Wounds and Bleeding

Define wound, closed wound and open wound

• Wound: break in continuity of body tissue due to external action

• Closed wound: soft tissue beneath surface damaged, no break in skin - bruise

• Open wound: break in surface of skin or mucous membrane exposing it to infection - cut

What are the categories of wounds?

• Contusion (bruises)

• Haematoma (swelling)

• Abrasion (graze)

• Lacerations (tear)

• Incision (cut)

• Puncture (stab)

• Burn

• Gunshot

What are some complications from wounds?

• Haemorrhage (internal and external)

• Damage to underlying structures (bones, organs, vessels)

• Infection

• Foreign body

What is the treatment order for wounds?

• DRCACBCDE

• History (to understand mechanism, e.g. stab)

• Clean (soapy or running water) and dress wound if able

Describe management for a foreign object in the wound

• If possible, wash out small objects with water

• Larger object not easily removed left in situ and non adhesive sterile dressing applied, secured as best as possible to avoid movement

Define types of bleeding, blood and how to recognise

• Arterial

  • Very bright red

  • Pulsing as it exits the wound

• Venous

  • Darker

  • Steady oozing/flowing

• Capillary

  • Slow, even flow (Between arterial and venous in colour)

How do we manage haemorrhage?

• Appropriate PPE

• IPC procedures

• Primary survey

  • Stop catastrophic haemorrhage using field dressings and direct pressure

  • Once airway and breathing assessed and life threatening issues corrected, continually reassess for catastrophic haemorrhage

    • Assess for pulses - noting rate, rhythm, character

    • Assess cap refill time and skin colour, texture and temperature

    • Remain alert for potential of internal bleeding ‘Blood on the floor and four more’

• Recognise need for advanced clinical interventions early

• Re-assess the patient at all times to detect any changes

Where would you find the different types of dressings for burns and minor wounds, and what are the types and when would you use them?

The green dressings pack ‘D’ on top

• Plasters

• Sterile adherent dressings pads

• Low adherent dressings (small and large)

  • Things we don’t want to stick on

  • E.g. directly on wound then tape, or on hair

• No2 Ambulance dressing

  • Low adherent dressings with bandage across

  • Can be cut to size

  • E.g. head lac, can use bandage to wrap around head and secure

• Conforming/adhesive Retention Bandages

  • Will stick to itself but not the patient

  • Use with dressing

  • Good for wrapping heads

Where would you find the Prometheus dressing for major wounds and when/how would you use it?

Small red dressings bag within the response bag

• Arterial bleeding where firm pressure is required

• Open up, raise limb above heart, and apply thick dressing part to wound, wrap bandage around dressing tighter and tighter

Where would you find the Combat Application Tourniquet and when would you use it?

• Found in green response bag, trauma bag and triage bag

• Arterial bleeding where firm pressure is required

  • Raise limb above heart

  • Apply direct pressure while getting tourniquet ready

  • Place tourniquet as low as possible proximal to bleeding point

  • Place windlass directly over artery, clip around limb, twist until cannot anymore, and lock in place - NOTE WHEN APPLIED (write on and of tourniquet)

  • If need to apply a second, apply directly above first with windlass on other side

  • Can be placed over two bones, i.e. tibula and fibula

Where would you find the blast dressing, when would you use it, and how would you apply it?

• Found in a brown package inside the green trauma bag

• Can be used in

  • Stump of amputation

  • Abdominal evisceration

How do you assess blood loss?

• Need to look at:

  • Loss in body tissues (swelling)

  • On floor (absorption on surface?)

  • In patient’s clothing

  • In wound dressing e.g.,

    • Soaked maternity pad 100ml

    • Soaked non-adhesive is 50ml

    • Soaked around and into bed, down legs is about 1000ml

• Also need to look at signs and symptoms of major blood loss

What amount of blood can you lose due to different fractures?

Closed fractures:

• Rib - 100-125ml

• Radius/ulna - 250-500ml

• Humerus - 500-750ml

• Tibia 500-1000ml

• Femur 1000-2000ml

• Pelvis 1000-5000ml

In open fractures, lose up to twice this amount!

What factors affect blood loss?

• Depth, type, size and position of wound

  • High risk areas include femoral, carotid, aortic

• Size and type of blood vessel

• Duration of bleeding

• Age and size of patient (smaller more concerning)

• Underlying injuries

What are some signs and symptoms of severe blood loss?

• Respiration rate increases - are hunger develops with no apparent reason if internal bleeding

• Pulse rate increases - weakens with deterioration

• Pupils become dilated with deterioration

• Skin pallor, ashen, cold extremities, cyanosis develops

• BP is least sensitive - very late but dramatic sign if drops