ATS - bleeding

Emergency Medical Technician
9 - Bleeding Emergencies
© 2014
• Injuries that cause
profuse bleeding are
among the most serious
emergencies you will
need to manage
3

© 2014
• Significant bleeding:
– Requires immediate
action
– If not controlled, it can
quickly lead to:
 Shock
 Death
• You must be able to
recognize the presence
of serious bleeding
4

© 2014
1. Dressings & Bandages
2. Anti-Shock Garments
3. External Bleeding
4. Internal Bleeding

© 2014
• Functions of dressings
and bandages:
– Control bleeding
– Absorb drainage of
fluids
– Prevent contamination
of an injury
7

© 2014
• Dressings:
– Typically sterile
– Placed directly over
wounds
• Common types of
dressings include:
– Sterile gauze pads
– Non-stick gauze pads
– Occlusive dressings
– Trauma dressings
8

© 2014
• Sterile gauze pads, like
all sterile dressings,
have been processed to
eliminate any possibility
of contamination:
– Microorganism
– Spore
• Non-stick gauze pads:
– Sterile pads
– Nonfibrous
– Designed not to stick
to wounds
9

© 2014
• Occlusive dressings:
– Specialized type
– Designed to create an
airtight seal around a
wound or body cavity
• Trauma dressings:
– Large, bulky
– Used for:
 Profuse bleeding
 Cover a large wound
 Stabilize an impaled
object
10

© 2014
• Stopping the bleeding is
more critical in the field
than worrying about
contamination since
wounds are considered
already contaminated
11

© 2014
• Bandages are used to
hold dressings in place:
– Adhesive bandages
– Roller gauze
– Tape
12

© 2014
• Adhesive bandages:
– Backing that sticks to
the patient’s skin
– Blood and sweat can
inhibit the ability of the
bandaging to adhere
13

© 2014
• Roller gauze :
– Long strip of material
rolled into a bundle
– Elastic and non-elastic
form
• Tape is used to secure:
– Small dressings in
place
– End of a bandage
14

© 2014
• The severity of bleeding
depends on:
– The volume and rate of
blood loss in relation to
the patient’s size
– Age
– Patient’s injuries
– Pre-existing health
conditions
• The body responds to
bleeding by constricting
the injured blood vessel
and clotting
– Serious injuries can result
in bleeding that is too
severe to clot effectively
16

© 2014
• Severe bleeding is a
major cause of shock in
trauma patients:
– Uncontrolled bleeding
can result in death
• Any signs or symptoms
of shock should be
considered serious and
treated immediately,
even if blood loss
appears to be small
17

© 2014
• Device used to control
bleeding in a manner
similar to an air splint:
– Pneumatic anti-shock
garment (PASG)
– Medical anti-shock
trousers (MAST)
• Helps to control
external bleeding in the
lower extremities by
applying direct pressure
18

© 2014
• Can help to stabilize
lower extremity and
pelvis fractures by
functioning as a splint
• Can help control
hypotension by applying
peripheral venous
compressions to move
blood up to the body’s
core
• Follow your protocols
on whether and how to
use any anti-shock
garment
19

© 2014
• Indications for the use
of an anti-shock
garment include:
– Hypotension, with a
systolic blood pressure
below ninety, along
with the following:
 Suspected pelvic
fracture
 Suspected internal
bleeding in the
abdomen
20

© 2014
• Contraindication use of the
PASG/MAST includes:
– Cardiopulmonary arrest or cardiac shock
– Abnormal lung sounds
– Pregnancy
– Abdominal evisceration or impaled object in
the abdomen
– Penetrating thoracic trauma
21

© 2014
• Open the garment
• Place it on a hard
surface or spine board
• Attach the foot pump
• Open the valves to the
leg sections only
• Positioning the patient
so that top of the
garment is three finger
lengths below the
lowest rib
22

© 2014
• The patient’s legs should
be exposed:
– Confirm that there are
no belt buckles or
contents in pockets
• Wrap device snugly
around the legs and
secure Velcro
• Enclose the abdomen and
secure
• Confirm that the valve to
the abdominal section is
closed
23

© 2014
• Inflate the legs of the
garment
• Pump until air exhausts
through the relief
valves or the Velcro
crackles
• Close the valves
• Reassess the patient’s
vital signs
24

© 2014
• If stable vital signs,
begin transport
procedures
• If systolic pressure
remains low, check with
medical direction:
– Inflation of the
abdominal section
may be ordered
25

© 2014
• If abdominal inflation is advised, keep
leg valves closed
• Open valve to abdominal section,
inflate until the Velcro crackles
– Close valve
26

© 2014
• Document vital signs
• Document time of
application
• Transport the patient
immediately and notify
the receiving hospital
• Continue to monitor the
patient
27

