Last saved by: JRGinder

Chapter 23
National EMS Education Standard Competencies (1 of 3)
Trauma
Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.
National EMS Education Standard Competencies (2 of 3)
Bleeding
•	Recognition and management of:
–	Bleeding
•	Pathophysiology, assessment, and management of:
–	Bleeding

National EMS Education Standard Competencies (3 of 3)
Pathophysiology
Applies fundamental knowledge of the pathophysiology of respiration and perfusion to patient assessment and management.
Introduction
•	Important to be able to:
–	Recognize bleeding
–	Understand how bleeding affects the body 
•	Bleeding can be external or internal.
•	Bleeding can cause weakness, shock, and death.
Anatomy and Physiology of the Cardiovascular System 
(1 of 3)
•	Functions of the cardiovascular system
–	Circulate blood to cells and tissues
–	Deliver oxygen and nutrients
–	Carry away metabolic waste products
Anatomy and Physiology of the Cardiovascular System (2 of 3)
Anatomy and Physiology of the Cardiovascular System 
(3 of 3)
•	Three parts
–	Pump (heart)
–	Container (blood vessels)
–	Fluid (blood and body fluids)
The Heart (1 of 4)
•	The heart is a hollow muscular organ about the size of a clenched fist.
•	Has its own regulatory system
•	Works as two paired pumps
–	Upper chamber (atrium)
–	Lower chamber (ventricle)
The Heart (2 of 4)
•	Blood leaves each chamber through a one-way valve.
•	Right side receives oxygen-poor blood from veins
•	Left side supplies oxygen-rich blood to arteries
The Heart (3 of 4)
The Heart (4 of 4)
Blood Vessels (1 of 4)
•	Arteries
–	Small blood vessels that carry blood away from the heart
•	Arterioles
–	Smaller vessels that connect the arteries and capillaries

Blood Vessels (2 of 4)
•	Capillaries
–	Small tubes that link arterioles and venules
•	Venules
–	Very small, thin-walled vessels that empty into the veins
•	Veins
–	Blood vessels that carry blood from the tissues to the heart
Blood Vessels (3 of 4)
•	As blood flows out of the heart, it passes into the aorta, the largest artery in the body.
•	Oxygen and nutrients easily pass from the capillaries into the cells, and waste and carbon dioxide diffuse from the cells into the capillaries.
Blood Vessels (4 of 4)
Blood (1 of 3)
•	Red blood cells
–	Responsible for the transportation of oxygen to the cells
–	Responsible for transporting carbon dioxide away from the cells to the lungs
•	White blood cells
Blood (2 of 3)
Blood (3 of 3)
•	Platelets
–	Responsible for forming clots
–	A blood clot forms depending on blood stasis, changes in the vessel walls, and the body’s ability to clot.
•	Plasma
Autonomic Nervous System
•	Constantly adapting to maintain homeostasis and perfusion 
•	Monitors the body’s needs 
•	Adjusts blood flow and vascular tone 
•	Automatically redirects blood away from other organs to the heart, brain, lungs, and kidneys in an emergency
Pathophysiology and Perfusion (1 of 5)
•	Blunt trauma can cause injury and significant bleeding that is unseen inside a body cavity or region.
•	Significant amounts of blood loss cause hypoperfusion, or shock.
–	In penetrating trauma, the patient may have only a small amount of bleeding that is visible.
Pathophysiology and Perfusion (2 of 5)
•	Perfusion is the circulation of blood within an organ or tissue to meet the cells’ needs for oxygen, nutrients, and waste removal.
Pathophysiology and Perfusion (3 of 5)
•	Some tissues need a constant supply of blood while others can survive with very little.
Pathophysiology and Perfusion (4 of 5)
•	All organs and organ systems are dependent on adequate perfusion to function properly.
–	Death of an organ system can quickly lead to death of the person.
Pathophysiology and Perfusion (5 of 5)
•	The heart requires a constant supply of blood.
–	Brain and spinal cord may last 4 to 6 minutes.
–	Kidneys may survive 45 minutes.
–	Skeletal muscles may last 2 hours.
–	Times are based on a normal body temperature.
External Bleeding
•	Hemorrhage means bleeding.
•	Examples include nosebleeds and bleeding from open wounds.
•	As an EMT, you must understand how to control external bleeding.

