DMACC EMT Chapter 28

PREHOSPITALPREHOSPITAL
EMERGENCY CAREEMERGENCY CARE
CHAPTER
Copyright © 2014, 2010, 2008 by Pearson Education, Inc.
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Prehospital Emergency Care, 10th
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TENTH EDITION
Part I
Bleeding and Soft
Tissue Trauma
28

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Learning ReadinessLearning Readiness
• EMS Education Standards, text p. 772

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ObjectivesObjectives
• Please refer to page 772 of your text to
view the objectives for this chapter.

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Key TermsKey Terms
• Please refer to page 772 of your text to
view the key terms for this chapter.

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Setting the StageSetting the Stage
• Overview of Lesson Topics
 External Bleeding
 Internal Bleeding
 Hemorrhagic Shock

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Case Study IntroductionCase Study Introduction
EMTs Mick Horton and Dave Bowling arrive
at the scene of a MVC, and quickly perform
a scene size-up. They have one patient, a
male in his 30s, who was the unrestrained
driver of a an older model truck that struck
a tree along the roadway. There is an EMR
maintaining spinal stabilization, and another
preparing a long backboard and stretcher.
continued on next slide

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Mick's general impression is that the patient
is awake, but confused, and is pale and
sweating, with blood running from his scalp
down onto his neck and clothing.

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Case StudyCase Study
• From the mechanism of injury and
general impression, what conditions
should the EMTs be suspecting?
• What are the priorities in assessing and
managing this patient?
• What are the consequences of failing to
recognize and manage this patient's
problems?

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IntroductionIntroduction
• Bleeding can be a life-threatening
emergency.
• Severe bleeding is controlled in the
primary assessment.
• Most soft tissue injuries are cared for
after the primary assessment.
• Recognizing shock is an important
element of emergency care.

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External BleedingExternal Bleeding
• Always use Standard Precautions for
patients with external bleeding.

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External bleeding from a soft tissue injury to the head.

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• The severity of blood loss depends
upon:
 Amount of blood loss
 Rate of blood loss
 Other injuries or existing conditions
 Patient's existing medical problems
 Patient's age

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• The severity of bleeding is relative to
the patient's size.
 A 70 kg adult has 4,900 mL of blood
 A 10 kg infant has 800 mL of blood
• A loss of 15% or more of blood volume
is significant.
 ≥735 mL in a 70 kg adult
 ≥120 mL in a 10 kg infant

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• The best way to estimate blood loss is
by assessing the patient's signs and
symptoms.

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Table 28-1 Classes of Hemorrhage

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• When injured, blood vessels constrict
and blood clots.
• The type and severity of injury can
interfere with these mechanisms.

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Types of bleeding.

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• Methods of controlling external
bleeding
 Direct pressure
 Tourniquets
 Elevation
 Splints
 Topical hemostatic agents

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• Direct pressure is the first method for
controlling bleeding.
• A pressure dressing can be used.
• Do not apply pressure to or remove
impaled objects.

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EMT SKILLS 28-1
Bleeding Control by Direct Pressure

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Bleeding from a wound to the forearm.

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Apply gloved fingertip pressure over a dressing directly on the point of bleeding.

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If the bleeding does not stop, remove the dressing and apply direct pressure with gloved fingertips to the point of
bleeding.

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Pack large, gaping wounds with sterile gauze and apply direct pressure.

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• Tourniquets are used when direct
pressure does not control bleeding.
• There are several types of commercial
tourniquets.
• Tourniquets can be improvised if a
commercial tourniquet is not available.

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EMT SKILLS 28-2
Application of a Tourniquet

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First attempt to control bleeding by direct pressure.

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If direct pressure is ineffective, apply direct pressure over a thick dressing while preparing the tourniquet.

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Apply the tourniquet proximal to the wound but not over a joint.

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Pack large, gaping wounds with sterile gauze and apply direct pressure. Twist the rod to tighten the tourniquet to
the extent necessary to control bleeding and secure the tightening rod. Write the time of tourniquet application
on tape and apply it to the tourniquet, leaving the tourniquet exposed to view, and notify the receiving facility
that a tourniquet has been applied. Continuously reassess the wound for recurrent bleeding. Do not loosen or
remove the tourniquet unless directed to do so by medical direction or local protocol.

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• There is no evidence to support the use
of elevation, but it is not known to be
harmful.
• Do not use elevation as the sole means
of bleeding control.
• Do not elevate an injured extremity
that is not splinted.

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• Splinting is an important way to reduce
bleeding from an injured extremity.
• A traction splint can be helpful for a
fractured femur.
• Do not delay at the scene for splinting
with an unstable patient.