© 2014
1. If the garment loses pressure, add air
as needed
2. Continue to monitor vital signs every
3 to 5 minutes after placement
3. Keep the garment in place
 It should only be deflated or removed in
the presence or by direction of a
physician
28

© 2014
• Three types of external
bleeding:
– Arterial
– Venous
– Capillary
30

© 2014
• Usually the most serious
• Blood spurts from the
wound with each heart
beat
• Blood is:
– Oxygenated
– Appears bright red
• Can be difficult to
control:
– High pressure in arteries
– Large volumes of blood
can be lost in a short
amount of time
31

© 2014
• As a result of blood
loss:
– Blood pressure drops
– Spurting may decrease
• Not seen as often as
venous or capillary
bleeding because the
arteries are located
deep in the body
32

© 2014
• Blood flows as a steady
stream from a vein
• Blood appears darker
red than arterial blood
because it lacks oxygen
• No pulsing in the flow
33

© 2014
• Depending on the size and location
of the vein affected, bleeding from a
vein can be:
– Severe
– Minor
• Usually easier to control than
arterial bleeding because of the
lower pressure in the veins

© 2014
• Blood oozes from a bed
of capillaries near the
surface of the skin
• Color is bright red
• Bleeding often clots
spontaneously:
– Typically within 6–8
minutes
• Seldom life threatening
35

© 2014
• Some serious injuries
may not bleed heavily
• Some otherwise minor
injuries can bleed
profusely
36

© 2014
• Pour a pint (.5 L) of a
liquid that has a similar
consistency to blood on
a surface
• Note of the size of the
puddle
37

© 2014
• Soak up the liquid with
a bandage typically
used to control bleeding
• See and feel how wet
the bandage is
38

© 2014
• Always take standard
precautions to reduce
your risk of exposure to
bloodborne pathogens
• Arterial and large vein
bleeding have priority
over small vein and
capillary bleeding
39

© 2014
• Any severe bleeding
must be:
– Considered an
immediate threat to
life
– Controlled while you
evaluate the patient’s:
 Airway
 Breathing
 Pulse
40

© 2014
• Most external bleeding
can be controlled by
direct pressure
• Apply steady pressure
directly over the wound
with a:
– Gloved hand
– Clean dressing
41

© 2014
• Continue applying
pressure until the
bleeding is controlled:
– 10–30 minutes
– Sometimes longer
• Refrain from releasing
pressure
• Assume bleeding has
been controlled if blood
is no longer seeping
through or around the
bandage
42

© 2014
• Pressure dressings can
help stop bleeding
• Place the dressing over
the wound and apply
pressure as you wrap it
in place with bandages
43

© 2014
• Begin wrapping at the
distal end of the injured
limb
• Work up toward the
injury to reduce the risk
of restricting circulation
• Wrap should be:
– Snug enough to
produce pressure on
the wound
– Loose enough to
permit sufficient blood
flow to the area
44

© 2014
• Make sure you have
covered the area both
above and below the
wound
• Check for a distal pulse
to confirm that the
extremity is receiving
sufficient blood flow
45

© 2014
• If bleeding continues,
apply more pressure
over the existing
bandaging with:
– Your hand
– Additional dressing and
bandaging
• Removing existing
dressings could:
– Interrupt clot
formation
– Cause additional
bleeding
46

© 2014
• Be sure to check the
distal pulse again
• Pressure dressings:
– Would not be effective
on the chest or
abdomen
– Would be exceptionally
dangerous on the neck
– In such cases, use
direct pressure
47

© 2014
• If pressure alone is
insufficient to control
bleeding in an
extremity, your
protocols may
recommend the use of
elevation
48

© 2014
• Typically, bleeding can
be controlled without
the need to resort to a
tourniquet
• If other methods fail,
the application of a
tourniquet should be
considered
• Follow your local
protocols
49

© 2014
• Tourniquets can cause:
– Permanent damage
– Limb loss
• Tourniquets must only
be used:
– As a last resort
– When all other efforts
to control bleeding
have failed
50

© 2014
• When possible use a
manufactured tourniquet
• Tourniquet placement
will depend on the injury
location:
– Apply it between the
wound and the heart
– About 2 inches (5 cm)
from the wound edge if
possible
– If the injury is near a
joint, place it higher up
from the wound
51

© 2014
• Do not leave the patient to retrieve a
tourniquet
• If you do not have a manufactured
tourniquet nearby, make one

© 2014
• Put a roll of dressing or
folded cloth over the
artery on the tourniquet
site
• Place the tourniquet on
top of this material
• Use a long strip of cloth,
or a belt, necktie or
stocking:
– Flat material
– At least 1 inch (3 cm)
wide
• Tie a half knot over the
dressing
53

