Chapter 26: Bleeding

Anatomy and Physiology of the Cardiovascular System

• The cardiovascular system circulates blood to cells and tissues.

  • Delivers oxygen and nutrients

  • Carries away metabolic waste products

  • Responsible for supplying and maintaining adequate blood flow

• Three parts

  • Pump (heart)

  • Container (blood vessels)

  • Fluid (blood and body fluids)

ok?

ok

The Heart

• Needs a rich and well-distributed blood supply

• Works as two paired pumps

  • Upper chamber (atrium)

  • Lower chamber (ventricle)

• Blood leaves each chamber through a one-way valve.

ok?

ok

Blood Vessels and Blood

• Arteries

  • Carry blood —- from the heart

  • Normally carry oxygenated blood except for —- —- which carry —- blood from the —- to the ——

• Arterioles

  • Smaller vessels that connect the arteries and capillaries

• Capillaries

  • Pass among all the cells and link arterioles and venules

• Venules

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

• Veins

  • Carry blood from the tissues and —- —- the heart

  • Normally carry deoxygenated blood except for — — which carry — blood from the —- to the —-

• Oxygen and nutrients pass from the —- into the peripheral —-.

• Waste and carbon dioxide diffuse into the capillaries.

away, pulmonary arteries, deoxygenated, heart, lungs

back to, pulmonary veins, oxygenated, lungs heart 

capillaries, cell

Blood Vessels and Blood

• Blood contains

  • Red blood cells

    • Responsible for the transportation of — to the cells and —- away from the cells to the lungs

  • White blood cells

    • Responsible for fighting —-

  • Platelets

    • Responsible for forming blood —-

  • Plasma

    • Transport medium 

• Blood clot formation depends on:

  • Blood stasis

  • Changes in the blood vessel —- 

  • Blood’s ability to clot  

• When tissues are injured, platelets begin to —— at the site of injury.

  • Red blood cells to become sticky and — together.  

O2, CO2, infection, clots, walls, gather, clump

Autonomic Nervous System

• Monitors the body’s needs 

• Adjusts —- flow 

• Automatically redirects blood —- from other organs to the heart, brain, lungs, and kidneys in an emergency (—-)

• Adapts to maintain homeostasis and perfusion 

blood, away, shock, 

Pathophysiology and Perfusion

• Perfusion is the circulation of blood within an organ or tissue to meet the cells’ —- for oxygen, nutrients, and waste removal.

• Speed of blood flow

  • Fast enough to maintain —-

  • Slow enough to allow cells to — oxygen and nutrients for carbon dioxide and waste

• Some tissues need a —- supply of blood, while others can survive with very —-.

• All organs and organ systems depend on adequate — to function properly.

  • Death of an organ system can quickly lead to death of the patient.

  • Emergency care supports adequate perfusion until the patient arrives at the hospital.

• The heart requires a —- supply of blood.

needs, circulation, exchange, constant, little, perfusion,constant

External Bleeding

• Hemorrhage means ——.

• External bleeding is —- hemorrhage.

bleeding, visible

Significance of External Bleeding

• With serious external bleeding, it may be difficult to tell the —- of blood loss.

  • Blood looks different on different —-.

  • Try to —- the amount of external blood loss.

    • A shot glass is about 50 cc/mL

    • Body carries 4-6L

• Body will not tolerate a blood loss greater than —- of blood volume

• Changes in vital signs may occur with significant blood loss.

  • — in heart rate

  • — in respiratory rate

  • — in blood pressure

• How well people compensate for blood loss is related to how — they bleed.

  • An adult can comfortably donate 1 unit (500 cc/mL) of blood over 15 to 20 minutes.

  • If a similar blood loss occurs in a much — time, the person may rapidly develop symptoms of —- shock.

  • Consider age and preexisting health.

amount, surfaces, estimate, 20%, increase, increase, decrease, rapidly, shorter, hypovolemic,

Characteristics of External Bleeding

• 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

• Arterial bleeding

  • Pressure causes blood to —- and makes bleeding —- to control.

  • Typically —- red and spurts in time with the —-

• Venous bleeding

  • — red, flows —- or —- depending on the — of the vein

  • Does — spurt and is — to manage

• Capillary bleeding

  • Bleeding from damaged capillary vessels

  • — red, oozes — but —

spurt, difficult, brighter, pulse

dark slowly rapidly, size, not, easier

dark, steadily slowly

Clotting

• Bleeding tends to stop rather quickly, within about — —

  • When skin is broken, blood flows rapidly.

