6

Bleeding and Shock

LEARNING OBJECTIVES

When you have mast ered t he mat erial in t his chapt er, you will be able t o

1 Describe and demonst rat e how t o cont rol ext ernal bleeding wit h direct pressure
2 Describe and demonst rat e how t o cont rol ext ernal bleeding wit h air splint s
3 Describe and demonst rat e how t o cont rol ext ernal bleeding wit h t ourniquet s
4 Ident ify t he most common signs and sympt oms of int ernal bleeding
5 Describe and demonst rat e t he general procedures for cont rolling int ernal
bleeding
6 Underst and t he basic pat hophysiology of shock
7 Underst and t he fact ors t hat may influence t he severit y of shock
8 Recognize t he various t ypes of shock
9 Ident ify t he signs and sympt oms of shock
10 Describe and demonst rat e t he management of shock
11 Ident ify t he signs and sympt oms of anaphylact ic shock
12 Describe t he management of anaphylact ic shock

ON THE SCENE
Fourteen-year-old Jessica Franklin rounded the curb on her new mountain bike, slid in an area
of loose gravel, and flipped up over the handlebars of the bike. A large, jagged laceration on her
leg caused by one of the gear handles began bleeding profusely.
Bart Billings, passing on his way to a job interview, stopped to provide aid. His rapid primary
assessment showed that the bleeding leg was the only serious injury; he shouted to a woman
standing on a neighboring lawn to call 911.
Because he didn’t have gloves, Bart quickly removed his clean shirt, folded it over a number
of times, and used it as a thick pad to prevent contact with Jessica’s blood. He then elevated
the leg, propping it on his knee, and applied direct pressure to the laceration. Bart maintained
direct pressure and monitored Jessica for signs of shock until EMTs arrived four minutes later.

The life processes depend on an adequate and uninterrupted supply of blood. The loss of two
pints of blood in an adult is usually serious; the loss of three pints of blood can be fatal if it
occurs over the course of a few hours. Bleeding in certain parts of the body–such as from the
large blood vessels in the neck–can prove fatal within just a few minutes.
The loss of blood causes a state of physical shock that results because there is insufficient
blood flowing through the body to provide tissues with nutrients and oxygen. All the body
processes are affected by shock. If the conditions causing shock are not reversed, the victim
will die.
This chapter discusses the various ways to control bleeding and outlines the first aid care
that should be given to a victim in shock.

6.1 Bleeding and Its Effects

The severity of bleeding depends on the following:

How fast the blood is flowing from the vessel

Size of the vessel

Whether the vessel is a vein or an artery

Whether the bleeding is internal or external

Where the bleeding originated

Victim’s age and weight

Victim’s general physical condition

 Whether the bleeding is a threat to the airway and respiration
Bleeding starts a specific chain of events in the body that are designed to compensate for
the loss of fluid and for the potential loss of oxygen that circulates to the heart, brain, lungs,
and other organs.

Simply, the body starts to constrict vessels that supply nonessential areas of the body such
as the skin; increase the heart rate and force of contraction; release hormones to reabsorb
fluid into the blood and maintain the other compensatory effects; and manufacture extra red
blood cells. Platelets collect at the wound site to promote clotting, and white blood cells collect
to help control infection.
If the bleeding is uncontrolled, the body can’t compensate quickly enough to maintain the
necessary volume of blood, and the bleeding becomes a life-threatening emergency (see
Figure 6.1). Uncontrolled bleeding can lead to shock.

FIGURE 6.1 Bleeding into the unconscious victim’s mouth or nose can be a serious threat to
the airway and respiration. Be sure to establish and maintain an open airway and position the
patient to allow for drainage of blood.

The severity of bleeding depends on its source: artery, vein, or capillary (see Table 6.1 and
Figure 6.2).

PROGRESS CHECK
1. When bleeding is uncontrolled, the body can’t compensate quickly enough, and
__________ results. (cardiac arrest/heart failure/shock)
2. A loss of __________ pints of blood can be fatal if it occurs over a period of a few hours.
(one/two/three)
3. Blood from an artery is __________. (red/bright red/dark red)
4. Blood from a vein is __________. (red/bright red/dark red)
5. Blood from a capillary is_. (red/dark red/medium red)
6. The most difficult bleeding to control comes from __________.
(arteries/veins/capillaries)

TABLE 6.1 Sources of Bleeding and Their Effect s

FIGURE 6.2 Bleeding sources and characteristics.
A hemophiliac (sometimes called a bleeder) is a person whose blood will not clot because
of congenital abnormalities in the clotting mechanisms. A slight wound that cuts a blood vessel
can cause a hemophiliac to bleed to death. Even though the wound would be considered minor
in other victims, when treating a victim who is a hemophiliac, in addition to providing aggressive
care, you must activate the EMS system immediately for rapid transport to a hospital.

