1

HAEMORRHAGE &

SHOCK

BLOOD COAGULATIONWhen a tissue is damaged

Prothrombin is converted into its active form thrombin

(In the presence of calcium) 

Fibrinogen then transformed by thrombin to fibrin 

Mesh is formed by platelets and other blood cells to form clot

 

CLOTTING FACTORS

3

I. FIBRINOGENII. PROTHROMBINIII. TISSUE FACTOR( THROMBOPLASTIN)IV. CALCIUM( CA2+)V. LABILE FACTOR, PROACCELERIN, AC-

GLOBULINVI. STABLE FACTOR

CONTD…VII. ANTIHAEMOPHILIC GLOBULIN( AHG),

ANTIHAEMOPHILIC FACTOR AVIII. CHRISTMAS FACTOR, PLASMA

THROMBOPLASTIN COMPONENT(PTA), ANTIHAEMOPHILIC FACTOR B 

IX. STUART POWER FACTOR X. PLASMA THROMBOPLASTIN

ANTECEDENT( PTA), ANTIHAEMOPHILIC FACTOR C 

XI. HAGEMAN FACTORXII. FIBRIN STABILISING FACTOR 4

CLASSIFICATION BY ATLS Based on blood volume1. Class I Haemorrhage2. Class II Haemorrhage3. Class III Haemorrhage 4. Class IV Haemorrhage 

5

CONTD… World Health Organization Grade 0 - no bleeding Grade 1 - Petechial  bleeding; Grade 2 - mild blood loss (clinically

significant); Grade 3 - gross blood loss, requires

transfusion (severe); Grade 4 - debilitating blood loss, retinal or

cerebral associated with fatality

6

According to Origin: Mouth

Hematemesis, Haemoptysis AnusHematochezia 

Urinary tractHematuria

Upper headIntracranial haemorrhageCerebral haemorrhage Intracerebral haemorrhage 

Subarachnoid haemorrhage (SAH) 7

LungsPulmonary haemorrhage

GynaecologicVaginal bleeding

Postpartum haemorrhageBreakthrough bleeding

Ovarian bleeding. Gastrointestinal

Upper gastrointestinal bleedLower gastrointestinal bleedOccult gastrointestinal bleed

8

9

According to source • Capillary• Venous• Arterial

According to situation• External (Revealed haemorrhage)• Internal (Concealed haemorrhage)• Subcutaneous/intramuscular

According to the time of wound:

• Primary haemorrhage• Reactionary or intermediate haemorrhage• Secondary haemorrhage  

10

CAUSES1.Traumatic Injury

Abrasion Excoriation Hematoma Laceration Incision Puncture Wound Contusion Crushing Injuries  Ballistic Trauma  11

2. Medical condition

Intravascular changes Intramural changes Extra vascular changes 

12

SIGNS & SYMPTOMS OF HAEMORRHAGE

Blood coming from an open wound. Bruising Shock, which may cause any of the

following symptoms:• Confusion or decreasing alertness• Clammy skin• Dizziness or light-headedness after an

injury• Low blood pressure• Paleness (pallor) 13

Contd…• Rapid pulse, increased heart rate• Shortness of breath• Weakness

Symptoms of internal bleeding may also include:

• Abdominal pain and swelling• Chest pain

14

• External bleeding through a natural opening– Blood in the stool(appears black, maroon, or bright

red)– Blood in the urine (appears red, pink, or tea-

colored)– Blood in the vomit (looks bright red, or brown like

coffee-grounds)– Vaginal bleeding (heavier than usual or after

menopause)• Skin colour changes that occur several days after an

injury (skin may black, blue, purple, yellowish green)  

15

CONTROL OF HAEMORRHAGE

16

Apply direct pressure:• with gloved hand,• sterile dressing(s).

Bleeding stopped? YesNo

Elevate extremity:• above victim’s heart,continue direct pressure

Locate pressure point,apply pressure:• maintain direct pressureover wound

Treat for shock:• care for wound,• seek definitive care

Bleeding stopped?