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• Topical hemostatic agents
 Can be used when direct pressure is
ineffective.
 Hemostatic agents promote blood
clotting.
 Use is generally reserved for long
transport times.
 There are some associated
complications.

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Topical hemostatic agents such as QuikClot can be used with pressure dressings to control bleeding.

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Click on the method that is always used first toClick on the method that is always used first to
control external hemorrhage.control external hemorrhage.
A. Pressure dressing
B. Tourniquet
C. Direct pressure
D. Topical hemostatic agents

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• Assessment-based approach
 Ensure that the scene is safe.
 Form a general impression, noting any
signs of shock and presence of
significant bleeding.
 Control significant bleeding immediately.
 Continue with the primary assessment.

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 Assess the airway and breathing.
 Assess oxygenation and maintain an
SpO2 of 94% or above.
 Assess the pulses and skin.
 Control bleeding, but do not let dramatic
injuries distract you from the primary
assessment.

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 Perform a rapid secondary assessment
if:
• There is significant bleeding.
• There is altered mental status.
• There are multiple injuries.
• There is a significant mechanism of
injury.

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 Obtain baseline vital signs.
 Assess for signs of hypoperfusion.

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• Emergency medical care
 Use Standard Precautions.
 Control bleeding with direct pressure.
 If direct pressure is ineffective, apply a
tourniquet.
 Provide care for shock.
 Immobilize injured extremities.
 Reassess.

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• Bleeding from the nose, ears, or mouth
can indicate serious injury.
 Skull injury
 Facial trauma
 Digital trauma to the nose
 Sinusitis
 Hypertension
 Clotting disorders
 Esophageal disease

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• Do not attempt to control bleeding from
the ears or nose if the patient has
experienced a head injury.
• Epistaxis is controlled by direct
pressure.

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EMT SKILLS 28-3
Controlling a Nosebleed

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Have the patient sit and lean forward.

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Pinch the fleshy part of the nostrils together.

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Internal BleedingInternal Bleeding
• Internal bleeding may result from
trauma or medical problems.
• Internal bleeding may not be obvious,
and can rapidly result in death.

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• Common sources of internal bleeding
are injured organs and fractured
extremities.
• A hematoma is a contained collection of
blood that can contain a significant
amount of blood.
• Use signs and symptoms to estimate
severity of blood loss.

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 Perform a scene size-up; look for a
mechanism of injury.
 Form a general impression.
 Immediately control major external
bleeding.
 Pay close attention to the mental status.

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 Assess airway, breathing, and
oxygenation.
 Assess the pulses, skin, and capillary
refill.
 Pay attention to changes in the
respirations, pulse, and skin that can
indicate blood loss.

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 Perform a rapid secondary assessment if
the mechanism of injury and
assessment suggest internal bleeding.

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 Look for external indications that there
is internal bleeding.
• Contusions
• Abrasions
• Deformity
• Impact marks
• Swelling

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 Signs and symptoms of internal bleeding
• Pain, tenderness, swelling, discoloration
• Bleeding from a bodily orifice
• Vomiting; bright red or coffee-ground
material

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 Signs and symptoms of internal bleeding
• Dark tarry stools or stools with bright red
blood
• Tender, rigid, or distended abdomen

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 Signs and symptoms of hemorrhagic
shock
• Anxiety, restlessness, combativeness,
altered mental status
• Weakness, faintness, dizziness
• Thirst

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shock
• Shallow, rapid breathing
• Thirst
• Shallow, rapid breathing
• Rapid, thready pulse

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shock
• Pale, cool, clammy skin
• Delayed capillary refill
• Narrow pulse pressure
• Dropping blood pressure
• Dilated, sluggish pupils
• Nausea, vomiting

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 Maintain an open airway and adequate
breathing.
 Administer oxygen if there are signs of
poor perfusion or to maintain an SpO2 of
94% or above.

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 Control external bleeding.
 Provide immediate transport.
 Treat for shock.
 Reassess.

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Factors that May IncreaseFactors that May Increase
BleedingBleeding
• Movement
• Low body temperature
• Medications
• Intravenous fluids
• Removal of dressings and bandages

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Hemorrhagic ShockHemorrhagic Shock
• Shock results from inadequate tissue
perfusion.
• Significant hemorrhage leads to
inadequate perfusion.
• Cells are deprived of oxygen and
nutrients, and begin to fail and die.
• Immediate recognition and treatment
are critical.

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Continuous cycle of shock.

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 Evaluate scene safety and the
 Assess the mental status, airway,
breathing, oxygenation, and circulation.
 Assist breathing and administer oxygen,
as needed.

