2National EMS Education Standard Competencies TraumaIntegrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient.
3National EMS Education Standard Competencies BleedingRecognition and management ofPathophysiology, assessment, and management ofFluid resuscitation
4Introduction Bleeding is potentially dangerous because: May cause weakness, leading to shockMay lead to serious injury and deathMost common cause of shock after trauma
5Anatomy and Physiology Cardiovascular system keeps blood flowing between lungs and peripheral tissuesRight side—blood to lungsLeft side—receives blood from lungs and pumps it throughout body
6Anatomy and Physiology In lungs, blood:Unloads waste productsPicks up oxygenIn peripheral tissues, blood:Unloads oxygenPicks up waste
7Anatomy and Physiology If blood stopped or slowed:Cells engulfed by waste productsOxygen delivery to tissues disruptedCells switch to anaerobic metabolism
8Anatomy and Physiology Circulatory system requires:Functioning pumpAdequate fluid volumeIntact system of tubing
9Structures of the Heart About the size of a closed fistConsists of:Two atriaTwo ventriclesAtrioventricular valves separate the upper and lower portions.Semilunar valves separate the ventricles and arteries.
10Structures of the Heart Blood enters the right atrium from superior and inferior vena cava and coronary sinus.Four pulmonary veins carry blood to the left atrium.
11Blood Flow within the Heart and Lungs Two large veins return deoxygenated blood to right atriumSuperior vena cava—blood from upper bodyInferior vena cava—blood from lower body
13The Cardiac Cycle Repetitive pumping process Preload: Amount of blood returned to heart to be pumped outAfterload: The pressure in the aorta, against which the left ventricle must pump blood
14The Cardiac CycleCardiac output: Amount of blood pumped through circulatory system in 1 minuteCO = Stroke volume × pulse rateIncreased venous return results in increased cardiac contractility.
15The Cardiac CycleA normal heart continues to pump the same percentage of blood returned to the right atrium.If more blood returns, the heart pumps harder.Maintained through position changes, coughs, etc.
16Blood and Its Components Blood consists of:PlasmaFormed elements in plasmaRed blood cellsWhite blood cellsPlatelets
17Blood and Its Components Purpose of blood:Carry oxygen and nutrients to tissuesCarry cellular waste products away from tissuesOther functions of formed elements
18Blood and Its Components Plasma: Watery, straw-colored fluidMore than half of total blood volumeErythrocytes: Disk-shaped RBCsMost numerous of formed elements
19Blood and Its Components HemoglobinBinds oxygen and transports it to tissuesOxygen saturation is often expressed as:Ratio of amount of oxygen bound to hemoglobin, to the oxygen-carrying capacity of hemoglobin
20Blood and Its Components Hemoglobin (cont’d)Amount of oxygen bound to hemoglobin is related to the partial pressure of oxygenOxyhemoglobin dissociation curve represents the relationship between the PO2 and SpO2
21Blood and Its Components Leukocytes: Different types of WBCsPrimary function: Fight infectionPlatelets: Small cells essential for clot formation
22Blood Circulation and Perfusion Arteries carry blood away from the heart.Veins transport blood back to the heart.Perfusion: Circulation of blood in adequate amounts to meet cells’ current needs
23Blood Circulation and Perfusion Autonomic nervous system adjusts blood flow to meet body’s needsSympathetic system—“Fight, flight, or freeze”Parasympathetic nervous system—“Rest and digest”
24Blood Circulation and Perfusion Vasomotor center in the medulla oblongata helps regulate blood pressureEndocrine system also responds to changesFall in blood pressure causes the release of:AldosteroneAntidiuretic hormone (ADH)
25Blood Circulation and Perfusion Insufficient circulation leads to hypoperfusion or shock.Delivery of oxygen depends on:Adequate heart rateStroke volumeHemoglobin levelsArterial oxygen saturation
26Pathophysiology of Hemorrhage Hemorrhage: BleedingExternal hemorrhage usually controlled by:Direct pressurePressure bandageInternal hemorrhage is usually only controlled by surgery.
