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Chapter 23
Bleeding
National EMS Education
Standard Competencies (1 of 3)
Trauma
Applies fundamental knowledge to provide
basic emergency care and transportation
based on assessment findings for an acutely
injured patient.
National EMS Education
Standard Competencies (2 of 3)
Bleeding
• Recognition and management of:
– Bleeding
• Pathophysiology, assessment, and
management of:
– Bleeding
National EMS Education
Standard Competencies (3 of 3)
Pathophysiology
Applies fundamental knowledge of the
pathophysiology of respiration and perfusion
to patient assessment and management.
Introduction
• Important to be able to:
– Recognize bleeding
– Understand how bleeding affects the body
• Bleeding can be external or internal.
• Bleeding can cause weakness, shock, and
death.
Anatomy and Physiology of the
Cardiovascular System
(1 of 3)
• Functions of the cardiovascular system
– Circulate blood to cells and tissues
– Deliver oxygen and nutrients
– Carry away metabolic waste products
Anatomy and
Physiology of the
Cardiovascular
System (2 of 3)
Anatomy and Physiology of the
Cardiovascular System
(3 of 3)
• Three parts
– Pump (heart)
– Container (blood vessels)
– Fluid (blood and body fluids)
The Heart (1 of 4)
• The heart is a hollow muscular organ about
the size of a clenched fist.
• Has its own regulatory system
• Works as two paired pumps
– Upper chamber (atrium)
– Lower chamber (ventricle)
The Heart (2 of 4)
• Blood leaves each chamber through a oneway valve.
• Right side receives oxygen-poor blood from
veins
• Left side supplies oxygen-rich blood to
arteries
The Heart (3 of 4)
The Heart (4 of 4)
Blood Vessels (1 of 4)
• Arteries
– Small blood vessels that carry blood away from
the heart
• Arterioles
– Smaller vessels that connect the arteries and
capillaries
Blood Vessels (2 of 4)
• Capillaries
– Small tubes that link arterioles and venules
• Venules
– Very small, thin-walled vessels that empty into
the veins
• Veins
– Blood vessels that carry blood from the tissues
to the heart
Blood Vessels (3 of 4)
• As blood flows out of the heart, it passes
into the aorta, the largest artery in the body.
• Oxygen and nutrients easily pass from the
capillaries into the cells, and waste and
carbon dioxide diffuse from the cells into the
capillaries.
Blood Vessels (4 of 4)
Blood (1 of 3)
• Red blood cells
– Responsible for the transportation of oxygen to
the cells
– Responsible for transporting carbon dioxide
away from the cells to the lungs
• White blood cells
Blood (2 of 3)
Source: © Phototake/Alamy Images
Blood (3 of 3)
• Platelets
– Responsible for
forming clots
– A blood clot forms
depending on
blood stasis,
changes in the
vessel walls, and
the body’s ability to
clot.
• Plasma
Autonomic Nervous System
• Constantly adapting to maintain
homeostasis and perfusion
• Monitors the body’s needs
• Adjusts blood flow and vascular tone
• Automatically redirects blood away from
other organs to the heart, brain, lungs, and
kidneys in an emergency
Pathophysiology and
Perfusion (1 of 5)
• Blunt trauma can cause injury and
significant bleeding that is unseen inside a
body cavity or region.
• Significant amounts of blood loss cause
hypoperfusion, or shock.
– In penetrating trauma, the patient may have
only a small amount of bleeding that is visible.
Pathophysiology and
Perfusion (2 of 5)
• Perfusion is the
circulation of blood
within an organ or
tissue to meet the
cells’ needs for
oxygen, nutrients,
and waste
removal.
Pathophysiology
and Perfusion (3 of 5)
• Some tissues
need a constant
supply of blood
while others can
survive with
very little.
Pathophysiology and
Perfusion (4 of 5)
• All organs and organ systems are
dependent on adequate perfusion to
function properly.
– Death of an organ system can quickly lead to
death of the person.
