Notes on Bleeding, Clotting, Trauma Assessment, and Shock Management

Fibrin and clot formation

  • Fibrin is the solidified protein mesh that forms the clot; the word fibrin evokes “fiber.” When you see a scab, you’re observing solidified fibrin that creates a woven pattern, which is the body’s way of stabilizing a wound and starting the healing/clotting process.
  • Clotting is a coordinated cascade: platelets gather and fibrin strands weave to form a stable clot. Medications can interfere with this normal clotting process, affecting our ability to control bleeding.

Medications that affect clotting

  • Blood thinners is a general term; in practice includes anticoagulants and antiplatelet drugs.
  • Aspirin:
    • Not strictly a blood thinner; it is an anticoagulant in common usage, specifically an antiplatelet medication.
    • It prevents platelets from gathering and cooperating to form a clot, rather than “thinning” blood per se.
    • It has multiple uses: antiplatelet, antipyretic (fever reduction), and analgesic (pain relief).
  • A fib and clot risk:
    • Atrial fibrillation (AFib) increases the risk of clot formation; people may take aspirin to reduce this risk, but it is not a guarantee against clots.
  • Warfarin (Coumadin):
    • A common oral anticoagulant; requires regular blood monitoring and dose adjustments (INR checks) to maintain therapeutic levels.
    • Reversal antidote: vitamin K is used to reverse warfarin’s effects.
  • Eliquis (apixaban) and other direct oral anticoagulants (DOACs):
    • Do not require routine INR monitoring like warfarin.
    • Historically, no widely available antidote for Eliquis existed for a long time; newer antidotes have since been developed, but the speaker couldn’t recall the exact antidote at that moment.
  • Warfarin/Coumadin is sometimes used for conditions like AFib to prevent clot formation; Coumadin is also the same drug used as a rat poison (warfarin) in rodent control products, which is why some households may recognize it under different names or formulations.
  • Hemophilia (genetic clotting disorder):
    • People with hemophilia lack certain clotting factors, leading to impaired clotting and excessive bleeding.
    • The lecture mentions a royal family with hemophilia and historical inbreeding consequences; also references the Tudors and a fictional/entertaining framing (Game of Thrones) to illustrate the seriousness of clotting disorders.

Trauma triad of death and its management

  • Trauma triad of death consists of:
    • Hypothermia (cold body temperature)
    • Coagulopathy (impaired clotting)
    • Acidosis (excess acid in the body, due to poor perfusion and hypoxia)
  • Management principles (EMT Level)
    • Hypothermia: keep the patient warm with blankets; consider warm IV fluids when appropriate; avoid overheating or exposing too much warmth that could be unsafe.
    • Coagulopathy: bleeding control is essential; ensure ongoing assessment and therapy to stop bleeding.
    • Acidosis: improve oxygen delivery to tissues; provide high-flow oxygen to help correct hypoxia and acidosis.
  • Practical framing: in shock care, the core actions are threefold: warm the patient, stop the bleed, and optimize oxygen delivery.

Shock treatment basics (EMT emphasis)

  • The three core actions to save a shock patient:
    • Warm blanket to preserve body temperature and prevent further hypothermia.
    • High-flow oxygen to correct hypoxia and acidosis.
    • Positioning to optimize perfusion and fluid distribution (see below).
  • The underlying message remains: these three actions are foundational regardless of advanced interventions.

External hemorrhage management

  • Immediate priorities:
    • Control life-threatening external bleeding first; if you see major bleeding, stop it before focusing on airway or breathing.
    • Use direct pressure and dressings to control bleeding.
    • If bleeding is uncontrolled, apply a tourniquet (CAT tourniquet) on extremities.
  • Basic principles:
    • Do not remove gauze that has started clotting; instead, add more gauze on top to maintain pressure and continue clot formation.
    • If direct pressure and dressings fail, advance to hemostatic agents (e.g., QuickClot), wound packing, or tourniquet.
  • Tourniquet specifics:
    • Cat tourniquet (Combat Application Tourniquet) is the preferred device; practice in labs.
    • Place tourniquet at least 2\text{ inches} above the bleeding site and as close to the body as possible.
    • Tighten until bleeding stops; the goal is hemorrhage control rather than preserving distal pulses (the distal pulse may be lost when the tourniquet is effective, which is acceptable to save life).
  • Other devices and concepts:
    • Pelvic splint / tourniquet can provide pelvic stabilization and help control bleeding from the groin area.
    • MAST trousers (military anti-shock trousers) are rarely used; historically inflated trousers to shift blood toward the core; now generally discouraged or restricted but discussed for potential reintroduction under local protocols.
    • Hemostatic dressings and wound packing with products like QuickClot may be used; expect to practice with these in labs.
    • For head trauma with bleeding from the ear, do not insert anything into the ear canal; focus on external bleeding control and take the patient to definitive care.
  • Special bleeding scenarios:
    • Digital trauma (fingers, nose, ears) and nosebleeds: manage with direct pressure and humidified environment to prevent mucosal drying.
    • Head trauma with suspected skull fracture: halo testing may be used to assess cerebrospinal fluid leakage (described below).
  • Environmental and protective notes:
    • Blood can look different on various surfaces; be mindful of visibility depending on glove color and surface background; dark gloves may obscure blood visibility.
    • Personal safety and PPE: minimize exposure to bodily fluids and work with additional help when multiple patients are involved.