  • The cut end of the vessel begins to ——, reducing the amount of bleeding.

  • Then a —- forms.

  • Bleeding will —- stop if a clot does not form.

10 minutes, narrow, clot, not

Hemophilia

• Patient lacks blood-clotting —-.

• Bleeding may occur —-.

• All injuries, no matter how trivial, are potentially —-.

• Patients should be transported immediately.

factors, spontaneously, serious,

Internal Bleeding

• Can be very serious because it is not easy to detect immediately

  • Injury or damage to —- —- commonly results in extensive internal bleeding.

  • Can cause —- shock

• Possible conditions causing internal bleeding:

  • Stomach — 

  • Lacerated — 

  • Ruptured — 

  • Broken —

internal organs, hypovolemic

ulcer liver spleen bones

MOI for Internal Bleeding

• High-energy MOI

  • Should increase your — — —- for serious — injuries

• Internal bleeding is possible whenever the MOI suggests that — — affected the body.

  • — or — trauma

• Signs of injury (DCAPP-BTLS) = ——

index of suspicion, unseen, severe forces

blunt penetrating

deformities, contusions, abrasions, punctures penetrations, burns, tenderness lacerations swelling

NOI for Internal Bleeding

• Internal bleeding is not always caused by trauma.

• Nontraumatic causes include:

  • Bleeding —

  • Bleeding from —

  • Ruptured — pregnancy

  • —

ulcers, colon, ectopic, aneurysms

Signs and Symptoms of Internal Bleeding

• — (most common)

• — in the area of bleeding

• Distention

• Three vital changes = — — —-

• Hematoma

• Bruising

• Bleeding from any body opening

• —

• — (black tarry stool indicating lower GI bleed)

• Pain, tenderness, bruising, guarding, or swelling

• Broken ribs

• Bruises over the lower part of the chest

• —, — abdomen

pain, swelling, dyspnea tachcardia, hypertension, hematemesis, melena, rigid distended

Signs and Symptoms of Internal Bleeding Cont’d

• Hypoperfusion

  • Change in — —

  • Weakness, faintness, or dizziness on standing

  • Changes in skin — or — (pale skin)

• Later signs of hypoperfusion:

  • —

  • Weakness, fainting, or dizziness at rest

  • Thirst, nausea and vomiting

  • —, — (clammy) skin

  • — and — breathing

  • Dull eyes, slightly — pupils

  • Capillary refill of — than — —- in infants and children

  • —/— and — pulse

  • — blood pressure

  • Altered —-

mental status, color pallor

tachycardia, cold moist, shallow rapid, dilated, more 2 seconds, weak, thready, rapid, decreasing, LOC

Scene Size-up

• Scene safety

  • Be alert to potential hazards.

  • In violent incidents, make sure the — are on the scene.

  • Follow standard precautions.

• Mechanism of injury/nature of illness

  • Determine the — or —.

  • Consider the need for — — and — —.

  • Consider environmental factors such as —.

police, NOI MOI, spinal immobilization, additional resources, weather

Primary Assessment

• Do not be distracted from identifying —- —.

• Form a general impression.

  • Note important indicators of the patient’s condition.

  • Be aware of obvious signs of injury.

  • Determine gender and age.

• Perform a rapid exam. 

  • Look for — — and treat them as you find them. 

  • If the patient has obvious, life-threatening external bleeding, address it —-.

  • Assess —- —-.

  • Determine ——.

• Airway and breathing

  • Consider the need for spinal stabilization.

  • Ensure a patent airway.

  • Look for adequate breathing.

  • Check for breath sounds.

  • Provide high-flow oxygen or assist ventilations with a bag-mask device or nonrebreathing mask.

  • Insert an oropharyngeal airway if the patient is unconscious. 

life threats, life threats, first, skin color, LOC

Primary Assessment

• Circulation

  • Assess pulse rate and quality.

  • Determine skin condition, color, and temperature.

  • Check capillary refill time.

  • Control external bleeding.

  • Treat for shock.

• Transport decision

  • Assessment of XABCs and life threats will determine the transport priority.