6.2 Control of Bleeding

When confronted with a bleeding victim, follow these steps:

1. Stop the bleeding.

2. Determine the cause and source of the bleeding and the general condition of the victim
(see Figure 6.3); expose the wound to determine where the blood is coming from.

3. Place the victim in a position in which he or she will be least affected by the loss of
blood.

4. Establish and maintain an open airway.

After bleeding is controlled, take measures to prevent or control shock, take vital signs every
five minutes, repeat the victim assessment every fifteen minutes, and stay alert for the
complications of blood loss.

T aking Body Substance Precautions

Whenever you help a victim who is bleeding or losing other body fluids, take the following
precautions to protect yourself against transmission of infectious disease (see Chapter 1):

Place a barrier between you and the victim’s blood. If you can, wear protective gloves; if
not, use plastic wrap, aluminum foil, extra gauze bandages, or a clean, thick, folded cloth.
As a last resort, use the victim’s own hand.
FIGURE 6.3 Detecting and controlling severe bleeding are parts of the primary survey.

Avoid touching your mouth, nose, or eyes or handling food while providing first aid care.

As soon as you finish treating the victim, wash your hands thoroughly with soap and hot
water or an antiseptic cleanser, even if you wore gloves. Use a fingernail brush to clean
thoroughly under your fingernails.

Wash all items that have the victim’s blood or body fluids on them in hot, soapy water.
Rinse well.

hemophiliac A person whose blood will not clot because of congenital abnormalities in
the clotting mechanism

Applying Direct Pressure and Elevation

LEARNING OBJECTIVE 1 Describe and demonst rat e how t o cont rol ext ernal
bleeding wit h direct pressure.

The best method of controlling bleeding–and the one you should try first–is applying pressure
directly to the wound (see Figures 6.4 through 6.9). To control bleeding, follow these steps:
1. Place a sterile dressing over the wound so that it is covered completely. If you do not
have a sterile dressing, use the cleanest available material (such as a handkerchief,
sanitary napkin, or bed sheet).

2. Press firmly over the dressing with your fingertips directly to the site of bleeding. Keep
the pressure firm and constant for at least ten minutes. Wounds on the scalp, face, and
hands will bleed more profusely because those areas are so richly supplied with blood.

3. Although its effectiveness has not been proven, elevation can be used along with direct
pressure. Elevate the bleeding part above heart level unless you suspect a fracture,
dislocation, impaled object, or spinal injury. Note that elevation alone is not effective in
controlling bleeding–it must be used along with direct pressure.

4. You can use a cold pack over the wound as you apply direct pressure and elevation;
cold can reduce blood flow to the area. Make sure you place a layer of gauze or other
thin material under the cold pack anywhere it might contact the victim’s skin.

FIGURE 6.4 Bleeding from a lacerated wound on the forearm.

FIGURE 6.5 Control bleeding with direct pressure. Although its effectiveness has not been
proven, elevation can also be used in addition to direct pressure if the wound is on an
extremity. If dressings are unavailable, use a gloved hand or other clean material, such as a
shirt, towel, or pillowcase.

FIGURE 6.6 If bleeding soaks through the dressing, do not remove the dressing.

FIGURE 6.7 Add a new dressing on top of the original. Continue with direct pressure and
elevation. After bleeding is under control, bandage the dressing in place.

FIGURE 6.8 In cases of profuse bleeding, do not waste time hunting for a dressing.
Immediately apply direct pressure to the bleeding vessel.
FIGURE 6.9 Bandage the wound.
5. Check the dressing every few minutes. If it soaks through with blood, do not remove it–
simply place another dressing on top of it, and continue to apply or reapply pressure.

