Describes the care of the patient with internal and external bleeding. Estimated teaching time 2 hours. Meets or exceeds current US DOT NHTSA 2009 requirements.

1. PREVIEW OF
EMT/EMR BLEEDING
POWERPOINT TRAINING
PRESENTATION

2. ANATOMY REVIEW

3. PERFUSION
Definition - circulation of blood through an
organ structure
Perfusion delivers oxygen and other
nutrients to the cells of all organ
systems and the removes waste
products

4. ARTERIAL BLEEDING
Bright red bleeding “spurting”
Difficult to control, due to size of vessels,
volume of blood, and pressure that blood is
pushed through arteries
As blood pressure drops, amount of spurting
blood drops

5. VENOUS BLEEDING
Darker red blood can vary from slow to severe
stream, depending on size of vein
Can be difficult to control, but easier to control
than arterial bleeds
Bleeding can be profuse and life-threatening

6. CAPILLARY BLEEDING
Blood oozes from wound
Usually easy to control or
stop without
intervention
Clots spontaneously
Photo by Sean McGinnis

7. SEVERITY
Related to
Volume of blood loss
Rate of blood loss
Age and pre-existing health of patient

8. SEVERITY
The sudden loss of one liter (1000cc) of
blood in the adult patient, 1/2 liter
(500cc) of blood in the child, and 100-
200cc of the blood volume in an infant is
considered serious. (For example, a one
year old only has 800cc of blood,
therefore 150cc is a major blood loss)

9. CLASSES OF HEMORRHAGE
Based upon American College of Surgeons ATLS
standards
4 classes based upon blood volume lost

10. CLASSES I
Involves <15% of blood volume loss
Normally no changes in vital signs

11. BLOOD CLOTTING
Bleeding normally stops within 5-10 minutes
Clotting disorders & diseases may prevent
clotting
Some injuries may not be able to clot

12. GENERAL ASSESSMENT
Mechanism of injury
Primary Survey
Identify and manage life threats related to bleeding
Mental status
Physical Exam
Blood pressure is not a reliable indicator of early shock
Lung sounds
Peripheral perfusion
Skin parameters

13. DIRECT PRESSURE
Application of even pressure to an
open injury that includes the
area just proximal and distal to the injury
Using a gloved hand and dressings, the wound is covered
and firm pressure applied until bleeding is controlled
Usually effective in capillary and minor venous bleeding
In cases of heavier bleeding or major wounds, multiple
dressings may be necessary; do not remove existing
dressings but apply additional dressings on top of
existing dressings in cases of continuing hemorrhage

14. TOURNIQUET
Use as a last resort to control bleeding of
an amputated extremity when all
other methods of bleeding control
have failed
Application of a tourniquet can cause
permanent damage to nerves,
muscles and blood vessels resulting
in the loss of an extremity

15. n

16. TOURNIQUET
Notify other emergency personnel who
may care for the patient that a
tourniquet has been applied
Document the use of a tourniquet and the
time applied in the prehospital patient
report
A continuously inflated blood pressure
cuff may be used as a tourniquet until
bleeding stops

17. TOURNIQUET
Precautions with the use of a tourniquet:
Use a wide bandage and secure
tightly
Never use wire, rope, a belt, or any
other material that may cut into the
skin and underlying tissue
Do not remove or loosen the tourniquet
once it is applied unless directed to
do so by medical control

18. HEMOSTATIC AGENT
AKA QUICK CLOT
Powder that can be
directly applied to
bleeding wound or
impregnated into
a bandage

19. SIGNS & SYMPTOMS
Bleeding may not slow after much blood loss
Some patients may be quiet and calm due to excessive
blood loss
The amount of blood at the scene does not always
indicate the amount of blood loss; the patient may
move
Estimating the amount of blood loss by the size of a
blood pool or the amount on clothing is not
accurate
Assess for signs and symptoms of shock

20. INTERNAL BLEEDING
Definition/description
Any bleeding in a cavity or space inside the
body
Internal bleeding can be severe and life
threatening
May initially go undetected without proper
assessment (mechanism of injury, signs,
and symptoms)

