Bleeding, Wounds, and Soft Tissue Injuries

Presence Regional EMS System

August 2014 C.E.

Objectives

• Describe the characteristics of external bleeding including differentiation between arterial, venous, and capillary bleeding

• Identify signs and symptoms of significant bleeding, including internal bleeding

Objectives

• Explain the use of traditional and new innovative means of managing external bleeding

• Describe the management of avulsions and amputations

• Define a significant crush injury

• Outline the management of patients who have sustained a significant crush injury

• Maintain Standard Precautions When Dealing with Body Substances!

Cardiovascular System Overview

• The cardiovascular system is

an organ system that allows for

the circulation of blood to cells

and tissues, the delivery of oxygen

and nutrients, and the removal

of waste products.

Parts of the Cardiovascular System

• Heart: The hollow organ that pumps blood throughout the body. – The right side receives deoxygenated blood

from the body and pumps it into the lungs

– The left side receives oxygenated blood from the lungs and pumps it to the tissues of the body

Parts of the Cardiovascular SystemBlood Vessels

• Arteries

– Small blood vessels that carry blood away from the heart

• Arterioles

– Smaller vessels that connect the arteries and capillaries

Parts of the Cardiovascular SystemBlood Vessels

• Capillaries– Small tubes that link arterioles and venules– Capillary beds are where the exchange of nutrients

and wastes take place

• Venules– Very small, thin-walled vessels that empty into the

veins

• Veins– Blood vessels that carry blood from the tissues to

the heart

Parts of the Cardiovascular SystemComponents of Blood

• 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– Cells of the immune system that function to

protect the body from foreign materials and infectious disease

Parts of the Cardiovascular SystemComponents of Blood

• 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

– Liquid component of blood that holds the blood cells in suspension

Why is this important?

• All organs of the body rely on the cardiovascular system to deliver oxygen and nutrients

• Bleeding causes hypoperfusion

• The death of an organ system due to lack of perfusion can lead to the death of

the patient

• Some organ systems can survive without perfusion for a limited period of time:

– 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.

• The heart requires constant perfusion in order to survive

External Bleeding

• With serious external bleeding, it may be difficult to determine 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 it’s blood volume.

Use familiar measurements to estimate blood loss

• 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

– SHOCK

• 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

• 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

• Capillary bleeding

– Bleeding from damaged capillary vessels

– Dark red, oozes steadily but slowly

Capillary Venous Arterial

Internal Bleeding

• Bleeding in a cavity or space inside the body

• Can be very serious

• Outward signs can be deceiving– Injury or damage to internal organs can result

in excessive internal bleeding

– Can cause hypovolemic shock even though there is no fluid loss outside of the body

Internal Bleeding

• Signs of internal bleeding– High-energy Mechanism of Injury– Pain – Swelling in the area of bleeding– Distention– Bruising– Dyspnea, Tachycardia, Hypotension– Hematoma– Bleeding from any body opening

Assessing for Bleeding

• Use DCAP-BLS-TIC to assess for traumatic injuries– Deformities– Contusion– Abrasions– Puncture/Penetrations/Paradoxical Movement– Burns– Lacerations– Swelling– Tenderness– Instability– Crepitus

Identify Bleeding

• Identify life threatening external bleeding– Assessed during the ‘Circulation phase’ of your

initial assessment

– Identify bleeding that is uncontrolled or bleeding with significant fluid loss

• Attempt to control life threatening bleeding as you find it!

Identify Shock

• Hypovolemic Shock is due to fluid loss outside of the system; results in hypoperfusion

• Early detection and identification of shock is paramount to patient survival

• SKINS DO NOT LIE

Signs of Shock

• Compensated Shock (Early Stage)– Anxiety

– Altered mental status

–Weak, rapid pulse

– Pale, cool, and moist skin

– Shallow, rapid breathing

– Nausea and/or vomiting

Signs of Shock

• Decompensated Shock (Late Stage)– Systolic Blood Pressure less than 90 in adults

– Labored or irregular breathing

– Ashen, mottled, or cyanotic skin

– Thready or absent peripheral pulses

– Dull eyes with dilated pupils

– Poor skin turgor

How to Control External Bleeding

•Direct Pressure

• Elevation

• Pressure Dressings/Splints

• Tourniquets

Direct Pressure

• 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

• 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

• 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

• Do not remove without a physician present

Tourniquet

• 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.