Significance of External Bleeding (1 of 4)
•	With serious external bleeding, it may be difficult to tell the amount of blood loss.
•	Presentation and assessment of the patient will direct care and treatment. 
•	Body will not tolerate a blood loss greater than 20% of blood volume.
Significance of External Bleeding (2 of 4)
•	Significant changes in vital signs may occur if the typical adult loses more than 1 L of blood.
–	Increase in heart rate
–	Increase in respiratory rate
–	Decrease in blood pressure
Significance of External Bleeding (3 of 4)
•	How well people compensate for blood loss is related to how rapidly they bleed.
–	An adult can comfortably donate 1 unit 
(500 mL) of blood over 15 to 20 minutes.
–	If a similar blood loss occurs in a much shorter time, the person may rapidly develop hypovolemic shock.
–	Consider age and preexisting health.
Significance of External Bleeding (4 of 4)
•	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
Characteristics of External Bleeding (1 of 2)
•	Arterial bleeding
–	Pressure causes blood to spurt and makes bleeding difficult to control.
–	Typically brighter red and spurts in time with the pulse
•	Venous bleeding
–	Dark red, flows slowly or severely
–	Does not spurt and is easier to manage
Characteristics of External Bleeding (2 of 2)
•	Capillary bleeding
–	Bleeding from damaged capillary vessels
–	Dark red, oozes steadily but slowly
Clotting (1 of 2)
•	Bleeding tends to stop rather quickly, within about 10 minutes.
–	When a person is cut, blood flows rapidly.
–	The cut end of the vessel begins to narrow, reducing the amount of bleeding.
–	Then a clot forms.
–	Bleeding will not stop if a clot does not form.
Clotting (2 of 2)
•	Despite the efficiency of the system, it may fail in certain situations.
–	Movement
–	Medications
–	Removal of bandages
–	External environment
–	Body temperature
–	Severe injury
Hemophilia
•	Patient lacks blood clotting factors.
•	Bleeding may occur spontaneously.
•	All injuries, no matter how trivial, are potentially serious.
•	Patients should be transported immediately.
Internal Bleeding (1 of 2)
•	Bleeding in a cavity or space inside the body
•	Can be very serious, yet with no outward signs
–	Injury or damage to internal organs commonly results in extensive internal bleeding.
–	Can cause hypovolemic shock
Internal Bleeding (2 of 2)
•	Possible conditions causing internal bleeding:
–	Stomach ulcer 
–	Lacerated liver 
–	Ruptured spleen 
–	Broken bones, especially the ribs or femur 
–	Pelvic fracture
MOI for Internal Bleeding (1 of 3)
•	High-energy MOI
•	Internal bleeding is possible whenever the MOI suggests that severe forces affected the body.
–	Blunt trauma
–	Penetrating trauma
MOI for Internal Bleeding (2 of 3)
•	Signs of injury (DCAP-BTLS)
–	Deformities
–	Contusions
–	Abrasions
–	Punctures/penetrations
MOI for Internal Bleeding (3 of 3)
•	Signs of injury (DCAP-BTLS) (cont’d)
–	Burns
–	Tenderness
–	Lacerations
–	Swelling

NOI for Internal Bleeding (1 of 3)
•	Bleeding is not always caused by trauma.
•	Nontraumatic causes include:
–	Bleeding ulcers
–	Bleeding from colon
–	Ruptured ectopic pregnancy
–	Aneurysms
NOI for Internal Bleeding (2 of 3)
•	Frequent signs
–	Abdominal tenderness
–	Guarding
–	Rigidity
–	Pain
–	Distention 
NOI for Internal Bleeding (3 of 3)
•	In older patients, signs include:
–	Dizziness
–	Faintness
–	Weakness
•	Ulcers or other GI problems may cause:
–	Vomiting of blood
–	Bloody diarrhea or urine
Signs and Symptoms of Internal Bleeding (1 of 4)
•	Pain (most common)
•	Swelling in the area of bleeding
•	Distention
•	Bruising
•	Dyspnea, tachycardia, hypotension
•	Hematoma
•	Bleeding from any body opening
Signs and Symptoms of Internal Bleeding (2 of 4)
•	Hematemesis
•	Melena
•	Hemoptysis
•	Broken ribs, bruises over the lower part of the chest, or a rigid, distended abdomen
•	Hypoperfusion
Signs and Symptoms of Internal Bleeding (3 of 4)
•	Later signs of hypoperfusion:
–	Tachycardia
–	Weakness, fainting, or dizziness at rest
–	Thirst
–	Nausea and vomiting
–	Cold, moist (clammy) skin
–	Shallow, rapid breathing
Signs and Symptoms of Internal Bleeding (4 of 4)
•	Later signs of hypoperfusion (cont’d):
–	Dull eyes
–	Slightly dilated pupils
–	Capillary refill of more than 2 seconds in infants and children
–	Weak, rapid (thready) pulse
–	Decreasing blood pressure
–	Altered level of consciousness
Patient Assessment for External and Internal Bleeding
•	Patient assessment steps
–	Scene size-up
–	Primary assessment
–	History taking
–	Secondary assessment
–	Reassessment
Scene Size-up (1 of 2)
•	Scene safety
–	Be alert to potential hazards.
–	At vehicle crashes, ensure the absence of leaking fuel and energized electrical lines.
–	In violent incidents, make sure the police are on the scene.
–	Follow standard precautions.
Scene Size-up (2 of 2)
•	Mechanism of injury/nature of illness
–	Determine the NOI or MOI.
–	Consider the need for spinal stabilization and additional resources.
–	Consider environmental factors such as weather.

