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HAEMORRHAGE &
SHOCK
BLOOD COAGULATIONWhen a tissue is damaged
Prothrombin is converted into its active form thrombin
(In the presence of calcium)
Fibrinogen then transformed by thrombin to fibrin
Mesh is formed by platelets and other blood cells to form clot
CLOTTING FACTORS
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I. FIBRINOGENII. PROTHROMBINIII. TISSUE FACTOR( THROMBOPLASTIN)IV. CALCIUM( CA2+)V. LABILE FACTOR, PROACCELERIN, AC-
GLOBULINVI. STABLE FACTOR
CONTD…VII. ANTIHAEMOPHILIC GLOBULIN( AHG),
ANTIHAEMOPHILIC FACTOR AVIII. CHRISTMAS FACTOR, PLASMA
THROMBOPLASTIN COMPONENT(PTA), ANTIHAEMOPHILIC FACTOR B
IX. STUART POWER FACTOR X. PLASMA THROMBOPLASTIN
ANTECEDENT( PTA), ANTIHAEMOPHILIC FACTOR C
XI. HAGEMAN FACTORXII. FIBRIN STABILISING FACTOR 4
CLASSIFICATION BY ATLS Based on blood volume1. Class I Haemorrhage2. Class II Haemorrhage3. Class III Haemorrhage 4. Class IV Haemorrhage
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CONTD… World Health Organization Grade 0 - no bleeding Grade 1 - Petechial bleeding; Grade 2 - mild blood loss (clinically
significant); Grade 3 - gross blood loss, requires
transfusion (severe); Grade 4 - debilitating blood loss, retinal or
cerebral associated with fatality
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According to Origin: Mouth
Hematemesis, Haemoptysis AnusHematochezia
Urinary tractHematuria
Upper headIntracranial haemorrhageCerebral haemorrhage Intracerebral haemorrhage
Subarachnoid haemorrhage (SAH) 7
LungsPulmonary haemorrhage
GynaecologicVaginal bleeding
Postpartum haemorrhageBreakthrough bleeding
Ovarian bleeding. Gastrointestinal
Upper gastrointestinal bleedLower gastrointestinal bleedOccult gastrointestinal bleed
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According to source • Capillary• Venous• Arterial
According to situation• External (Revealed haemorrhage)• Internal (Concealed haemorrhage)• Subcutaneous/intramuscular
According to the time of wound:
• Primary haemorrhage• Reactionary or intermediate haemorrhage• Secondary haemorrhage
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CAUSES1.Traumatic Injury
Abrasion Excoriation Hematoma Laceration Incision Puncture Wound Contusion Crushing Injuries Ballistic Trauma 11
2. Medical condition
Intravascular changes Intramural changes Extra vascular changes
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SIGNS & SYMPTOMS OF HAEMORRHAGE
Blood coming from an open wound. Bruising Shock, which may cause any of the
following symptoms:• Confusion or decreasing alertness• Clammy skin• Dizziness or light-headedness after an
injury• Low blood pressure• Paleness (pallor) 13
Contd…• Rapid pulse, increased heart rate• Shortness of breath• Weakness
Symptoms of internal bleeding may also include:
• Abdominal pain and swelling• Chest pain
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• External bleeding through a natural opening– Blood in the stool(appears black, maroon, or bright
red)– Blood in the urine (appears red, pink, or tea-
colored)– Blood in the vomit (looks bright red, or brown like
coffee-grounds)– Vaginal bleeding (heavier than usual or after
menopause)• Skin colour changes that occur several days after an
injury (skin may black, blue, purple, yellowish green)
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CONTROL OF HAEMORRHAGE
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Apply direct pressure:• with gloved hand,• sterile dressing(s).
Bleeding stopped? YesNo
Elevate extremity:• above victim’s heart,continue direct pressure
Locate pressure point,apply pressure:• maintain direct pressureover wound
Treat for shock:• care for wound,• seek definitive care
Bleeding stopped?
Bleeding stopped?