Pathophysiology and
Perfusion (5 of 5)
• The heart requires a constant supply of
blood.
– Brain and spinal cord may last 4 to 6 minutes.
– Kidneys may survive 45 minutes.
– Skeletal muscles may last 2 hours.
– Times are based on a normal body
temperature.
External Bleeding
• Hemorrhage means bleeding.
• Examples include nosebleeds and bleeding
from open wounds.
• As an EMT, you must understand how to
control external bleeding.
Significance of External
Bleeding (1 of 4)
• With serious external bleeding, it may be
difficult to tell the amount of blood loss.
• Presentation and assessment of the patient
will direct care and treatment.
• Body will not tolerate a blood loss greater
than 20% of blood volume.
Significance of External
Bleeding (2 of 4)
• Significant changes in vital signs may occur
if the typical adult loses more than 1 L of
blood.
– Increase in heart rate
– Increase in respiratory rate
– Decrease in blood pressure
Significance of External
Bleeding (3 of 4)
• How well people compensate for blood loss
is related to how rapidly they bleed.
– An adult can comfortably donate 1 unit
(500 mL) of blood over 15 to 20 minutes.
– If a similar blood loss occurs in a much shorter
time, the person may rapidly develop
hypovolemic shock.
– Consider age and preexisting health.
Significance of External
Bleeding (4 of 4)
• Serious conditions with bleeding:
– Significant MOI
– Patient has a poor general appearance and is
calm.
– Signs and symptoms of shock
– Significant blood loss
– Rapid blood loss
– Uncontrollable bleeding
Characteristics of External
Bleeding (1 of 2)
• Arterial bleeding
– Pressure causes blood to spurt and makes
bleeding difficult to control.
– Typically brighter red and spurts in time with the
pulse
• Venous bleeding
– Dark red, flows slowly or severely
– Does not spurt and is easier to manage
Characteristics of External
Bleeding (2 of 2)
• Capillary bleeding
– Bleeding from damaged capillary vessels
– Dark red, oozes steadily but slowly
Capillary
Venous
Arterial
Clotting (1 of 2)
• Bleeding tends to stop rather quickly, within
about 10 minutes.
– When a person is cut, blood flows rapidly.
– The cut end of the vessel begins to narrow,
reducing the amount of bleeding.
– Then a clot forms.
– Bleeding will not stop if a clot does not form.
Clotting (2 of 2)
• Despite the efficiency of the system, it may
fail in certain situations.
– Movement
– Medications
– Removal of bandages
– External environment
– Body temperature
– Severe injury
Hemophilia
• Patient lacks blood clotting factors.
• Bleeding may occur spontaneously.
• All injuries, no matter how trivial, are
potentially serious.
• Patients should be transported immediately.
Internal Bleeding (1 of 2)
• Bleeding in a cavity or space inside the
body
• Can be very serious, yet with no outward
signs
– Injury or damage to internal organs commonly
results in extensive internal bleeding.
– Can cause hypovolemic shock
Internal Bleeding (2 of 2)
• Possible conditions causing internal
bleeding:
– Stomach ulcer
– Lacerated liver
– Ruptured spleen
– Broken bones, especially the ribs or femur
– Pelvic fracture
MOI for Internal Bleeding (1 of 3)
• High-energy MOI
• Internal bleeding is possible whenever the
MOI suggests that severe forces affected
the body.
– Blunt trauma
– Penetrating trauma
MOI for Internal Bleeding (2 of 3)
• Signs of injury (DCAP-BTLS)
– Deformities
– Contusions
– Abrasions
– Punctures/penetrations
MOI for Internal Bleeding (3 of 3)
• Signs of injury (DCAP-BTLS) (cont’d)
– Burns
– Tenderness
– Lacerations
– Swelling
NOI for Internal Bleeding (1 of 3)
• Bleeding is not always caused by trauma.
