Chapter 26-Bleeding

Hemorrhage

Bleeding

Difficulties in determining the amount of blood loss

• absorbed in clothing

• diluted in water

• dark environment

Blood loss the body can tolerate

up to 20%

How well a patients body can compensate for blood loss

dependent on how rapidly blood loss occurs

Signs of Severe Bleeding

• The patient has a poor general appearance and has no response to

  external stimuli.

• Assessment reveals signs and symptoms of shock (hypoperfusion).

• You note a significant amount of blood loss.

• The blood loss is rapid and ongoing

• You cannot control the bleeding

• The bleeding is associated with a significant MOI

Arterial Bleeding

• Bright red due to being O2 rich

• spurts in time with pulse

Venous Bleeding

• Darker due to being O2 poor

• easier to manage but can be profuse/life threatning

Capillary Bleeding

• dark red

• oozes steadily but slowly

• more likely to clot spontaneously

Clotting Process

• Cut ends of blood vessel narrow (vasoconstriction)

• Clot forms sealing the injured portions of the blood vessel (Coagulation)

Vasoconstriction

The narrowing of a blood vessel, such as with hypoperfusion or cold extremities

Coagulation

The formation of clots to plug openings in injured blood vessels and stop blood flow

Factors that Affect Blood Clotting Factors

• movement

• disease process

• meds like blood thinners

• removal of bandages

• external environment

• body temp

Hemophilia

A hereditary condition in which the patient lacks one or more of the blood’s normal clotting factors

Internal Bleeding

bleeding in a cavity/space inside the body

Main Result of Extensive Internal Bleeding

hypovolemic shock

Contusion

A bruise from an injury that causes bleeding beneath the skin without breaking the skin

Ecchymosis

buildup of blood beneath the skin that produces a characteristic blue or black discoloration as the result of an injury

MOI for internal bleeding

• usually high energy

• blunt trauma

  • falls

  • blast injuries

  • motor vehicle crashes

• penetrating trauma

NOI for internal bleeding

• Ulcers

• colon bleeding

• raptured ectopic pregnancy

• aneurysms

Signs & Symptoms of Internal Bleeding

• Pain

• Swelling (if massive loss has occurred)

• hematoma

• External blood

  • Mouth

  • urine

• vomiting blood

• Melena

• guarding

• tenderness

• broken ribs

• rigid distended abdomen

• bruises

Common places of internal bleeding

• head

• extremity

• pelvic

• significant abdominal trauma

Signs of internal bleeding into chest cavity/lung

• dyspnea

• tachycardia

• hemoptysis

• hypotension

Hemoptysis

coughing up blood

Hematoma

A mass of blood that has collected within damaged tissue beneath the skin or in a body cavity

Hematuria

blood in urine

Hematemesis

vomiting of blood

• can look like coffee ground

Melena

Black, foul-smelling, tarry stool containing digested blood

Hypovolemic Shock signs that suggest internal bleeding

• Tachycardia

• Weakness, fainting, or dizziness at rest

• Thirst

• Nausea and vomiting

• Cold, moist (clammy) skin

• Shallow, rapid breathing

• Dull eyes

• Slightly dilated pupils that are slow to respond to light

• Capillary refill time longer than 2 seconds in infants and children

• Weak, rapid (thready) pulse

• Decreasing blood pressure

• Altered level of consciousness

First Signs of Hypovolemic Shock

• altered mental status

• weakness/faintness/dizziness on standing

• pale skin

Scene Size Up

• Be alert for potential hazards

• Follow safety precautions

• Determine # of patients needing care

• Figure out MOI/NOI

Primary Assessment

• Note factors that determine seriousness of patients condition

• Determine patient sex & age

• Preform rapid exam identifying & treating life threats

• Address extreme bleeding first

• ABCs

• Assess skin color, condition, & temp

• LOC

• Pulse rate

History Taking

• be aware of signs & symptoms of other injuries based on MOI/NOI

• avoid focusing solely on the bleeding

• obtain SAMPLE

• get info from family/bystanders if possible

• look for symptoms of hypoperfusion

Blood Thinner Examples

• aspirin

• clopidogrel (Plavix)