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 For unstable patients, perform a rapid
secondary assessment.
 Obtain baseline vital signs; loss of
>15% of blood volume will cause
changes in vital signs.

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• Signs and symptoms
 Mental status
• Restlessness
• Anxiety
• Altered mental status

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 Peripheral perfusion
• Pale, cool, clammy skin
• Weak thready, or absent peripheral
pulses
• Delayed capillary refill

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 Vital signs
• Increased pulse rate; weak, thready
pulse
• Increased breathing rate; deep, shallow,
labored, or irregular breathing
• Narrow pulse pressure
• Decreased blood pressure

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 Other signs and symptoms
• Dilated pupils
• Thirst
• Nausea, vomiting
• Pallor; cyanosis of the lips

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 Maintain an open airway, administer
oxygen, and assist ventilations as
needed.
 Control external bleeding.
 Apply and inflate PASG according to
protocol.

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 Place the patient supine.
 Splint bone and joint injuries.
 Keep the patient warm.
 Transport immediately.

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EMT SKILLS 28-4
Emergency Care for Shock

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Take all necessary Standard Precautions.

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Administer supplemental oxygen or positive pressure ventilation as indicated.

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Cover the patient to prevent loss of body heat.

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• Pneumatic antishock garment (PASG)
 Controversial device used in some cases
of hemorrhagic shock
 Follow protocols.

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A pneumatic antishock garment (PASG).

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• PASG indications
 Suspected pelvic fracture with SBP <90
mmHg
 Suspected intraperitoneal hemorrhage
with hypotension
 Suspected retroperitoneal hemorrhage
with hypotension

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• PASG contraindications
 Penetrating thoracic trauma
 Splinting of lower extremity fractures
 Eviscerated abdominal organs
 Impaled object in the abdomen

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• PASG contraindications
 Pregnancy
 Cardiopulmonary arrest
 Congestive heart failure
 Pulmonary edema

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• Do not deflate PASG once it has been
inflated unless ordered to do so by
medical direction.
• Contact medical direction about
deflation if:
 You suspect ruptured diaphragm.
 The patient experiences respiratory
distress after inflation.

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EMT SKILLS 28-5
Applying the PASG

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Place the PASG on the spine board, then the patient on the PASG. Position so the top of the garment is three
finger-widths below the bottom of the rib cage.

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Apply the garment.

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Inflate the garment.

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Monitor and record vital signs every 5 minutes. If the garment loses pressure, add air as needed.

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Case Study ConclusionCase Study Conclusion
Mick ensures that the patient has an open
airway and adequate breathing as Dave applies
direct pressure to the scalp wound. Mick
detects a weak, thready, rapid radial pulse. He
performs a rapid secondary assessment, noting
tenderness to the chest and abdomen.
Breath sounds are present on both sides, but
seem to be deceased on the right side. There
are swelling, deformity, and tenderness of the
right femur and right lower leg.

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The EMTs recognize indications of significant
internal bleeding, and rapidly extricate the
patient, securing him to a long backboard. They
begin transport immediately, applying oxygen
by nonrebreather mask, assessing baseline vital
signs, and performing a head-to-toe secondary
assessment.

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At the emergency department, the patient
receives a chest tube for a right pneumothorax,
then is quickly prepared for surgery to repair
damage to his liver and right leg.

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Lesson SummaryLesson Summary
• Hypoperfusion and shock can result
from blood loss.
• Bleeding can be arterial, venous, or
capillary.
• Bleeding can be external or internal.
• The first method of controlling external
bleeding is direct pressure.

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• Tourniquets and hemostatic agents are
only used if direct pressure is not
effective for on-going significant
bleeding.

PREHOSPITALPREHOSPITAL
EMERGENCY CAREEMERGENCY CARE
CHAPTER
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TENTH EDITION
Part II
Bleeding and Soft
Tissue Trauma
28

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Setting the StageSetting the Stage
• Overview of Lesson Topics
 Open Soft Tissue Trauma
 Closed Soft Tissue Trauma
 Dressings and Bandages

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Seven-year-old Tara Lambert shrieks as her
older brother, Denny, chases her through the
living room. She is taken by surprise as she
slips on a rug in the entryway. Losing her
balance, she falls hands-first into the panes of
glass in the door. The glass shatters as Tara's
left hand and forearm break through it. She sits
down, stunned, as blood begins pouring out
from a long laceration below the crease of her
elbow.
"Mom!" Denny screams. "Come quick!"

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• What will be the EMTs' first steps as
they arrive at the scene?
• What methods do EMTs have to control
bleeding?
• Once bleeding is controlled, what other
treatment should EMTs perform?