• Nontraumatic causes include:
– Bleeding ulcers
– Bleeding from colon
– Ruptured ectopic pregnancy
– Aneurysms
NOI for Internal Bleeding (2 of 3)
• Frequent signs
– Abdominal tenderness
– Guarding
– Rigidity
– Pain
– Distention
NOI for Internal Bleeding (3 of 3)
• In older patients, signs include:
– Dizziness
– Faintness
– Weakness
• Ulcers or other GI problems may cause:
– Vomiting of blood
– Bloody diarrhea or urine
Signs and Symptoms of
Internal Bleeding (1 of 4)
• Pain (most common)
• Swelling in the area of bleeding
• Distention
• Bruising
• Dyspnea, tachycardia, hypotension
• Hematoma
• Bleeding from any body opening
Signs and Symptoms of
Internal Bleeding (2 of 4)
• Hematemesis
• Melena
• Hemoptysis
• Broken ribs, bruises over the lower part of
the chest, or a rigid, distended abdomen
• Hypoperfusion
Signs and Symptoms of
Internal Bleeding (3 of 4)
• Later signs of hypoperfusion:
– Tachycardia
– Weakness, fainting, or dizziness at rest
– Thirst
– Nausea and vomiting
– Cold, moist (clammy) skin
– Shallow, rapid breathing
Signs and Symptoms of
Internal Bleeding (4 of 4)
• Later signs of hypoperfusion (cont’d):
– Dull eyes
– Slightly dilated pupils
– Capillary refill of more than 2 seconds in infants
and children
– Weak, rapid (thready) pulse
– Decreasing blood pressure
– Altered level of consciousness
Patient Assessment for
External and Internal Bleeding
• Patient assessment steps
– Scene size-up
– Primary assessment
– History taking
– Secondary assessment
– Reassessment
Scene Size-up (1 of 2)
• Scene safety
– Be alert to potential hazards.
– At vehicle crashes, ensure the absence of
leaking fuel and energized electrical lines.
– In violent incidents, make sure the police are on
the scene.
– Follow standard precautions.
Scene Size-up (2 of 2)
• Mechanism of injury/nature of illness
– Determine the NOI or MOI.
– Consider the need for spinal stabilization and
additional resources.
– Consider environmental factors such as
weather.
Primary Assessment (1 of 4)
• Do not be distracted from identifying life
threats.
• Form a general impression.
– Note important indicators of the patient’s
condition.
– Be aware of obvious signs of injury.
– Determine gender and age.
– Assess skin color and the LOC.
Primary Assessment (2 of 4)
• Airway and breathing
– Consider the need for spinal stabilization.
– Ensure a patent airway.
– Look for adequate breathing.
– Check for breath sounds.
– Provide high-flow oxygen or assist ventilations
with a bag-mask device or nonrebreathing
mask.
Primary Assessment (3 of 4)
• Circulation
– Assess pulse rate and quality.
– Determine skin condition, color, and
temperature.
– Check capillary refill time.
– Control external bleeding.
– Treat for shock.
Primary Assessment (4 of 4)
• Transport decision
– Assessment of ABCs
and life threats will
determine the
transport priority.
– Signs that imply rapid
transport:
• Tachycardia or
tachypnea
• Low blood
pressure
• Weak pulse
• Clammy skin
Tachycardia
History Taking (1 of 3)
• Investigate the chief complaint.
– Look for signs and symptoms of other injuries
due to the MOI and/or NOI.
– You may have identified severe bleeding in the
primary assessment.
– Note obvious signs of internal bleeding.
– Determine if there are any preexisting illnesses.
History Taking (2 of 3)
History Taking (3 of 3)
• SAMPLE history
– Ask the patient about blood-thinning
medications.
– If the patient is unresponsive, obtain history
from medical alert tags or bystanders.
– Look for signs and symptoms of shock.
– Determine the amount of blood loss.
Secondary Assessment (1 of 5)
• Record vital signs.
• Complete a focused assessment of pain.
• Attach appropriate monitoring devices.
• With a critically injured patient or a short
transport time, there may not be time to
conduct a secondary assessment.
