Bleeding and Hemorrhage Notes

External Bleeding

• Identification of bleeding types:
  • Arterial
  • Venous
  • Capillary

Stop the Bleed Class

• Supplemental class for continuing education.
• Counts for three hours towards recertification.
• Involves a lecture and hands-on practice.
• Practice includes:
  • Tourniquet placement on partners.
  • Using hemostatic agents to pack wounds.
  • Experimenting with various tourniquet types and bleeding control methods.

Cardiovascular System Review

• Circulates blood to body cells and tissues.
• Delivers oxygen and nutrients.
• Carries away metabolic waste.
• Maintains adequate blood flow.
• Components:
  • Pump: Heart
  • Container: Blood vessels
  • Content: Blood
• Heart:
  • Requires a rich and well-distributed blood supply.
  • Functions as two paired pumps (left and right sides).
  • Blood leaves each chamber via a one-way valve.
• Blood Circulation:
  • Deoxygenated blood from the lower body enters the right atrium via the inferior vena cava.
  • Passes through the tricuspid valve into the right ventricle.
  • Flows through the pulmonary valve to the lungs where it releases carbon dioxide and picks up oxygen.
  • Oxygenated blood returns to the heart and is pumped to the rest of the body.
  • Arteries branch off from the aorta.
  • Arteries get smaller and turn into arterioles.
  • Capillaries: Connect arterioles and venules; very thin vessels where diffusion occurs.
  • Venules: Where blood starts to return.
  • Veins: Formed as venules get bigger.
  • Vena cava: Large vein that returns blood to the heart.
• Gas Exchange:
  • Bronchioles: Divide from the left main stem bronchus.
  • Alveoli: Clusters at the end of bronchioles, site of simple diffusion.
  • CO₂ moves from blood to alveoli; O₂ moves from alveoli to blood (passive process).
  • Exhalation removes CO₂.

Blood Clot Formation

• Depends on:
  • Blood stasis (pooling).
  • Changes in blood vessel walls (wounds, trauma).
  • Blood's ability to clot (affected by diseases, blood thinners).
• Platelets: Go to the injury site, clump together, and coagulate to stop bleeding.
• Red blood cells become sticky and clump together

Autonomic Nervous System and Perfusion

• Autonomic Nervous System:
  • Monitors body's needs automatically (not consciously controlled).
  • Redirects blood to heart, brain, lungs, and kidneys during emergencies.
  • Diverts blood away from digestive and other systems.
  • Adapts to changing conditions to maintain homeostasis and perfusion.
• Perfusion:
  • Circulation of blood within an organ or tissue in adequate amounts.
  • Meets cells' needs for oxygen, nutrients, and waste removal.
  • Blood flow must be fast enough for circulation but slow enough for nutrient diffusion.
  • Brain, heart, and kidneys need constant blood supply.
  • Digestive system can tolerate minor interruptions.
• Organ System Failure:
  • Can quickly lead to patient death.
  • Heart requires a constant blood supply.
• Shock:
  • Results if the system fails to provide sufficient circulation.

Hemorrhage

• Hemorrhage = Bleeding.
  • External: Visible.
  • Internal: Not always visible
• Blood Loss:
  • The body doesn't tolerate blood loss greater than about 20% of blood volume (roughly two pints).
  • Difficult to estimate blood loss amount visually.
• Case Example:
  • Patient stabbed in the ankle, hit an artery, and lost a significant amount of blood.
  • Initial assessment: Minor, but the scene had an extreme amount of blood.
  • Blood pressure was 60/30.
  • Arterial wound was no longer spurting due to lack of pressure.
  • A tourniquet was not required due to the low blood pressure
  • Specialized crime scene cleaning teams clean up after incidents.

