Chapter 29

1. Chapter 29 Bleeding and Shock Prehospital Emergency Care 7e Mistovich/Hafen/Karren

2. Topics 29 • The Circulatory System • External Bleeding • Internal Bleeding • Shock (Hypoperfusion) • Enrichment Prehospital Emergency Care 7e Mistovich/Hafen/Karren

3. Introduction 29 • Active external or internal bleeding can be an extremely graphic, as well as life threatening emergency. • Whereas external bleeding is typically obvious, internal bleeding is less discernable, but equally deadly, as either type can lead to poor perfusion and death if not properly treated. • Serious bleeding must be treated immediately, with only the airway and breathing systems taking a higher priority. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

4. The Circulatory System 29 • The Heart, Blood Vessels, and Blood • Understanding the basic components of the circulatory system helps to illustrate the types of bleeding that may occur, as well as provide a rationale as to why the presentation of shock occurs. • The major components that comprise the circulatory system are the heart (the pump), the blood vessels (the container), and the blood (the volume). Prehospital Emergency Care 7e Mistovich/Hafen/Karren

5. The Circulatory System 29 • Heart • Blood Vessels • Blood Prehospital Emergency Care 7e Mistovich/Hafen/Karren

6. The Circulatory System 29 • The Heart, Blood Vessels, and Blood • It is the relationship of these three variables that provides perfusion to the body. The heart, brain, lungs, and kidneys are especially sensitive to disturbances in blood flow and perfusion that commonly accompany bleeding and shock. • Many clinical findings of bleeding and shock are actually due to the body trying to maintain perfusion despite the volume of blood that has been lost. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

7. The Circulatory System 29 • Perfusion • This refers to the delivery of oxygen and other metabolic nutrients to the cells of the body. It includes also the removal of waste products created by the cells. • When the body is unable (due to major bleeding, for example) to maintain perfusion to the cells, they begin to cease functioning normally and die. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

8. The Circulatory System 29 • Perfusion • When there is inadequate perfusion available to deliver oxygen to the cells and remove waste products, a state of shock (or hypoperfusion) is known to exist. • Since all parts of the body need perfusion, any alteration can be life threatening. The brain, for example, can only survive 4-6 minutes without perfusion. So proper management is essential. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

9. External Bleeding 29 • Severity • Depends upon • Amount of blood loss • Other concurrent injuries • The patient’s health status • The patient’s age Prehospital Emergency Care 7e Mistovich/Hafen/Karren

10. External Bleeding 29 • Severity • Since blood volume is dependent upon the weight of the patient, one cannot conclude that loss of a specific amount is severe. • The severity of the loss is thus determined by the presenting signs and symptoms the patient displays as a result of the blood loss. • The EMT-B must be keenly aware of these signs and symptoms since they greatly influence the subsequent care. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

11. External Bleeding 29 • Severity Prehospital Emergency Care 7e Mistovich/Hafen/Karren

12. External Bleeding 29 • Severity Prehospital Emergency Care 7e Mistovich/Hafen/Karren

13. External Bleeding 29 • Severity Prehospital Emergency Care 7e Mistovich/Hafen/Karren

14. External Bleeding 29 • Severity Prehospital Emergency Care 7e Mistovich/Hafen/Karren

15. External Bleeding 29 • Types of Bleeding • Arterial • Bright red, spurting possibly, difficult to control due to the the driving pressure of blood in the arteries • Can easily result in a large amount of blood loss with symptoms of shock developing rapidly Prehospital Emergency Care 7e Mistovich/Hafen/Karren

16. External Bleeding 29 • Types of Bleeding • Venous • Darker red blood from a damaged vein. A steady flow of blood usually means a vein has been damaged. • Bleeding may still be profuse if a larger vessel is damaged, but still it is generally easier to control. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

17. External Bleeding 29 • Types of Bleeding • Capillary • Also dark red, usually oozing from the skin. Very easy to control; in fact it usually clots off spontaneously. • If a large portion of the skin is involved, bleeding may still be severe. Also, risk of infection is great due to the break in the skin. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

18. External Bleeding 29 • Assessment and Care: External Bleeding • Scene Size-Up, Initial Assessment, Rapid Trauma Assessment • Ensure BSI precautions are taken. • After assuring scene safety, scan the scene for the MOI. • Form a general impression and rapidly complete the initial assessment. • Assess for airway patency, determine breathing adequacy, and assess the circulatory status. Assign the patient a priority status. • Complete the rapid trauma assessment, vitals, and SAMPLE history. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

