Class I Hemorrhage

up to 15% blood loss, minimal tachicardia, no measurable changes in BP or pulse pressure, or RR

Class II Hemorrhage

15-30% Most adults are capable of compensating, incresed RR, Tachycardia, narrowed pulse pressure,

Class III Hemorrhage

30-40% no longer able to compensate for volume loss, hypotension occurs, HR >120 BPM, RR 30-40, severe anxiety or confusion

Class IV Hemorrhage

more than 40% loss, severe shock, HR >140 BPM, RR >35, confusion lethargy, decresed systolic blood pressure, typically in the range of 60 mm Hg.

Ratio for loss blood replacement

3 litres of electrolyte solution replacement for each liter of blood lost

Distributive Shock

uncontrolled vasodialation causes reduced resistance causing a decrease in the diastolic blood pressure

Distributive Shock

Decrease in preload+decrease in cardiac output

Psychogenic Shock

Vasovagal - stimulation of the tenth cranial nerve (vagus nerve) produces bradycardia. May also cause vasodilation.
Typically occurs in a very brief period.

Septic Shock

Cytokines released because of an infection can cause damage to blood vessel walls and cause vasodilation

Anaphylactic Shock

Respiratory distress, airway obstruction and vasodilation

Potential Blood loss from a single femoral fracture


Amount of blood loss that can happen before signs of compensatory mechanisms fail and BP become <90 mmHq

Greater than 30%

Hypertension medications that may prevent compensatory tachycardia to maintain BP

Beta Adrenergic blocking agents and calcium channel blockers

Managing Volume Resuscitation
Uncontrolled hemorrhage-suspected chest, abdomen, retroperitonium

Maintain a systolic bp 80-90 or MAP 60-65

Managing Volume Resuscitation
CNS injuries or TBI

maintaining the systolic BP (SBP) above 90 or MAP 85-90

Managing Volume Resuscitation
Controlled Hemorrhage
large scalp or extremity controlled with a tourniquet, PT falls into class II,III,IV shock

rapid bolus of 1-2 litres

Three responses of initial fluid bolus
Rapid Response

vital signs return indicating that PT lost less than 20%
PT is best managed at SBP between 80-90, IV fluid should be titrated

Three responses of initial fluid bolus
Transient Response

Vital signs improve (pulse slows, BP increases) however PT shows deterioration. PT has typically lost 20-40% of blood volume

Three responses of initial fluid bolus
Minimal or no response

No change in PT after 1-2 liter Bolus

Leading cause of TBI


Three seperate membranes that surround the brain


Outer most meninges

Dura mater- composed of tough fibrous tissue

The inner most meninges that is directly in contact with the brain

Pia Mater-

Vessels that lay on top of the Pia Mater

Cerebral Blood Vessels

The meninge that lays in the middle between the dura and pia matter

Arachnoid membrane-loosely covers the brain and its blood vessels

MAP-Mean Arterial Pressure

The average pressure for the entire cardiac cycle
MAP=Diastolic Pressure + 1/3 of the Pulse Pressure

PP- Pulse Pressure

The difference between the systolic and diastolic
PP= Systolic (SBP) - Distolic (DBP)

CPP- Cerebral Perfusion Pressure

The amount of pressure it takes to push blood through the cerebral circulation. CPP=Mean Arterial pressure (MAP) - Intercranial pressure (ICP)

CPP- is normally below ? mmHg

CPP is normally 15 mmHg or below


The brain changes the cerebral blood vessel resistance (CVR) to compensate for changes in the cerebral pulse pressure (CPP)

For neurological injured PT's the systolic blood pressure is best if maintained at or above

90 mmHg

Hyperventilation and TBI

Hyperventilation can reduced CBF by causing vasoconstriction due to hypocapnia, PaCO2 >35 increases risk of cerebral ischemia

Primary Brain injury

The direct trauma or mechanical injury, includes contusions, hemorrhages and lacerations

Secondary brain injury

pathologic mechanisms that related to intercranial mass effect, elevated ICP, and herniation, hemotoma, hypoxia and hypotension

Mass effect

The effect of a growing mass or tumor

Uncal Herniation

temporal lobe epidural hematoma forces pressure on the medial portion of the temporal lobe (uncus) which in turn puts pressure on the 3rd cranial nerve causing dilation or blown pupil on the side of the herniation. May also cause loss of function of the motor track on the same side.

