BLEEDING

State Standards 24) Research and evaluate National Trauma Triage Protocol. Identify and perform skills to manage life threatening injuries based on assessment findings of a patient with trauma emergencies, utilizing rubrics from textbooks, National HOSA guidelines, or clinical standards of practice in the following areas: a. Internal and external bleeding b. Chest trauma such as sucking chest wound and impaled objects in chest c. Abdominal trauma such eviscerations and impaled objects d. Orthopedic trauma such as fractures, dislocations, amputations e. Soft tissue trauma, burns, dressings, and bandages f. Head, facial, neck and spine trauma such as head injuries, scalp injuries, and injuries to spine g. Environmental emergencies such as submersion and exposure to heat and cold h. Multi-system trauma

Objectives Students will be able to… Determine types of bleeding Treatments for bleeding Apply direct pressure and a dressing Recognize and treat shock due to blood loss

Bleeding Body substance isolation (BSI) precautions Risk of infectious disease should always be assessed and minimized when caring for bleeding patients. Discussion Question: Is it necessary to wear gloves, goggles, mask, and gown when treating all patients that are bleeding?

Bleeding Body's automatic response to bleeding is blood vessel constriction and clotting. Severity of blood loss based on patient's signs and symptoms and estimation of visible blood loss. Shock Decreased ability to clot

Bleeding External Bleeding Arterial bleeding Arteries carrying blood away from heart are damaged. Bright red and spurting action with each beat of heart Discussion Question: Why does arterial bleeding and venous bleeding present differently? continued on next slide

Bleeding External Bleeding Venous bleeding Vessels that return blood to heart are damaged. Steady flow of dark red blood Discussion Question: Why does arterial bleeding and venous bleeding present differently? continued on next slide

Bleeding External Bleeding Capillary bleeding Slow oozing of bright red blood from tissues Minor scrapes and abrasions to skin Discussion Question: Why does capillary bleeding present as such?

Figure 18.3 Three types of bleeding.

Bleeding Evaluating External Bleeding Arterial bleeding is the most serious. May take several minutes or more to clot Bleeding from deep vein can produce rapid blood loss. Discussion Question: Why would an airway problem take priority over a bleeding problem? What are the exceptions? Discuss the concept of "tunnel vision" as it relates to the EMR getting too focused on a dramatic injury at the expense of missing a more subtle, critical problem. continued on next slide

Bleeding Evaluating External Bleeding Surface bleeding from vein can be profuse. Blood loss is not as rapid. Capillary bleeding requires care to stop blood flow and reduce contamination. Discussion Question: Why would an airway problem take priority over a bleeding problem? What are the exceptions? Discuss the concept of "tunnel vision" as it relates to the EMR getting too focused on a dramatic injury at the expense of missing a more subtle, critical problem.

Bleeding Controlling External Bleeding Three steps Direct pressure Pressure bandage Elevation combined with direct pressure Tourniquet Teaching Tip: Using a student volunteer, demonstrate application of direct pressure and elevation of an upper extremity.

18.1.1 Use BSI precautions. continued on next slide

Bleeding Direct Pressure Most external bleeding is controlled by direct pressure. Never remove or attempt to replace dressing applied directly to the wound May interrupt clot formation and restart bleeding. continued on next slide

Bleeding Direct Pressure Pressure bandage should not be removed once in place. If you used your gloved hand or dressing to apply direct pressure, you can apply pressure bandage once bleeding is controlled. Class Activity: Distribute bandages and direct students to work in pairs to practice applying direct pressure to a simulated wound on an upper extremity.

Figure 18.4 In cases of profuse bleeding, use your gloved hand to apply pressure to the wound. Do not waste time hunting for a dressing.

Bleeding Elevation May be used in combination with direct pressure when dealing with bleeding from arm or leg Effects of gravity help reduce blood pressure at wound and slow bleeding. Do not elevate fractures to extremities or spine injury. Class Activity: Distribute bandages and direct students to work in pairs to practice applying direct pressure as well as elevation to a simulated wound on an upper extremity.

Bleeding Tourniquet Device used to cut off all blood supply past point of application Used only when other methods of controlling life-threatening bleeding (direct pressure, elevation) have failed Teaching Tip: Using a manikin, demonstrate the use of a tourniquet. Review local protocols regarding EMR authorization to use a tourniquet.

