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Chapter 30Chapter 30
Bleeding
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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.
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National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
Bleeding
• Recognition and management of– Bleeding
• Pathophysiology, assessment, and management of– Bleeding
• Fluid resuscitation
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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
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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
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Anatomy and PhysiologyAnatomy and Physiology
• In lungs, blood:– Unloads waste
products
– Picks up oxygen
• In peripheral tissues, blood:– Unloads oxygen
– Picks up waste
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Anatomy and PhysiologyAnatomy and Physiology
• If blood stopped or slowed:– Cells engulfed by waste products
– Oxygen delivery to tissues disrupted
– Cells switch to anaerobic metabolism
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Anatomy and PhysiologyAnatomy and Physiology
• Circulatory system requires:– Functioning pump
– Adequate fluid volume
– Intact system of tubing
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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.
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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.
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Blood Flow within the Heart and Lungs
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
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Blood Flow within the Heart and Lungs
Blood Flow within the Heart and Lungs
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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
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The Cardiac CycleThe 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.
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The Cardiac CycleThe 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.
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Blood and Its ComponentsBlood and Its Components
• Blood consists of:– Plasma
– Formed elements in plasma• Red blood cells
• White blood cells
• Platelets
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Blood and Its ComponentsBlood and Its Components
• Purpose of blood:– Carry oxygen and nutrients to tissues
– Carry cellular waste products away from tissues
– Other functions of formed elements
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Blood and Its ComponentsBlood and Its Components
• Plasma: Watery, straw-colored fluid– More than half of total blood volume
• Erythrocytes: Disk-shaped RBCs– Most numerous of formed elements
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Blood and Its ComponentsBlood 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
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Blood and Its ComponentsBlood 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
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Blood and Its ComponentsBlood and Its Components
• Leukocytes: Different types of WBCs– Primary function: Fight infection
• Platelets: Small cells essential for clot formation
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Blood Circulation and Perfusion
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
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Blood Circulation and Perfusion
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”
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Blood Circulation and Perfusion
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)
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Blood Circulation and Perfusion
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
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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.
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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
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Internal HemorrhageInternal Hemorrhage
• Hemorrhage may appear in any area.
• Nontraumatic internal hemorrhage usually occurs in cases of:– GI bleeding
– Ruptured ectopic pregnancies
– Ruptured aneurysms
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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.
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The Significance of Hemorrhage
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.
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The Significance of Hemorrhage
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
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Physiologic Response to Hemorrhage
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.
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Physiologic Response to Hemorrhage
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
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Physiologic Response to Hemorrhage
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.
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ShockShock
• Shock can result from many conditions.
• Damage occurs from insufficient perfusion to organs and tissues.
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ShockShock
• Hypovolemic shock: Shock from inadequate blood volume– Volume can be lost as:
• Blood
• Plasma
• Electrolyte solution
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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
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Hemorrhagic ShockHemorrhagic 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)
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Hemorrhagic ShockHemorrhagic Shock
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Hemorrhagic ShockHemorrhagic 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
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Hemorrhagic ShockHemorrhagic Shock
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Hemorrhagic ShockHemorrhagic Shock
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Scene Size-UpScene Size-Up
• Recognize hazards and traffic safety.
• Protect bystanders.
• Stabilize involved vehicles.
• Follow standard precautions.
• Determine the number of patients present.
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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.
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Primary AssessmentPrimary Assessment
• Determine patient’s mental status using the AVPU scale.
• Locate and manage immediate life threats.
• Manage any major external hemorrhage.
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Primary AssessmentPrimary 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
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Primary AssessmentPrimary 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.
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History TakingHistory Taking
• Investigate the chief complaint using OPQRST.
• Obtain history of present illness using SAMPLE.
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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.
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Secondary AssessmentSecondary Assessment
• Other signs of internal hemorrhage include:– Hematoma
– Melena
– Hematuria
– Pain, tenderness, guarding
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Secondary AssessmentSecondary Assessment
• Assess the respiratory system.– Airway patency
– Rate and quality of respiration
– Distended neck veins and deviated trachea
– Paradoxical chest movement
– Bilateral breath sounds
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Secondary AssessmentSecondary 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
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Secondary AssessmentSecondary Assessment
• Assess the neurologic system.
• Assess the musculoskeletal system.
• Assess all anatomic regions.
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ReassessmentReassessment
• Reassess, especially where abnormal findings were found.
• Reassess interventions.
• In cases of severe hemorrhage, obtain vital signs every 5 minutes en route.
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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.
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Managing External 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.
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Managing External Hemorrhage
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.
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Managing External Hemorrhage
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.
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TourniquetsTourniquets
• Useful if severe hemorrhaging from extremity injury below axilla or groin
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TourniquetsTourniquets
• If commercial tourniquet is not available, apply a triangular bandage and a stick or rod.– Blood pressure cuff
can be used as well.
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TourniquetsTourniquets
• Precautions:– Do not apply directly over a joint.
– Use widest bandage possible.
– Never use narrow material.
– Use wide padding underneath.
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TourniquetsTourniquets
• Precautions (cont’d):– Never cover with a bandage.
– Inform hospital of the tourniquet.
– Do not loosen after application.
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SplintsSplints
• Broken bones can lacerate tissue, causing bleeding.
• Immobilizing a fracture is a priority in bleeding control.
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SplintsSplints
• Air splints– Control hemorrhage
associated with venous bleeding and stabilize fracture.
– Monitor distal extremity circulation.
– Use only approved valve stems.
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SplintsSplints
• Rigid 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.
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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
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Managing Internal HemorrhageManaging Internal Hemorrhage
• Management focuses on:– Treatment of shock
– Minimizing movement of part or region
– Rapid transport
• Eventual surgery will be needed.
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Management of Hemorrhagic Shock
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.
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Management of Hemorrhagic Shock
Management of Hemorrhagic Shock
• Monitor:– ECG rhythm for dysrhythmias
– State of consciousness
– Pulse
– Blood pressure
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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.
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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.
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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.
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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.
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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.
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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.