  • Signs that imply rapid transport:

    • — or —        

    • — blood pressure

    • — pulse

    • — skin

tachycardia tachypnea, low, weak, clammy

History Taking

• Investigate the chief complaint.

  • Look for signs and symptoms of other injuries due to the MOI and/or NOI.

  • Note obvious signs of —- bleeding.

  • Assess the — patient. 

• SAMPLE history

  • Ask the patient about — —- medications.

  • If the patient is unresponsive, obtain history from medical alert tags or bystanders.

  • Look for signs and symptoms of —.

  • Determine the — of blood loss.

internal, entire, blood thinning, shock, amount 

Secondary Assessment

• Assess all areas for —— (this is a —- — —- exam)

• Record vital signs.

• Attach appropriate monitoring devices.

• With a critically injured patient or a short transport time, there may not be time to conduct a secondary assessment.

DCAPP-BTLS, head to toe

Reassessment

• Reassess the patient in areas that showed —- findings.

  • Signs and symptoms of internal bleeding are often —- to present.

• Reassess an unstable patient every 5 minutes and a stable patient every 15 minutes. 

• Interventions

  • Provide high-flow oxygen.

  • Control external bleeding. 

  • Provide treatment for shock and transport rapidly.

  • Do not delay transport of a patient to complete an assessment.

• Communication and documentation

  • Recognize, —-, and report the amount of blood loss and how —- or over what period of time it occurred.

  • Communicate all relevant information to the staff at the receiving hospital.

  • Document all injuries, the care provided, and the patient’s response.

abnormal, slow

estimate, rapidly,

Emergency Medical Care for External Bleeding

• Follow standard precautions.

  • Wear gloves, eye protection, and possibly a mask or gown.

  • Make sure the patient has an open airway and is breathing adequately.

  • Provide high-flow oxygen.

  • Control obvious, life-threatening bleeding as quickly as possible. 

• Several methods are available to control external bleeding.

  • —, even pressure and —

  • Pressure — and/or —

  • —

  • — dressing

  • Wound — 

direct, elevation
dressings, splints

tourniquets, hemostatic packing

Direct Pressure 

• Most — and — 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 —- of a sterile dressing.

• Hold — pressure for at least — —-

• Most bleeding will stop from direct pressure

  • The rarer cases need tourniquets or hemostatic dressing

  • If the wound is in the torso/back or too high up on the leg or arm and cannot use a tourniquet you use hemostatic dressing

common effective, top, uninterrupted, 5 minutes,

Pressure Dressing 

• Firmly wrap a —-, self-adhering roller bandage around the —- wound.

• Stretch the band —- enough to control bleeding.

• Do not remove a dressing until a —- has evaluated the patient.

• A tourniquet is useful if the bleeding —- be managed with direct pressure or pressure dressings

sterile, entire, tight, physician, cannot

Hemostatic Agents

• Gauze can be packed into —- wounds when direct pressure is —-, or application of a tourniquet is —- —.

• A hemostatic dressing is impregnated with a chemical compound that slows or stops bleeding by —- clot formation.

larger, inadequate, not possible, promoting

Tourniquets

• Useful if a patient has substantial bleeding from an —- injury

• Several types of commercial tourniquets are available. 

• — tourniquets allow for compression of life-threatening bleeding in areas where standard tourniquet application is not possible.

  • May be indicated for severe hemorrhage at the junction of the torso with the arms and legs.

extremity, junctional

Splints

• Air splints

  • Soft splints or pressure splints

  • Can control — or — bleeding associated with severe injuries

  • Immobilize —

  • Act like a — —

  • Use only approved, clean, or disposable valve stems.

• Pelvic binder

  • A type of splint that may be indicated for a suspected — unstable — fracture

  • There are many arteries and veins going through the pelvis, so any fractures near these vessels can result in severe hemorrhage

  • Helps to control —- bleeding caused by these fractures 

internal external, fractures, pressure dressing 

closed pelvic, internal 

Bleeding From the Nose, Ears, and Mouth

• Several conditions

  • Skull fracture

  • Facial injuries

  • Sinusitis, infections, use and abuse of nose drops, dried or cracked nasal mucosa

  • High blood pressure

  • Coagulation disorders

  • Digital trauma

  • Cancer

• Epistaxis (nosebleed) is a common emergency.

