Signs and Symptoms
• Hypovolemia will
cause
– Weak, rapid pulse
– Pale, cool, clammy
skin
• Cardiogenic shock
may cause:
– Weak, rapid pulse
or weak, slow pulse
– Pale, cool, clammy
skin
• Neurogenic shock will
cause:
– Weak, slow pulse
– Dry, flushed skin
• Sepsis and anaphylaxis
will cause:
– Weak, rapid pulse
– Dry, flushed skin
Shock:
Signs and Symptoms
• Patients with anaphylaxis will usually:
– Develop hives (urticaria)
– Itch
– Develop wheezing and difficulty breathing
(bronchospasm)
Shock:
Signs and Symptoms
Shock is NOT the same thing
as a low blood pressure!
A falling blood pressure
is a LATE sign of
shock!
Shock:
Signs and Symptoms
• Obscure/less viewed symptoms of
shock
– Drop in end tidal carbon dioxide
(ETCO2) level
– Indicative of respiratory failure
resulting in poor oxygenation,
therefore, poor perfusion or Shock
Treatment
– Secure, maintain airway (ABC’s)
– High concentration oxygen
– Assist ventilations
– Control obvious bleeding
– Stabilize fractures
– Replace Fluids (paramedics only)
– Prevent loss of body heat
– Transport rapidly to appropriate facility
Treatment
• Elevate lower extremities 8 to 12 inches
Treatment in Hypovolemic shock
– Do NOT elevate the lower extremities in
Cardiogenic shock
• Administer nothing by mouth, even if
the patient complains of thirst
Bleeding
• Severe bleeding or hemorrhage is a major
cause of shock (hypoperfusion), which can
be life threatening if the body loses an
excessive amount of blood.
• If the body loses enough blood, the cells of
the body will not receive enough oxygen
and begin to die.
• Once cells begin to die, bigger cells such
as organs will also fail and eventually the
entire body will fail and death will occur.
Control of External Bleeding
• Direct Pressure
– gloved hand
– dressing/bandage
• Elevation
• Arterial pressure points
• Tourniquet (last resort)
Three Types Of External Bleeding:
• Arterial
• Venous
• Capillary bleeding
Arterial bleeding
Usually bright red in color because it is
rich in oxygen.
Bleeding from an artery is often profuse
and spurting due to the high pressure
from the heart as it contracts, forcing
blood out to the rest of the body.
This is the reason why it is so hard to
control and direct pressure will be
required all the way to the hospital.
Venous bleeding
oUsually dark red/maroon in color because it
does not contain much oxygen.
oThe red blood cells have already left its
oxygen behind with the cells of the body,
picked up carbon dioxide and wastes, and
are on their way back to the lungs to get rid
of them and pick up more oxygen.
oIt is usually easy to control venous bleeding
because the veins are under low pressure.
oThe main difficulty with venous bleeding is
in the neck because it can actually suck in
air and cause further complications.
Capillary bleeding
 Usually slow and oozing due to their small
size and low pressure.
 Although there may be a significant amount of
bleeding, the majority of capillary bleeding is
considered to be minor and is easy to control.
 Capillary bleeding is usually the result of an
abrasion.
 The color of capillary bleeding can be bright
red or darker red depending on the amount of
oxygen it is carrying.
 The majority of problems that arise with
capillary bleeding is infection due to due to
contaminants becoming embedded in the skin.
Care For External Bleeding
Direct Pressure
Direct pressure is
applied to the injury
with sterile gauze.
 If bleeding is profuse or
seeps through the
gauze, add more
gauze, but do not
remove the existing
pieces.
 This will prevent the
clotting process from
being interrupted
Elevation
 If bleeding continues
to be severe, the
extremity or body part
should be elevated
above the level of the
heart.
 This will decrease the
amount of blood
flowing to the injury
site by using gravity
to help decrease the
amount of blood flow.
Bleeding Continues
If bleeding
continues, add
more gauze to the
existing dressing
and tie a pressure
bandage to the
site of injury.
Pressure Points
 If direct pressure,
elevation, and
pressure bandage fail
to control bleeding,
apply pressure to a
pressure point of the
injury if it is to an
extremity.
 This will aid in further
decreasing the flow of
blood to the injury site.
Pressure Points
www.armystudyguide.com
Tourniquet
 A tourniquet should only be applied after
all other means have failed to control life
threatening blood loss .