Bleeding stopped?

No

Bleeding fromextremity?

No

Apply tourniquet(last resort)

Yes

No

Definitive therapy 17

Apply pressure directly to wound site:– Gloved hand, dressing– If dressing soaks

through, add more gauze on top and press harder

18

Direct pressure

If possible, raise wound site above level of victim’s heart

19

Elevate wound site

Find proximal “pressure point” and press on it (radial, ulnar, brachial, axillary, femoral arteries—not carotid)

Apply direct pressure to site

20

Pressure points

Yes

Yes

Tourniquet Apply band above injury site, tighten to stop

bleeding:– Last resort—risky– Note time of application– Reassess frequently

21

22

FIRST AID IN EXTERNAL BLEEDING

Bring the sides of wound together and press firmly. Press on the pressure point for 10-15 min. Place the causality in comfortable position and raise

the injured Part and reassure him. Apply a clean pad larger than the wound and press

it firmly with the palm until bleeding becomes less. If bleeding continues do not take off original

dressing but add more pads. Bandage, it but not too tightly.

CONTROL OF INTERNAL HAEMORRHAGE

The organ is emptied of blood clots if possible.

The vessels are encouraged to contract.

Packing Surgical ligature Internal pressure.

23

FIRAT AID IN INTERNAL BLEEDING

Lay the causality down with head low; raise his legs by Use of pillow.

Keep him calm and relaxed. Reassure him. Do not allow him to move. Keep up the body heat with thin blankets or

coat.

24

CONTD…

Do not give anything to eat or drink aspiration may occur.

Do not apply ice bags or hot water bottles to chest or abdomen.

Take him to the hospital as early as possible.

Transport gently25

RESTORATION OF BLOOD VOLUME Transfusion under increased

pressurePressure cuff Pressure pump administration

26

NURSING MANAGEMENT

Risk for bleeding related to pregnancy related complications, postpartum complication, treatment related side effects, circumcision, DIC, inherent coagulopathies, GI disorders, aneurysm, impaired liver function, trauma or history of falls.

27

28

Shock

DEFINITION

1. Shock can be best be defined as a condition in which tissue perfusion is inadequate to deliver oxygen and nutrients to support vital organs and cellular function.

2. Shock is a syndrome characterized by decreased tissue perfusion and impaired cellular metabolism. This results in an imbalance between the supply of and demand for oxygen and nutrients.

29

Contd….

3. Shock is a condition where the tissues in the body do not receive enough oxygen and to allow cells to function.

4. Shock is defined as failure of the circulatory system to maintain adequate perfusion to vital organs.

30

31

Shock

Homeostasis– cellular state of balance– perfusion of cells with oxygen and

glucose is one of its cornerstones– Transfer of waste materials from the

cell to blood for elimination

32

Shock

Inadequate oxygenation or perfusion causes:

Inadequate cellular oxygenationShift from aerobic to anaerobic

metabolism

33

AEROBIC METABOLISM

6 O2

GLUCOSE

METABOLISM

6 CO2

6 H2O

36 ATP

HEAT (417 kcal)

Glycolysis: Inefficient source of energy production; 2 ATP for every glucose; produces pyruvic acid

Oxidative phosphorylation: Each pyruvic acid is converted into 34 ATP

34

ANAEROBIC METABOLISM

GLUCOSE METABOLISM

2 LACTIC ACID

2 ATP

HEAT (32 kcal)

Glycolysis: Inefficient source of energy production; 2 ATP for every glucose; produces pyruvic acid

35

Anaerobic Metabolism Occurs without oxygen

– oxydative phosphorylation can’t occur without oxygen

– glycolysis can occur without oxygen– cellular death leads to tissue and organ

death– can occur even after return of perfusion

organ or organism death

VASCULAR RESPONSES Oxygen attaches to the haemoglobin

molecule in red blood cells, and the blood carries it to body cells.

