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Bleeding and Soft Tissue Trauma. Chapter 28. Objectives. Discuss External Bleeding Discuss Internal Bleeding Discuss Factors that may Increase bleeding Cover Hemorrhagic Shock Learn about Soft Tissue Trauma Closed and Open Discuss Bandages and Dressing. External Bleeding - Severity.

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objectives
Objectives
  • Discuss External Bleeding
  • Discuss Internal Bleeding
  • Discuss Factors that may Increase bleeding
  • Cover Hemorrhagic Shock
  • Learn about Soft Tissue Trauma
    • Closed and Open
  • Discuss Bandages and Dressing
external bleeding severity
External Bleeding - Severity

Variables that determine severity of blood loss

  • Amount of blood loss
  • Rate of blood loss
  • Other injuries or existing conditions
  • Patient’s existing medical conditions
  • Patient’s age

The severity and amount is dependent on the patient

Uncontrolled or significant bleeding can lead to hemorrhagic shock and possibly death

types of bleeding
Types of Bleeding
  • Arterial
  • Venous
  • Capillary
arterial bleeding
Arterial Bleeding

Bright red, spurting blood from a wound usually indicates severed or damaged artery

  • Rich in oxygen
  • Spurts with pulse
  • Can be more difficult to control due to higher pressure in the arteries
  • Decreases with patient’s blood pressure
venous bleeding
Venous Bleeding

Dark red blood that flows steadily indicating severed or damaged veins

  • Depleted of oxygen
  • Steady flow
capillary bleeding
Capillary Bleeding

Dark or intermediate color of red; slowly oozing indicating damaged capillaries

  • Easily controlled
  • Clots spontaneously
  • Can pose a threat of infection
methods of controlling external bleeding
Methods of controlling external bleeding
  • Direct pressure
  • Tourniquets
  • Elevation
  • Splints
  • Topical hemostatic agents
direct pressure
Direct pressure
  • Place a sterile gauze over the injury site
  • Applying fingertip pressure directly to the point of bleeding
  • Remove dressings and apply direct pressure to the point of bleeding if necessary
  • Apply direct pressure on either side of an impaled object
  • Pressure points
tourniquets
Tourniquets
  • Use a bandage or device that is 4” wide
  • Wrap the tourniquet around the extremity proximally to the bleeding
  • Tighten the tourniquet until bleeding ceases
  • Secure the tightening rod or device
  • Write the time on tape and secure it to the tourniquet
tourniquets1
Tourniquets
  • Never cover the tourniquet or site of bleeding
  • Notify the hospital that a tourniquet is in place
  • Document the use of the tourniquet and time it was applied
  • Inflated blood pressure cuff may be used as a tourniquet until bleeding stops
elevation and splints
No evidence shows that elevation is effective for controlling or stopping bleeding

No evidence shows its harmful

Elevation can only be considered in conjunction with direct pressure

Splinting may assist with control of bleeding with a fracture

A traction splint serves not only as a splint but also a method of controlling bleeding

Apply splints on scene to extremity fractures only if patient is stable without life threatening injuries

Elevation and splints
topical hemostatic agents
Topical hemostatic agents

Dressings that promote clotting

  • Hemostatic
  • Chitosan

Hemostatic agents that pour onto the wound

  • Celox and Quickclot
  • TraumaDex
assessment based approach external bleeding
Assessment Based approach: External bleeding

Scene size-up, primary assessment, secondary assessment

  • Begin preparing while enroute
  • BSI
  • Ensure support resources are notified
  • Scene safety
  • Number of patients
  • General impression
  • Patent airway
  • Control bleeding, continue with primary assessment
  • Perform rapid secondary assessment with patient who has suffered significant bleeding, altered mental status, multiple injuries, or significant MOI
  • Obtain baseline vitals
emergency care
Emergency Care
  • BSI
  • Apply direct pressure
  • Apply tourniquet if unable to control bleeding
  • Provide care for shock
  • Immobilize injured extremities
  • Reassess by ensuring bleeding is still controlled, wounds that start bleeding again, repeat primary assessment, vital signs every 5 minutes, upgrade to ALS if necessary
bleeding from nose ears or mouth
Bleeding from Nose, ears or mouth

Possible causes;

  • Skull injury
  • Facial trauma
  • Digital trauma
  • Sinusitis or upper respiratory infection
  • Hypertension
  • Clotting disorders
  • Esophageal disease
epistaxis
Epistaxis

