Severe Bleeding

    Severe bleeding involves loss of large amount of blood This may occur externally through natural openings, like mouth A cut on the skin too can lead to bleeding Internal bleeding occurs due to an injury to blood vessel

Causes
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Accidents/Falls Blow to the head Injuries, like scalp wounds Tooth Extraction Certain medications Illnesses like o Hemophilia o Scurvy o Cancer o Thrombocytopenia o A plastic Anemia o Leukemia o Hemorrhage o Peptic Ulcer o Platelet Disorder o Liver Disease o Septicemia

Symptoms
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Discharge of blood from a wound Bruising Blood in stool/urine Blood coming from other areas, like mouth/ear

Treatment
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Wash hands well before administering to patient Wear synthetic gloves Make the victim lie down Slightly elevate the legs If possible keep the affected area elevated Remove any obvious debris/particle Apply direct pressure using clean cloth/bandage Use hand if cloth is not available Apply pressure continuously for at least 20 minutes Do not remove the cloth to check the bleeding Hold the bandage in place using an adhesive tape If bleeding seeps through bandage, do not remove it Add extra bandage on top of the first one Apply direct pressure on the artery if necessary The pressure points for arm--below arm- pit/above elbow For leg--behind knee/near groin Squeeze the artery keeping finger flat Continue applying pressure on the wound Once bleeding stops immobilize the affected part See a doctor

Jo-anne N. Cordero BSN Amaryllis

Consult a Doctor
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If bleeding does not stop If bleeding occurs through nose, ears etc Coughing up blood Vomiting Bruising/deep wounds Abdominal tenderness Fracture Shock

Steps to Avoid
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Do not try to replace a displaced organ Just cover the wound with a clean cloth Do not try to remove an embedded object

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 outweighs supply, both the cell and the organism are in a state of shock.  On a multicellular level, the definition of shock becomes more difficult because not all tissues and organs will experience the same amount of oxygen imbalance for a given clinical disturbance. The 4 classes of shock, as proposed by Alfred Blalock, are as follows:
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Hypovolemic Vasogenic (septic) Cardiogenic Neurogenic

Causes:
Hemorrhagic shock is caused by the loss of both circulating blood volume and oxygencarrying capacity. The most common clinical etiologies are penetrating and blunt trauma, gastrointestinal bleeding, and obstetrical bleeding.

Treatment:
The primary treatment of hemorrhagic shock is to control the source of bleeding as soon as possible and to replace fluid. In controlled hemorrhagic shock (CHS), where the source of bleeding has been occluded, fluid replacement is aimed toward normalization of hemodynamic parameters. In uncontrolled hemorrhagic shock (UCHS), in which the bleeding has temporarily stopped because of hypotension, vasoconstriction, and clot formation, fluid treatment is aimed at restoration of radial pulse or restoration of sensorium or obtaining a blood pressure of 80 mm Hg by aliquots of 250 mL of lactated Ringer's solution (hypotensive resuscitation).

Jo-anne N. Cordero BSN Amaryllis

When evacuation time is shorter than 1 hour (usually urban trauma), immediate evacuation to a surgical facility is indicated after airway and breathing (A, B) have been secured ("scoop and run"). Precious time is not wasted by introducing an intravenous line. When expected evacuation time exceeds 1 hour, an intravenous line is introduced and fluid treatment is started before evacuation. The resuscitation should occur before, or concurrently with, any diagnostic studies. Crystalloid is the first fluid of choice for resuscitation. Immediately administer 2 L of isotonic sodium chloride solution or lactated Ringers solution in response to shock from blood loss. Fluid administration should continue until the patient's hemodynamics become stabilized. Because crystalloids quickly leak from the vascular space, each liter of fluid expands the blood volume by 20-30%; therefore, 3 L of fluid need to be administered to raise the intravascular volume by 1 L. Alternatively, colloids restore volume in a 1:1 ratio. Currently available colloids include human albumin, hydroxy-ethyl starch products (mixed in either 0.9% isotonic sodium chloride solution or lactated Ringers solution), or hypertonic saline-dextran combinations. The sole product that is avoided routinely in large-volume (>1500 mL/d) restoration is the hydroxy-ethyl starch product mixed in 0.9% isotonic sodium chloride solution because it has been associated with the induction of coagulopathy. The other products have not been so implicated. PRBCs should be transfused if the patient remains unstable after 2000 mL of crystalloid resuscitation. For acute situations, O-negative noncrossmatched blood should be administered. Administer 2 U rapidly, and note the response. For patients with active bleeding, several units of blood may be necessary.

If at all possible, blood and crystalloid infusions should be delivered through a fluid warmer. A blood sample for type and cross should be drawn, preferably before blood transfusions are begun. Start type-specific blood when available. Patients who require large amounts of transfusion inevitably will become coagulopathic. FFP generally is infused when the patient shows signs of coagulopathy, usually after 6-8 U of PRBCs. Platelets become depleted with large blood transfusions. Platelet transfusion is also recommended when a coagulopathy develops.

Complications
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The primary complication is death. The entire spectrum of organ failures may be the sequelae of resuscitated hemorrhagic shock. The cascade of systemic inflammatory response syndrome (SIRS) progressing to multiple organ failure syndrome (as described by the late Roger Bone, MD) complicates the cases of approximately 30-70% of patients who present with hemorrhagic shock and survive their initial resuscitation.

References: http://www.medindia.net/patients/Firstaid_SevereBleeding.htm#1 http://emedicine.medscape.com/article/432650-overview

Jo-anne N. Cordero BSN Amaryllis