Secondary Assessment (2 of 5)
• Physical examinations
– Should include a systematic full-body scan
– Assess the respiratory system.
– Assess the airway for patency.
– Determine the rate and quality of respirations.
– Look for distended neck veins and a deviated
trachea.
Secondary Assessment (3 of 5)
• Physical examinations (cont’d)
– Check for paradoxical movement of the chest
wall and bilateral breath sounds.
– Assess the cardiovascular, neurologic, and
musculoskeletal systems.
– Determine the level of consciousness.
– Examine pupil size and reactivity.
– Assess motor and sensory response.
Secondary Assessment (4 of 5)
• Assess all anatomic regions.
– Check the head for raccoon eyes, Battle’s sign,
and drainage of blood or fluid from the ears or
nose.
– Feel all four quadrants of the abdomen for
tenderness or rigidity.
– Record pulse, motor, and sensory function in all
four extremities.
Secondary Assessment (5 of 5)
• Vital signs
– Assess vital signs to observe the changes that
may occur during treatment.
– A systolic blood pressure of less than 100 mm
Hg with a weak, rapid pulse should suggest the
presence of hypoperfusion.
– Cool, moist skin that is pale or gray is an
important sign.
Reassessment (1 of 3)
• Repeat the primary assessment in areas
that showed abnormal findings.
– Signs and symptoms of internal bleeding are
often slow to present.
• Assess interventions and treatments.
• Vital signs show how well your patient is
doing internally.
– In severe cases, assess every 5 minutes.
Reassessment (2 of 3)
• Interventions
– Provide high-flow oxygen.
– Provide treatment for shock and transport
rapidly.
– Do not delay transport of a patient to complete
an assessment.
Reassessment (3 of 3)
• Communication and documentation
– Communicate all relevant information to the
staff at the receiving hospital.
– Give an estimate of the amount of blood loss
that has occurred.
– Describe the MOI/NOI and the signs and
symptoms.
– Document all injuries, the care provided, and
the patient’s response.
Emergency Medical Care for
External Bleeding (1 of 2)
• Follow standard precautions.
– Wear gloves, eye protection, and possibly a
mask or gown.
– Make sure the patient has an open airway and
is breathing adequately.
– Provide high-flow oxygen.
Emergency Medical Care for
External Bleeding (2 of 2)
• Several methods are available to control
external bleeding.
– Direct, even pressure and elevation
– Pressure dressings and/or splints
– Tourniquets
• It will often be useful to combine these
methods.
Direct Pressure (1 of 2)
• Most effective way to control external
bleeding
• Pressure stops the flow of blood and
permits normal coagulation to occur.
• Apply pressure with your gloved fingertip or
hand over the top of a sterile dressing.
Direct Pressure (2 of 2)
• Never remove an impaled object from
a wound.
• Hold uninterrupted pressure for at least
5 minutes.
Elevation
• Elevate a bleeding extremity by as little as
6" while applying direct pressure.
• Never elevate an open fracture to control
bleeding.
– Fractures can be elevated after splinting.
– Splinting helps control bleeding.
Pressure Dressing (1 of 2)
• Firmly wrap a sterile, self-adhering roller
bandage around the entire wound.
• Cover the entire dressing above and below
the wound.
• Stretch the bandage tight enough to control
bleeding.
– You should still be able to palpate a distal pulse.
Pressure Dressing (2 of 2)
• Do not remove a dressing until a physician
has evaluated the patient.
• Bleeding will almost always stop when the
pressure of the dressing exceeds arterial
pressure.
• Follow the steps in Skill Drill 23-1.
Tourniquet (1 of 3)
• If direct pressure fails, apply a tourniquet
above the level of bleeding.
• It should be applied quickly and not
released until a physician is present.
• Follow the steps in Skill Drill 23-2 to apply
a commercial tourniquet.
Tourniquet (2 of 3)
• Observe the following precautions:
– Do not apply a tourniquet directly over any joint.
