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Table of Contents
- Course Home
- Objectives
- Matching Exercise
- Introduction
- Anatomy: The Heart
- Anatomy: The Vessels
- Physiology: Introduction
- Physiology: Review of Circulation
- Physiology: The Cardiac Cycle
- Physiology: Innervation of the Heart
- Cardiac Electrophysiology: Introduction
- Cardiac Electrophysiology: Electrolytes
- Cardiac Electrophysiology: Cardiac Automaticity
- Cardiac Electrophysiology: The Cardiac Conduction System
- Cardiac Electrophysiology: Myocardial Contraction
- Sample Cases
- Case 1: Cardiac Tamponade
- Figure 1: Assessment
- Figure 2: Management
- Case 2: Cocaine Overdose
- Figure 3: Assessment
- Figure 4: Management
- Case 3: Hemorrhagic Shock
- Figure 5: Assessment
- Figure 6: Management
- Conclusion
- References
- Bibliography
Case 3: Hemorrhagic Shock
-Presentation:
A concerned wife calls the emergency medical services complaining that her husband is bleeding uncontrollably. The woman tells the dispatcher that the man was using a chain saw to cut down a tree when he lost control of the saw and sliced his thigh open. She states that he cut himself an hour ago and that she was hesitant to call an ambulance because her husband kept stating that he was, “fine and not goin’ to any darn hospital.” The woman says that she became concerned because the man had bled through 6 to 7 bath towels and was getting more pale and weak by the minute.
On arrival to the house, you find a very pale 35 year old man surrounded by blood-soaked towels, barely holding his head up. You quickly ask the wife some questions. You specifically inquire if the patient has any history of heart disease or bleeding disorders. In addition, you ask about the time of her husband’s last food or drink intake and about any medications that he may be taking. She states he has generally been healthy and that he does not take any regular medications.
Upon examination, the patient is tachycardic, with a pulse of 145, and hypotensive, with a blood pressure of 75/30. You notice that, as soon as direct pressure is removed, the wound spurts bright red blood nearly to the ceiling.
-Keys to the History and Physical Exam:
-The Patient History:
1) This patient is a healthy man who has sustained a laceration to his thigh.
2) The patient’s wife states that it has been over an hour since the patient was lacerated, and the bleeding is still not controlled. This places the patient at risk for serious hemorrhage.
3) The patient’s pallor and the presence of several blood soaked towels suggest a significant loss of blood.
-The Physical Exam:
1) The patient is pale, indicating poor tissue perfusion secondary to hemorrhage.
2) The patient’s laceration appears very deep, and the blood coming from the wound is projectile, indicating an arterial bleed. Recall that the arterial system is under much more pressure than the venous system. Consequently, wounds in which the bleeding is pulsatile or projectile, suggest that the bleed is most likely originating from an artery. Venous bleeding can also be very significant but the flow from the wound is generally slow and steady.
3) The patient’s vital signs (tachycardia and hypotension) suggest that he has lost a significant amount of blood and may be in hemorrhagic shock.
-Hemorrhagic Shock:
-Causes:
Injuries to major vascular structures, solid organs, and large bones are the most common causes of severe traumatic hemorrhage. Common non-traumatic causes of hemorrhage include: gastrointestinal bleeding, vascular aneurysm rupture, and ruptured ectopic pregnancy.
-Pathophysiology:
The acute loss of vascular volume triggers a wide range of physiological regulatory responses aimed at compensating for the blood loss and maintaining perfusion to the most important vascular beds in the body. The compensatory physiologic responses to acute hemorrhage attempt to maintain adequate tissue oxygen delivery and sustain cellular function.
The loss of circulating blood volume stimulates the sympathetic nervous system, which results in increased heart rate, arterial and venous vasoconstriction, increased cardiac contractility, and vascular fluid shifts. Despite the body’s compensatory mechanisms, if severe hemorrhage is not controlled, the body’s lack of perfusion eventually affects the heart and brain, and will result in death.
The normal blood volume in an adult is around 5 to 7 liters. Usually, loss of blood in the range of 1 liter to 1.5 liters will result in tachycardia. As blood loss exceeds 1.5 liters, the patient will exhibit further tachycardia and hypotension. With blood losses greater than 2 liters, the body’s compensatory responses to the blood loss will begin to become overwhelmed, unless adequate resuscitation is initiated.2,3,5
-Initial Assessment and Management:
-See figures that follow.