Final stage of uncal herniation

The RAS is affected patient lapses into coma

decorticate posturing

flexion of the upper extremities with rigidity and extension of the lower extremities.

decerebrate posturing

all extrem become flaccid and motor activity is absent

Cheyne strokes ventilation

repeating cycle of slow hallow breaths that become deeper and more rapid and then return to slow

Central neurogenic hyperventilation

rapid deep breaths

Ataxic breathing

erratic ventilatory efforts that lack any discernible pattern

Cushings phenomenon

greatly increased arterial blood pressure and the resultant bradycardia (increase BP + decreased HR) may occur with severely increasing ICP

Hypercapnia (high CO2)

causes vasodilation

Hypocapnia (low CO2)

causes vasoconstriction

When people have 20 mmHg CO2 in their blood (half of the official norm),

they have about 40% less blood supply to the brain in comparison with normal conditions

Indication of TBI

One sided weakness

Indication of TBI

One sided paralysis

Indications for a nose fracture

ecchymosis, edema, nasal deformity, swelling, epistaxis

Epidural Hematoma
1-brief Loss of consciousness
2-Lucid Interval
3-Rapid decline in level of consciousness

The period of time after a brief loss of consciousness where the PT may be oriented, lethargic or confused followed by a rapid decline of consciousness

Subdural Hematoma

Account for 30% of TBI-Generally results from venous blood from bridging viens that are torn during a violent blow to the head.

Epidural Hematoma

Account for 2% of TBI-Arterial blood starts to dissect or peal the dura off of the inner table of the skull creating an epidural space filled with blood

Epidural Hematoma Signs

Altered LOC, dilated and sluggish non reactive pupil on the side of herniation, hemiparesis or hemiplegia on opposite side of injury.

Subdural Hematoma

Can be chronic or acute. Pt on coumadin are at high risk of un identified subdural hematomas that may be chronic. Often may be confused with stroke, infection or general decline of PT

Cerebral Contusions

actual bleeding into the substance of the brain, CC's often take 12-24 hrs to appear on CT scans, only indicator is a depressed GCS of 9-13

Subarachnoid Hemorrhage

rarely causes mass effect and does not require surgery, it does increase the risk of cerebral contusion by 63-73%

Normal ventilatory rates

10 BPM

Normal ventilatory rates

20 BPM

Normal ventilatory rates


Warning signs of possible ICP

Decline in GCS
sluggish or non reactive pupils
Hemiplegia or hemiparesis
Cushings phenomenon


the use of osmotically active agents that may assist in the treatment of intracranial hypertension`

Number of cervical vertebrae


Number of thoracic vertebrae


Number of lumbar vertebrae


Number of coccygeal vertebrae


Number of pounds the human head averages

16-22 pounds

Space between the spinal cord and the spinal canal wall


Name of the 1st cervical vertebrae


Name of the 2nd cervical vertebrae


Function of the ascending nervee tracts

Sensory impulses from body parts through the cord up to the brain

Function of the descending nerve tracts

impulses from the brain through the cord down to the body

Dorsal root=


Ventral root=



The sensory area on the body for which a nerve root is responsible

The phrenic nerve originates from

the cervical vertebrae c2-c5

Skeletal Injuries

Compression fractures that produce wedge compression or total flattening of the body of the vertebra

Skeletal Injuries

Produce small fragments of bone that may lie in the spinal canal near the cord

Skeletal Injuries

a partial dislocation of the vertebra from its normal alignment in the spinal column

Skeletal Injuries

Tearing of the ligaments and muscles producing instability between the vertebrae

Skeletal Injuries
Percentage of falls from a height greater than 15 feet involve an associated lumbar spine fracture


Cause and Symptoms
Anterior Cord syndrome

Results from bony fragments or pressure on spinal arteries
Symptoms-loss of motor function and pain, temperature and light touch PT's will have some light touch sensations such as vibration.

Cause and Symptoms
Central cord syndrome

usually occurs with hyperextension
Symptoms include weakness or paresthesia (tickling, tingling, burning, pricking, or numbness) in the upper extremities but normal strength in the lower extremities

Cause and Symptoms
Brown Sequard syndrome

Caused by penetrating injury and involves hemi-transection of the cord.
Symptoms include complete cord damage and loss of function of the affected side with loss of pain, temp and sensation on the opposite side of the injury

Conditions that should mandate spinal immobilization

Altered LOC
Spinal Pain or tenderness
Neurologic deficit or complaint
Anatomic deformity of the spine

Pulmonary Volume Terminology
Dead Space

Amount of air brought into the lungs that does not have the opportunity to exchange oxygen and carbon dioxide

Pulmonary Volume Terminology
Minute Volume (Ve)

Total volume of air moved into and out of during a 1 minute interval.

Pulmonary Volume Terminology
Tidal Volume (Vo)

Amount of air that is inhaled then exhaled druing a normal breath (.4-.5 litres)

Pulmonary Volume Terminology
Total Lung Capacity (TLC)

Total volume the lungs contain when maximally inflated. This volume declines with age from 6 L. in young adults to 4 L. in elderly.

Pulmonary Contusion

Blunt force can tear lung tissue resulting in bleeding into the alveoli

Thoracic Trauma
Four components to the phys exam

Observation, palpation, percussion, auscultation

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