1. Bleeding: Chapter 22 page 650

2. The Significance of Bleeding When patient have serious external blood loss it is often difficult to determine the amount of blood that is present because it may be absorbed into the surface the patient is on or clothing. It may also be diluted when mixed with other liquid When patient have serious external blood loss it is often difficult to determine the amount of blood that is present because it may be absorbed into the surface the patient is on or clothing. It may also be diluted when mixed with other liquid

3. Blood Volume The body will not tolerate more than 20% blood volume loss Blood volume: 70mL per 1kg of body weight – Adult= about 6L – 1 year old infant= about 800mL The body will not tolerate more than 20% blood volume loss Blood volume: 70mL per 1kg of body weight – Adult= about 6L – 1 year old infant= about 800mL

4. Hypovolemic shock Hypovolemic shock- a condition in which low blood volume results in inadequate perfusion – Be aware for the following conditions: Significant MOI Poor General Appearance Assessment reveals signs and symptoms of shock: – Pale – Clammy/diaphoretic – Increased pulse – Decreased BP – You note significant blood loss – Blood loss is rapid – You cannot control bleeding *all bleeding should be treated as soon as the airway is managed and the patient is breathing Hypovolemic shock- a condition in which low blood volume results in inadequate perfusion – Be aware for the following conditions: Significant MOI Poor General Appearance Assessment reveals signs and symptoms of shock: – Pale – Clammy/diaphoretic – Increased pulse – Decreased BP – You note significant blood loss – Blood loss is rapid – You cannot control bleeding *all bleeding should be treated as soon as the airway is managed and the patient is breathing

5. Characteristics of Bleeding Arterial- Blood is bright red and spurts. Venous- Blood is dark red and does not spurt. Capillary- Blood oozes out and is controlled easily Arterial- Blood is bright red and spurts. Venous- Blood is dark red and does not spurt. Capillary- Blood oozes out and is controlled easily

6. Coagulation Bleeding normally stops within 10 minutes due to coagulation- the process in which a clot forms to close a hole in a blood vessel Some medications interfere with clotting Some injuries will be unable to clot Patients with hemophilia lack clotting factors Bleeding normally stops within 10 minutes due to coagulation- the process in which a clot forms to close a hole in a blood vessel Some medications interfere with clotting Some injuries will be unable to clot Patients with hemophilia lack clotting factors

7. Emergency Medical Care Follow BSI precautions Ensure patient has an open airway and adequate breathing Provide oxygen if necessary There are several methods to control bleeding – Direct pressure and elevation – Pressure bandage – Pressure points – Splints – Air splints – Pneumatic anti-shock garment – Tourniquet Follow BSI precautions Ensure patient has an open airway and adequate breathing Provide oxygen if necessary There are several methods to control bleeding – Direct pressure and elevation – Pressure bandage – Pressure points – Splints – Air splints – Pneumatic anti-shock garment – Tourniquet

8. Direct Pressure and Elevation: Direct pressure is the most common and effective way to control bleeding Apply pressure with gloved finger or hand Elevating a bleeding extremity often stops venous bleeding Use both direct pressure and elevation whenever possible Apply a pressure dressing Direct pressure is the most common and effective way to control bleeding Apply pressure with gloved finger or hand Elevating a bleeding extremity often stops venous bleeding Use both direct pressure and elevation whenever possible Apply a pressure dressing

9. Pressure Points If bleeding continues, apply pressure on pressure point. Pressure points are located where a blood vessel lies near a bone Be familiar with the location of pressure points If bleeding continues, apply pressure on pressure point. Pressure points are located where a blood vessel lies near a bone Be familiar with the location of pressure points

10. Splints Splints can help control bleeding associated with a fracture Air splints can be used to control bleeding of soft-tissue injuries Splints can help control bleeding associated with a fracture Air splints can be used to control bleeding of soft-tissue injuries

11. Pneumatic Antishock Garment (PASG) Stabilizes fractures of the pelvis and proximal femurs Controls significant internal bleeding Controls massive soft-tissue bleeding of the lower extremities (Refer to local protocol) Contraindications include: – Pregnancy – Pulmonary edema – Acute heart failure – Penetrating chest injuries – Groin injuries – Major head injuries – Less than 30 minute transport time Stabilizes fractures of the pelvis and proximal femurs Controls significant internal bleeding Controls massive soft-tissue bleeding of the lower extremities (Refer to local protocol) Contraindications include: – Pregnancy – Pulmonary edema – Acute heart failure – Penetrating chest injuries – Groin injuries – Major head injuries – Less than 30 minute transport time