Bleeding from the nose

  • May result from injury, disease or environment
  • Place patient in sitting position and have them lean forward
  • Apply direct pressure by pinching fleshy portion of the nostrils together
  • Apply ice or cold pack over the bridge of nose
  • Use of oxymetazoline (Afrin™) helps with vasoconstriction (review Whatcom County Permissive Protocol, page 26)
internal bleeding severity
Internal bleeding - Severity

Severity depends on the patient’s overall condition, age, other medical conditions, and source of internal bleeding

Common sources;

  • Injured or damaged internal organs
  • Fractured extremities

Hematoma is a contained collection of blood

Always suspect internal bleeding in cases of unexplained signs/symptoms of hemorrhagic shock

assessment based approach internal bleeding
Assessment based approach Internal bleeding

Scene size-up/primary assessment

  • Look for and evaluate potential MOI
  • Look for any obvious major external bleeding
  • If a major bleed is found, control immediately with direct pressure
  • Assess mental status
  • Asses airway
  • Assess pulses, skin, and capillary refill
assessment based approach internal bleeding1
Assessment based approach Internal bleeding

Secondary Assessment

  • Internal bleeding suspected, do a rapid secondary assessment
  • Evidence of contusions, abrasions, deformity, impact marks, swelling, or other trauma, treat for internal bleeding
assessment based approach internal bleeding2
Assessment based approach Internal bleeding

Signs/Symptoms of internal bleeding

  • Pain, tenderness, swelling, or discoloration at site of injury
  • Bleeding from mouth, rectum, vagina or other orifice
  • Vomiting bright red blood or blood the color of dark coffee grounds
  • Dark, tarry stools with bright red blood
  • Tender, rigid, and/or distended abdomen
assessment based approach internal bleeding3
Assessment based approach Internal bleeding

Signs/Symptoms of internal bleeding that also indicates hemorrhagic shock;

  • Anxiety, restlessness, combativeness, or altered mental status
  • Weakness, faintness, or dizziness
  • Thirst
  • Shallow, rapid breathing
  • Rapid, thready pulse
  • Pale, cool, clammy skin
  • Delayed capillary refill
  • Dropping blood pressure (late sign)
  • Narrow pulse pressure
  • Dilated pupils that are sluggish in responding to light
  • Nausea and vomiting
emergency care1
Emergency Care
  • BSI
  • Maintain open airway, ensure adequate breathing
  • Oxygen via NRB
  • Control external bleeding with direct pressure or tourniquet if unable to control
  • Provide immediate transport
  • Provide care for shock
  • Reassess vital signs every 5 minutes
factors that may increase internal bleeding
Factors that may increase internal bleeding

Several factors may interfere with the clotting process

  • Movement
  • Low body temperature
  • Medications
  • Intravenous fluids
  • Removal of dressings and bandages
hemorrhagic shock
Hemorrhagic Shock

Scene size-up/Primary assessment

  • Note MOI
  • Ensure scene safety and police presence
  • Assess mental status and ABC’s
  • Note abnormalities or signs of shock
  • Oxygen via NRB
  • Ventilation with supplemental oxygen, if needed
hemorrhagic shock secondary assessment
Perform rapid secondary

Assess for signs of hemorrhagic shock

Signs/Symptoms

Mental Status – Restlessness, anxiety, altered mental status

Peripheral perfusion and perfusion to the skin – Pale, cool, clammy skin; Weak, thready, or absent peripheral pulses; delayed capillary refill

Vital Signs – Increased pulse rate (early sign) with weak, thready pulse (early sign); Increased respiratory rate; decreased BP (late sign); Narrow pulse pressure

Other signs/symptoms – Dilated pupils, Marked thirst, Nausea/vomiting, Pallor with cyanosis to the lips

Hemorrhagic Shock Secondary Assessment
emergency care2
Emergency Care
  • BSI
  • Maintain open airway
  • Control external bleeding
  • Apply and inflate PASG if symptoms warrant (Refer to Whatcom Co. protocols, page 17)
  • Place in supine position
  • Splint suspected bone or joint injuries
  • Keep patient warm
  • Transport immediately
  • Reassess mental status and vital signs every 5 minutes
pneumatic antishock garment pasg aka mast
Pneumatic Antishock garment (PASG) aka MAST

pneumatic antishock garment (PASG).

Per Whatcom County Protocol page 17:

PASG/MAST is no longer recommended in Whatcom county.