  • Occasionally it can cause enough blood loss to send a patient into ——.

  • Can usually be controlled by pinching the nostrils together

shock

Bleeding From the Nose, Ears, and Mouth Cont’d

• Bleeding from the nose or ears following a head injury:

  • May indicate a skull —

  • May be —- to control

  • Do not attempt to —- blood flow.

  • — cover the bleeding site with a sterile gauze pad.

  • Apply —- compression with a dressing.

• A target or halo-shaped stain may occur on the dressing if blood or drainage contains —- —-.

  • Called the —- —-

  • Can determine an — —- —

  • CSF will move through gauze faster than blood because it's less dense

  • You will see red dot in center and larger —- circle (CSF)

fracture, difficult, stop, loosely, light, cerebrospinal fluid, halo sign, open skull fracture, yellow

Emergency Medical Care for Internal Bleeding

• Definitive management of internal bleeding usually requires —- or other hospital procedures

• Keep the patient calm, reassured, and as still and quiet as possible.

• Provide high-flow oxygen.

• Maintain body —-.

• — the injured extremity (air splint).

surgery , temperature, splint,

Which of the following is NOT a component of the cardiovascular system?

Heart

Lungs

Venules

Plasma

lungs

Perfusion is MOST accurately defined as:

the removal of adequate amounts of carbon dioxide during exhalation.

the intake of adequate amounts of oxygen during the inhalation phase. 

circulation of blood within an organ with sufficient amounts of oxygen. 

the production of carbon dioxide, which accumulates at the cellular level.

circulation of blood within an organ with sufficient amounts of oxygen. 

A man involved in a motorcycle crash has multiple abrasions and lacerations. Which of the following injuries has the HIGHEST treatment priority?

Widespread abrasions to the back with pinkish ooze

3-inch laceration to the forehead with dark red, flowing blood

Laceration to the forearm with obvious debris in the wound

1-inch laceration to the thigh with spurting, bright red blood

1-inch laceration to the thigh with spurting, bright red blood

Which of the following sets of vital signs is LEAST indicative of internal bleeding?

BP, 140/90 mm Hg; pulse rate, 58 beats/min; respirations, 8 breaths/min

BP, 100/50 mm Hg; pulse rate, 120 beats/min; respirations, 24 breaths/min

BP, 98/60 mm Hg; pulse rate, 110 beats/min; respirations, 28 breaths/min

BP, 102/48 mm Hg; pulse rate, 100 beats/min; respirations, 22 breaths/min

BP, 140/90 mm Hg; pulse rate, 58 beats/min; respirations, 8 breaths/min

When caring for a patient with internal bleeding, the EMT must first:

ensure a patent airway.

obtain baseline vital signs.

control any external bleeding.

take appropriate standard precautions.

take appropriate standard precautions.

The quickest and MOST effective way to control external bleeding from an extremity is:

a pressure bandage.

direct pressure and elevation.

a splint.

a tourniquet.

direct pressure and elevation.

When applying a tourniquet to an amputated arm, the EMT should:

use the narrowest bandage possible.

avoid applying the tourniquet over a joint.

cover the tourniquet with a sterile bandage.

use rope to ensure that the tourniquet is tight.

avoid applying the tourniquet over a joint.

A 70-year-old man is experiencing a severe nosebleed. When you arrive, you find him leaning over a basin, which contains an impressive amount of blood. He has a history of coronary artery disease, diabetes, and migraine headaches. His BP is 180/100 and his heart rate is 100 beats/min. Which of the following is the MOST likely contributing factor to his nosebleed?

His blood pressure

His history of diabetes

The fact that he is elderly

His heart rate of 100 beats/min

His blood pressure

When caring for a patient with severe epistaxis, the MOST effective way to prevent aspiration of blood is to:

insert a nasopharyngeal airway and lean the patient back.

tilt the patient’s head forward while he or she is leaning forward.

place the patient supine with his or her head in the flexed position.

tilt the patient’s head forward while he or she is leaning backward.

tilt the patient’s head forward while he or she is leaning forward.

Controlling internal bleeding requires:

applying a tourniquet.

surgery in a hospital.

positioning the patient in the sitting position.

providing slow and considerate transport.

surgery in a hospital.