6. Never apply direct pressure to a wound if there is an object embedded in the wound or if
a bone is protruding from the wound. In these cases, use a doughnut-shaped pad over
the wound, then apply pressure to the pad. To make a doughnut-shaped pad, loop a
cravat or other narrow bandage around your four fingers several times, then wind the
remainder of the bandage in and out around the ring until the entire bandage is wound
into the pad.

Leave the dressing in place for at least ten minutes after the bleeding has stopped. Taking
the dressing off earlier can disturb the clot and cause the bleeding to start again.

If necessary, you can increase the pressure on the dressing with a pressure bandage, air
splint, or blood pressure cuff.

Using a Pressure Bandage

A pressure bandage is used to create pressure over a dressing (see Figure 6.10). To use a
pressure bandage, follow these steps:
1. Cover the wound completely with a thick dressing; make sure all edges of the wound
are covered.

2. Holding the dressing in place, wrap the pressure bandage around the dressing tightly
enough to exert moderate pressure.

3. Periodically check the distal pulses, and frequently check for mottled skin or blanched
nails, signs that the pressure bandage is too tight.

Using an Air Splint

LEARNING OBJECTIVE 2 Describe and demonst rat e how t o cont rol ext ernal
bleeding wit h air splint s.

An air splint (see Figure 6.11) can be used to create a pressure bandage and control bleeding
in an extremity. Using an air splint has one additional benefit: It frees your hands so that you
can manage other injuries. Use an air splint as follows:
1. Cover the wound with a thick, sterile dressing.

2. Slip the splint over the dressing, taking care not to shift or remove the dressing.

3. Inflate the splint. Take care not to overinflate–you should be able to depress the
surface of the splint at least half an inch with your fingertips.

4. Check distal pulses often if they are not covered by the splint; check frequently for
mottled skin or blanched nails, signs that the splint is too tight.

Never deflate an air splint unless directed to by EMS personnel.

FIGURE 6.10 Applying a pressure bandage.

FIGURE 6.11 Air splints can be used to apply pressure and control bleeding from an extremity.

Using a T ourniquet

LEARNING OBJECTIVE 3 Describe and demonst rat e how t o cont rol ext ernal
bleeding wit h t ourniquet s.

A tourniquet should be used if direct pressure fails to control the bleeding. It can be used only
on an extremity; as a general rule, consider using a tourniquet only under one of these
conditions:

A large artery has been severed, and the bleeding cannot be controlled by direct
pressure.

A limb has been partially or totally severed, and bleeding is uncontrollable.

Several patients are injured in a mass casualty incident, and you are unable to spend the
time applying pressure to a bleeding wound.
You can use a commercial tourniquet, or you can improvise a tourniquet from a strap, belt,
suspender, handkerchief, towel, necktie, cloth, folded triangular bandage, or other suitable
material that is at least 3 inches wide. Never use wire, cord, or anything else that could cut into
the flesh. Never use a clamp or hemostat on a blood vessel.

To apply a tourniquet (see Figure 6.12), follow these steps:

1. Hold the appropriate pressure point to control bleeding temporarily, then place the
tourniquet between the heart and the wound, leaving at least 2 inches of uninjured
 flesh between the tourniquet and the wound.

2. Put a thick pad over the tissue that will be compressed.

3. Wrap the tourniquet material tightly around the limb twice, then tie the tourniquet in a
half-knot on the upper surface of the limb.

4. Place a short stick or other similar object at the half-knot, then tie a square knot.

FIGURE 6.12 Apply a tourniquet only if direct pressure fails to control the bleeding.
5. Twist the stick to tighten the tourniquet only until the bleeding stops. Secure the stick
in place with the ends of the tourniquet or another strip of cloth. Leave the tourniquet
uncovered.

6. Write a note detailing the location of the tourniquet, the time it was applied, and the
victim’s vital signs at the time you applied it. Pin the note to the victim’s clothing. Then
write T or T/K (to indicate the application of a tourniquet) on the victim’s forehead with
lipstick or marker, and write the time the tourniquet was applied.

Never loosen or remove a tourniquet except under the direction of a physician.

Using a Blood Pressure Cuff

In some cases, you can use a blood pressure cuff to control bleeding (see Figure 6.13). If you
use a cuff, follow these guidelines:

Secure the cuff well so that the Velcro does not pop open.

Inflate the cuff to a pressure that causes the bleeding to stop, usually 10 to 20 mm Hg
above the systolic blood pressure.

