Hemorrhage Question (Check My Work)

VickyRN, MSN, DNP, RN · Mar 19, 2006

i just started working on a question for pharmacology class. it asks what effect does hemorrhage due to trauma (auto accident) have on blood volume, blood pressure, cardiac output and electrolyte balance?
here are my answers so far:
1. re: blood volume - hemorrhage reduces blood volume for obvious reasons.
2. re: blood pressure - hemorrhage reduces blood pressure due to diminished stroke volume.
3. re: cardiac output - hemorrhage reduces co due to less ventricular filling from diminished venous return. reflex tachycardia results in an attempt to compensate for reduced co. - correct :)
4. re: electrolyte balance - (i'm guessing here ) since na is the predominant extracellular electrolyte, hyponatremia would result with hyperkalemia due to compensatory movement of intracellular fluids into the blood.
then it says "based on your knowledge of hemodynamics, what immediate nursing interventions would be indicated to facilitate survival?"
my answer would be:
1. have the patient supine to improve venous return.
2. monitor vitals to assess bp and co (pulse rate).
3. apply pressure to the wound to stop loss of blood volume.
4. elevate the site of trauma if possible to improve venous return.
5. provide hypertonic iv fluids to increase blood volume
6. dopamine could be given iv to increase co.
------------------------------------------------------------------------
it seems obvious to me that this is question about what effect hypovolemia has on hemodynamics and how hypovolemic shock is treated. my main stumbling block (there are others i'm sure) is the electrolyte part of the question.
cheers,
dave

overall good critical thinking here. my critique:

hemorrhage would not affect electrolyte balance (since you're loosing blood, isotonic, from intravascular space only). lab values affected are rbc's, h & h.

you have to replace blood with blood, not crystalloids. for the hemorrhage, send off stat h & h, and type and cross for 4-6 units prbc (since this is a trauma victim). the patient needs prbc stat! have at least 2 large bore iv's (#16, 18 or 20). bolus ns until the blood arrives, to maintain bp and organ perfusion.

very rarely will one ever infuse a hypertonic solution. even in the case of severe hyponatremia (which blood loss will not cause), replacement is with ns only.

pt should be supine with legs elevated above level of heart.

no dopamine, since volume is low. dopamine does no good, and will produce harm (shut down kidneys), without volume. the patient needs stat infusion of blood, and lots of it. again, bolus ns until blood arrives.

pt should be on continous telemetry, oxygen at 4-6 liters, q15 minutes bp.

may need mast trousers, if blood loss severe.

felixfelix · Mar 19, 2006

Wow, what a great Q & A. This forum rocks.

Daytonite, BSN, RN · Mar 19, 2006

there are degrees of hemorrage and the treatment is based on how severe the degree of hemorrhage is. here are some links you might want to check out.

http://www.fpnotebook.com/er47.htm - this page in outline form will give you the signs and symptoms you will see in the various levels of severity of hemorrhage

http://www.trauma.org/resus/permissivehypotension.html - current research in fluid treatment for hemorrhage

http://www.nursingcenter.com/pdf.asp - an article on nursing care of hypovolemic shock secondary to hemorrhage in a critical care setting

outlierrn · Mar 19, 2006

hypovolemic shock is a question of degrees,

B/P and C/O are maintained in compensated shock by tachycardia and peripheral vasoconstriction, when these mechanisms fail, B/P and C/O fall as uncompesated shock begins, a very slippery slope, best avoided.

Volume replacement is the treatment, I would not hesitate to give isotonic saline while I wait for blood products to arrive. Hypertonic fluids are only used in special cases such as hyponatremic or head trauma induced cerebral edema,

Larry

RNDave · Mar 19, 2006

Thanks for the great replies. Before I get into my post here, I wanted to alert Daytonite that your 3rd link for the pdf article doesn't work. I'd love to see that article.

Hemorrhage would not affect electrolyte balance (since you're loosing blood, isotonic, from intravascular space only). Lab values affected are RBC's, H & H.

I couldn't find anything regarding hemorrhage and electrolytes in my texts. Intuitively I thought it should be an isotonic fluid loss since there is a loss of whole blood, not certain components of blood or body fluid. But, I did read in my pathophys text that tissue trauma and burns could result in fluid loss and hyponatremia. From that I guessed a hypertonic fluid replacement was needed. So, my take now is that the fluid loss in other nonhemorrhagic trauma has to do with the loss of serous fluid and the electrolytes that are in serous fluid. (I'm just thinking out loud - via my keyboard - here.)

You have to replace blood with blood, not crystalloids. For the hemorrhage, send off STAT H & H, and type and cross for 4-6 units PRBC (since this is a trauma victim). The patient needs PRBC STAT! Have at least 2 large bore IV's (#16, 18 or 20). Bolus NS until the blood arrives, to maintain BP and organ perfusion.

So, the first fluid replacement intervention is normal saline (NS). Transfusion of type-matched blood should be given as soon as possible. I have some q's about that abbreviations, being a student who has yet to experience anything close to the clinical real world. Does H & H stand for hematocrit and hemoglobin? Does PRBC stand for packed rbc's?

Pt should be supine with legs elevated above level of heart.

I should have added "elevate the legs above the heart", not just "have the patient supine."

NO dopamine, since volume is low. Dopamine does no good, and will produce harm (shut down kidneys), without volume. The patient needs STAT infusion of blood, and lots of it. Again, bolus NS until blood arrives.

With this part of the question, I was trying to come up with something related to the meds we've been taught in lecture. This apparently is more a pathophysiology and hemodynamics question than a pharmacology question.

What about my other nursing intervention suggestions - applying pressure or somehow closing the wound and elevating the site of trauma? My thinking is that the EMT's would have performed some first aid to stop or slow the bleeding. As a nurse my job would be to check the EMT's first aid efforts and do something to stop the bleeding if needed.

Anyway, thanks. It's fun to be able to think this stuff out and interact with such helpful RN's!

Cheers,

Dave

outlierrn · Mar 19, 2006

Lets see,

Pressure on the bleeders is fine, be careful about making injuries worse.

Can't remember the last time I saw a pair of MAST trouser let alone used them.

You're right about the abbreviations.

I can't believe no one, myself included, mentioned oxygen. Even if your pt's o2 sats are good and they're not dyspneac; you want every single red cell you have left carrying o2

Larry

Daytonite, BSN, RN · Mar 19, 2006

thanks for the great replies. before i get into my post here, i wanted to alert daytonite that your 3rd link for the pdf article doesn't work. i'd love to see that article.

to access the article, try going to this website first:

http://www.nursingcenter.com/prodev/ce_article.asp?tid=499797 then click on the button for "pdf version". that should open up a pdf file window with the article.

Daytonite, BSN, RN · Mar 20, 2006

dave. . .more links on information about shock and it's treatment.

http://www2.nursingspectrum.com/ce/self-study_modules/course.html?id=330 - "shock states: knowing the similarities and differences is vital" from nursing spectrum. the purpose of this article is to increase nurses' understanding of the five types of shock states, including risk factors, pathophysiology, signs and symptoms and treatment.

http://www2.nursingspectrum.com/ce/self-study_modules/course.html?id=43 - "hemodynamics for the bedside nurse". information on preload and afterload and the therapeutic interventions for each.