21. SEVERITY
Internal bleeding can result in severe blood
loss with resultant shock and subsequent
death
Injured or damaged internal organs
commonly lead to extensive bleeding that
is concealed
Fractures can lead to serious internal blood
loss

22. SEVERITY
Painful, swollen, deformed extremities may
also lead to serious internal blood loss
Suspicion and severity of internal bleeding
should be based on the mechanism of
injury and clinical signs and symptoms

23. RELATIONSHIP TO
MECHANISM OF INJURY
Blunt trauma
Falls
Motorcycle crashes
Pedestrian impacts
Automobile collisions
Blast injuries
Look for evidence of contusions,
abrasions, deformity, impact marks, &
swelling

24. SOURCES OF HIDDEN BLOOD LOSS
SITE AMOUNT OF BLOOD
LOSS
% OF BLOOD VOLUME
Abdomen > 1 Liter 40%
Thorax 2 Liters 50%
Femur > 1 liter 20%
Pelvis 0.5 Liters for fracture 10% for fracture
Skull No significant loss
unless infant

25. SIGNS & SYMPTOMS
Discolored, painful, tender, swollen, or firm
tissue
Increased respiratory rate
Increased pulse rate
Pale, cool skin
Nausea and vomiting
Thirst
Mental status changes
Photo by Glen Bowman

26. SIGNS & SYMPTOMS
Guarding, tenderness, deformity, discoloration
of the affected area
Coughing up blood, blood in urine, rectal
bleeding
Abdominal tenderness, guarding, rigidity,
distention
Bleeding from a body orifice.
Signs of shock

27. MANAGEMENT STRATEGIES
Stabilize Body Temperature
Psychological Support
Transport Considerations
Trauma center
Aeromedical transport
ALS mutual aid

28. INTERNAL BLEEDING
Injured or damaged internal organs
May lead to extensive, concealed bleeding
May cause unexplained shock
Injuries to the extremities may lead to serious
internal blood loss from long bone fractures

29. MANAGEMENT OF BLEEDING
SOFT TISSUE INJURIES
Expose the wound
Control the bleeding
Apply fingertip pressure (use flat part of
fingers) directly on the point of bleeding
Large wounds may require sterile gauze
and direct hand pressure if fingertip
pressure does not control bleeding

30. MANAGEMENT OF BLEEDING
SOFT TISSUE INJURIES (CONT.)
If bleeding oozes through dressing, do not lift
off; apply another gauze dressing on top of
the first and continue to apply pressure
Consider other measures for bleeding control
based on local guidelines
Prevent further contamination
Apply sterile dressing to the wound and bandage
securely in place with tape or roller gauze

31. MANAGEMENT OF BLEEDING
SOFT TISSUE INJURIES (CONT.)
Keep patient warm
Position patient flat on back
Do not give food or drink if shock is suspected
Treat other injuries

32. NOSEBLEED
AKA Epistaxis
Causes
General assessment findings
& symptoms
Techniques to stop bleeding in conscious patient
if no risk of spine injury

33. CAUSES
Trauma
Nasal fracture
Nose picking
Middle ear barotrauma
Medical
Dryness
High blood pressure
Cocaine snorting

34. GENERAL ASSESSMENT
FINDINGS & SYMPTOMS
Pain or tenderness
Bleeding from nose
Vomit
Vomits swallowed blood
Can block airway if patient is unresponsive

35. TECHNIQUES TO STOP BLEEDING
IN CONSCIOUS PATIENT
IF NO RISK OF SPINE INJURY
Sit patient up and lean forward
Pinch the nostrils together
firmly
Tell patient not to sniffle or
blow nose

36. COMPLICATIONS
Blood can run up in the nasolacrimal duct (tear
duct) into the eye
Blood can drain into the stomach causing
nausea & vomiting
About 4 deaths in the US each year

37. GERIATRIC COMPLICATIONS
Anticoagulant medicines, thinning of the nasal
mucosa, & high blood pressure can be
predispositions for elderly males

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