27External HemorrhageExtent/severity is often a function of the type of wound and vessel.Capillary—blood oozesVein—blood flowsArtery—blood spurts
28Internal Hemorrhage Hemorrhage may appear in any area. Nontraumatic internal hemorrhage usually occurs in cases of:GI bleedingRuptured ectopic pregnanciesRuptured aneurysms
29Internal Hemorrhage Must be treated promptly Pay close attention to: Complaints of pain and tendernessDevelopment of tachycardiaPallorBe alert to development of shock.
30The Significance of Hemorrhage The body cannot tolerate more than 20% blood loss.Typically, more than 1 L of blood loss will change vital signs.Compensation depends on how rapid a person bleeds.
31The Significance of Hemorrhage Consider bleeding to be serious if:Significant MOIPoor general appearanceSigns and symptoms of shockSignificant amount of blood lossRapid blood lossUncontrollable bleeding
32Physiologic Response to Hemorrhage Bleeding from an open artery is bright red.Blood from open veins is darker.Bleeding from damaged capillary vessels is dark red.
33Physiologic Response to Hemorrhage Venous/capillary bleeding is more likely to clot than arterial bleeding.Bleeding tends to stop within 10 minutes.Will not stop if clot does not form
34Physiologic Response to Hemorrhage System may fail in certain situationsHemophilia: Condition where one or more of the blood’s clotting factors are missingAll injuries are potentially serious.
35Shock Shock can result from many conditions. Damage occurs from insufficient perfusion to organs and tissues.
36Shock Hypovolemic shock: Shock from inadequate blood volume Volume can be lost as:BloodPlasmaElectrolyte solution
37Hemorrhagic Shock Often due to: High incidence of exsanguinations: Blunt or penetrating injuriesLong bone or pelvic fracturesVascular injuriesMultisystem injuryHigh incidence of exsanguinations:HeartThoracic systemAbdominal systemVenous systemLiver
38Hemorrhagic ShockHypovolemic shock caused by hemorrhagic trauma is classified into four classes.Compensated shock (classes I and II)Decompensated shock (class III)Irreversible shock (class IV)
40Hemorrhagic Shock Initial stage is characterized by: Low circulating blood volumeMinimal signs of hypoperfusionAs the body begins to compensate, patients have:TachycardiaHypotensionSigns of poor tissue perfusion
43Scene Size-Up Recognize hazards and traffic safety. Protect bystanders.Stabilize involved vehicles.Follow standard precautions.Determine the number of patients present.
44Scene Size-Up High-energy MOI should increase suspicion. Attempt to determine amount of blood.If significant MOIs, scene time should not exceed 10 minutes.
45Primary AssessmentDetermine patient’s mental status using the AVPU scale.Locate and manage immediate life threats.Manage any major external hemorrhage.
46Primary AssessmentA patient with internal hemorrhage needs rapid transport.Late signs of internal hemorrhage include:Weakness, fainting, or dizziness at restDull eyesAltered level of consciousness
47Primary Assessment If minor external hemorrhage: Make note and complete assessment.Manage after patient has been properly prioritized.If internal hemorrhage:Keep patient warm.Administer supplemental oxygen.
48History Taking Investigate the chief complaint using OPQRST. Obtain history of present illness using SAMPLE.
49Secondary Assessment Perform a systematic full-body scan. Symptoms of internal hemorrhage often include:Pain and swellingHemorrhage from any body openingNote bleeding characteristics and try to determine source.
50Secondary Assessment Other signs of internal hemorrhage include: HematomaMelenaHematuriaPain, tenderness, guarding
51Secondary Assessment Assess the respiratory system. Airway patency Rate and quality of respirationDistended neck veins and deviated tracheaParadoxical chest movementBilateral breath sounds
52Secondary Assessment Assess the cardiovascular system. Use an ECG to monitor cardiac rhythm.Pulses are related to perfusion status.Patient will often present with:Pale, cool, mottled skinDecreased or absent radial pulsesIncreased capillary refill time
53Secondary Assessment Assess the neurologic system. Assess the musculoskeletal system.Assess all anatomic regions.