• Never use a tourniquet over a joint

• Pad below the tourniquet

• Use only proper equipment; i.e. a commercial tourniquet

• Document the date/time the tourniquet was placed

Hemostatic Agents• Hemostatic agents are used to promote the

body’s natural clotting abilities

• For uncontrollable bleeding– Unable to use tourniquet (groin, axilla, neck)

• Used in conjunction with direct pressure and pressure dressings

• Be mindful of local protocols

regarding their use

Internal Bleeding

• Identify internal bleeding and initiate rapid transport

• Control cervical spine through use of Spinal Motion Restriction

• Control fractures with splinting

• Internal bleeding requires surgery – Do not delay transport!

Avulsions

• An injury that separates various layers of soft tissue

• Treat by placing partially separated piece back into original location and covering with sterile gauze– Be careful to make sure the site is free of debris

• Wrap pieces that have been completely removed in sterile gauze and transport with patient

Avulsions

• Avulsions involving large areas of tissue may cause large amounts of bleeding

• Never remove an avulsion skin flap, regardless of size!

Amputations

• An injury in which part of the body is completely severed

• Includes both incomplete and complete amputations– A complete amputation involves an extremity

that has been completely removed from the body

– An incomplete amputation involves an extremity that is still attached to the body by a small amount of tissue

Amputations

• Attempt to control bleeding via direct pressure over the stump

• If bleeding cannot be controlled by direct pressure, apply a commercial tourniquet proximal to the amputation

• Amputation extremities can possibly be saved by a surgical team

Amputation

• Note incomplete

amputation to the right

leg on image

• Note complete

amputation to the left

leg on image

Amputation• DO NOT delay care in order to retrieve entrapped or lost part• DO NOT complete an incomplete amputation

FR/BLS TREATMENT:• INITIAL TRAUMA CARE.• Treat for shock if indicated.• Tissue Preservation:

– Rinse part gently with normal saline if gross contamination (DO NOT SCRUB)

– Wrap part in moist sterile gauze (part should never be immersed in water).– Place wrapped part in water tight bag and seal.– Label bag with name, date and time.– Place sealed bag into container filled with water and ice and transport with

patient.(DO NOT PLACE DIRECTLY ON ICE)

Amputation

Call for intercept per INTERCEPT CRITERIA.• ALS may administer pain medications following

Region 6 protocols.

Crush Injury• Pressure on extremities for extended time– Disrupts blood flow

– Promotes anaerobic metabolism

• Pressure released– Blood flow to crushed tissue reinstated

– Toxins distributed throughout entire body

–May induce cardiac dysrhythmia and severe kidney damage• “Crush or Compression Syndrome”

Examples of Crush Injuries

• Hand trapped in an industrial roller

• Foot caught in railroad tracks

• Lower extremities caught between a car and a wall

• Arm caught between two large rocks

Management of Crush Injuries

– Perform frequent ongoing exams

– Alkalizing the blood• Fluid resuscitation – large volumes

• NaCO3 infusion

• Osmotic diuretics

– If administration of fluids or medications prior to releasing the entrapped body area is not possible, consider application of a tourniquet proximal to the injury site.

– Contact Medical Control early; follow local protocols regarding treatment of crush injuries

Case Study 1

• Dispatch: 1100 to farm outside of town for a 19 y/o male patient with a bandsaw related injury

Scene Size Up• Scene Safety: Upon arrival directed to barn

out back; no safety hazards noted • BSI: Gloves• Nature of Illness: Sick• Number of Patients: 1• Additional Resources: ALS Intercept possible

(If Applicable)

Primary Assessment• General Impression: The patient is sitting on a chair with his

hand wrapped with a shirt; appears very anxious• Level of Consciousness: Awake, alert and obeys commands.• Airway: Open, clear• Breathing: Respirations slightly fast and non-labored• Circulation• Skins: pale, warm, and diaphoretic • Pulses: Radial pulse weak and rapid• Bleeding: Note bleeding from left hand• Rapid Head to Toe: Note amputation of thumb on the left

hand; no further findings• Priority: Stable but sick

Focused History

• Signs and Symptoms: Was cutting a board when he got distracted and felt his thumb go through the saw

• Allergies: Bees• Medications: None• Past Medical History: None• Last Oral Intake: Breakfast around 0700• Events: No complaints prior to accident;

amputated thumb with saw

Detailed Physical Exam

Vital Signs

• Clean amputation distal to the first joint of the thumb• Thumb has been retrieved by coworker; appears to be

in good condition

• Blood Pressure: 102/60• Pulse: 140• Respirations: 24• O2 Saturation: 99%• Blood Sugar: 79