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IntroductionIntroduction
• Soft tissue injuries may be closed or
open.
• The appearance of soft tissue injuries
can be dramatic, but don't be distracted
from the priorities of care.
• Dressings and bandages are used to
help control bleeding and prevent
further wound contamination.

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Soft Tissue TraumaSoft Tissue Trauma
• Skin functions
 Protects the body from the environment
and organisms
 Helps regulate body temperature
 Senses heat, cold, touch, pressure, pain
 Assists in elimination of water and salts

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• Skin layers
 Epidermis
 Dermis
 Subcutaneous layer

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• Soft tissue injuries can be open or
closed.

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EMT SKILLS 28-6
Soft Tissue Injuries

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During a street altercation, one participant struck the other with a tire iron—blunt trauma resulting in an open
soft tissue injury to the arm.

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This patient, a salesman in a sporting goods store, was demonstrating a bow with a carbon fiber arrow. During
the demonstration, the apparatus broke, releasing the arrow that penetrated the patient's hand. (© Charles
Stewart, MD, FACEP)

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Closed Soft Tissue InjuryClosed Soft Tissue Injury
• In closed injuries, there is no break in
the skin.
• Three types of closed injury
 Contusions
 Hematomas
 Crush injuries

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• Contusions
 A bruise
 Injury to blood vessels in the dermis
 Swelling, discoloration (ecchymosis)

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Contusions.

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• Hematoma
 Involves larger blood vessels and areas
of tissue than a contusion
 A pocket of blood forms beneath the
skin, and can separate the tissues.
 Presents as a lump with discoloration

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• Crush injury
 Results from significant blunt trauma or
crushing force
 May be open or closed
 Serious damage to underlying tissues
 Internal bleeding

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 Perform a scene size-up; look for
 Perform spinal stabilization, if indicated.
 Primary assessment
 Secondary assessment

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 Standard Precautions
 Ensure an open airway, adequate
breathing, and maintain oxygenation.
 Treat for shock, if indicated.
 Splint suspected fractures.
 Reassess.

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Open Soft Tissue InjuryOpen Soft Tissue Injury
• In open injuries, the continuity of the
skin is broken.
• Open injuries are at risk for external
bleeding and contamination.
• An open injury may be a sign of a
deeper underlying injury.

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• Six types of open injuries
 Abrasions
 Lacerations
 Avulsions
 Amputations
 Penetrations/punctures
 Crush injuries

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Classification of open injuries.

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• Abrasion
 Caused by scraping or rubbing way the
epidermis
 Superficial, but painful
 Bleeding is easily controlled
 If large areas of the body are involved,
infection is a concern.

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Abrasions.

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• Laceration
 A break in the skin
 Depth may vary
 May be linear or stellate
 Bleeding can be significant

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Lacerations and deep abrasions.

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Lacerations to the leg.

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Lacerations to the face.

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• Avulsion
 A flap of skin is torn loose or pulled off
completely.
 Bleeding can be severe.
 Healing can be prolonged and scarring
may be extensive.

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Forearm avulsion.

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Ring avulsion.

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• Amputations
 Disruption in the continuity of an
extremity or other body part
 Result from ripping or tearing forces
 Bleeding can be minimal or massive.
 May be partial or complete

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Finger amputation.

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Finger amputations.

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• Penetrations/punctures
 Result from a sharp, pointed object
pushed or driven into the soft tissues
 The entry wound may be small, but
underlying damage and be severe.

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Penetration/puncture wound to the chest. (© Edward T. Dickinson, MD)

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• Gunshot wounds are a type of
penetrating/puncture wound.
 There may be entrance and exit
wounds.
 Always assess for the possibility of
multiple gunshot wounds.

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• Stab wounds can be hidden.
 Expose the patient for assessment.
 Assess for underlying injuries and
hemorrhagic shock.

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EMT SKILLS 28-7
Gunshot Wounds

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Powder burns from gunshot. (© Edward T. Dickinson, MD)

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• Crush injuries
 The affected part may be painful,
swollen, and deformed; bleeding can be
minimal or absence.
 Suspect internal injuries and bleeding.
 Shock can develop rapidly when the
crushing object is lifted from the
patient.

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• Other soft tissue injuries
 Dog bites can be complicated by
infection, cellulitis, septicemia, and
concerns of rabies and tetanus.
 Human bites can result in infection and
hepatitis.

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• Clamping injuries
 A body part is caught or strangled in
machinery.
 Often include a finger or hand.
 Removal becomes more difficult with
time because of swelling.

