Ch. 30 Bleeding

Hemophilia

A bleeding disorder that is primarily hereditary, where clotting does not occur or occurs insufficiently; they lack one or more clotting factor.

When assessing an open skull fracture, how would you know if CSF is. present?

A bull's-eye target mark on the bandage, or testing the blood with a glucometer- it will come back abnormally high if CSF is present

Hematoma

A mass blood in the soft tissues beneath the skin; indicates bleeding into soft tissues and be of result of a minor or severe injury

When assessing a nose bleed causes by trauma or environmental factors (dry air), what should you also check?

BP to make sure the bleed is not from a HTN crisis

Melena

Black, foul-smelling tarry stool; indicates lower GI bleeding

Hematuria

Blood in the urine; may suggest serious rental injury or illness

Class 3 (hemorrhagic trauma hypovolemic shock)

Blood loss: 1500-2000 mL % blood loss: 3- 40% HR: > 120, thready Systolic: Significant drop Pulse pressure: Narrow RR: Markedly elevated Mental status: Anxious and confused Skin: Cold, pale, moist Fluid replacement: Crystalloid and blood

Class 2 (hemorrhagic trauma hypovolemic shock)

Blood loss: 750-1500 mL % blood loss: 15- 30% HR: 100-120 Systolic: Minimal ro no change Pulse pressure: Narrow RR: 20 - 24 Mental status: Mildly anxious Skin: Cool, moist Fluid replacement: Crystalloid

Class 1 (hemorrhagic trauma hypovolemic shock)

Blood loss: < 750 mL % blood loss: < 15% HR: Minimally elevated Systolic: WNL Pulse pressure: WNL RR: 14 - 20 Mental status: Slightly anxious Skin: Cool, pink Fluid replacement: Crystalloid

Class 4 (hemorrhagic trauma hypovolemic shock)

Blood loss: > 2000 mL % blood loss: > 40% HR: Marked tachy Systolic: Significant depression Pulse pressure: Very narrow RR: Markedly elevated Mental status: Confused and lethargic Skin: Cold, pale Fluid replacement: Crystalloid and blood

How does wound packing work?

By absorbing the liquid from the blood and helping concentrate the clotting factors at the site while providing direct pressure to control bleeding

How do traction splits help with femur fractures?

By reducing thigh muscle spasms and preventing one end of the femur from impacting/overriding the other

Pump failure causes what kind of shock?

Cardiogenic: Intrinsic Extrinsic- cardiac tamponade, tension pneumothorax (Obstructive shock)

What do baroreceptors detect?

Changes in stretch or pressure; ex: in the aortic arch which indicates decrease in BP, stimulus is sent to the brain via CN 9/10, where the vasomotor center (medulla) increases sympathetic resistance

Air splints are good for:

Controlling hemorrhage asc with venous bleeding, and stabilizing the fracture; acts like a pressure dressing.

Electron transport chain

Converts the high-energy electrons into more ATP; yields a high amount of ATP when O2 demands are present.

Hemoptysis

Coughed-up blood; usually bright red

Tranexamic acid (TXA)

Used to aid in the control of internal bleeding; used in pt with known bleeding disorders before surgery

Hematemisis

Vomited blood; sign of upper GI bleeding, can be bright red, dark red, or like coffee grounds

How does a drop in BP affect the endocrine system?

When BP falls, and so does changes in osmolality, it triggers a release of aldosterone from the adrenal glands, and ADH from the pituitary gland; Aldosterone and ADH cause peripheral vasoconstriction and water conservation in the kidneys.

Frank-Starling mechanism

When increased venous return stretches the ventricles, there will be an increase in cardiac contractility; stretched before contraction = greater force. Also called the Starling law of the heart.

Perfusion

circulation of blood in adequate amounts to meet the cells' current needs for oxygen, nutrients, and waste removal

Platelets

small cell fragments produced from larger cells (megakarocytes) that are essential for clot formation

Plasma

watery, straw-colored fluid that makes up more than half of the total blood volume

Trauma triad of death

Hypothermia, coagulopathy, and acidosis

Low fluid volume causes what kind of shock?

Hypovolemic shock: Can be hemorrhagic (internal or external bleeding), nonhemmorhagic (dehydration), or third space loss (fractures, burns)

Poor vessel function causes what kind of shock?

Hypovolemic shock: Septic shock CNS disruption = neurogenic shock Anaphylactic shock

What changes in vitals will you see with significant blood loss?

Increased HR and RR, and decreasing BP.

What are 2 places you should avoid placing the tourniquet to avoid nerve damage?

Just below the knee (common perineal nerve), and the proximal forearm just below the elbow (ulnar nerve).

When assessing neurologic system in a hemorrhagic pt, what should you check?

Level of consciousness, pupil size and reactivity, motor response, and sensory response.

Patients may experience referred right shoulder pain with what injury?

Liver injury

Normal hematocrit levels

Men: 40.7 - 50.3% Women: 36.1 - 44.3%

How can respiratory failure cause shock?

Obstruction- airway or embolism Chest wall movement problems- flail chest Diffusion failure- ARDS: acute respiratory distress syndrome Toxic exposure- carbon monoxide, cyanide

How does cellular respiration proceed in an anaerobic state?

Only glycolysis and fermentation will occur; producing lactic acid and ethanol as products, with substantially less efficiency and ATP.

