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Chapter 30 Bleeding.

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1 Chapter 30 Bleeding

2 National EMS Education Standard Competencies
Trauma Integrates 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.

3 National EMS Education Standard Competencies
Bleeding Recognition and management of Pathophysiology, assessment, and management of Fluid resuscitation

4 Introduction Bleeding is potentially dangerous because:
May cause weakness, leading to shock May lead to serious injury and death Most common cause of shock after trauma

5 Anatomy and Physiology
Cardiovascular system keeps blood flowing between lungs and peripheral tissues Right side—blood to lungs Left side—receives blood from lungs and pumps it throughout body

6 Anatomy and Physiology
In lungs, blood: Unloads waste products Picks up oxygen In peripheral tissues, blood: Unloads oxygen Picks up waste

7 Anatomy and Physiology
If blood stopped or slowed: Cells engulfed by waste products Oxygen delivery to tissues disrupted Cells switch to anaerobic metabolism

8 Anatomy and Physiology
Circulatory system requires: Functioning pump Adequate fluid volume Intact system of tubing

9 Structures of the Heart
About the size of a closed fist Consists of: Two atria Two ventricles Atrioventricular valves separate the upper and lower portions. Semilunar valves separate the ventricles and arteries.

10 Structures 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.

11 Blood Flow within the Heart and Lungs
Two large veins return deoxygenated blood to right atrium Superior vena cava—blood from upper body Inferior vena cava—blood from lower body

12 Blood Flow within the Heart and Lungs

13 The Cardiac Cycle Repetitive pumping process
Preload: Amount of blood returned to heart to be pumped out Afterload: The pressure in the aorta, against which the left ventricle must pump blood

14 The Cardiac Cycle Cardiac output: Amount of blood pumped through circulatory system in 1 minute CO = Stroke volume × pulse rate Increased venous return results in increased cardiac contractility.

15 The Cardiac Cycle A 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.

16 Blood and Its Components
Blood consists of: Plasma Formed elements in plasma Red blood cells White blood cells Platelets

17 Blood and Its Components
Purpose of blood: Carry oxygen and nutrients to tissues Carry cellular waste products away from tissues Other functions of formed elements

18 Blood and Its Components
Plasma: Watery, straw-colored fluid More than half of total blood volume Erythrocytes: Disk-shaped RBCs Most numerous of formed elements

19 Blood and Its Components
Hemoglobin Binds oxygen and transports it to tissues Oxygen saturation is often expressed as: Ratio of amount of oxygen bound to hemoglobin, to the oxygen-carrying capacity of hemoglobin

20 Blood and Its Components
Hemoglobin (cont’d) Amount of oxygen bound to hemoglobin is related to the partial pressure of oxygen Oxyhemoglobin dissociation curve represents the relationship between the PO2 and SpO2

21 Blood and Its Components
Leukocytes: Different types of WBCs Primary function: Fight infection Platelets: Small cells essential for clot formation

22 Blood 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

23 Blood Circulation and Perfusion
Autonomic nervous system adjusts blood flow to meet body’s needs Sympathetic system—“Fight, flight, or freeze” Parasympathetic nervous system—“Rest and digest”

24 Blood Circulation and Perfusion
Vasomotor center in the medulla oblongata helps regulate blood pressure Endocrine system also responds to changes Fall in blood pressure causes the release of: Aldosterone Antidiuretic hormone (ADH)

25 Blood Circulation and Perfusion
Insufficient circulation leads to hypoperfusion or shock. Delivery of oxygen depends on: Adequate heart rate Stroke volume Hemoglobin levels Arterial oxygen saturation

26 Pathophysiology of Hemorrhage
Hemorrhage: Bleeding External hemorrhage usually controlled by: Direct pressure Pressure bandage Internal hemorrhage is usually only controlled by surgery.

27 External Hemorrhage Extent/severity is often a function of the type of wound and vessel. Capillary—blood oozes Vein—blood flows Artery—blood spurts

28 Internal Hemorrhage Hemorrhage may appear in any area.
Nontraumatic internal hemorrhage usually occurs in cases of: GI bleeding Ruptured ectopic pregnancies Ruptured aneurysms

29 Internal Hemorrhage Must be treated promptly Pay close attention to:
Complaints of pain and tenderness Development of tachycardia Pallor Be alert to development of shock.

30 The 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.

31 The Significance of Hemorrhage
Consider bleeding to be serious if: Significant MOI Poor general appearance Signs and symptoms of shock Significant amount of blood loss Rapid blood loss Uncontrollable bleeding

32 Physiologic 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.

33 Physiologic 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

34 Physiologic Response to Hemorrhage
System may fail in certain situations Hemophilia: Condition where one or more of the blood’s clotting factors are missing All injuries are potentially serious.