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Click on the type of injury that occurs when a flapClick on the type of injury that occurs when a flap
of skin is partially or completely torn away fromof skin is partially or completely torn away from
the body.the body.
A. Laceration
B. Avulsion
C. Abrasion
D. Amputation

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 Ensure scene safety and evaluate the
 Perform spinal stabilization, if indicated.
 Form a general impression.
 Ensure adequate airway, breathing, and
oxygenation.

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 Secondary assessment
• For an unstable patient or significant
mechanism of injury, perform a rapid
• For a stable patient without significant
mechanism of injury, perform a modified

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 Ensure an open airway and adequate
breathing and oxygenation.
 Expose the wound.
 Control bleeding with direct pressure.
 Prevent further contamination.

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• Penetrating chest wounds
 Use an occlusive dressing to prevent air
from entering through the wound.
 Secure the dressing with tape on three
sides.
 Position the patient according to his
condition and comfort.

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 Cover the exposed organs with a sterile
dressing moistened with sterile water or
saline.
• Do not use absorbent materials.
• Cover the moist dressing with an
occlusive dressing taped on four sides.
• Maintain the temperature of the affected
area.

edition
Mistovich | Karren
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• Caring for amputated parts
 Remove gross contamination by flushing
with sterile water or saline.
 Wrap the part in dry, sterile gauze.
 Wrap or bag the part in plastic.
 Keep the amputated part cool.
 Transport the part with the patient, if
possible.
 Never complete a partial amputation.

edition
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• Caring for open neck wounds
 Use a gloved hand to control bleeding.
 Apply an occlusive dressing, taped on
four sides.
 Cover the occlusive dressing with a
regular dressing.

edition
Mistovich | Karren
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• Caring for open neck wounds
 Apply only enough pressure to control
bleeding.
 Once bleeding is controlled, apply a
pressure dressing; do not use a
circumferential dressing.
 Provide spinal immobilization if
appropriate.

edition
Mistovich | Karren
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EMTs arrive to find a pale and sobbing Tara
sitting on the floor. Her mother is kneeling next
to her, holding a blood-soaked hand towel
around her arm.
"Please help," her mother says. "I can't seem to
get the bleeding to stop."
"Okay. We're here to help," says one of the
EMTs as he removes the towel and uses his
gloved fingertips to firmly apply pressure to the
laceration. His partner pulls out packages of
sterile gauze to help with bleeding control.

edition
Mistovich | Karren
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Dressing and BandagesDressing and Bandages
• Dressings
 Cover the wound to help control
bleeding and prevent further
contamination.
 Should be sterile
 Various types of dressings are available.

edition
Mistovich | Karren
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• Applying a pressure dressing
 Cover the wound with sterile dressings.
 Apply direct pressure over the wound to
control bleeding.
 Bandage firmly to maintain bleeding
control; reassess pulses.
 If blood soaks through, remove the
dressings and apply fingertip pressure.

edition
Mistovich | Karren
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• General principles
 Sterile materials are preferred.
 Do not apply a bandage until bleeding is
controlled.
 A dressing should cover the entire
wound.
 Remove all jewelry from the injured
part.
 Do not bandage too loosely.

edition
Mistovich | Karren
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• General principles
 Bandage snugly, but not too tightly.
 If the wound is small, use a wider
bandage to avoid creating a pressure
point.
 Position the part before bandaging.
 If bleeding is not controlled with direct
pressure, apply a tourniquet.

edition
Mistovich | Karren
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After several minutes of direct pressure, the
bleeding from the laceration is under
control. Meanwhile, the EMTs have assessed
Tara for other injuries and obtained a
baseline set of vital signs.
Tara's color has improved, and her sobs
have diminished to occasional sniffles. Her
heart rate is 96, respirations 20, and BP
94/74. Her skin is warm and moist, and her
SpO2 is 100%.

edition
Mistovich | Karren
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The EMTs apply a snug pressure dressing
and splint the arm, then recheck Tara's
pulse, motor, and sensory function below the
injury.
The EMTs transport Tara to the emergency
department, where she receives 22 stitches
to close the wound in her arm. Fortunately,
there was no damage to the arteries,
nerves, or tendons, and the wound is
expected to heal without complications.

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• Soft tissue injuries can be closed or
open.
• Closed injuries include contusions,
hematomas, and crush injuries.
• Open injuries include abrasions,
avulsions, amputations, lacerations,
punctures/penetrations, and crush
injuries.

edition
Mistovich | Karren
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• Do not let the appearance of soft tissue
injuries distract you from the priorities
of patient care.
• Dressings and bandages are used to
help control bleeding and prevent
further contamination of wounds.

DMACC EMT Chapter 28

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DMACC EMT Chapter 28