Internal bleeding and hemorrhagic shock

1. You findThe mechanism could have injured the abdomen, chest, pelvis or a long bone, and there is no external blood.You doAssume internal bleeding is possible and look for it, because a patient can lose a large share of their blood without a drop reaching the outside.
2. You findYou find bruising over the trunk, a distended, rigid or tender abdomen, vomited blood (it may look like coffee grounds), black tarry stool, coughed-up blood, or a painful, swollen, deformed long bone.You doThese are the signs of internal bleeding. A femur fracture alone can hold over a liter; a pelvic fracture far more.
3. You findThe pulse is fast, the skin pale, cool and clammy, the patient anxious, restless and thirsty, breathing faster, and the gap between systolic and diastolic pressure is narrowing.You doThat is compensated shock: the body is still holding the blood pressure up. Recognize it here, while the blood pressure is still normal.
4. You findThe blood pressure starts to fall, mental status worsens, peripheral pulses weaken and the skin becomes mottled.You doThat is decompensated shock. The compensation has run out, and hypotension is a late sign, not an early one.
5. You findYou suspect internal bleeding or shock.You doThere is no field fix for bleeding into the chest or abdomen. Stabilize long-bone and pelvic fractures (splint, and a pelvic binder per protocol), keep the patient supine, give oxygen if indicated, keep them warm, give nothing by mouth even if they are thirsty, and transport rapidly to a facility that can operate.

• Shock with no external bleeding to explain it is itself the finding that points to internal bleeding.
• The pulse pressure narrows in compensated shock, because vasoconstriction raises the diastolic pressure while the systolic holds.
• Hypotension is late. Waiting for the blood pressure to fall means waiting for the patient to get worse.
• Children compensate very well and then crash suddenly, so a normal blood pressure in an injured child is not reassurance.
• Beta blockers can stop a patient from becoming tachycardic, hiding the earliest sign of shock.
• The EMT's part is early recognition and a short time to surgery, and that is a large contribution.

The wrong idea: If the blood pressure is normal, the patient is not in shock.

What is actually true: In compensated shock the blood pressure is still normal while the heart rate rises, the skin turns pale, cool and clammy and the patient becomes anxious and thirsty. A falling blood pressure is a late sign that compensation has failed.

Internal bleeding is found from the mechanism and the signs, not from visible blood, and shock with no external bleeding to explain it is the key finding. Compensated shock shows a rising heart rate, pale, cool, clammy skin, anxiety, thirst, faster breathing and a narrowing pulse pressure with a normal blood pressure; a falling blood pressure is late. Children crash suddenly, and beta blockers hide the tachycardia. Care is stabilizing long-bone and pelvic fractures, keeping the patient supine and warm, oxygen if indicated, nothing by mouth, and rapid transport to surgery.

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