"Rest and digest" system and how it affects the body

Parasympathetic nervous system; slows heart rate, slows breathing, accelerates digestion

Hematochezia

Passage of bloody stools; bright red indicate bleeding near exit; hemorrhoids in lower colon.

Amount of plasma in blood fluids and its components:

Plasma makes up about half of blood volume, and is 92% water and 8% dissolved substances (chemicals, nutrients, minerals)

Hemostasis

Platelets aggregate at the site of injury, plugging the hole and sealing the injured portion of the vessel

Pulses begin to disappear in what order?

Radial, brachial/femoral, then carotid last.

An artery that is cut directly across will often:

Recoil and attempt to slow its own bleeding

Cellular respiration

Series of metabolic processes to make energy

3 steps of hemostasis:

1. Vasoconstriction 2. Platelet aggregation 3. Fibrinogen weaving into clot to form fibrin which holds the clot together

Steps in managing external hemorrhage:

1. While taking spinal and air way precautions, apply direct pressure with a dry, sterile dressing 2. If bleeding stops, apply pressure dressing and/or split 3. If direct pressure is not enough, apply a tourniquet above level of bleeding 4. Tighten tourniquet until bleeding stops, noting the time; administer O2, keep pt warm, monitor vitals.

A laceration or tear of a large artery can cause someone to exsanguinate in less than _____ , so you should be able to apply a tourniquet in less than _____ .

2 minutes ; 20 seconds.

Significant changes in vitals will occur when someone has lost how much blood?

2 pints; 1 L.

How much blood loss before a small child has significant symptoms?

3 - 6 ounces (100-200 mL); less than a can of soda.

Percentages of blood components:

45% RBC 1% White blood cells and Platelets ~50% Plasma

Average adult total blood volume:

(80 kg adult) about 5L

Blood pressure is calculated by:

(Stroke volume) x (HR) x (PVR)

Patients may experience referred left shoulder pain with what injury?

Spleen injury

Rigid splints are good for:

Stabilizing fractures, reducing pain, and preventing further damage to soft-tissue injuries.

How do Calcium channel blockers interfere with compensating in hemorrhagic shock?

They interfere with vasoconstriction, not allowing the body to shunt blood to vital organs.

Organs/organ systems with high risk of exsanguination:

Heart, thoracic vascular system, abdominal vascular system (abdominal aorta, superior mesenteric artery), venous system (IVC, portal vein), and liver.

What is the most common cause of shock?

Hemmorhagic shock

The three successive phases of shock:

1. Compensated shock 2. Decompensated shock 3. Irreversible shock

Signs of compensated shock:

Agitation, anxiety, restlessness Sense of impending doom Weak, rapid (thready) pulse ClammyPallor with cyanotic lips Shortness of breath N/V Delayed cap refill Thirst Normal BP*

Signs of decompensated shock:

Altered mental status Hypotension* Labored/irregular breathing Thready or absent radial pulses Ashen, mottled, or cyanotic skin Dilated pupils Diminished urine output Impending cardiac arrest

Shock

An abnormal state associated with inadequate oxygen and nutrient delivery to the metabolic apparatus of the cell

Average 1 year old child total blood volume:

Approx 2 pints

In cases of hemorrhagic shock, what questions should you include with your normal history taking?

Asking about current medications that may include blood thinners (aspirin, warfarin, rivaroxaban, dabigatran, apixaban, and clopidogrel), anticoagulants, or beta blockers, calcium channel blockers, antidysrhythmics, or nitro, which interfere with shock compensation. Ask about pain, tenderness, swelling, bruising, guarding.

Which nervous system monitors the body needs and adjusts blood flow accordingly?

Automatic Nervous system (maintains homeostasis): divides into sympathetic and parasympathetic nervous systems.

How would someone go into nonhemmorhagic shock?

Electrolyte solution loss through vomiting, diarrhea, or sweating

Citric Acid Cycle

Enzymatic reactions break down pyruvic acid into APT, H2O, Co2, acetyl Coenzyme A, and high-energy electrons

Examples of nontraumatic internal bleeding:

GI bleed (upper or lower), ruptured ectopic pregnancy, ruptured aneurysm

Glycolysis

Glucose is broken down into pyruvic acid and 2 ATP

The three steps of cellular respiration:

Glycolysis, the Citric Acid Cycle, and the electron transport chain

What is an early sign hypoperfusion that indicated internal hemorrhage?

Tachycardia

To keep blood flowing continuously through the body, what 3 components are needed?

The "pump", the "pipes", and the "fluid".

Cardiac output

The amount of blood pumped through the circulatory system in 1 minute; (stroke volume) x (pulse rate).

Preload

The amount of blood returned to the heart to be pumped out

Ejection fraction

The amount of blood that leaves the heart each time it contracts

Water enters plasma via:

The digestive tract, from fluids between cells, and as a by-product of metabolism

Exsanguination

The loss of total blood volume

Afterload

The pressure in the aorta or the peripheral vascular resistance, which the left ventricle pumps blood against

What system initiates the body normal response to stress, and what happens when it is activated?

The sympathetic nervous system; "fight or flight", faster/stronger heart contractions, faster/deeper respirations, bronchodilation, shunting of blood to vital organs, slowing digestion.

Pediatric patients have underdeveloped kidneys. How does this interfere with blood loss compensation?

They are not able to conserve fluids as easily, and therefore are less tolerant to volume loss.

How do Beta blockers affect compensating in hemorrhagic shock?

They interfere with the normal sympathetic response, not allowing the heart to pump harder/faster.