Hemorrhagic Shock

• Vital Sign Changes:
  • Blood pressure decreases.
  • Respiratory rate increases.
• How well people compensate for blood loss depends on bleeding rate.
  • Rapid bleed (two pints in five minutes): difficult to recover.
  • Slower bleed: better chance of recovery.
• Blood Loss Volume:
  • 300-350
    ewline milliliters is significant.
  • The same amount of blood loss is more critical for a small child (e.g., 4-year-old) than a large adult.

Characteristics of External Bleeding

• Significant MOI: be alert for signs of bleeding.
• Poor general appearance or calm for the situation.
• Signs and symptoms of shock or hypoperfusion.
• Significant or rapid blood loss.
• Uncontrolled bleeding.

Types of Bleeding

• Capillary:
  • Dark red, oozes slowly.
  • More likely to clot spontaneously.
• Venous:
  • Dark red, doesn't spurt.
  • Easier to manage and likely to clot.
  • Can be profuse and life-threatening (especially in hemophiliacs or patients on blood thinners).
• Arterial:
  • Caused by pressure in the arterial system.
  • Blood spurts and doesn't clot on its own.
  • Requires pressure, tourniquets, or intervention.

Clotting Process

• Minor bleeds (capillary, venous) stop quickly (within 10 minutes).
• Involves internal mechanisms and contact with air.
• Vessel Response:
  • When skin breaks, blood flows rapidly.
  • Vessel cut ends narrow (vasoconstriction) to reduce blood flow.
  • A clot forms to stop the bleeding.
  • Bleeding won't stop if a clot doesn't form.

Hemophilia

• Patients lack one or more clotting factors.
• Bleeding can occur spontaneously.
• Injuries, even small ones, can be life-threatening.
• Require immediate transport.
• Still need bleeding control methods.
• Blood feels like normal blood but lacks clotting factors.
• Patients on blood thinners may require more effort to stop bleeding.

Internal Bleeding

• Can be serious due to difficulty in detection.
• Interior damage to internal organs results in extensive internal bleeding.
• Causes:
  • Stomach ulcer
  • Lacerated liver
  • Ruptured spleen
  • Broken bones (especially large bones like the femur).
  • Bone marrow is the site of blood production.
• Signs:
  • Contusions and ecchymosis (bruising).
• High-energy MOI increases suspicion for unseen injuries.
• Can be caused by blunt or penetrating trauma.
• Non-Traumatic Causes:
  • Ruptured ulcers
  • GI bleeds
  • Ruptured ectopic pregnancies
  • Ruptured aneurysms.
• Most common signs:
  • Pain
  • Swelling
  • Distention (gastric or abdominal)
  • Dyspnea
  • Tachycardia
  • Hypotension
  • Hematoma (goose egg)
  • Bruising or ecchymosis
  • Bleeding from any body opening
  • Hematemesis (vomiting blood)
  • Melena (dark, tarry stools - sign of upper GI bleed)
  • Pain, tenderness, bruising, guarding, and swelling during abdominal assessment
  • Broken ribs
  • Bruises over the lower chest
  • Rigid or distended abdomen.

Early Signs of Shock

• Anxiety
• Restlessness
• Air hunger
• Still alert and oriented.

Early Signs of Hemorrhagic Shock or Hypovolemic Shock

• Weakness
• Faintness
• Dizziness
• Pallor
• Changes in skin color.

Later Signs of Hemorrhagic Shock or Hypovolemic Shock

• Changes in vital signs
  • Tachycardia
• Weakness and faintness
• Thirst
• Nausea and vomiting
• Clammy skin
• Shallow but tachypneic respirations
• Eyes may appear dull
• Slightly dilated pupils that are sluggish
• Delayed capillary refill (more than two seconds in infants and children)
• Weak, rapid, or thready pulse
• Diminished blood pressure
• Altered mental status
• Require immediate and high priority transport

Scene Safety

• Prioritize safety: self, partner, then patient.
• Consider spinal immobilization for trauma patients.