54Reassessment Reassess, especially where abnormal findings were found. Reassess interventions.In cases of severe hemorrhage, obtain vital signs every 5 minutes en route.
55Emergency Medical Care of Bleeding and Hemorrhagic Shock Follow standard precautions.Suspect shock in cases of severe hemorrhage.
56Managing External Hemorrhage Hemorrhaging from nose, ears, and mouthEar or nose hemorrhage may indicate skull fracture.Do not attempt to stop blood flow.Cover bleeding site loosely with sterile gauze pad.
57Managing External Hemorrhage Hemorrhaging from nose, ears, and mouth (cont’d)Nosebleed from other conditionsApply cold compresses to end of nose.Or, place rolled gauze under the upper lip.
58Managing External Hemorrhage Hemorrhaging from other areasControl through use of direct pressure.Pack large, gaping wounds with sterile dressing.Keep patient warm and in appropriate position.Patient’s condition should indicate mode of transport.
59TourniquetsUseful if severe hemorrhaging from extremity injury below axilla or groin
60TourniquetsIf commercial tourniquet is not available, apply a triangular bandage and a stick or rod.Blood pressure cuff can be used as well.
61Tourniquets Precautions: Do not apply directly over a joint. Use widest bandage possible.Never use narrow material.Use wide padding underneath.
62Tourniquets Precautions (cont’d): Never cover with a bandage. Inform hospital of the tourniquet.Do not loosen after application.
63Splints Broken bones can lacerate tissue, causing bleeding. Immobilizing a fracture is a priority in bleeding control.
64SplintsAir splintsControl hemorrhage associated with venous bleeding and stabilize fracture.Monitor distal extremity circulation.Use only approved valve stems.
65Splints Rigid splints Traction splints Stabilize fracture and reduce pain.Monitor distal extremity circulation.Traction splintsStabilize femur fractures.Pad areas to prevent excessive pressure.Monitor distal extremity circulation.
66Courtesy of Medtrade Products Ltd., UK Hemostatic AgentsCause vasoconstriction in the wound sitePowder formImpregnated in dressingsEffectiveness based on military useCourtesy of Medtrade Products Ltd., UK
67Managing Internal Hemorrhage Management focuses on:Treatment of shockMinimizing movement of part or regionRapid transportEventual surgery will be needed.
68Management of Hemorrhagic Shock Priorities are the ABCs.Blood products should be started early.Do not give anything by mouth.Keep patient at normal temperature.
69Management of Hemorrhagic Shock Monitor:ECG rhythm for dysrhythmiasState of consciousnessPulseBlood pressure
70SummaryThe cardiovascular and respiratory systems have roles in keeping blood flowing.Perfusion is the circulation of blood in adequate amounts within organs or tissues to meet current needs of cells.Hemorrhage means bleeding.External hemorrhage can often be controlled using direct pressure or a pressure bandage.
71SummaryInternal hemorrhage often cannot be controlled until a surgeon closes it.The most common cause of shock is hemorrhagic shock.The American College of Surgeons Committee on Trauma has developed four classifications of hypovolemic shock.
72SummaryShock occurs in three phases—compensated shock (classes I and II), decompensated shock (class III), and irreversible shock (class IV).Shock occurs when the level of tissue perfusion decreases below normal.Early decreased tissue perfusion may produce subtle changes long before a patient’s vital signs appear abnormal.
73SummaryAirway and ventilatory support are top priority in treating a patient with shock.Stabilizing a serious fracture is a high priority in bleeding control.Methods to control external hemorrhage include direct, even pressure; pressure dressing and/or splints; and tourniquets.If direct pressure fails, apply a tourniquet about the level of bleeding.
74SummaryIf a skull fracture is suspected and bleeding is present at the nose, place a gauze pad loosely under the nose.Management of internal hemorrhaging focuses on treatment of shock, minimizing movement, and rapid transport.If shock is suspected, early surgical intervention can be of benefit.Search for early signs of shock.