Primary Assessment (1 of 4)
•	Do not be distracted from identifying life threats.
•	Form a general impression.
–	Note important indicators of the patient’s condition.
–	Be aware of obvious signs of injury.
–	Determine gender and age.
–	Assess skin color and the LOC.
Primary Assessment (2 of 4)
•	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.
Primary Assessment (3 of 4)
•	Circulation
–	Assess pulse rate and quality.
–	Determine skin condition, color, and temperature.
–	Check capillary refill time.
–	Control external bleeding.
–	Treat for shock.
Primary Assessment (4 of 4)
•	Transport decision
–	Assessment of ABCs and life threats will determine the transport priority.
–	Signs that imply rapid transport:
•	Tachycardia or tachypnea	
•	Low blood pressure
•	Weak pulse
•	Clammy skin
History Taking (1 of 3)
•	Investigate the chief complaint.
–	Look for signs and symptoms of other injuries due to the MOI and/or NOI.
–	You may have identified severe bleeding in the primary assessment.
–	Note obvious signs of internal bleeding.
–	Determine if there are any preexisting illnesses.
History Taking (2 of 3)
History Taking (3 of 3)
•	SAMPLE history
–	Ask the patient about blood-thinning medications.
–	If the patient is unresponsive, obtain history from medical alert tags or bystanders.
–	Look for signs and symptoms of shock.
–	Determine the amount of blood loss.
Secondary Assessment (1 of 5)
•	Record vital signs.
•	Complete a focused assessment of pain.
•	Attach appropriate monitoring devices.
•	With a critically injured patient or a short transport time, there may not be time to conduct a secondary assessment.
Secondary Assessment (2 of 5)
•	Physical examinations
–	Should include a systematic full-body scan
–	Assess the respiratory system.
–	Assess the airway for patency.
–	Determine the rate and quality of respirations.
–	Look for distended neck veins and a deviated trachea.
Secondary Assessment (3 of 5)
•	Physical examinations (cont’d)
–	Check for paradoxical movement of the chest wall and bilateral breath sounds.
–	Assess the cardiovascular, neurologic, and musculoskeletal systems.
–	Determine the level of consciousness.
–	Examine pupil size and reactivity.
–	Assess motor and sensory response.
Secondary Assessment (4 of 5)
•	Assess all anatomic regions.
–	Check the head for raccoon eyes, Battle’s sign, and drainage of blood or fluid from the ears or nose.
–	Feel all four quadrants of the abdomen for tenderness or rigidity.
–	Record pulse, motor, and sensory function in all four extremities.
Secondary Assessment (5 of 5)
•	Vital signs
–	Assess vital signs to observe the changes that may occur during treatment.
–	A systolic blood pressure of less than 100 mm Hg with a weak, rapid pulse should suggest the presence of hypoperfusion.
–	Cool, moist skin that is pale or gray is an important sign.
Reassessment (1 of 3)
•	Repeat the primary assessment in areas that showed abnormal findings.
–	Signs and symptoms of internal bleeding are often slow to present.
•	Assess interventions and treatments.
•	Vital signs show how well your patient is doing internally.
–	In severe cases, assess every 5 minutes.
Reassessment (2 of 3)
•	Interventions
–	Provide high-flow oxygen.
–	Provide treatment for shock and transport rapidly.
–	Do not delay transport of a patient to complete an assessment.
Reassessment (3 of 3)
•	Communication and documentation
–	Communicate all relevant information to the staff at the receiving hospital.
–	Give an estimate of the amount of blood loss that has occurred.
–	Describe the MOI/NOI and the signs and symptoms.
–	Document all injuries, the care provided, and the patient’s response.
Emergency Medical Care for External Bleeding (1 of 2)
•	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.
Emergency Medical Care for External Bleeding (2 of 2)
•	Several methods are available to control external bleeding.
–	Direct, even pressure and elevation
–	Pressure dressings and/or splints
–	Tourniquets
•	It will often be useful to combine these methods.