No
Bleeding fromextremity?
No
Apply tourniquet(last resort)
Yes
No
Definitive therapy 17
Apply pressure directly to wound site:– Gloved hand, dressing– If dressing soaks
through, add more gauze on top and press harder
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Direct pressure
If possible, raise wound site above level of victim’s heart
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Elevate wound site
Find proximal “pressure point” and press on it (radial, ulnar, brachial, axillary, femoral arteries—not carotid)
Apply direct pressure to site
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Pressure points
Yes
Yes
Tourniquet Apply band above injury site, tighten to stop
bleeding:– Last resort—risky– Note time of application– Reassess frequently
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FIRST AID IN EXTERNAL BLEEDING
Bring the sides of wound together and press firmly. Press on the pressure point for 10-15 min. Place the causality in comfortable position and raise
the injured Part and reassure him. Apply a clean pad larger than the wound and press
it firmly with the palm until bleeding becomes less. If bleeding continues do not take off original
dressing but add more pads. Bandage, it but not too tightly.
CONTROL OF INTERNAL HAEMORRHAGE
The organ is emptied of blood clots if possible.
The vessels are encouraged to contract.
Packing Surgical ligature Internal pressure.
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FIRAT AID IN INTERNAL BLEEDING
Lay the causality down with head low; raise his legs by Use of pillow.
Keep him calm and relaxed. Reassure him. Do not allow him to move. Keep up the body heat with thin blankets or
coat.
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CONTD…
Do not give anything to eat or drink aspiration may occur.
Do not apply ice bags or hot water bottles to chest or abdomen.
Take him to the hospital as early as possible.
Transport gently25
RESTORATION OF BLOOD VOLUME Transfusion under increased
pressurePressure cuff Pressure pump administration
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NURSING MANAGEMENT
Risk for bleeding related to pregnancy related complications, postpartum complication, treatment related side effects, circumcision, DIC, inherent coagulopathies, GI disorders, aneurysm, impaired liver function, trauma or history of falls.
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Shock
DEFINITION
1. Shock can be best be defined as a condition in which tissue perfusion is inadequate to deliver oxygen and nutrients to support vital organs and cellular function.
2. Shock is a syndrome characterized by decreased tissue perfusion and impaired cellular metabolism. This results in an imbalance between the supply of and demand for oxygen and nutrients.
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Contd….
3. Shock is a condition where the tissues in the body do not receive enough oxygen and to allow cells to function.
4. Shock is defined as failure of the circulatory system to maintain adequate perfusion to vital organs.
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Shock
Homeostasis– cellular state of balance– perfusion of cells with oxygen and
glucose is one of its cornerstones– Transfer of waste materials from the
cell to blood for elimination
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Shock
Inadequate oxygenation or perfusion causes:
Inadequate cellular oxygenationShift from aerobic to anaerobic
metabolism
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AEROBIC METABOLISM
6 O2
GLUCOSE
METABOLISM
6 CO2
6 H2O
36 ATP
HEAT (417 kcal)
Glycolysis: Inefficient source of energy production; 2 ATP for every glucose; produces pyruvic acid
Oxidative phosphorylation: Each pyruvic acid is converted into 34 ATP
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ANAEROBIC METABOLISM
GLUCOSE METABOLISM
2 LACTIC ACID
2 ATP
HEAT (32 kcal)
Glycolysis: Inefficient source of energy production; 2 ATP for every glucose; produces pyruvic acid
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Anaerobic Metabolism Occurs without oxygen
– oxydative phosphorylation can’t occur without oxygen
– glycolysis can occur without oxygen– cellular death leads to tissue and organ
death– can occur even after return of perfusion
organ or organism death
VASCULAR RESPONSES Oxygen attaches to the haemoglobin
molecule in red blood cells, and the blood carries it to body cells.
Central regulatory mechanisms Local regulatory mechanisms
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B.P REGULATION Three major components of the circulatory
system blood volume, the cardiac pump, and the vasculature must respond effectively to complex neural, chemical, and hormonal feedback systems to maintain an adequate blood pressure and ultimately perfuse body tissues.