19. External Bleeding 29 • Emergency Medical Care: Active External Bleed • Take the necessary BSI precautions. • Apply direct pressure to the site of bleeding. • Elevate the injured extremity. • Use pressure points to help slow an uncontrolled bleed. • Immobilize the injured extremity (this also helps to limit the bleed). • Use a tourniquet ONLY as a last resort. • Provide continued supportive care for shock. • Ensure bleeding is still controlled en route during the ongoing assessment phase. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

20. External Bleeding 29 • Methods of Controlling an External Bleed • Direct Pressure • Expose and identify the wound first. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

21. External Bleeding 29 • Methods of Controlling an External Bleed • Direct Pressure • Apply direct pressure with the hand to initially control the bleed. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

22. External Bleeding 29 • Methods of Controlling an External Bleed • Direct Pressure • With continued bleeding, remove dressing and attempt direct pressure on the site of the bleed. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

23. External Bleeding 29 • Methods of Controlling an External Bleed • Direct Pressure • If the bleeding is from a large gaping wound, pack it with a large dressing and apply direct pressure. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

24. External Bleeding 29 • Methods of Controlling an External Bleed • Elevation and Cold Application • Elevation of the injury site to above the level of the heart along with direct pressure also helps to control bleeding. • The application of ice or a cold pack promotes vasoconstriction, which in turn, helps to slow bleeding. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

25. External Bleeding 29 • Methods of Controlling an External Bleed • Pressure Points • By compressing an artery at a pressure point, arterial blood flow to that extremity can be reduced. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

26. External Bleeding 29 • Methods of Controlling an External Bleed • Pressure Points • By placing digital pressure on the blood vessel, it will pinch off the blood flow as the vessel is compressed between your fingers and the bone. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

27. External Bleeding 29 • Methods of Controlling an External Bleed • Pressure Points • Brachial location for bleeding to the upper extremity Prehospital Emergency Care 7e Mistovich/Hafen/Karren

28. External Bleeding 29 • Methods of Controlling an External Bleed • Pressure Points • Femoral pressure point location for lower extremity bleeding Prehospital Emergency Care 7e Mistovich/Hafen/Karren

29. External Bleeding 29 • Methods of Controlling an External Bleed • Splints • Fractured bone ends may cause vascular damage and resultant hemorrhaging. • Injured muscles or bones (pelvis and femurs) may also result in bleeding. • The application of splints will help to stabilize the injured bone, as well as promote clotting and the stopping of blood loss. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

30. External Bleeding 29 • Methods of Controlling an External Bleed • Pressure splints • The air pressure in an inflated splint can provide excellent pressure to stop a bleed. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

31. External Bleeding 29 • Methods of Controlling an External Bleed • Pressure splints • The PASG can also be used in a similar manner. • You could inflate either leg, or both. With a pelvic injury, inflate all quadrants. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

32. External Bleeding 29 • Methods of Controlling an External Bleed • Tourniquets • Used only as a last resort to control bleeding. • Should be avoided unless an amputation is present. • May cause permanent damage to nerves, muscles, and blood vessels. • Use a wide bandage. Once tight do not remove until directed by the physician, and avoid placing it over joints. • Keep the tourniquet in open view at all times. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

33. External Bleeding 29 • Methods of Controlling an External Bleed • Applying a tourniquet • Apply padding to location of tourniquet. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

34. External Bleeding 29 • Methods of Controlling an External Bleed • Applying a tourniquet • Wrap a wide bandage around the extremity twice. • Tie in a stick or similar object. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

35. External Bleeding 29 • Methods of Controlling an External Bleed • Applying a tourniquet • Twist the knot tighter until bleeding stops. • Tie off the ends to keep tourniquet tight. • Document time of application. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

36. External Bleeding 29 • Bleeding from the Nose, Ears, or Mouth • Area of concern because it may indicate: • Skull injury • Facial trauma • Digital trauma • Sinusitis or other URI • Hypertension • Clotting disorders • Esophageal disease Prehospital Emergency Care 7e Mistovich/Hafen/Karren

37. External Bleeding 29 • Methods of Controlling an External Bleed • Epistaxis • Control by sitting the patient forward, and pinch together the fleshy portion of the nose. • Keep the patient as calm as possible. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

38. Internal Bleeding 29 • May result from a variety of causes. • Blunt trauma • Abnormal clotting • Rupture of a blood vessel or vascular structure • Bone fractures • Because it is not visible and seldom obvious, internal bleeding can easily result in hypoperfusion and death to the patient. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