Halo test and cranial injuries

  • Internal hemorrhage indicators include possible CSF leakage from ears or nose.
  • Halo test: dab a small quantity of the fluid onto a white gauze or dressing; if CSF is present, a pale ring (halo) will form around the central bloodstain.
    • A positive halo test suggests cranial vault breach with CSF leakage; communicate suspected intracranial injury to the hospital and prepare for neurosurgical involvement.

Assessment workflow and history taking

  • Primary survey focus (X ABCs):
    • X stands for exsanguination; assess for life-threatening external bleeding and control it immediately.
    • A: Airway; B: Breathing; C: Circulation; then proceed to trauma assessment.
    • If major bleeding is present, prioritize bleeding control before airway interventions.
  • Rapid assessment steps:
    • Rapid full-body scan to identify injuries.
    • Determine level of consciousness and responsiveness (AVPU: Alert, Verbal, Pain, Unresponsive).
    • Assess signs of internal bleeding and determine urgency of transport.
  • History gathering (OPQRST and SAMPLE):
    • OPQRST:
    • O = Onset: what were you doing when the pain began?
    • P = Provocation/Palliation: does anything make it better or worse?
    • Q = Quality: describe the pain in your own words; avoid leading questions (no forced two-choice answers).
    • R = Region/Radiation: where is the pain and does it radiate elsewhere?
    • S = Severity: use a 1–10 scale where 10 is the worst pain imaginable; explain that 1 is mild (e.g., stubbing a toe) and 10 is extreme (e.g., childbirth or severe injury).
    • T = Time: duration of the pain and when it started.
    • I = Interventions: what has already been done for the patient (medications, treatments).
    • SAMPLE:
    • S: Signs and symptoms observed
    • A: Allergies
    • M: Medications
    • P: Past medical history
    • L: Last oral intake
    • E: Events leading to the incident
  • Reassessment intervals:
    • If unstable or signs of shock: reassess every 5\text{ minutes}.
    • If stable with no signs of shock: reassess every 15\text{ minutes}.
    • Continuous monitoring and vital signs are essential during transport.

Clinical features and practical nuances

  • Observation of pain and bleeding:
    • Pain is a key symptom; document intensity and quality through OPQRST.
    • Bleeding is a major red flag; manage it promptly to prevent exsanguination.
  • Glove visibility and scene awareness:
    • Glove color can affect visibility of blood; ensure gloves provide good contrast with surfaces to detect contamination or exposure.
  • Scene management and multi-patient care:
    • Call for additional help when patient load exceeds capacity.
    • Prioritize life-saving interventions and transport decisions.
  • Practical cautions:
    • When head trauma involves suspected CSF leakage, avoid inserting objects into ears or nose.
    • In nasal or sinus dryness environment (e.g., heating in winter), mucous membranes dry and bleed more easily; monitor for nosebleeds and trauma.
    • Appreciate the role of thermoregulation and perfusion in trauma care; warming and oxygen delivery are foundational.

Key takeaways and connections

  • The clotting process is a balance between coagulation (fibrin clot formation) and factors that can impede it (medications, genetic conditions like hemophilia).
  • The trauma triad highlights how hypothermia, coagulopathy, and acidosis reinforce each other and worsen outcomes; management focuses on warming, bleeding control, and supporting oxygen delivery.
  • In hemorrhagic emergencies, prioritize stopping external bleeding with direct pressure, dressings, wound packing, hemostatic agents, and, if needed, tourniquets placed correctly.
  • A strong foundation in history-taking (OPQRST and SAMPLE) and rapid assessment (AVPU, X ABCs) guides triage decisions and treatment urgency.

5\text{ minutes}, 15\text{ minutes}, 2\text{ inches}, and other numerical references appear in context to emphasize timing, placement, and thresholds crucial for effective hemorrhage control and shock management.