35 Shock Shock can result from many conditions.
Damage occurs from insufficient perfusion to organs and tissues.

36 Shock Hypovolemic shock: Shock from inadequate blood volume
Volume can be lost as: Blood Plasma Electrolyte solution

37 Hemorrhagic Shock Often due to: High incidence of exsanguinations:
Blunt or penetrating injuries Long bone or pelvic fractures Vascular injuries Multisystem injury High incidence of exsanguinations: Heart Thoracic system Abdominal system Venous system Liver

38 Hemorrhagic Shock Hypovolemic shock caused by hemorrhagic trauma is classified into four classes. Compensated shock (classes I and II) Decompensated shock (class III) Irreversible shock (class IV)

39 Hemorrhagic Shock

40 Hemorrhagic Shock Initial stage is characterized by:
Low circulating blood volume Minimal signs of hypoperfusion As the body begins to compensate, patients have: Tachycardia Hypotension Signs of poor tissue perfusion

41 Hemorrhagic Shock

42 Hemorrhagic Shock

43 Scene Size-Up Recognize hazards and traffic safety.
Protect bystanders. Stabilize involved vehicles. Follow standard precautions. Determine the number of patients present.

44 Scene Size-Up High-energy MOI should increase suspicion.
Attempt to determine amount of blood. If significant MOIs, scene time should not exceed 10 minutes.

45 Primary Assessment Determine patient’s mental status using the AVPU scale. Locate and manage immediate life threats. Manage any major external hemorrhage.

46 Primary Assessment A patient with internal hemorrhage needs rapid transport. Late signs of internal hemorrhage include: Weakness, fainting, or dizziness at rest Dull eyes Altered level of consciousness

47 Primary 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.

48 History Taking Investigate the chief complaint using OPQRST.
Obtain history of present illness using SAMPLE.

49 Secondary Assessment Perform a systematic full-body scan.
Symptoms of internal hemorrhage often include: Pain and swelling Hemorrhage from any body opening Note bleeding characteristics and try to determine source.

50 Secondary Assessment Other signs of internal hemorrhage include:
Hematoma Melena Hematuria Pain, tenderness, guarding

51 Secondary Assessment Assess the respiratory system. Airway patency
Rate and quality of respiration Distended neck veins and deviated trachea Paradoxical chest movement Bilateral breath sounds

52 Secondary 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 skin Decreased or absent radial pulses Increased capillary refill time

53 Secondary Assessment Assess the neurologic system.
Assess the musculoskeletal system. Assess all anatomic regions.

54 Reassessment Reassess, especially where abnormal findings were found.
Reassess interventions. In cases of severe hemorrhage, obtain vital signs every 5 minutes en route.

55 Emergency Medical Care of Bleeding and Hemorrhagic Shock
Follow standard precautions. Suspect shock in cases of severe hemorrhage.

56 Managing External Hemorrhage
Hemorrhaging from nose, ears, and mouth Ear or nose hemorrhage may indicate skull fracture. Do not attempt to stop blood flow. Cover bleeding site loosely with sterile gauze pad.

57 Managing External Hemorrhage
Hemorrhaging from nose, ears, and mouth (cont’d) Nosebleed from other conditions Apply cold compresses to end of nose. Or, place rolled gauze under the upper lip.

58 Managing External Hemorrhage
Hemorrhaging from other areas Control 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.

59 Tourniquets Useful if severe hemorrhaging from extremity injury below axilla or groin

60 Tourniquets If commercial tourniquet is not available, apply a triangular bandage and a stick or rod. Blood pressure cuff can be used as well.

61 Tourniquets Precautions: Do not apply directly over a joint.
Use widest bandage possible. Never use narrow material. Use wide padding underneath.

62 Tourniquets Precautions (cont’d): Never cover with a bandage.
Inform hospital of the tourniquet. Do not loosen after application.

63 Splints Broken bones can lacerate tissue, causing bleeding.
Immobilizing a fracture is a priority in bleeding control.

64 Splints Air splints Control hemorrhage associated with venous bleeding and stabilize fracture. Monitor distal extremity circulation. Use only approved valve stems.

65 Splints Rigid splints Traction splints
Stabilize fracture and reduce pain. Monitor distal extremity circulation. Traction splints Stabilize femur fractures. Pad areas to prevent excessive pressure. Monitor distal extremity circulation.

66 Courtesy of Medtrade Products Ltd., UK
Hemostatic Agents Cause vasoconstriction in the wound site Powder form Impregnated in dressings Effectiveness based on military use Courtesy of Medtrade Products Ltd., UK

67 Managing Internal Hemorrhage
Management focuses on: Treatment of shock Minimizing movement of part or region Rapid transport Eventual surgery will be needed.

68 Management of Hemorrhagic Shock
Priorities are the ABCs. Blood products should be started early. Do not give anything by mouth. Keep patient at normal temperature.

69 Management of Hemorrhagic Shock
Monitor: ECG rhythm for dysrhythmias State of consciousness Pulse Blood pressure

70 Summary The 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.

71 Summary Internal 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.

72 Summary Shock 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.

73 Summary Airway 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.

74 Summary If 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.

75 Credits Chapter opener: © Jones and Bartlett Publishers. Courtesy of MIEMSS. Backgrounds: Gold—Jones & Bartlett Learning. Courtesy of MIEMSS; Blue—Courtesy of Rhonda Beck; Red—© Margo Harrison/ShutterStock, Inc; Purple—Courtesy of Rhonda Beck. Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.

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