Never deflate the cuff unless a physician orders you to do so.

A blood pressure cuff can safely remain inflated for as long as thirty minutes.

PROGRESS CHECK
1. Direct pressure is pressure applied directly to the __________. (artery/pressure
point/wound)
2. If a dressing soaks through with blood, you should __________. (remove it/remove and
replace it/leave it in place and put another one over it)
FIGURE 6.13 A blood pressure cuff can be used to apply pressure and control bleeding from
an extremity.
3. In addition to applying direct pressure, __________the limb and apply cold packs.
(elevate/compress/splint)
4. Material used for a tourniquet should be at least __________inches wide. (2/3/4)
5. Release a tourniquet only when __________. (bleeding has stopped/EMTs arrive/a
physician is present)

6.3 Internal Bleeding

Internal bleeding generally results from blunt or penetrating trauma or certain fractures (such
as a pelvic fracture). Though not visible, internal bleeding can be very serious–even fatal–
because a large amount of blood can be lost and shock can develop rapidly (see Figure 6.14).
You should suspect internal bleeding based on signs and symptoms as well as the
mechanism of injury.

Signs and Symptoms

LEARNING OBJECTIVE 4 Ident ify t he most common signs and sympt oms of
int ernal bleeding.

When assessing for internal bleeding, look for evidence of injury to the body, such as bruising
to the abdomen or chest or a deformed upper thigh. Internal bleeding commonly leads to a
large amount of blood loss and shock; therefore, also continuously assess for signs and
symptoms of shock. The signs and symptoms of shock include restlessness and anxiety; cool,
clammy skin; weak, rapid pulse; rapid breathing; and, ultimately, a drop in blood pressure. There
may be additional signs and symptoms, depending on the source of the bleeding (see Table
6.2). If the bleeding is from a small vessel or a slower-bleeding organ, signs or symptoms may
not be apparent for hours or days; realize that internal bleeding may be occurring even if there
are no signs or symptoms.

First Aid Care

LEARNING OBJECTIVE 5 Describe and demonst rat e t he general procedures for

cont rolling int ernal bleeding.

Internal bleeding is most often associated with injury to organs or structures in the chest
cavity, abdominal cavity, and pelvic cavity and with the femur when fractured.
For victims who have internal bleeding, activate the EMS system; then follow these steps:
1. Establish and maintain an open airway, and monitor the ABCDs (Airway, Breathing,
Circulation, and Disability–from Chapter 3, Section 3.2).

2. Assess for fractures; splint if appropriate.

FIGURE 6.14 Internal bleeding.
3. Keep the victim quiet. Position and treat the victim for shock by covering him or her to
maintain body heat. If the victim starts to vomit, place in the coma position.

4. Monitor vital signs every five minutes until emergency personnel arrive.

PROGRESS CHECK
1. Internal bleeding is extremely serious because it can cause __________. (extremity
damage/brain damage/shock)
2. If internal bleeding is present, the heart rate will be __________.
(decreased/normal/increased)
3. The most common cause of internal bleeding is __________. (blunt and penetrating
trauma/perforated ulcer/skull fracture)
4. The signs and symptoms of internal bleeding are much like those of __________.
(external bleeding/cardiopulmonary disease/shock)
5. Basic treatment of internal bleeding involves ___________, opening the airway, and
keeping the victim warm. (applying pressure/activating the EMS system/elevating the
affected part)

TABLE 6.2 Common Causes of Int ernal Bleeding and Their Signs and Sympt oms

6.4 Nosebleed

Nosebleeds are a relatively common source of bleeding that can result from injury, disease,
activity, temperature extremes, or other causes. Severe, uncontrolled nosebleeds can result in
enough blood loss to cause shock.
If you suspect the nosebleed was caused by a fractured skull, do not try to stop the flow of
blood; to do so will increase pressure on the brain. Cover the opening of the nose loosely with
a dry, sterile dressing to absorb the blood, activate the EMS system, and treat the victim for
skull fracture, as outlined in Chapter 13.
If you suspect a nosebleed is caused by something other than a fractured skull, follow these
steps:
 1. Keep the victim quiet and in a sitting position, leaning forward to prevent the blood from
being swallowed or going into the lungs (see Figure 6.15). Never have the victim tilt his
or her head back.