 Tourniquets are to be used in rare
circumstances and only by trained EMS
personnel. Once applied a tourniquet
may only be removed by direct physician
order.
 Application of a tourniquet greatly
increases loss of limb below the
tourniquet since blood flow is stopped to
the area.
OLD
VS.
NEW
Complicated and takes Simple one handed
more than two hands to application
apply correctly
SOF Tactical Tourniquet Components
Windlass
Safety Screw
Windlass
Strap
Buckle
Tri-Rings
Strap
Applying the SOF Tactical Tourniquet
1. Pull Strap until
Tourniquet is tight
around the injured
extremity
2. Twist the aluminum
windlass until the
bleeding is controlled
Applying the SOF Tactical Tourniquet
3. Secure the windlass
in the tri-ring
4. Tighten the safety
screw
Applying the SOF Tactical Tourniquet
5. It is not necessary to
secure the windlass on
both tri-rings.
6. Once secured
reassess the limb for
bleeding.
7. Document the time the
tourniquet was applied
on the PCR or START
triage tag.
SOF Tactical Tourniquet Training Video
To view video click on link below:
Note: The first link is required for this
course, the second video link provides
additional instruction on the use and care of
the tourniquet.
SOF Tactical Tourniquet Application
•SOF Tactical Tourniquet Instruction
Answers to some exam questions come
from this video
Emergency Bandage
Emergency Bandage
 The Emergency Bandage consolidates
numerous treatment equipment into a single
unit and provide in one device:
 Non-adherent pad: Eliminating the risk of
causing pain and having the wound reopened upon removal of the bandage.
 Pressure Applicator: Creating the immediate
direct pressure to the wound site.
 Secondary Sterile Dressing: Keeping the
wound area clean and maintaining the pad
and pressure on the wound firmly in place,
including immobilization of the injured limb or
body part.
Emergency Bandage
 Closure Bar: Enabling closure and fixation
of the Emergency Bandage at any point, on
all parts of the body: no pins and clips, no
tape, no Velcro, no knots.
 Quick and easy application and Selfapplication. Designed with the end-user in
mind; for the first-aid trained and the lay
care-giver.
 Significant per treatment time and cost
savings.
Emergency Bandage
The Emergency Bandage has efficient blood
staunching capability and offers ease of
operation:
The application of immediate direct pressure
to the wound site is achieved by wrapping the
elasticized woven leader over the topside of
the bandage pad where the specially
designed pressure bar is situated. The
pressure bar is designed to readily accept
and hold the wrapping leader.
Emergency Bandage
After engagement of the pressure bar,
wrapping the leader in any direction
around the limb or body part and onto
the pressure bar forces the pressure bar
down onto the pad creating the direct
pressure needed to bring about
homeostasis.
The sterile, non-adherent pad is placed
on the wound.
Emergency Bandage
• In addition to its primary function, the pressure
bar also facilitates bandaging. The elastic
bandage uses the rigid shape of the pressure bar
to change direction while bandaging, thus
affording the caregiver more options for
effective dressing of the wound.
• Subsequent wrappings of the leader secures and
maintains the pad in place over the wound, and
by covering all the edges of the pad acts as a
sterile secondary dressing. The bandage leader is
woven to remain at its full width and will not
bunch up or twist itself into a rope.
Emergency Bandage
•
The closure system of the bandage is
multi-functional yet simple, quick, and
familiar. Situated at the end of the
leader is a closure bar (dowel with
hooking clips) at each end to secure
the wrapping leader the same way
that a pen is secured in a shirt
pocket. The closure bar holds the
bandage securely in place over the
wound site.
Emergency Bandage
 If additional pressure is required the
closure bar is easily removed from its
first closure position and inserted
between previous layers of the leader
directly above the protruding pressure
bar and rotated.
 This rotation of the closure bar acts to
further press down the pressure bar
onto the wound to exert bloodstaunching pressure. The closure bar is
used as before to secure the dressing.
Emergency Bandage Training Video
To view video click on link below:
Emergency Bandage Application
Answers to some exam questions come from this
video.
Post Test and Course Evaluation
To complete the post test and evaluation,
please click on the following links:
Examination for Shock and Bleeding
Online Continuing Education Course
Evaluation
Once you have completed both, please mail
to: San Joaquin County EMS Agency, PO Box
220, French Camp, CA 95231 or it can be
faxed to 209-468-6725