Mean arterial blood pressure = cardiac output × peripheral resistance
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CONTD… Cardiac output is determined by stroke volume
(the amount of blood ejected at systole) and heart rate.
Blood pressure is regulated by the baroreceptors (pressure receptors) located in the carotid sinus and aortic arch.
Chemoreceptor’s, also located in the aortic arch and carotid arteries, regulate blood pressure and respiratory rate using much the same mechanism in response to changes in oxygen and carbon dioxide concentrations in the blood.
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CONTD…
The kidneys also play an important role in blood pressure regulation.
Adequate blood volume, an effective cardiac pump, and an effective vasculature are necessary to maintain blood pressure and tissue perfusion.
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STAGES OF SHOCK
Initial Stage Compensatory
Stage Progressive
Stage Irreversible
Stage
INITIAL STAGE
Initially, the body compensates with the onset of shock.
No changes are noted clinically. Changes are beginning to occur
on the cellular level.
COMPENSATORY STAGE
Activation of SNS - activation of epinephrine and nor epinephrine.
Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output.
Kidneys release renin into blood formation of angiotensin & release of aldosterone, ADH
Decreased CO
SNS stimulation
Epinephrine & nor epinephrine released
Vasoconstriction
Increased SVR
Renin secreted by kidney
Angiotension
Aldosterone
ADH
Increase blood volume
hydrostatic pressure
fluid pulled into capillary
Blood Pressure Maintained
CLINICAL MANIFESTATIONS
Normal B.P Increased respiratory rate Skin- cold & clammy Hypoactive bowel sounds Decreased urine output Mental status changes- confusion
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MANAGEMENT MEDICAL MANGEMENT• Fluid replacement• Medication therapy NURSING MANAGEMENT• Monitoring tissue perfusion• Reducing anxiety• Promoting safety
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PROGRESSIVE STAGE
Vicious circle of compensation eventually leads to decompensation.
Mean arterial pressure starts to fall - SBP below 90.
CLINICAL FEATURES RESPIRATORY: o rapid & shallowo Crackleso Decreased arterial oxygeno Increased CO2o Pulmonary edemao Interstitial inflammation & fibrosiso ARDS 47
CARDIOVASCULAR:o Dysrhythmiaso Ischemiao Rapid HR- > 150 bpmo Chest paino Rised cardiac enzyme levels NEUROLOGICo Mental status changes-Confusiono Lethargyo Dilated pupils, sluggish reaction to light
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RENAL EFFECTSo Acute renal failure
HEPATIC EFFECTSo susceptible to Infectiono Elevated liver enzymes& bilirubin
levels
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GI EFFECTSo Stress ulcero Bloody diarrheao Bacterial toxin translocation
HEMATOLOGIC EFFECTSo DIC
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MEDICAL MANAGEMENT
IV FLUIDS& MEDICATIONS Early enteral support Antacids, histamine-2 blockers, or
anti-peptic agents.
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NURSING MANAGEMENT Preventing complications Promoting rest and comfort Supporting family members
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IRREVERSIBLE STAGE
Severe organ damage Low B.P Complete renal and liver failure Multiple organ dysfunction
progressing to complete organ failure has occurred, and death is imminent.