Central regulatory mechanisms Local regulatory mechanisms

36

B.P REGULATION Three major components of the circulatory

system blood volume, the cardiac pump, and the vasculature must respond effectively to complex neural, chemical, and hormonal feedback systems to maintain an adequate blood pressure and ultimately perfuse body tissues.

Mean arterial blood pressure = cardiac output × peripheral resistance

37

CONTD… Cardiac output is determined by stroke volume

(the amount of blood ejected at systole) and heart rate.

Blood pressure is regulated by the baroreceptors (pressure receptors) located in the carotid sinus and aortic arch.

Chemoreceptor’s, also located in the aortic arch and carotid arteries, regulate blood pressure and respiratory rate using much the same mechanism in response to changes in oxygen and carbon dioxide concentrations in the blood.

38

CONTD…

The kidneys also play an important role in blood pressure regulation.

Adequate blood volume, an effective cardiac pump, and an effective vasculature are necessary to maintain blood pressure and tissue perfusion.

39

STAGES OF SHOCK

Initial Stage Compensatory

Stage Progressive

Stage Irreversible

Stage

INITIAL STAGE

Initially, the body compensates with the onset of shock.

No changes are noted clinically. Changes are beginning to occur

on the cellular level.

COMPENSATORY STAGE

Activation of SNS - activation of epinephrine and nor epinephrine.

Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output.

Kidneys release renin into blood formation of angiotensin & release of aldosterone, ADH

Decreased CO

SNS stimulation

Epinephrine & nor epinephrine released

Vasoconstriction

Increased SVR

Renin secreted by kidney

Angiotension

Aldosterone

ADH

Increase blood volume

hydrostatic pressure

fluid pulled into capillary

Blood Pressure Maintained

CLINICAL MANIFESTATIONS

Normal B.P Increased respiratory rate Skin- cold & clammy Hypoactive bowel sounds Decreased urine output Mental status changes- confusion

44

MANAGEMENT MEDICAL MANGEMENT• Fluid replacement• Medication therapy NURSING MANAGEMENT• Monitoring tissue perfusion• Reducing anxiety• Promoting safety

45

PROGRESSIVE STAGE

Vicious circle of compensation eventually leads to decompensation.

Mean arterial pressure starts to fall - SBP below 90.

CLINICAL FEATURES RESPIRATORY: o rapid & shallowo Crackleso Decreased arterial oxygeno Increased CO2o Pulmonary edemao Interstitial inflammation & fibrosiso ARDS 47

CARDIOVASCULAR:o Dysrhythmiaso Ischemiao Rapid HR- > 150 bpmo Chest paino Rised cardiac enzyme levels NEUROLOGICo Mental status changes-Confusiono Lethargyo Dilated pupils, sluggish reaction to light

48

RENAL EFFECTSo Acute renal failure

HEPATIC EFFECTSo susceptible to Infectiono Elevated liver enzymes& bilirubin

levels

49

GI EFFECTSo Stress ulcero Bloody diarrheao Bacterial toxin translocation

HEMATOLOGIC EFFECTSo DIC

50

MEDICAL MANAGEMENT

IV FLUIDS& MEDICATIONS Early enteral support Antacids, histamine-2 blockers, or

anti-peptic agents.

51

NURSING MANAGEMENT Preventing complications Promoting rest and comfort Supporting family members

52

IRREVERSIBLE STAGE

Severe organ damage Low B.P Complete renal and liver failure Multiple organ dysfunction

progressing to complete organ failure has occurred, and death is imminent.

53

MANAGEMENT MEDICAL Same as progressive stage Antibiotic agents & immunomodulation

therapy

NURSING Offering brief explanations to the patient Provide opportunities for the family to

see, touch, and talk to the patient.54

OVERALL MANAGEMENT IN SHOCK

Fluid replacement Vasoactive medications Nutritional support

55

TYPES OF SHOCK Hypovolemic Shock Cardiogenic Shock Distributive Shock

– Neurogenic shock– Septic shock– Anaphylactic shock

Most common type of shock

– Decreased intravascular volume

• Primary cause = loss of blood or body fluids from an internal or external source