However, the rest of the country still has these in use

Indications;

  • Suspected pelvic fractures with hypotension
  • Profound hypotension
  • Suspected intraperitoneal hemorrhage with hypotension
  • Suspected retroperitoneal hemorrhage with hypotension

Contraindications;

  • Penetrating thoracic trauma
  • Splinting of lower extremities
  • Evisceration of abdominal organs
  • Impaled object in abdomen
  • Pregnancy
  • Cardiopulmonary arrest
hemophilia
Hemophilia
  • A congenital disease that prevents activation of the normal clotting mechanisms found in the blood
  • Bleeding in this patient is always considered to be significant
  • Transport immediately
soft tissue trauma the skin
Soft Tissue Trauma – The Skin
  • One of the most durable and largest organs of the body
  • Composed of 3 layers – Epidermis, Dermis, and subcutaneous layer
  • Protects the body
  • Serves as a receptor organ
  • Wounds
    • Open
    • Closed
    • Single
    • Multiple
closed injury contusions
Closed injury - Contusions

Closed injury – a wound in which there is no break in the skin

  • Contusion – injury to the tissue and blood vessels contained with in the dermis
  • Will cause localized swelling and pain
  • Discoloration may occur due to blood leaking from damaged vessels
  • Black and blue call Ecchymosis
closed injury hematomas
Closed injury - Hematomas
  • Usually involves damage to a larger blood vessel and a larger amount of tissue
  • Characterized by a large lump with bluish discoloration
  • The size of the patient’s fist can be equal to 10% blood loss
closed injury crush injuries
Closed injury – Crush injuries
  • Force great enough to cause injury has been applied to the body
  • Severe blunt trauma or crushing force may result in internal bleeding an hemorrhagic shock
  • Internal organs may actually rupture
assessment based approach closed soft tissue injuries
Assessment based approachClosed soft-tissue injuries

Scene size-up/primary assessment

  • Scan for MOI
  • BSI
  • Conduct primary assessment
  • Establish in-line stabilization of the cervical spine if spinal injury suspected
  • Assess mental status
  • Ensure adequate airway
  • Check and treat signs of severe bleeding and shock
  • Oxygen
  • Ventilation with supplemental oxygen if needed
secondary assessment
Secondary Assessment
  • Check for evidence of trauma
  • Assess baseline vitals
  • Obtain history
  • Signs/symptoms
    • Swelling, pain, and discoloration at injury site
    • Signs/symptoms of internal bleeding and hemorrhagic shock
emergency care3
Emergency Care
  • BSI
  • Ensure open airway and adequate breathing
  • Treat for shock
  • Splint suspected fractures
  • Reassess by repeating primary assessment, vital signs every 5 – 10 minutes
open injury abrasion
Open injury - Abrasion

An open injury is a wound in which the skin is broken

  • Abrasion – scraping, rubbing, or shearing away of the epidermis
  • Often is extremely painful due to exposed nerve endings
  • Capillary bleeding controlled with direct pressure
  • Abrasions to large areas of body surface may be cause for concern due to threat of contamination, infection, and underlying injuries
open injury lacerations
Open injury - Lacerations

A break in the skin of varying depth

  • Linear
  • Stellate
  • May bleed more than other types of open soft-tissue injuries
open injury avulsions
Open injury - Avulsions

Partial avulsion – loose flap of skin and underlying soft tissue that has been torn loose

Total avulsion – loose flap of skin and underlying soft-tissue that has been pulled completely off

Bleeding may be severe due to blood vessel injury

Healing will be prolonged, scarring may be extensive

open injury amputations
Open injury - Amputations

Disruption in the continuity of an extremity or other body part

  • Bleeding may be massive, often very little bleeding occurs
  • Always consider shock
open injury penetrations punctures
Open injury – Penetrations/Punctures

Results of a sharp, pointed object being pushed or driven into the soft tissues

  • Entry wound may appear small and cause little bleeding
  • Injuries may be deep and cause severe internal bleeding
  • Severity factors;
    • Location
    • Size of object
    • Depth of penetration
    • Forces involved
    • Structures in pathway
  • Always assess for underlying internal injuries and hemorrhagic shock
open injury crush injuries
Open injury – Crush injuries
  • May not appear to be serious
  • Only external sign may be an injury site that is painful, swollen, an deformed
  • External bleeding may be absent or minimal
  • Always suspect internal bleeding
  • Patients may deteriorate rapidly into shock
open injury bites clamping
Open injury – Bites & Clamping