2. If you do not suspect nasal fracture, pinch the nostrils together (see Figure 6.16).

3. Apply cold compresses to the bridge of the nose.

4. If the bleeding does not stop, activate EMS.

PROGRESS CHECK
1. To control nosebleed, keep the victim __________. (sitting up/lying down/in a position of
comfort)
2. Unless you suspect nasal fracture, pinch the nostrils together, then apply __________.
(pressure/cold compresses/indirect pressure)
3. If you suspect __________, do not try to stop a nosebleed. (heart attack/elevated blood
pressure/skull fracture)

FIGURE 6.15 For a nosebleed, keep the victim quiet and leaning forward in a sitting position.

FIGURE 6.16 Apply pressure by pinching the nostrils and, if necessary, apply cold compresses
to the nose and face.

6.5 Shock

Shock is defined as an inadequate delivery of oxygen and glucose to the cells. Left untreated,
shock is fatal. Unless you recognize and treat shock immediately, the victim can die.

Causes of Shock

LEARNING OBJECTIVE 6 Underst and t he basic pat hophysiology of shock.

Shock is a progressive process that can be either gradual or rapid in onset; throughout the
development of shock, the victim’s condition constantly changes. Figures 6.17 and 6.18
illustrate the continuous cycle of traumatic shock.

LEARNING OBJECTIVE 7 Underst and t he fact ors t hat may influence t he severit y
of shock.

Basically, shock is the inadequate delivery of oxygen and nutrients to the cells. This is also
known as inadequate tissue perfusion. Perfusion refers to the circulation of oxygen-rich blood
through organs and tissues. The cells most sensitive to a lack of oxygen are those in the heart,
brain, and lungs.

shock Inadequate tissue perfusion

perfusion Circulation of oxygen-rich blood to cells

FIGURE 6.17 Continuous cycle of traumatic shock.

FIGURE 6.18 The progressive circle of hermorrhagic shock.

There are four basic causes of shock (see Table 6.3):

1. Fluid is lost from the circulatory system (generally a result of bleeding, burns, or
dehydration) (see Figure 6.19).

2. The heart fails to pump the blood effectively.

3. The blood vessels dilate, causing blood to pool in extremities and nonvital areas.

4. The forward movement of blood throughout the body is obstructed.

Factors influencing the severity of shock include age (infants and the elderly are at most
risk), multiple injuries, preexisting medical conditions, pregnancy, physical condition, and amount
of blood loss. Shock often progresses rapidly in children and the elderly.
T ypes of Shock

LEARNING OBJECTIVE 8 Recognize t he various t ypes of shock.

Shock is progressive and occurs in three stages: compensat ory, progressive

(decompensat ory), and irreversible shock (see Table 6.4).

compensat ory shock The first stage of shock, in which the body attempts to
compensate for the decrease in tissue perfusion
progressive (decompensat ory) shock The second stage of shock, in which the
compensatory mechanisms have failed, the blood pressure begins to decrease, and the
organs are beginning to suffer from the lack of perfusion
irreversible shock The final stage of shock, in which multiple body organs start to die

TABLE 6.3 Types of Shock

FIGURE 6.19 Loss of body fluids can be external and internal.

Shock in a child can present a somewhat different picture–generally, it develops early, with
little evidence, and progresses extremely rapidly. A child may show no signs or symptoms at all,
or only very subtle ones, then suddenly exhibit the dramatic signs of progressive shock. For this
reason, maintain a high index of suspicion when treating an injured child or one suspected of
losing blood. Never wait to see if symptoms develop.

TABLE 6.4 Signs and Sympt oms of t he Three St ages of Shock

Pregnant patients will lose large amounts of blood before signs and symptoms of shock
become evident.
Signs and Symptoms

LEARNING OBJECTIVE 9 Ident ify t he signs and sympt oms of shock.

Figure 6.20 illustrates the signs and symptoms of shock. Signs of shock in a dark-skinned
victim may be more subtle (see Figure 6.21).
A healthy person with dark skin will usually have a red undertone and show a healthy pink
color in the nail beds, lips, mucous membranes of the mouth, and tongue. However, a dark-
skinned victim suffering from a lack of oxygen does not exhibit marked skin color changes.
Rather, the skin around the nose and mouth will have a grayish cast, the mucous membranes
of the mouth and tongue may be blue (cyanotic), and the lips and nail beds will have a blue
tinge. If shock is due to bleeding, the mucous membranes in the mouth and tongue will not look
blue but will have a pale, graying, waxy pallor. Other landmarks include the tips of the ears,
which may be red during fever. The palms of the hands and soles of the feet will appear more
pale.