57

HYPOVOLEMIC SHOCK

Scalp laceration 3rd degree/full thickness burn

CONTD…• INTERNAL: Hemorrhage, severe

burns, severe dehydration

• EXTERNAL: Trauma, Surgery, Vomiting, Diarrhoea, Diuresis, Diabetes insipidus

58

CLINICAL FEATURES A rapid, weak, thready pulse Cool, clammy skin Rapid and shallow breathing Hypothermia Thirst and dry mouth Cold and mottled skin (Livedo

reticularis)59

MANAGEMENT MEDICAL Treatment of the underlying cause- Fluid & blood replacement- Redistribution of fluid by positioning Pharmacologic therapy NURSINGo Administering blood & fluids safelyo oxygen

60

CARDIOGENIC SHOCKPATHOPHYSIOLOGY

Decreased cardiac contractility

Decreased stroke volume and cardiac output

Pulmonary congestion, Decreased systemic tissue perfusion,

Decreased coronary artery perfusion 61

MANAGEMENT

MEDICALCorrection of underlying causes Initiation of first-line treatment• Supplying supplemental oxygen • Controlling chest pain• Providing selected fluid support

62

CONTD…

• Administering vasoactive medications • Controlling heart rate with medication

or by implementation of a transthoracic or intravenous pacemaker

• Implementing mechanical cardiac support

63

NURSING Preventing cardiogenic shock. Monitoring hemodynamic status. Administering medications and

intravenous fluids. Maintaining intra-aortic balloon

counter pulsation.

64

Circulatory or distributive shock – abnormal displacement of blood volume in the vasculature.

65

DISTRIBUTIVE SHOCK

Urticaria/anaphylaxis Meningococcic sepsis

TYPES

1.Septic shock2. Neurogenic shock3. Anaphylactic shock

66

RISK FACTORS Septic shock- immuno suppression,

extremes of age, malnourishment, chronic illness, invasive procedures.

Neurogenic shock – spinal cord injury, spinal anesthesia, depressant action of medications, glucose deficiency.

Anaphylactic shock- penicillin sensitivity, transfusion reaction.bee sting allergy, latex sensitivity. 67

SEPTIC SHOCK Caused by widespread infection.

VasodilationMaldistribution of blood volume

Decreased venous returnDecreased stroke volumeDecreased cardiac output

Decreased tissue perfusion68

MANAGEMENT

MEDICAL• identifying and eliminating the

cause of infection.• Fluid replacement. PHARMACOLOGIC THERAPY• Antibiotic sensitivity.• 3rd generation cephalosporin +

amino glycoside69

NUTRITIONAL THERAPY• Nutritional supplementation - within the

first 24 hours .• Enteral feedings NURSING MANAGEMENT• Follow aseptic technique.• Monitor for signs of infection.• Monitor hemodynamic status, fluid

intake& output& nutritional status.• Daily weight & close monitoring of serum

albumin.70

NEUROGENIC SHOCK

vasodilation occurs as a result of a loss of sympathetic tone.

may have a prolonged course (spinal cord injury) or a short one (syncope or fainting)

Dry, warm skin & bradycardia.

71

MANAGEMENT MEDICAL1. Restoring sympathetic tone through

stabilization of a spinal cord injury or, in the instance of spinal anaesthesia, by positioning the patient properly.

2. Specific treatment depends on its cause. If hypoglycemia (insulin shock) is the cause, glucose is rapidly administered.

72

NURSING• Elevate and maintain the head of the

bed at least 30 degrees.• . In suspected spinal cord injury,

neurogenic shock may be prevented by carefully immobilizing the patient.

• Applying elastic compression stockings and elevating the foot of the bed

73

• Check the patient daily for any redness, tenderness, warmth of the calves, and positive Homans sign (calf pain on dorsiflexion of the foot).

• Administering heparin or low-molecular-weight heparin (Lovenox) as prescribed, applying elastic compression stockings, or initiating pneumatic compression of the legs may prevent thrombus formation.

74

• Performing passive range of motion of the immobile extremities.