Bites – Complications;

  • Infection
  • Cellulitis
  • Septicemia
  • Rabies
  • Tetanus
  • Hepatitis
  • Bite should be evaluated
  • Always ensure scene safety
  • Arrange for containment/isolate animal

Clamping injuries

  • Body part caught or strangled by a piece of machinery
  • Longer clamped, more damage
  • Edema makes removal difficult
  • Apply lubricant
  • Transport immediately
  • Call for specialized help to cut away parts of the clamping object
assessment base approach open soft tissue injuries
Assessment base approach Open soft-tissue injuries

Scene size-up/primary assessment

  • Ensure scene is safe
  • Note potential MOI
  • Be prepared to stabilize cervical spine
  • General impression
  • Assess mental status, ensure open airway
  • Oxygen via NRB
  • Ventilation with supplemental oxygen if needed
  • Bring any severe bleeding under control using direct pressure
secondary assessment1
Secondary Assessment
  • Baseline vitals
  • Obtain history
  • Signs/symptoms
    • Break in skin & external bleeding
    • Localized swelling
    • Pain
    • Discoloration at injury site
    • Possible signs/symptoms of internal bleeding and hemorrhagic shock
emergency care4
BSI

Ensure open airway, adequate breathing

Expose wound

Control bleeding

Prevent further contamination

Dress and bandage

Keep patient calm and quiet

Treat for shock

Transport

Reassess with repeat primary assessment, vital signs, check dressings

Special considerations;

Chest injuries

Abdominal injuries

Impaled objects

Amputations

Large open neck wounds

Emergency Care
chest wounds
Chest Wounds
  • A penetrating wound to the chest may cause air to enter the chest.
chest wound management
Chest Wound Management
  • Keep the patient supine and administer oxygen.
  • Seal the wound.
abdominal wounds
Abdominal Wounds
  • An open wound in the abdomen may expose organs.
  • An organ protruding through the abdomen is called an evisceration.
abdominal wound management
Abdominal Wound Management
  • Do not touch exposed organs.
  • Cover organs with a moist sterile dressing.
  • Transport immediately.
impaled objects
Impaled Objects
  • Do not attempt to move or remove the object.
  • Control bleeding and stabilize object.
  • Transport patient to the hospital carefully.
amputations
Amputations
  • Immobilize a partial amputation with bulky dressings and a splint.
  • Wrap a complete amputation in a dry sterile dressing and place in a plastic bag.
  • Put the bag in a cool container filled with ice.
  • Transport severed part with patient.
neck injuries
Neck Injuries
  • An open neck injury can be life threatening.
  • Air can get into the veins and cause an air embolism.
  • Cover the wound with an occlusive dressing.
  • Apply manual pressure.
  • Secure a pressure dressing loosely over the neck and firmly through the opposite axilla.
slide58
ICES
  • Ice slows bleeding.
  • Compression over an injury slows bleeding.
  • Elevation above the level of the heart reduces swelling.
  • Splinting decreases bleeding and reduces pain.
dressings
Dressings

Covers an open wound to aid in the control of bleeding and to prevent further damage of contamination

  • Must be sterile
  • Common types
    • Gauze pad
    • Self-adhering dressing
    • Universal or multitrauma dressing
    • Occlusive dressing
bandage
Bandage

Used to secure a dressing in place

Common types;

  • Self-adhering bandage
  • Gauze rolls
  • Triangular bandage
  • Air splint
pressure dressings
Pressure Dressings

Used to maintain control of bleeding

Application;

  • Cover wound with sterile gauze dressing
  • Apply direct pressure
  • Bandage firmly
  • If severe bleeding continues, remove dressing and bandage, apply direct finger-tip pressure
  • Once bleeding controlled, apply dressings and bandage over wound again
general principle of dressing and bandaging
General principle of Dressing and Bandaging
  • Use the materials you have on hand
  • Adapt the methods as best you can
  • General guidelines;
    • Dressings should be clean as possible
    • Do not bandage a dressing in place until bleeding has stopped
    • A dressing should cover the entire wound
    • Remove all jewelry from injured body part
    • Do not bandage too loosely
    • Do not bandage too tightly
    • If bandaging a small wound, cover a larger area with the bandage
    • Always place the body part to be bandaged in the position in which it is to remain
    • Apply a tourniquet if bleeding is not controlled with direct pressure