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MANAGEMENT MEDICAL Same as progressive stage Antibiotic agents & immunomodulation
therapy
NURSING Offering brief explanations to the patient Provide opportunities for the family to
see, touch, and talk to the patient.54
OVERALL MANAGEMENT IN SHOCK
Fluid replacement Vasoactive medications Nutritional support
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TYPES OF SHOCK Hypovolemic Shock Cardiogenic Shock Distributive Shock
– Neurogenic shock– Septic shock– Anaphylactic shock
Most common type of shock
– Decreased intravascular volume
• Primary cause = loss of blood or body fluids from an internal or external source
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HYPOVOLEMIC SHOCK
Scalp laceration 3rd degree/full thickness burn
CONTD…• INTERNAL: Hemorrhage, severe
burns, severe dehydration
• EXTERNAL: Trauma, Surgery, Vomiting, Diarrhoea, Diuresis, Diabetes insipidus
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CLINICAL FEATURES A rapid, weak, thready pulse Cool, clammy skin Rapid and shallow breathing Hypothermia Thirst and dry mouth Cold and mottled skin (Livedo
reticularis)59
MANAGEMENT MEDICAL Treatment of the underlying cause- Fluid & blood replacement- Redistribution of fluid by positioning Pharmacologic therapy NURSINGo Administering blood & fluids safelyo oxygen
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CARDIOGENIC SHOCKPATHOPHYSIOLOGY
Decreased cardiac contractility
Decreased stroke volume and cardiac output
Pulmonary congestion, Decreased systemic tissue perfusion,
Decreased coronary artery perfusion 61
MANAGEMENT
MEDICALCorrection of underlying causes Initiation of first-line treatment• Supplying supplemental oxygen • Controlling chest pain• Providing selected fluid support
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CONTD…
• Administering vasoactive medications • Controlling heart rate with medication
or by implementation of a transthoracic or intravenous pacemaker
• Implementing mechanical cardiac support
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NURSING Preventing cardiogenic shock. Monitoring hemodynamic status. Administering medications and
intravenous fluids. Maintaining intra-aortic balloon
counter pulsation.
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Circulatory or distributive shock – abnormal displacement of blood volume in the vasculature.
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DISTRIBUTIVE SHOCK
Urticaria/anaphylaxis Meningococcic sepsis
TYPES
1.Septic shock2. Neurogenic shock3. Anaphylactic shock
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RISK FACTORS Septic shock- immuno suppression,
extremes of age, malnourishment, chronic illness, invasive procedures.
Neurogenic shock – spinal cord injury, spinal anesthesia, depressant action of medications, glucose deficiency.
Anaphylactic shock- penicillin sensitivity, transfusion reaction.bee sting allergy, latex sensitivity. 67
SEPTIC SHOCK Caused by widespread infection.
VasodilationMaldistribution of blood volume
Decreased venous returnDecreased stroke volumeDecreased cardiac output
Decreased tissue perfusion68
MANAGEMENT
MEDICAL• identifying and eliminating the
cause of infection.• Fluid replacement. PHARMACOLOGIC THERAPY• Antibiotic sensitivity.• 3rd generation cephalosporin +
amino glycoside69
NUTRITIONAL THERAPY• Nutritional supplementation - within the
first 24 hours .• Enteral feedings NURSING MANAGEMENT• Follow aseptic technique.• Monitor for signs of infection.• Monitor hemodynamic status, fluid
intake& output& nutritional status.• Daily weight & close monitoring of serum
albumin.70
NEUROGENIC SHOCK
vasodilation occurs as a result of a loss of sympathetic tone.
may have a prolonged course (spinal cord injury) or a short one (syncope or fainting)
Dry, warm skin & bradycardia.
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MANAGEMENT MEDICAL1. Restoring sympathetic tone through
stabilization of a spinal cord injury or, in the instance of spinal anaesthesia, by positioning the patient properly.
2. Specific treatment depends on its cause. If hypoglycemia (insulin shock) is the cause, glucose is rapidly administered.
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NURSING• Elevate and maintain the head of the
bed at least 30 degrees.• . In suspected spinal cord injury,
neurogenic shock may be prevented by carefully immobilizing the patient.
• Applying elastic compression stockings and elevating the foot of the bed
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• Check the patient daily for any redness, tenderness, warmth of the calves, and positive Homans sign (calf pain on dorsiflexion of the foot).
• Administering heparin or low-molecular-weight heparin (Lovenox) as prescribed, applying elastic compression stockings, or initiating pneumatic compression of the legs may prevent thrombus formation.
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• Performing passive range of motion of the immobile extremities.