• In the immediate post injury period, the nurse must monitor the patient closely for signs of internal bleeding that could lead to hypovolemic shock.

75

ANAPHYLACTIC SHOCK Caused by severe allergic reaction

when a patient who has already produced antibodies to a foreign substance (antigen) develops a systemic antigen–antibody reaction.

76

Due to antibody responsesRelease of histamine Vasodilatation

Increased capillary PermeabilitySevere bronchoconstriction

Decreased oxygen supply and utilization

Inadequate tissue Perfusion

77

MANAGEMENT

MEDICAL Removing the causative antigen

(e.g., discontinuing an antibiotic agent), administering medications that restore vascular tone, and providing emergency support of basic life functions.

78

Epinephrine Diphenhydramine Nebulized medications ( albuterol) cardiopulmonary resuscitation ET Intubation or tracheotomy NURSING Assessing all patients for allergies or

previous reactions to antigens and communicating the existence of these allergies or reactions to others.

79

Assess the patient’s understanding of previous reactions and steps taken by the patient and family to prevent further exposure to antigens.

Advise the patient to wear or carry identification that names the Specific allergen or antigen.

When administering any new medication, the nurse observes the patient for an allergic reaction.

80

Identify patients at risk for anaphylactic reactions to contrast agents (radiopaque, dye-like substances that may contain iodine) used for diagnostic tests.

Take immediate action if signs and symptoms occur, and must be prepared to begin cardiopulmonary resuscitation if cardio respiratory arrest occurs.

81

In addition to monitoring the patient’s response to treatment, the nurse assists with intubation if needed, monitors the hemodynamic status, ensures intravenous access for administration of medications, and administers prescribed medications and fluids, and documents treatments and their effects.

82

Community health and home care nurses whose role includes administering medications, including antibiotic agents, in the patient’s home or other settings must be prepared to administer epinephrine subcutaneously or intramuscularly in the event of an anaphylactic reaction.

83

PREVENTION OF SHOCK Preoperatively: His blood should be adequate in quantity

and volume. His tissues should be adequately

hydrated. He should be mobile. Patient should be kept warm on his

journey from ward to theatre.84

Post operatively: Fluid and electrolyte replacement

normal saline, dextrose 5%, plasma and rest and relief from the pain continues.

Gentle handling by nursing staff will help in prevention of shock.

Diuretics like mannitol . If oliguria persists furosemide can be

given. Dopamine  

COMPLICATIONS

1. ARDS2. Multiple Organ Failure

86

BIBLIOGRAPHY1. Joyce B M. Medical- Surgical

Nursing. 8th Edition. U.P. Elsevier Publications; 2009. Page No: 2154-2182

2.Chintamani. Moroney’s Surgery For Nurses. 17th Edition. New Delhi: Elsevier Publications; 2008. Page No: 67-81

87

3. Ignatavicius. Workman. Medical Surgical Nursing-Patient Centred Collaborative Care. USA: Elsevier Publications; 2010. Page No:827-830

4. Lewis. Medical Surgical Nursing: Assessment And Management Of Clinical Problems. 8th Edition. USA: Elsevier Publications; 2011. Page No: 1722-1744

88

5. Soni S. Textbook Of Advance Nursing Practice.1st Edition. Jaypee Brothers Medical Publishers; 2003. Page No: 450-464

6. Basheer S P. A Concise Textbook Of Advanced Nursing Practice. Bangalore: Emmess Medical Publishers; Page No: 9-20

89

7. Smeltzer S C. Brunner And Suddarth’s Textbook Of Medical Surgical Nursing.11th Edition. New Delhi: Wolters Kluwer Pvt. Ltd; 2008.Page No: 356-378

8. En. Wikipedia.Org/ Wiki/ Emergency Bleeding Control

9. Http:// Nursing Care plans BlogSpot. In/ 2012

90

10. En.Wikipedia.Org/ Wiki/ Bleeding11. En. Wikipedia. Org/ Wiki/ Shock12. Journals. Iwww.Com/ Shock

Journal

91