Direct Pressure (1 of 2)
•	Most effective 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 top of a sterile dressing.
Direct Pressure (2 of 2)
•	Never remove an impaled object from a wound.
•	Hold uninterrupted pressure for at least 5 minutes.
Elevation
•	Elevate a bleeding extremity by as little as 6" while applying direct pressure.
•	Never elevate an open fracture to control bleeding.
–	Fractures can be elevated after splinting.
–	Splinting helps control bleeding.
Pressure Dressing (1 of 2)
•	Firmly wrap a sterile, self-adhering roller bandage around the entire wound.
•	Cover the entire dressing above and below the wound.
•	Stretch the bandage tight enough to control bleeding.
–	You should still be able to palpate a distal pulse.
Pressure Dressing (2 of 2)
•	Do not remove a dressing until a physician has evaluated the patient.
•	Bleeding will almost always stop when the pressure of the dressing exceeds arterial pressure.
•	Follow the steps in Skill Drill 23-1.
Tourniquet (1 of 3)
•	If direct pressure fails, apply a tourniquet above the level of bleeding.
•	It should be applied quickly and not released until a physician is present.
•	Follow the steps in Skill Drill 23-2 to apply a commercial tourniquet.
Tourniquet (2 of 3)
•	Observe the following precautions:
–	Do not apply a tourniquet directly over any joint.
–	Make sure the tourniquet is tightened securely.
–	Never use wire, rope, a belt, or any other narrow material.
–	Use wide padding under the tourniquet.
Tourniquet (3 of 3)
•	Precautions (cont’d):
–	Never cover a tourniquet with a bandage.
–	Do not loosen the tourniquet after you have applied it.
Splints (1 of 4)
•	Air splints
–	Can control internal or external bleeding associated with severe injuries
–	Stabilize fractures
–	Act like a pressure dressing
–	Commonly referred to as soft splints or pressure splints
Splints (2 of 4)
•	Air splints (cont’d)
–	Once the splint is applied, monitor circulation in the distal extremity.
–	Use only approved, clean, or disposable valve stems.
Splints (3 of 4)
•	Rigid splints
–	Can help stabilize fractures
–	Reduce pain
–	Prevent further damage to soft-tissue injuries
–	Once the splint is applied, monitor circulation in the distal extremity.
Splints (4 of 4)
•	Traction splints
–	Designed to stabilize femur fractures
–	When the EMT pulls traction to the ankle, countertraction is applied to the ischium and groin.
–	Once the splint is applied, monitor circulation in the distal extremity.
Bleeding From the Nose, Ears, and Mouth (1 of 3)
•	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
Bleeding From the Nose, Ears, and Mouth (2 of 3)
•	Epistaxis (nosebleed) is a common emergency.
–	Occasionally it can cause enough blood loss to send a patient into shock.
–	Can usually be controlled by pinching the nostrils together
•	Follow the steps in Skill Drill 23-3 to control epistaxis.
Bleeding From the Nose, Ears, and Mouth (3 of 3)
•	Bleeding from the nose or ears following a head injury:
–	May indicate a skull fracture
–	May be difficult to control
–	Do not attempt to stop blood flow.
–	Loosely cover the bleeding site with a sterile gauze pad.
–	Apply light compression with a dressing.
Emergency Medical Care for Internal Bleeding (1 of 2)
•	Usually requires surgery or other hospital procedures
•	Keep the patient calm, reassured, and as still and quiet as possible.
•	If spinal injury is not suspected, place the patient in the shock position.
•	Provide high-flow oxygen.
Emergency Medical Care for Internal Bleeding (2 of 2)
•	Maintain body temperature.
•	Splint the injured extremity (usually with an air splint).
•	Never use a tourniquet to control bleeding from closed, internal, soft-tissue injuries.
•	Follow the steps in Skill Drill 23-4.
Summary (1 of 6)
•	Perfusion is the circulation of blood in adequate amounts to meet the cells’ current needs for oxygen, nutrients, and waste removal.
Summary (2 of 6)
•	The cardiovascular system has three main components:
–	Pump (heart)
–	Container (blood vessels)
–	Fluid (blood and bodily fluids)
Summary (3 of 6)
•	Hypoperfusion (shock) occurs when the cardiovascular system fails to provide adequate perfusion.
•	Both internal and external bleeding can cause shock. You must know how to recognize and control both.
Summary (4 of 6)
•	The methods to control bleeding, in order, are:
–	Direct, even pressure
–	Elevation
–	Pressure dressings
–	Tourniquets
–	Splinting device

Summary (5 of 6)
•	Bleeding around the face always presents a risk of airway obstruction or aspiration.
•	Any patient you suspect of having internal bleeding or significant external bleeding should be transported promptly. 
Summary (6 of 6)
•	Signs of serious internal bleeding:
–	Vomiting blood (hematemesis)
–	Black tarry stools (melena)
–	Coughing up blood (hemoptysis)
–	Distended abdomen
–	Broken ribs