Management of Shock

LEARNING OBJECTIVE 10 Describe and demonst rat e t he management of shock.

Activate the EMS system immediately; then follow these steps:

1. Secure and maintain an open airway.

2. Place the victim on his or her back unless the victim has an object impaled in the back of
the body, difficulty breathing, or heart attack symptoms. In these cases, position the
victim in a half-sitting position to make breathing easier. A victim who is obviously
pregnant should be placed on her left side or supine with her right hip elevated. Any
victim who has a suspected spinal injury should be placed in a supine position with the
head and neck maintained in a neutral inline position.

3. Immediately control any major external bleeding.

4. Cover the patient to keep him warm.

5. Splint any fractures; this can reduce shock by controlling bleeding and relieving pain.

6. Keep the victim quiet and still; shock is aggravated by rough and/or excessive handling.
FIGURE 6.20 Signs and symptoms of shock.
7. Give the victim nothing by mouth because of the possible need for surgery, possible
injury to the digestive system, and possible vomiting. If the victim complains of intense
thirst, moisten his or her lips with a wet towel.

8. Monitor vital signs and mental status at five-minute intervals until emergency personnel
arrive.

Preventing Shock

Never wait for the signs or symptoms of shock to develop; it is much better to prevent shock.
Any victim of injury or illness can develop shock; you can prevent shock by:

Making sure the victim has an open airway and is breathing adequately; if necessary,
provide rescue breathing

Controlling any bleeding

Splinting and immobilizing fractures

Taking measures to relieve pain (properly dressing, bandaging, splinting, and positioning
the victim)

Positioning the victim supine

Keeping the victim warm without overheating

Figures 6.22 through 6.27 illustrate body positioning and care for preventing shock.

PROGRESS CHECK
1. Basically, shock occurs when the heart does not pump adequate amounts of blood to
provide __________to the cells. (adequate carbon dioxide/adequate oxygen)
2. The loss of blood causes __________shock. (hypovolemic/cardiogenic/distributive)
FIGURE 6.21 Look for more subtle signs of shock in a dark-skinned person.

3. Congestive heart failure could result in __________ shock.

(hypovolemic/obstructive/cardiogenic)
4. A victim with sustained vomiting and diarrhea could develop __________shock.
(hypovolemic/cardiogenic/distributive)
5. Shock is a progressive condition that involves __________stages. (two/three/four)
6. During __________shock, the body tries to use its normal defenses to maintain normal
function. (compensatory/progressive)
7. During __________shock, the body shunts blood away from the extremities and
abdomen to the heart, brain, and lungs. (compensatory/progressive)
8. Always begin first aid care for shock very __________if the victim is a child.
(early/aggressively/gently)
9. The preferred position for a shock victim is __________. (on his side/supine/face down)
10. You should keep a shock victim warm without __________. (using sources of artificial
heat/overheating the victim/shifting the victim’s position)

6.6 Anaphylactic Shock

Anaphylactic shock is a severe allergic reaction caused by misdirected immune response to an

allergen– usually to insect stings, foods, medicines, or other allergens or antigens. Anaphylactic
shock is a dire medical emergency (see Figure 6.28). (See the section on insect stings in
Chapter 23.) An allergen or antigen is usually a protein that is viewed as a foreign substance
by the body. As a rule, anaphylactic reactions occur more frequently and rapidly if the antigen
is injected. Untreated, victims of anaphylactic shock can die–often within a few minutes of
contacting the allergen or antigen.

FIGURE 6.22 Maintain body heat.

FIGURE 6.23 If shock is due to a heart attack or heart failure and there are breathing
difficulties, let the victim assume a position of comfort, which is usually in a seated or semi-
seated position. Never force the victim to lie flat.

FIGURE 6.24 If the victim is unconscious, he or she should be placed on his or her side in the
recovery position.