© 2014
• Lay a rigid stick, dowel
or metal rod over the
half knot and tie the
material into a full knot
• Tighten the tourniquet
by turning the rigid
object until the bleeding
stops, then stop
tightening
54

© 2014
• Once you have fully
applied the tourniquet:
– Tie or tape it in place
– Do not loosen it
• Mark a tag indicating
that a tourniquet has
been applied and the
time it was applied:
– Attach the tag to the
patient
– Write on the patient’s
forehead if necessary
55

© 2014
• Treat the patient for
shock
• Do NOT cover the
tourniquet
• The tourniquet MUST
remain visible so
hospital staff will not
miss it
56

© 2014
• Internal bleeding:
– Exceptionally
dangerous condition
– Can potentially lead to:
 Shock
 Heart and lung failure
 Death in minutes
58

© 2014
• Internal bleeding can be
difficult to assess
because it can occur:
– Where there is no
visible external injury
– Farther away from the
location of an obvious
injury
59

© 2014
• Assess for and treat the
patient based on the
mechanism of injury
• Assume there is
potential for internal
injury and bleeding
when the mechanism of
injury is significant
60

© 2014
• Most internal bleeding is caused by
blunt force trauma:
– No penetration of the skin
– Blood vessels or organs can be
crushed or ruptured
• Common causes:
– Automobile accidents
– Falls

© 2014
• Penetrating wounds that
exhibit only minor
external bleeding, may
have penetrated deep
enough to sever major
blood vessels
• Penetrating wounds to
these areas should be
considered to have
already caused serious
internal bleeding:
– Skull
– Abdomen
– Chest
62

© 2014
• Assess for internal
bleeding, particularly
for fractures of the:
– Pelvis
– Ribs
– Long bones of the:
 Upper arms
 Thighs
63

© 2014
• Bruising is an important
indicator for internal
bleeding, particularly if
found on the:
– Neck
– Chest
– Abdomen
65

© 2014
• A severe injury that
causes internal bleeding
could:
– Present with only a
bruise
– Be followed by rapid
patient decline
• Look carefully for
bruises, especially if the
patient is unresponsive
66

© 2014
• Tissue that is:
– Discolored
– Painful
– Tender
– Swollen
– Firm
• Bleeding from any orifice
• Stools that are dark and tarry or have bright red
blood
• Nausea
• Vomiting

© 2014
• Vomiting blood
indicates:
– Presence of bleeding in
the upper
gastrointestinal tract
• If the patient vomits
red blood it indicates:
– Blood is fresh
• Vomiting a dark,
granular substance that
resembles coffee-
grounds indicates:
– Bleeding has slowed or
stopped

© 2014
• Assume the presence of
and treat for internal
bleeding if you observe
abdominal:
– Tenderness
– Rigidity
– Distention
69

© 2014
• A severe injury that
causes internal bleeding
could present with only a
contusion or bruise, but
can be followed by rapid
patient decline
• Look carefully for
bruises, especially if the
patient is unresponsive
• A contusion the size of
the patient’s fist equates
approximately to ten
percent of his blood
volume
70

© 2014
• Treat early for shock:
– Signs and symptoms
may not be
immediately apparent
• Suspect internal
bleeding if the signs
and symptoms of
hemorrhagic shock:
– Are present
– Cause is unexplained
72

© 2014
Increased pulse rate,
becoming weak and thready:
• Increased respiratory rate,
becoming shallow and
labored
• Decreasing blood pressure
• Narrowing pulse pressure,
– Means that the systolic
and diastolic pressure
numbers will become
closer together
74

© 2014
• Perform a physical
examination
– Loosening restrictive
clothing where
necessary
• Administer oxygen at
15 lpm by
nonrebreather mask or
per protocol
• Do not give the patient
anything by mouth
• Monitor for vomiting
76

© 2014
• Provide emotional
support
• Keep the patient calm
and warm
• Immediately report any
suspicion of internal
bleeding to advanced
EMS as soon as they
arrive
77

© 2014
• If there are NO serious
injuries or trauma, your
focus for a nosebleed
will be:
– Maintaining an open
airway
– Controlling bleeding
• Do not assume all
nosebleeds are minor;
some can be serious
78

© 2014
• Maintain an open
airway by having the
patient sit and lean
slightly forward:
• Helps prevent an airway
obstruction caused by
blood and mucus
• Prevents nausea and
vomiting by directing
blood and mucus away
from the throat and
stomach
79

© 2014
• Serious life threats are possible even if no
external injuries are visible
• You must always anticipate the potential
for internal bleeding, especially if the
mechanism of injury is significant
• By acting quickly, and recognizing the signs
and symptoms of serious bleeding, you will
be able to provide the life-saving care your
patient depends on

ATS - bleeding

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