• In the immediate post injury period, the nurse must monitor the patient closely for signs of internal bleeding that could lead to hypovolemic shock.
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ANAPHYLACTIC SHOCK Caused by severe allergic reaction
when a patient who has already produced antibodies to a foreign substance (antigen) develops a systemic antigen–antibody reaction.
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Due to antibody responsesRelease of histamine Vasodilatation
Increased capillary PermeabilitySevere bronchoconstriction
Decreased oxygen supply and utilization
Inadequate tissue Perfusion
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MANAGEMENT
MEDICAL Removing the causative antigen
(e.g., discontinuing an antibiotic agent), administering medications that restore vascular tone, and providing emergency support of basic life functions.
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Epinephrine Diphenhydramine Nebulized medications ( albuterol) cardiopulmonary resuscitation ET Intubation or tracheotomy NURSING Assessing all patients for allergies or
previous reactions to antigens and communicating the existence of these allergies or reactions to others.
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Assess the patient’s understanding of previous reactions and steps taken by the patient and family to prevent further exposure to antigens.
Advise the patient to wear or carry identification that names the Specific allergen or antigen.
When administering any new medication, the nurse observes the patient for an allergic reaction.
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Identify patients at risk for anaphylactic reactions to contrast agents (radiopaque, dye-like substances that may contain iodine) used for diagnostic tests.
Take immediate action if signs and symptoms occur, and must be prepared to begin cardiopulmonary resuscitation if cardio respiratory arrest occurs.
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In addition to monitoring the patient’s response to treatment, the nurse assists with intubation if needed, monitors the hemodynamic status, ensures intravenous access for administration of medications, and administers prescribed medications and fluids, and documents treatments and their effects.
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Community health and home care nurses whose role includes administering medications, including antibiotic agents, in the patient’s home or other settings must be prepared to administer epinephrine subcutaneously or intramuscularly in the event of an anaphylactic reaction.
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PREVENTION OF SHOCK Preoperatively: His blood should be adequate in quantity
and volume. His tissues should be adequately
hydrated. He should be mobile. Patient should be kept warm on his
journey from ward to theatre.84
Post operatively: Fluid and electrolyte replacement
normal saline, dextrose 5%, plasma and rest and relief from the pain continues.
Gentle handling by nursing staff will help in prevention of shock.
Diuretics like mannitol . If oliguria persists furosemide can be
given. Dopamine
COMPLICATIONS
1. ARDS2. Multiple Organ Failure
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BIBLIOGRAPHY1. Joyce B M. Medical- Surgical
Nursing. 8th Edition. U.P. Elsevier Publications; 2009. Page No: 2154-2182
2.Chintamani. Moroney’s Surgery For Nurses. 17th Edition. New Delhi: Elsevier Publications; 2008. Page No: 67-81
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3. Ignatavicius. Workman. Medical Surgical Nursing-Patient Centred Collaborative Care. USA: Elsevier Publications; 2010. Page No:827-830
4. Lewis. Medical Surgical Nursing: Assessment And Management Of Clinical Problems. 8th Edition. USA: Elsevier Publications; 2011. Page No: 1722-1744
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5. Soni S. Textbook Of Advance Nursing Practice.1st Edition. Jaypee Brothers Medical Publishers; 2003. Page No: 450-464
6. Basheer S P. A Concise Textbook Of Advanced Nursing Practice. Bangalore: Emmess Medical Publishers; Page No: 9-20
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7. Smeltzer S C. Brunner And Suddarth’s Textbook Of Medical Surgical Nursing.11th Edition. New Delhi: Wolters Kluwer Pvt. Ltd; 2008.Page No: 356-378
8. En. Wikipedia.Org/ Wiki/ Emergency Bleeding Control
9. Http:// Nursing Care plans BlogSpot. In/ 2012
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10. En.Wikipedia.Org/ Wiki/ Bleeding11. En. Wikipedia. Org/ Wiki/ Shock12. Journals. Iwww.Com/ Shock
Journal
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