– Make sure the tourniquet is tightened securely.
– Never use wire, rope, a belt, or any other
narrow material.
– Use wide padding under the tourniquet.
Tourniquet (3 of 3)
• Precautions
(cont’d):
– Never cover a
tourniquet with a
bandage.
– Do not loosen the
tourniquet after you
have applied it.
Splints (1 of 4)
• Air splints
– Can control internal or external bleeding
associated with severe injuries
– Stabilize fractures
– Act like a pressure dressing
– Commonly referred to as soft splints or pressure
splints
Splints (2 of 4)
• Air splints (cont’d)
– Once the splint is
applied, monitor
circulation in the
distal extremity.
– Use only approved,
clean, or
disposable valve
stems.
Splints (3 of 4)
• Rigid splints
– Can help stabilize fractures
– Reduce pain
– Prevent further damage to soft-tissue injuries
– Once the splint is applied, monitor circulation in
the distal extremity.
Splints (4 of 4)
• Traction splints
– Designed to stabilize femur fractures
– When the EMT pulls traction to the ankle,
countertraction is applied to the ischium and
groin.
– Once the splint is applied, monitor circulation in
the distal extremity.
Bleeding From the Nose, Ears,
and Mouth (1 of 3)
• Several conditions:
– Skull fracture
– Facial injuries
– Sinusitis, infections, use and abuse of nose
drops, dried or cracked nasal mucosa
– High blood pressure
– Coagulation disorders
– Digital trauma
Bleeding From the Nose, Ears,
and Mouth (2 of 3)
• Epistaxis (nosebleed) is a common
emergency.
– Occasionally it can cause enough blood loss to
send a patient into shock.
– Can usually be controlled by pinching the
nostrils together
• Follow the steps in Skill Drill 23-3 to control
epistaxis.
Bleeding From the Nose, Ears,
and Mouth (3 of 3)
• Bleeding from the nose or ears following a
head injury:
– May indicate a skull fracture
– May be difficult to control
– Do not attempt to stop blood flow.
– Loosely cover the bleeding site with a sterile
gauze pad.
– Apply light compression with a dressing.
Emergency Medical Care for
Internal Bleeding (1 of 2)
• Usually requires surgery or other hospital
procedures
• Keep the patient calm, reassured, and as
still and quiet as possible.
• If spinal injury is not suspected, place the
patient in the shock position.
• Provide high-flow oxygen.
Emergency Medical Care for
Internal Bleeding (2 of 2)
• Maintain body temperature.
• Splint the injured extremity (usually with an
air splint).
• Never use a tourniquet to control bleeding
from closed, internal, soft-tissue injuries.
• Follow the steps in Skill Drill 23-4.
Summary (1 of 6)
• Perfusion is the circulation of blood in
adequate amounts to meet the cells’ current
needs for oxygen, nutrients, and waste
removal.
Summary (2 of 6)
• The cardiovascular system has three main
components:
– Pump (heart)
– Container (blood vessels)
– Fluid (blood and bodily fluids)
Summary (3 of 6)
• Hypoperfusion (shock) occurs when the
cardiovascular system fails to provide
adequate perfusion.
• Both internal and external bleeding can
cause shock. You must know how to
recognize and control both.
Summary (4 of 6)
• The methods to control bleeding, in order,
are:
– Direct, even pressure
– Elevation
– Pressure dressings
– Tourniquets
– Splinting device
Summary (5 of 6)
• Bleeding around the face always presents a
risk of airway obstruction or aspiration.
• Any patient you suspect of having internal
bleeding or significant external bleeding
should be transported promptly.
Summary (6 of 6)
• Signs of serious internal bleeding:
– Vomiting blood (hematemesis)
– Black tarry stools (melena)
– Coughing up blood (hemoptysis)
– Distended abdomen
– Broken ribs
Credits
• Chapter Opener: © Mark C. Ide
• Background slide images: © Jones & Bartlett
Learning. Courtesy of MIEMSS.