12. Tourniquet Only to be used as a last resort for uncontrolled bleeding Application: – Fold a triangular bandage into 4˝ cravat – Wrap the bandage – Use a stick as a handle to twist and secure the stick – Write “TK” and time. Place on patient Precautions: – Place as close to injury as possible, but not over joint – Never use narrow material – Use wide padding under the tourniquet – Never cover a tourniquet with a bandage Do not loosen the tourniquet once applied Only to be used as a last resort for uncontrolled bleeding Application: – Fold a triangular bandage into 4˝ cravat – Wrap the bandage – Use a stick as a handle to twist and secure the stick – Write “TK” and time. Place on patient Precautions: – Place as close to injury as possible, but not over joint – Never use narrow material – Use wide padding under the tourniquet – Never cover a tourniquet with a bandage Do not loosen the tourniquet once applied

14. Bleeding from the Nose, Ears, and Mouth Causes include: – Skull fractures – Facial injuries – Sinusitis – High blood pressure – Coagulation disorders – Digital trauma Causes include: – Skull fractures – Facial injuries – Sinusitis – High blood pressure – Coagulation disorders – Digital trauma

15. Controlling a Nose Bleed Epistaxis- Nose Bleed – Follow BSI precautions – Help the patient sit and lean forward – Apply direct pressure by pinching the patient’s nostrils – Or place a piece of gauze bandage under the patient’s upper lip and gum – Apply ice over the nose – Provide transport Epistaxis- Nose Bleed – Follow BSI precautions – Help the patient sit and lean forward – Apply direct pressure by pinching the patient’s nostrils – Or place a piece of gauze bandage under the patient’s upper lip and gum – Apply ice over the nose – Provide transport

16. Bleeding from skull fractures Do not attempt to stop the blood flow Loosely cover bleeding site with sterile gauze If cerebrospinal fluid is present, a target (or halo) sign will be apparent Do not attempt to stop the blood flow Loosely cover bleeding site with sterile gauze If cerebrospinal fluid is present, a target (or halo) sign will be apparent

17. Internal Bleeding NOTE: Internal bleeding may not be readily apparent. Assess patient’s: – Mechanism of injury – Nature of illness NOTE: Internal bleeding may not be readily apparent. Assess patient’s: – Mechanism of injury – Nature of illness

18. Signs and Symptoms Ecchymosis: Bruising Hematoma: Bleeding beneath the skin Hematemesis: Blood in vomit Melena: Black, tarry stool Hemoptysis: Coughing up blood Pain, tenderness, bruising, guarding, or swelling Broken ribs, bruises over the lower chest, or rigid, distended abdome Ecchymosis: Bruising Hematoma: Bleeding beneath the skin Hematemesis: Blood in vomit Melena: Black, tarry stool Hemoptysis: Coughing up blood Pain, tenderness, bruising, guarding, or swelling Broken ribs, bruises over the lower chest, or rigid, distended abdome

19. Hypoperfusion Signs and Symptoms: – Change in mental status – Tachycardia – Weakness – Thirst – Nausea or vomiting – Cold, moist skin – Shallow, rapid breathing – Dull eyes – Dilated pupils – Weak, rapid pulse – Decreased blood pressure – Altered level of consciousness Signs and Symptoms: – Change in mental status – Tachycardia – Weakness – Thirst – Nausea or vomiting – Cold, moist skin – Shallow, rapid breathing – Dull eyes – Dilated pupils – Weak, rapid pulse – Decreased blood pressure – Altered level of consciousness

20. Treatment of Hypoperfusion Follow BSI precautions Maintain airway and administer oxygen Control external bleeding and care for any internal bleeding Monitor and record vital signs Elevate legs and keep patient warm Transport immediately Follow BSI precautions Maintain airway and administer oxygen Control external bleeding and care for any internal bleeding Monitor and record vital signs Elevate legs and keep patient warm Transport immediately