FIGURE 6.25 If circumstances require it, the individual should be left in the position found.
FIGURE 6.26 and FIGURE 6.27 Along with proper positioning to prevent shock, it is also
important to assure adequate breathing, control bleeding, immobilize fractures, maintain body
heat, and reassure the victim.
Of those who die from anaphylactic shock, more than two-thirds die because they cannot
breathe (because of swollen air passages) and approximately one-fourth die from shock
(because not enough blood is circulating through the body due to loss of fluid and an increase
in the size of the blood vessels).

Signs and Symptoms

LEARNING OBJECTIVE 11 Ident ify t he signs and sympt oms of anaphylact ic

shock.

The initial signs and symptoms of anaphylactic shock can occur in any combination, affecting
the skin, heart and blood vessels, respiratory tract, gastrointestinal tract, and central nervous
system.

FIGURE 6.28 Anaphylactic shock

Skin
 Itching and burning, with flushing

Cyanosis around the lips

Raised, hivelike patches with severe itching

Swelling of the face, tongue, hands, feet

Redness or flushed, pale or mottled face

Heart and Blood Vessels

Weak, rapid pulse

Low blood pressure

Dizziness or lightheadedness

Respiratory Tract

A painful, squeezing sensation in the chest

Difficulty in breathing

Coughing

Wheezing

Gastrointestinal Tract

Nausea

Vomiting Abdominal cramps Diarrhea

Central Nervous System

Restlessness

Faintness

Convulsions

Altered mental status (occurs very early in anaphylactic shock)

These initial signs and symptoms progress rapidly to acute airway obstruction, respiratory
failure, or circulatory collapse and then death.

Management of Anaphylactic Shock

LEARNING OBJECTIVE 12 Describe t he management of anaphylact ic shock.

Activate the EMS system immediately; the victim will need rapid transport for life-saving
treatment. While emergency personnel are en route, proceed as follows:
1. Secure and maintain an open airway.

2. If indicated, begin rescue breathing or CPR.

3. If the victim has an epinephrine auto-injector, help the victim use it if allowed by local
protocol.

PROGRESS CHECK
1. As a rule, anaphylactic shock occurs most rapidly if the antigen is _________.
(swallowed/inhaled/injected)
2. Initial signs and symptoms may lead swiftly to _________, respiratory failure, or
circulatory collapse, and then death. (loss of consciousness/acute airway
restriction/irregular heartbeat)
3. To manage anaphylactic shock, activate the EMS system; then immediately
__________. (start CPR/secure an open airway/start rescue breathing)
Summary

The sudden loss of three pints of blood in an adult can be fatal.

Severity of bleeding depends on how fast the blood is flowing, whether it is flowing from
an artery or a vein, where the bleeding originated, and whether the blood is flowing
freely externally or into a body cavity.

Bleeding from an artery is more difficult to control than bleeding from a vein or capillary;
arterial blood is bright red and spurts or pulsates out.

You can control bleeding with direct pressure, elevation, and the use of splints.

A tourniquet should be used to control bleeding when direct pressure has failed or when
the incident involves mass casualties.

Internal bleeding can be a serious cause of shock and usually requires surgical
intervention.

Shock occurs when the cells do not receive an adequate amount of oxygenated blood.

Shock is a progressive condition that occurs in three stages; left untreated, shock
causes death.

Shock in a child develops early and progresses extremely rapidly; never wait for signs and
symptoms to occur before beginning treatment.

Key Terms

Make sure you understand the following key terms:

compensatory shock
hemophiliac
irreversible shock
perfusion
progressive (decompensatory) shock
shock

Critical T hinking Exercise

You are out working in the yard when you hear your neighbor screaming for help. She runs out
onto the front porch with a dish towel soaked in blood wrapped around her right wrist. She tells
you she was moving her glass-top coffee table when the glass cracked and sliced into her
wrist. You remove the towel to inspect the injury and note bright red blood spurting from the
wound.
1. Would you consider the bleeding to be severe?