• ticagrelor (Brilinta)

• warfarin (Coumadin)

• rivaroxaban (Xarelto)

• dabigatran (Pradaxa)

• apixaban (Eliquis)

• edoxaban (Savaysa)

Secondary Assessment

• Vitals

• assessment of pain

• attach monitoring devices

• Assess for DCAP-BTLS

Reassessment

• do frequently

• 5 or 15 minutes depending on pt stability

• provide high flow o2 if shock is present

• treat bleeding as it comes up

• Transport

• Estimate amount of blood loss

Controlling External Bleeding

• Direct Pressure

• Pressure Dressings

• Splints

• Tourniquets

• Hemostatic dressing

• wound packing

Applying Pressure with Protruding Object

• Don’t remove unless its blocking the airway

• apply bulk dressings to stabilize

• pressure for 5 minutes

Direct Pressure

• Pressure + dressing like gauze

• Wrap bandage around the wound

• Tight enough to control bleeding

• If bleed oozes slowly → tighter!

If direct pressure doesn't stop hemorrhage

apply tourniquet or wound packing with hemostatic dressing

Hemostatic Dressing

A dressing impregnated with a chemical compound that slows or stops bleeding by assisting with clot formation

Packing a Wound

1. Follow standard precautions.

2. Remove or open the patient’s clothing as needed to expose the wound

3. Wipe away any pooled blood.

4. Pack the wound tightly with hemostatic gauze (preferred) or plain gauze

5. Apply steady pressure by pressing with both hands directly on top of the bleeding wound. Push down as hard as you can.

6. Continue holding pressure until relieved by another prehospital provider or the patient is delivered to definitive care.

Tourniquet

• The bleeding control method used when a wound continues to bleed despite the use of direct pressure

• useful if a patient is bleeding severely from a partial or complete amputation

Applying a Tourniquet

1. Standard precautions

2. Direct pressure on bleeding site

3. Place tourniquet high and tight

4. Secure buckle and strap

5. Turn rod until pulses are no longer palpable

6. Write on tourniquet when put on

Where to place tourniquet

high and tight to injury

• Not on joint!

Tourniquet Precautions

• Don’t apply over joint

• Apply a second one if bleeding isn’t controlled

• Tighten securely

• Don’t use material that can cut the skin

• If possible place padding

• Never cover

• Do not loosen unless directed to by med control

Info to give hospital personnel about tourniquet

• Time of application

• site of application

• reason for application

Junctional Tourniquet

device that provides proximal compression of severe bleeding near the axial or inguinal junction with the torso

Air Splint

inflatable splint that can act like a large pressure dressing

Pelvic Binder

A device to splint the bony pelvis to reduce hemorrhage from bone ends, venous disruption, and pain

open-book pelvic fracture

A life-threatening fracture of the pelvis caused by a force that displaces one or both sides of the pelvis laterally and posteriorly.

Applying Pelvic Binder

1. slide binder under patient centered over the hips

2. Secure & tighten

Causes for nose/ears/mouth bleeding

• Fracture of the base of the skull

• Facial injuries, including those caused by a direct blow to the nose

• Sinusitis, infections, nose drop use and abuse, dried or cracked nasal mucosa, intranasal use of street drugs (snorting), or other abnormalities

• High blood pressure

• Coagulation disorders

• Digital trauma (nose picking)

• Cancer

Epistaxis

nosebleed

Controlling nose bleeds

1. Patient needs to be sitting leaning forward

2. pinch fleshy part of nostrils together

3. Apply ice over nose

Controlling Internal Bleeding

1. Control external bleeding

2. Use splint & apply tourniquet if necessary

3. maintain airway

4. Administer o2 if needed

5. monitor vital sings & keep patient warm

6. transport if there are signs of shock