Management• Oxygen to keep patient’s O2 saturation above

94%• Control bleeding with direct pressure• Wrap thumb in moist sterile gauze; place in

watertight bag and seal with patient’s name, date, and time on outside of bag

• ALS: IV access with 500cc fluid bolus of 0.9NS • ALS: Pain management per Regional 6 protocol

 

Ongoing Assessment

• Bleeding controlled with direct pressure; Patient voices little to no discomfort 

Repeat Vital Signs:

•  Blood Pressure: 110/72

• Pulse: 108

• Respirations: 20

• O2 saturation: 100% on Oxygen at 4lpm

Case Study 2• Dispatch: 2345 to industrial site for a 25 y/o patient

pinned against the wall by a forkliftScene Size Up• Scene Safety: Directed into warehouse upon arrival;

met by coworkers who have shut down operations in the area

• BSI: Gloves• Nature of Illness: Sick• Number of Patients: 1• Additional Resources: ALS Intercept possible (If

Applicable), Consider need for Aeromedical Services

Primary Assessment• General Impression: The patient is trapped against the wall with a

stand up forklift; his right leg appears to be pinned by the edge of the drivers compartment

• Level of Consciousness: Awake, alert and obeys commands.• Airway: Open, clear• Breathing: Respirations normal• Circulation

– Skins: Pink, warm, and dry– Pulses: Radial pulse strong and regular– Bleeding: None

• Rapid Head to Toe: Note right leg cyanotic and pulseless distal to the area that is pinned• Priority: Stable but sick

Focused History

• Signs and Symptoms: Was coming around a corner near the wall when he lost control; leg went out of the forklift and became trapped against the wall when the machine lost power. Complains of severe pain to his right leg with loss of sensation below the injury

• Allergies: None• Medications: None• Past Medical History: None• Last Oral Intake: Hamburgers at 1700• Events: No complaints prior to accident; Machine has

been acting weird all night

Detailed Physical Exam

Vital Signs

• Note right leg cyanotic distal to point of entrapment; approximately mid-femur; no pedal pulse

• Patient unable to move leg• Machine is not operating; will have to be pushed off of patient

• Blood Pressure: 134/76• Pulse: 110• Respirations: 20• O2 Saturation: 98% on room air• Blood Sugar: 102

Management

• Oxygen to keep patient O2 Saturation above 94%

• Contact Medical Control with information regarding patient and injury

• Place tourniquet proximal to trapped area• Carefully remove vehicle from position on

patient; do not cause harm to patient• ALS: IV access with 500cc bolus of 0.9NS • Pain management per Regional 6 protocol 

Ongoing Assessment• Carefully monitor patient for any changes in

mental status or vital signs

• Expedited transport to closest appropriate facility

 Repeat Vital Signs:

•  Blood Pressure: 124/68

• Pulse: 114

• Respirations: 20

• O2 saturation: 100% on Oxygen at 4lpm

Review

• If doing this CE individually, please e-mail your answers to:

• Shelley.Peelman@presencehealth.org• Use “August 2014 CE” in subject box.• IDPH site code: 06-7100-E-1214• You will receive an e-mail confirmation.

Print this confirmation for your records and document in your PREMSS CE record book.

Short Answer1) Describe the differences between arterial

and venous bleeding.

2) Give 3 signs of compensated shock

3) List the 4 primary methods used to control external hemorrhage

4) What does DCAP-BLS-TIC stand for?

5) Give 2 examples of crush injuries

True or False

1) A partial amputation should be fully removed prior to transport

2) Splinting can be used to control bleeding3) There is no blood loss associated with

internal bleeding4) The brain may survive 4-6 minutes without

perfusion5) The body is able to tolerate losing 40% of

it’s blood volume

Answers – Short Answer questions1. Arterial bleeding is bright red, under pressure and is

difficult to control. Venous bleeding is dark red, slow flowing and easier to manage.

2. Anxiety, altered mental status, weak, rapid pulse, pale, cool, and moist skin, shallow and rapid breathing, nausea and/or vomiting.

3. Direct pressure, elevation, pressure dressing, tourniquet

4. Deformities, contusions, abrasions, punctures/penetrations, burns, lacerations, swelling, tenderness, instability, crepitus

5. Hand trapped in an industrial roller, foot caught in railroad tracks, lower extremities caught between a car and a wall, arm caught between two large rocks

Answers – True or False questions

1. False

2. True

3. False

4. True

5. False