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Hemorrhage
Hemorrhage
• Hemorrhage
– Abnormal internal or external loss of blood
Hemorrhage Classification
External Hemorrhage
• Results from soft tissue injury.
• The seriousness of the injury is dependent on:
– Anatomical source of the hemorrhage (arterial, venous,
capillary)
– Degree of vascular disruption
– Amount of blood loss that can be tolerated by the patient
Internal Hemorrhage
• Can result from:
– Blunt or penetrating trauma
– Acute or chronic medical illnesses

• Internal bleeding that can cause hemodynamic
instability usually occurs in one of four body cavities:
–
–
–
–

Chest
Abdomen
Pelvis
Retroperitoneum
Internal Hemorrhage
• Signs and symptoms :
– Bright red blood from mouth, rectum, or other
orifice
– Coffee-ground appearance of vomitus
– Melena (black, tarry stools)
– Dizziness or syncope on sitting or standing
– Orthostatic hypotension
Internal hemorrhage is associated
with higher morbidity and
mortality than external
hemorrhage.
Physiological Response to Hemorrhage
• The body’s initial response to hemorrhage is
to stop bleeding by chemical means
(hemostasis).
– This vascular reaction involves:
•
•
•
•

Local vasoconstriction
Formation of a platelet plug
Coagulation
Growth of tissue into the blood clot that permanently
closes and seals the injured vessel
Hemorrhage Control
• External Hemorrhage

– Direct pressure and pressure dressing
– General management
•
•
•
•
•
•

Direct pressure
Elevation
Ice
Pressure points
Constricting band
Tourniquet

– May use a BP cuff by inflating the cuff 20–30 mmHg above the
SBP
– Release may send toxins to heart
» Lactic acid and electrolytes
Tourniquets are ONLY used as a
last resort!
Internal Hemorrhage Control
• Hematoma

– Epistaxis: Nose Bleed
• Causes: trauma,
hypertension
• Treatment: lean forward,
pinch nostrils

– Pocket of blood between
muscle and fascia

• General Management
– Immobilization, stabilization, el
evation

–
–
–
–
–

Hemoptysis
Esophageal Varices
Melena
Diverticulosis
Chronic Hemorrhage
• Anemia
Stages of Hemorrhage
• 60% of body weight is fluid.
– 7% circulating blood volume (CBV) in men
• 5 L (10 units)

– 6.5% CBV in women
• 4.6 L (9–10 units)
Stages of Hemorrhage
Stage 1
• 15% loss of CBV
– 70 kg pt = 500–750 mL

• Compensation
– Vasoconstriction
– Normal BP, pulse pressure, respirations
– Slight elevation of pulse
– Release of catecholamines
• Epinephrine
• Norepinephrine
– Anxiety, slightly pale and clammy skin
Stages of Hemorrhage
Stage 2
• 15–25% loss of CBV
– 750–1250 mL

• Early decompensation
– Unable to maintain BP
– Tachycardia and tachypnea
Stages of Hemorrhage
Stage 2
• Decreased pulse strength
• Narrowing pulse pressure
• Significant catecholamine release
– Increase PVR
– Cool, clammy skin and thirst
– Increased anxiety and agitation
– Normal renal output
Stages of Hemorrhage
Stage 3
• 25–35% loss of CBV
– 1250–1750 mL

• Late decompensation (early irreversible)
– Compensatory mechanisms unable to cope with
loss of blood volume
Stages of Hemorrhage
Stage 3
• Classic Shock
– Weak, thready, rapid pulse
• Narrowing pulse pressure

– Tachypnea
– Anxiety, restlessness
– Decreased LOC and AMS
– Pale, cool, and clammy skin
Stages of Hemorrhage
Stage 4
• >35% CBV loss
– >1750 mL

• Irreversible
–
–
–
–
–
–

Pulse: Barely palpable
Respiration: Rapid, shallow, and ineffective
LOC: Lethargic, confused, unresponsive
GU: Ceases
Skin: Cool, clammy, and very pale
Unlikely survival
Hemorrhage Assessment
• Initial Assessment
– General Impression
• Obvious bleeding

– Mental Status
– CABC
– Interventions
• Manage as you go
–
–
–
–

O2
Bleeding control
Shock
BLS before ALS!
Hemorrhage Assessment
Fractures and Blood Loss
•
•
•
•

Pelvic fracture:
Femur fracture:
Tibia/fibula fracture:
Hematomas and contusions:

2,000 mL
1,500 mL
500–750 mL
500 mL
Hemorrhage Assessment (5 of 5)
• Ongoing Assessment

– Reassess vitals and mental status:
• Q 5 min: UNSTABLE patients
• Q 15 min: STABLE patients

– Reassess interventions:
•
•
•
•

Oxygen
ET
IV
Medication actions

– Trending: improvement vs. deterioration
• Pulse oximetry
• End-tidal CO2 levels
Bleeding
Severe Bleeding is a life-threatening condition, therefore the bleeding must be controlled quickly.
There are 4 procedures to follow;

Apply Pressure

Elevate

Dress the Wound

Monitor

4. Monitor
1. Apply Direct Pressure
This is to try and stop the flow of blood
and encourage a clot to form.

2. Apply a Dressing
Applying a sterile non-fluffy dressing
covers the wound protecting it and
preventing the spread of infection.

If the wound is severe you may need to
monitor the player as they may go into
shock due to blood loss. You may also
want to check that the dressing isn’t too
tight and restricting circulation.