39. Internal Bleeding 29 • Internal Bleeding: Severity • Like external bleeding, internal bleeding is dependant upon several factors: • The patient’s age • The patient’s overall health • The amount and rate of internal bleeding • Always suspect internal bleeding with penetrating wounds to the skull, chest, abdomen, or pelvis. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

40. Internal Bleeding 29 • Internal Bleeding: Severity • A hematoma the size of a fist equates to about 10% of the blood volume. • A fracture of the tibia, fibula, or humerus can cause the loss of 500-750 ml of blood. • Femur fractures can lose as much as 1,500-2,000 ml of blood. • Bleeding into the thoracic cavity could total as high as 3,000 ml of blood. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

41. Internal Bleeding 29 • Internal Bleeding: Severity • Your estimation of the amount of blood loss is based upon the severity of the patient’s condition. • As such, let the signs and symptoms the patient’s body tells you guide your estimation of blood loss (beyond what may be obviously on scene from external sources). • Always suspect internal bleeding in cases of unexplained shock (hypoperfusion). Prehospital Emergency Care 7e Mistovich/Hafen/Karren

42. Internal Bleeding 29 • Assessment and Care: Internal Bleeding • Scene Size-Up and Initial Assessment • Evaluate the potential mechanism of injury. • Approach the patient and develop your general impression. • Assess the mental status; diminishing cognition is associated with shock as well as hypoxemia. • Assess the airway and assure that it is patent. • Asses the respiratory rate and tidal volume. • Determine circulatory status (pulse, skin findings, capillary refill). Prehospital Emergency Care 7e Mistovich/Hafen/Karren

43. Internal Bleeding 29 • Assessment and Care: Internal Bleeding • Focused History and Physical Exam • If your initial assessment yields a critical patient, proceed with a rapid trauma assessment followed by vital sign assessment, and then the SAMPLE history. • If, however, the patient presents as stable and has a bleed which is easily controlled, then perform a focused physical exam prior to the vitals and SAMPLE history. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

44. Internal Bleeding 29 • Assessment and Care: Internal Bleeding • Signs and Symptoms • Pain, tenderness, swelling, or discoloration of the suspected injury site • Bleeding from the mouth, rectum, vagina, or other orifice • Vomiting blood or vomitus that has dark coffee-grounds appearing material • Tender, rigid, and/or distended abdomen Prehospital Emergency Care 7e Mistovich/Hafen/Karren

45. Internal Bleeding 29 • Assessment and Care: Internal Bleeding • Signs and Symptoms also Indicating Hypoperfusion • Anxiety, restlessness, combativeness, altered mentation • Weakness, faintness, or dizziness • Thirst • Shallow and rapid breathing • Pale, cool, clammy skin • Delayed capillary refill and a narrowing pulse pressure • Dropping blood pressure • Dilated pupils that are sluggish in response to light • Nausea and vomiting Prehospital Emergency Care 7e Mistovich/Hafen/Karren

46. Internal Bleeding 29 • Assessment and Care: Internal Bleeding • Emergency Medical Care • Take body substance isolation precautions. • Maintain an open airway and adequate breathing. • Administer oxygen NRB or PPV as needed at 15 lpm. • Control any external bleeding. • Provide immobilization as warranted. • Provide for immediate transport. • Treat for shock (hypoperfusion). Prehospital Emergency Care 7e Mistovich/Hafen/Karren

47. Internal Bleeding 29 • Assessment and Care: Internal Bleeding • Detailed Physical Exam and Ongoing Assessments • Reassess the status of the airway and breathing. • Be alert for renewed bleeding. • Reevaluate the critical patient every 5 minutes. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

48. Shock (Hypoperfusion) 29 • Hypoperfusion is said to exist when the body is unable to meet the metabolic demands of the tissues. • When cells cease to receive an adequate amount of oxygenated blood and other necessary nutrients, they begin to fail and die. • As perfusion drops and inadequate blood reaches the tissue beds, there is also inadequate waste removal, and as these waste products accumulate, they hasten the cellular death. Prehospital Emergency Care 7e Mistovich/Hafen/Karren

49. Shock (Hypoperfusion) 29 Prehospital Emergency Care 7e Mistovich/Hafen/Karren

50. Shock (Hypoperfusion) 29 • Certain major organs of the body are extremely sensitive to this diminished blood flow, and failure of these organs results in death: • Heart • Brain • Lungs • Kidneys Prehospital Emergency Care 7e Mistovich/Hafen/Karren