Chapter 30 Bleeding. National EMS Education Standard Competencies Trauma Integrates assessment findings with principles of epidemiology and pathophysiology.

Chapter 30Chapter 30

Bleeding

National EMS Education Standard CompetenciesNational 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.

National EMS Education Standard CompetenciesNational EMS Education Standard Competencies

Bleeding

• Recognition and management of– Bleeding

• Pathophysiology, assessment, and management of– Bleeding

• Fluid resuscitation

IntroductionIntroduction

• 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

Anatomy and PhysiologyAnatomy 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


• In lungs, blood:– Unloads waste

products

– Picks up oxygen

• In peripheral tissues, blood:– Unloads oxygen

– Picks up waste


• If blood stopped or slowed:– Cells engulfed by waste products

– Oxygen delivery to tissues disrupted

– Cells switch to anaerobic metabolism


• Circulatory system requires:– Functioning pump

– Adequate fluid volume

– Intact system of tubing

Structures of the HeartStructures 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.

Structures of the HeartStructures 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.

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



The Cardiac CycleThe 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


• 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.


• 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.

Blood and Its ComponentsBlood and Its Components

• Blood consists of:– Plasma

– Formed elements in plasma• Red blood cells

• White blood cells

• Platelets


• Purpose of blood:– Carry oxygen and nutrients to tissues

– Carry cellular waste products away from tissues

– Other functions of formed elements


• Plasma: Watery, straw-colored fluid– More than half of total blood volume

• Erythrocytes: Disk-shaped RBCs– Most numerous of formed elements


• 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


• 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


• Leukocytes: Different types of WBCs– Primary function: Fight infection

• Platelets: Small cells essential for clot formation

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



• Autonomic nervous system adjusts blood flow to meet body’s needs– Sympathetic system—“Fight, flight, or freeze”

– Parasympathetic nervous system—“Rest and digest”



• 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)



• Insufficient circulation leads to hypoperfusion or shock.– Delivery of oxygen depends on:

• Adequate heart rate

• Stroke volume

• Hemoglobin levels

• Arterial oxygen saturation

Pathophysiology of Hemorrhage

Pathophysiology of Hemorrhage

• Hemorrhage: Bleeding– External hemorrhage usually controlled by:

• Direct pressure

• Pressure bandage

– Internal hemorrhage is usually only controlled by surgery.

External HemorrhageExternal Hemorrhage

• Extent/severity is often a function of the type of wound and vessel.

• Capillary—blood oozes

• Vein—blood flows

• Artery—blood spurts

Internal HemorrhageInternal Hemorrhage

• Hemorrhage may appear in any area.

• Nontraumatic internal hemorrhage usually occurs in cases of:– GI bleeding

– Ruptured ectopic pregnancies

– Ruptured aneurysms

Internal HemorrhageInternal Hemorrhage

• Must be treated promptly– Pay close attention to:

• Complaints of pain and tenderness

• Development of tachycardia

• Pallor

– Be alert to development of shock.

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.



• 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

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.



• 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



• 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.

ShockShock

• Shock can result from many conditions.

• Damage occurs from insufficient perfusion to organs and tissues.

ShockShock

• Hypovolemic shock: Shock from inadequate blood volume– Volume can be lost as:

• Blood

• Plasma

• Electrolyte solution

Hemorrhagic ShockHemorrhagic Shock

• Often due to:– 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


• 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)



• 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



Scene Size-UpScene Size-Up

• Recognize hazards and traffic safety.

• Protect bystanders.

• Stabilize involved vehicles.

• Follow standard precautions.

• Determine the number of patients present.

Scene Size-UpScene Size-Up

• High-energy MOI should increase suspicion.– Attempt to

determine amount of blood.

– If significant MOIs, scene time should not exceed 10 minutes.

Primary AssessmentPrimary Assessment

• Determine patient’s mental status using the AVPU scale.

• Locate and manage immediate life threats.

• Manage any major external hemorrhage.


• 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


• 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.

History TakingHistory Taking

• Investigate the chief complaint using OPQRST.

• Obtain history of present illness using SAMPLE.

Secondary AssessmentSecondary 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.


• Other signs of internal hemorrhage include:– Hematoma

– Melena

– Hematuria

– Pain, tenderness, guarding


• Assess the respiratory system.– Airway patency

– Rate and quality of respiration

– Distended neck veins and deviated trachea

– Paradoxical chest movement

– Bilateral breath sounds


• 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


• Assess the neurologic system.

• Assess the musculoskeletal system.

• Assess all anatomic regions.

ReassessmentReassessment

• Reassess, especially where abnormal findings were found.

• Reassess interventions.

• In cases of severe hemorrhage, obtain vital signs every 5 minutes en route.

Emergency Medical Care of Bleeding and Hemorrhagic Shock

Emergency Medical Care of Bleeding and Hemorrhagic Shock

• Follow standard precautions.

• Suspect shock in cases of severe hemorrhage.

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.



• 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.



• 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.

TourniquetsTourniquets

• Useful if severe hemorrhaging from extremity injury below axilla or groin


• If commercial tourniquet is not available, apply a triangular bandage and a stick or rod.– Blood pressure cuff

can be used as well.


• Precautions:– Do not apply directly over a joint.

– Use widest bandage possible.

– Never use narrow material.

– Use wide padding underneath.


• Precautions (cont’d):– Never cover with a bandage.

– Inform hospital of the tourniquet.

– Do not loosen after application.

SplintsSplints

• Broken bones can lacerate tissue, causing bleeding.

• Immobilizing a fracture is a priority in bleeding control.

SplintsSplints

• Air splints– Control hemorrhage

associated with venous bleeding and stabilize fracture.

– Monitor distal extremity circulation.

– Use only approved valve stems.

SplintsSplints

• Rigid splints– Stabilize fracture

and reduce pain.


• Traction splints– Stabilize femur

fractures.

– Pad areas to prevent excessive pressure.


Hemostatic AgentsHemostatic Agents

• Cause vasoconstriction in the wound site– Powder form

– Impregnated in dressings

• Effectiveness based on military use

Courtesy of Medtrade Products Ltd., UK

Managing Internal HemorrhageManaging Internal Hemorrhage

• Management focuses on:– Treatment of shock

– Minimizing movement of part or region

– Rapid transport

• Eventual surgery will be needed.

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.



• Monitor:– ECG rhythm for dysrhythmias

– State of consciousness

– Pulse

– Blood pressure

SummarySummary

• 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.

SummarySummary

• 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.

SummarySummary

• 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.

SummarySummary

• 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.

SummarySummary

• 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.

CreditsCredits

• 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.

Chapter 30 Bleeding. National EMS Education Standard Competencies Trauma Integrates assessment findings with principles of epidemiology and pathophysiology.

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blood circulation

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deoxygenated blood

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