3. Elevation
Elevate the bleeding limb or area above
player’s heart (if practicable). This will
reduce the amount of blood flow to the
wound.
Thank you

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Hemorrhage

  • 2. Hemorrhage • Hemorrhage – Abnormal internal or external loss of blood
  • 3.
  • 5. External Hemorrhage • Results from soft tissue injury. • The seriousness of the injury is dependent on: – Anatomical source of the hemorrhage (arterial, venous, capillary) – Degree of vascular disruption – Amount of blood loss that can be tolerated by the patient
  • 6. Internal Hemorrhage • Can result from: – Blunt or penetrating trauma – Acute or chronic medical illnesses • Internal bleeding that can cause hemodynamic instability usually occurs in one of four body cavities: – – – – Chest Abdomen Pelvis Retroperitoneum
  • 7. Internal Hemorrhage • Signs and symptoms : – Bright red blood from mouth, rectum, or other orifice – Coffee-ground appearance of vomitus – Melena (black, tarry stools) – Dizziness or syncope on sitting or standing – Orthostatic hypotension
  • 8. Internal hemorrhage is associated with higher morbidity and mortality than external hemorrhage.
  • 9. Physiological Response to Hemorrhage • The body’s initial response to hemorrhage is to stop bleeding by chemical means (hemostasis). – This vascular reaction involves: • • • • Local vasoconstriction Formation of a platelet plug Coagulation Growth of tissue into the blood clot that permanently closes and seals the injured vessel
  • 10. Hemorrhage Control • External Hemorrhage – Direct pressure and pressure dressing – General management • • • • • • Direct pressure Elevation Ice Pressure points Constricting band Tourniquet – May use a BP cuff by inflating the cuff 20–30 mmHg above the SBP – Release may send toxins to heart » Lactic acid and electrolytes
  • 11. Tourniquets are ONLY used as a last resort!
  • 12. Internal Hemorrhage Control • Hematoma – Epistaxis: Nose Bleed • Causes: trauma, hypertension • Treatment: lean forward, pinch nostrils – Pocket of blood between muscle and fascia • General Management – Immobilization, stabilization, el evation – – – – – Hemoptysis Esophageal Varices Melena Diverticulosis Chronic Hemorrhage • Anemia
  • 13. Stages of Hemorrhage • 60% of body weight is fluid. – 7% circulating blood volume (CBV) in men • 5 L (10 units) – 6.5% CBV in women • 4.6 L (9–10 units)
  • 14. Stages of Hemorrhage Stage 1 • 15% loss of CBV – 70 kg pt = 500–750 mL • Compensation – Vasoconstriction – Normal BP, pulse pressure, respirations – Slight elevation of pulse – Release of catecholamines • Epinephrine • Norepinephrine – Anxiety, slightly pale and clammy skin
  • 15. Stages of Hemorrhage Stage 2 • 15–25% loss of CBV – 750–1250 mL • Early decompensation – Unable to maintain BP – Tachycardia and tachypnea
  • 16. Stages of Hemorrhage Stage 2 • Decreased pulse strength • Narrowing pulse pressure • Significant catecholamine release – Increase PVR – Cool, clammy skin and thirst – Increased anxiety and agitation – Normal renal output
  • 17. Stages of Hemorrhage Stage 3 • 25–35% loss of CBV – 1250–1750 mL • Late decompensation (early irreversible) – Compensatory mechanisms unable to cope with loss of blood volume
  • 18. Stages of Hemorrhage Stage 3 • Classic Shock – Weak, thready, rapid pulse • Narrowing pulse pressure – Tachypnea – Anxiety, restlessness – Decreased LOC and AMS – Pale, cool, and clammy skin
  • 19. Stages of Hemorrhage Stage 4 • >35% CBV loss – >1750 mL • Irreversible – – – – – – Pulse: Barely palpable Respiration: Rapid, shallow, and ineffective LOC: Lethargic, confused, unresponsive GU: Ceases Skin: Cool, clammy, and very pale Unlikely survival
  • 20. Hemorrhage Assessment • Initial Assessment – General Impression • Obvious bleeding – Mental Status – CABC – Interventions • Manage as you go – – – – O2 Bleeding control Shock BLS before ALS!
  • 21. Hemorrhage Assessment Fractures and Blood Loss • • • • Pelvic fracture: Femur fracture: Tibia/fibula fracture: Hematomas and contusions: 2,000 mL 1,500 mL 500–750 mL 500 mL
  • 22. Hemorrhage Assessment (5 of 5) • Ongoing Assessment – Reassess vitals and mental status: • Q 5 min: UNSTABLE patients • Q 15 min: STABLE patients – Reassess interventions: • • • • Oxygen ET IV Medication actions – Trending: improvement vs. deterioration • Pulse oximetry • End-tidal CO2 levels
  • 23. Bleeding Severe Bleeding is a life-threatening condition, therefore the bleeding must be controlled quickly. There are 4 procedures to follow; Apply Pressure Elevate Dress the Wound Monitor 4. Monitor 1. Apply Direct Pressure This is to try and stop the flow of blood and encourage a clot to form. 2. Apply a Dressing Applying a sterile non-fluffy dressing covers the wound protecting it and preventing the spread of infection. If the wound is severe you may need to monitor the player as they may go into shock due to blood loss. You may also want to check that the dressing isn’t too tight and restricting circulation. 3. Elevation Elevate the bleeding limb or area above player’s heart (if practicable). This will reduce the amount of blood flow to the wound.