Initial Interventions

• Airway, breathing, circulation (ABCs) and intervene as possible.
• Do blood sweep before ABCs.
• Look for red flag vital signs for rapid transport
  • Tachycardia
  • Tachypnea
  • Hypotension
  • Weak pulse
  • Clammy skin
• Treat life-threatening external hemorrhaging first with direct pressure, tourniquets, or hemostatics.
• Limit scene time to ten minutes.
• Get a SAMPLE history and perform a secondary assesment enroute. Assess for blood thinners and allergies.
• Assess for signs of shock.
• Determine the amount of blood loss and photograph scene
• Rapidly transport

Assessment

• Decaf ETLS.
• Assess for tenderness and rigidity on the abdomen
• Asses CMS in all extremities.
• Record vital signs and check frequently.

Reassessment

• Reassess frequently, especially in areas with abnormal findings.
• If patient is unstable or unconscious, repeat full body assessment.
• If a tourniquet is in place, make sure that it is still maintaining pressure and reassess
• For treatments of shock use your treatments:Blanky, oxygen, diesel, ALS

Management

• Suspected internal bleeding: High-flow oxygen via non-rebreather and rapid transport.
• Document the time of injury
• Follow standard precautions and wear appropriate PPE
• Don’t hesitate to wear eye production eye protection or a mask or a gown.

Bleeding Control Methods

• First thing you will do is Direct Pressure
  • The most common and effective way to stop bleeding.
  • Gloved hand and sterile dressing.
  • Apply direct pressure and apply weight to close vessels
  • If there is an object protruding from the wound, put bulky dressings around it.
  • Hold pressure for at least five minutes before reassessing.
• Pressure Dressings or Pressure Splints
  • Wrap firmly in a roll bandage for the entire wound till bleeding stops.
  • Ensure a pulse can still be palpated.
• Touirniquets
  • For substantial bleeding from an external injury that cannot be controlled with direct pressure.
  • Apply tourniquet above the level of bleeding and never over a joint.
  • Should be two to three inches above the wound and not over a point
• Junctional Tourniquet
  • This can be used on pelvis and shoulders
• Hemostatic Dressing
  • Impregnated with clotting factors, the fine powder clots the blood when contact
  • Pack the wounds with direct pressure.
  • Gauze can be packed into larger wounds where a tourniquet is not possible.
• A combination of all of the above can be used to control bleeding
• Just because direct pressure is good at one point doesn't mean it will be good 10 minutes from now.
• You can change your mind when treating a wound.
• There are several different types of commercial tourniquets avaialble.
• Know that air splints exist, but they are not common.

Pelvic Binder

• Specific type of splint indicated for a suspected closed unstable pelvic fracture.
• Hip Dislocation and pelvic fracture are two totally different things, so only for Pelvic fractures.
• Pelvic Binders are only for fractures and helps control bleeding.
• Pelvis has large bones, bones are the site of marrow and high risk of hemmorage.
• This isn't an immediate intervention but can wait since you have 20 minutes before bleeds out.
• Only wound immediately stopping the assessment for is sucking chest.

Bleeding from the nose, ears, and mouth

• Significatn bleeding from nose ears and mouths can be trauma signs
• Result from :
  • Skull fracture, facial injuries, sinusitis, use and abuse of nose drops or drugs, crack nasal mucosa, high blood pressure, bleeding disorders, digital trauma, and different types of cancers.
• Epistaxis (nose bleed) can be emergent, espcially with blood thinners or hemophillia
• Most patients with nose bleeds will swallow large amounts of blood
• Control non traumatic bleeds by patient pinching nose leaning forward.
• Halo sign is a way to detect cerebral spinal fluid
• CSF normally in spinal cord, but can be found in back for severe injuries. but commonly back of head and neck.

Interal Bleeding

• Requires surgery
• There is nothing to do to help in field other than maybe give blood and fluids.
• Treatment will be surgical
• Keep patient calm, quiet and still.
• Proved high flow O2
• Splint injury
• Ensure airway is free for breathing
• Control bleeding via pressure, turniquets, hemostats.