2. How would you manage the bleeding?

3. If you fail to control the bleeding, what steps would you take next?

4. What signs and symptoms would heighten your suspicion that the patient is going into
shock?

6
CHAPT ER 6 Self-Test
St udent :__________________ Dat e:__________________

Course:__________________ Sect ion #:_______________

PART 1 True/False
If you believe the statement is true, circle the T. If you believe the statement is false, circle the
F.
T F 1. Elevation is the first step in controlling bleeding.
T F 2. Blood from a vein flows in spurts with each heartbeat.
T F 3. Bleeding from capillaries rarely clots spontaneously.
T F 4. A victim with internal bleeding can develop life-threatening shock before the
bleeding is apparent.
T F 5. A completely severed artery can sometimes constrict and seal itself off.
T F 6. Internal bleeding usually results from blunt trauma or fractures.
T F 7. Normally, the lower extremities should be elevated to treat for shock.
T F 8. During shock, the oxygen supply is decreased because the heart needs less
oxygen.
T F 9. Losing fluid from the circulatory system is one of the primary causes of shock.
T F 10. Give a shock victim fluids if he or she is conscious.
T F 11. If a victim is unconscious, place her or him in a semi-sitting position.

PART 2 Mult iple Choice

For each item, circle the correct answer or the phrase that best completes the statement.
1. Which of the following is the best method for controlling severe bleeding and should be
applied first?

a. elevation
b. pressure point
c. direct pressure
d. tourniquet
2. List the three methods of controlling bleeding in order of preference: (1) elevation; (2)
direct pressure at the wound; (3) tourniquet.

a. 2, 1, 3
b. 2, 3, 1
c. 1, 2, 3
d. 3, 2, 1
3. When a dressing becomes saturated with blood, you should

a. remove it and apply a new dressing

b. apply a tourniquet
c. leave the dressing in place and apply an additional dressing on top of it
d. tie the knot on the bandage tighter
4. What condition may cause a person to bleed to death from a minor wound?

a. anemia
b. leukemia
c. hypochondria
d. hemophilia
5. Do not try to stop a nosebleed if you suspect

a. a broken nose
b. a fractured skull
c. a fractured jaw
d. high blood pressure
6. A victim with a nosebleed should

a. lean forward and then pinch the nostrils to apply pressure

b. blow the nose until the bleeding stops
c. tilt the head back or lie flat while applying pressure to the bridge of the nose
d. lean forward, pack the nostrils, and apply heat
7. Perfusion is

a. the process of blood clotting

b. the manufacture of red blood cells
c. another word for transfusion
d. delivery of blood to an organ
8. Which of the following characterizes arterial bleeding?

a. dark red color and spurting flow

b. bright red color and spurting flow
c. dark red color and steady flow
d. bright red color and steady flow
9. Use a tourniquet only if
 a. the bleeding is arterial or venous
b. bleeding cannot be controlled by direct pressure
c. the bleeding has stopped and direct pressure is no longer needed
d. the wound appears to be severe and deep
10. Anaphylactic shock should be considered
a. a true medical emergency
b. an emergency only in a sensitized person
c. an emergency only if the person has been stung on the face or hand
d. a nonemergency situation
11. Which of the following shock processes occurs first?
a. the brain loses its ability to function
b. vital organs and the brain do not receive enough blood
c. blood rushes to the brain and vital organs, thus depriving other body cells of nutrients
d. internal organs and brain cells begin to die
12. Which of the following is a means of preventing shock?
a. keep the victim’s body temperature normal
b. reassure the victim
c. loosen constrictive clothing
d. give fluids by mouth
13. Which of the following is not a type of shock?
a. hypothermic
b. hypovolemic
c. distributive
d. cardiogenic
14. A person may be in anaphylactic shock from
a. seeing a bloody accident
b. eating nuts
c. a head injury
d. a spinal injury

PART 3 Mat ching

1. Tourniquets should be used only for severe, life-threatening bleeding that cannot be
controlled by direct pressure. Place numbers in front of the steps shown below to
indicate the correct procedural sequence for the proper application of a tourniquet:

_______Secure the stick in place.

_______Wrap the tourniquet around the limb twice and tie in a half-knot on the limb’s
upper surface.
_______Do not cover a tourniquet.
_______Twist the stick to tighten the tourniquet only until bleeding stops.
_______Place the tourniquet between the heart and the wound.
_______Activate the EMS system.
_______Place a short stick at the half-knot and tie a square knot.
_______Make a written note of the location and time the tourniquet was applied.
2. Match each type of shock (from the left column, under Type) with the correct cause
(from the right column, under Definition)

PART 4 What Would You Do?

1. You arrive at the scene of an auto/bicycle accident and find a teenager who has a large
laceration on the lower leg and is bleeding profusely.

2. Your neighbor is stung by a bee and has flushed, itching skin; watery eyes; and
tightness in the chest. He feels as if his throat is closing.