Bleeding Hemostatic Dressings and Agents Dressings treated with specialized chemical that when placed onto wound, promote clotting Agents in form of powder-like substance that can be poured directly into open wound to help promote clotting Teaching Tip: Review local protocols regarding EMR authorization to use hemostatic dressings and agents.

Figure 18.6 Examples of hemostatic dressings.

Bleeding Dressing and Bandaging Dressing Bandage Material (preferably sterile) placed over wound to help control bleeding and prevent contamination Bandage Material used to hold dressing in place Teaching Tip: Provide a variety of dressings and bandages (both packaged and unpackaged) for students to examine. continued on next slide

Bleeding Dressing and Bandaging Bulky dressings (multi-trauma) Thick dressings, often large enough to allow for complete covering of large wounds Occlusive dressings Sterile gauze saturated with petroleum jelly Creates airtight seal Teaching Tip: Provide a variety of bulky dressings and occlusive dressings (both packaged and unpackaged) for students to examine. continued on next slide

Bleeding Dressing and Bandaging Improvised dressings Clean handkerchiefs, towels, sheets, or a piece of clothing Will not be sterile, but can help provide proper emergency care for patient Teaching Tip: Provide a variety of improvised dressings and bandages for students to examine. What other items could be used if commercial products are unavailable? continued on next slide

Bleeding Dressing and Bandaging Bandages Roller gauze, cravats, handkerchief, strips of cloth, and material that will not cut into patient's skin Avoid use of elastic bandages. Self-adherent, form-fitting roller bandage makes bandaging easier. Critical Thinking: Why should the use of elastic bandages be avoided? continued on next slide

Bleeding Dressing and Bandaging Do not bandage too tightly. Do not bandage too loosely. Do not leave loose ends. Do not cover fingers and toes unless they are injured. Critical Thinking: Why should you avoid covering fingers and toes unless they are injured? continued on next slide

Bleeding Dressing and Bandaging Wrap bandage around limb starting at its far end and working toward its origin or near end. Check distal circulation, sensation, and motor function before and after bandaging. Class Activity: Direct students to work in pairs to demonstrate the proper techniques for controlling external bleeding, including checking distal circulation, sensation, and motor function. Circulate around the room to monitor progress and provide guidance.

Figure 18.7a Begin by securing the end of the bandage with several overlapping wraps. continued on next slide

Bleeding Internal Bleeding Ranges from minor bruise to major life-threatening problem Can bring about shock, heart and lung failure, and eventual death Caused by wounds deep enough to sever major blood vessels or vessels within organ Discussion Question: How might you recognize internal bleeding? What are the signs and symptoms? continued on next slide

Bleeding Internal Bleeding Blunt trauma Penetrating trauma Caused by impact with large objects or surfaces Non-penetrating trauma Penetrating trauma Caused by object that punctures skin Pay special attention to bruises on neck, chest, and abdomen.

Figure 18. 13 Often a puncture wound has very little external bleeding Figure 18.13 Often a puncture wound has very little external bleeding. (© Edward T. Dickinson, MD)

Bleeding Signs of Shock with Internal Bleeding Decreasing level of responsiveness Restlessness or combativeness Shaking and trembling Shallow and rapid breathing Rapid and weak pulse Pale, cool, moist skin Dilated (enlarged) pupils May respond sluggishly Class Activity: Direct students to work in pairs to demonstrate the proper care for a patient with suspected internal bleeding. Circulate around the room to monitor progress and provide guidance.

Think About It You are assessing a 30-year-old male who fell about 20 feet while working on a utility pole. He has pale skin, a rapid pulse, and a slightly altered mental status. There is no obvious blood loss. Could this patient be in shock? Could blood loss be an issue? How will you proceed?

Activity ***We have now met all of our objectives -You will now demonstrate how to treat bleeding of various extremities using provided scenarios. You must state the PPE that you would need before giving treatment Create an education brochure that details how to give first aid in a situation with heavy bleeding. Include information about how to apply a tourniquet, use pressure points to decrease bleeding, how to bandage a site of bleeding. What to do if you can not stop the bleeding. -Research and correctly identify all of the major pulse points and draw a diagram for your reference. Exit ticket: In at least 2 sentences, explain when and how you could use pulse points to control heavy bleeding.