1. BLEEDING

2. 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
Standard 19: NoseBleeds

3. 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

4. Bell Work
What would you want to access on a patient before splinting an injury?
When would a paramedic manually align a dislocated bone?
What three items would you need to observe before and after splinting?

5. 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?

6. Use BSI precautions.
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7. Bleeding = Hemorrhage
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 ( medical emergency in which the organs and tissues of the body are not receiving an adequate flow of blood. This deprives the organs and tissues of oxygen (carried in the blood) and allows the buildup of waste products.
Decreased ability to clot

8. Bleeding External Bleeding Arterial bleeding
Arteries carrying blood away from heart are damaged.
Bright red and spurting action with each beat of heart
Arterial bleeding is the most serious.
May take several minutes or more to clot
Discussion Question: Why does arterial bleeding and venous bleeding present differently?
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9. Bleeding External Bleeding Venous bleeding
Vessels that return blood to heart are damaged.
Steady flow of dark red blood
Bleeding from deep vein can produce rapid blood loss.
Discussion Question: Why does arterial bleeding and venous bleeding present differently?
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10. Bleeding External Bleeding Capillary bleeding
Slow oozing of bright red blood from tissues
Minor scrapes and abrasions to skin
Capillary bleeding requires care to stop blood flow and reduce contamination.
Discussion Question: Why does capillary bleeding present as such?

11. Figure 18.3 Three types of bleeding.

12. Controlling Bleeding Three steps 1. Direct pressure Pressure bandage
2. Elevation – above heart level so blood can clot
3. Tourniquet- Arterial constriction band. This is a life over limb scenario. Why?
Teaching Tip: Using a student volunteer, demonstrate application of direct pressure and elevation of an upper extremity.

13. 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.
If you used your gloved hand or dressing to apply direct pressure, you can apply pressure bandage once bleeding is controlled.
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14. In cases of profuse bleeding, use your gloved hand to apply pressure to the wound. Do not waste time hunting for a dressing.

15. 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
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 dressings and bandages (both packaged and unpackaged) for students to examine.

16. 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?
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17. 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?
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18. 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.

19. Figure 18.7a Begin by securing the end of the bandage with several overlapping wraps.
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20. Applying Bandage/Dressing
Arm Wound
Shoulder

21. 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.

22. 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.

23. 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
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Teaching Tip: Using a manikin, demonstrate the use of a tourniquet. Review local protocols regarding EMR authorization to use a tourniquet.

24. 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

25. Internal Bleeding Blunt 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.

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

27. 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.

28. GI Bleeding – Standard 19 d
Bleeding occurs in any part of the gastrointestinal tract. The GI tract includes your esophagus, stomach, small intestine, large intestine (colon), rectum, and anus.
GI bleeding itself is not a disease, but a symptom of any number of conditions.
First appears as blood in the vomit or stool
Severe Abdominal Pain, SOB, Weak, Fatigue, Pale Skin
Serious gastrointestinal bleeding can destabilize the vital signs of a patient. The patient's blood pressure may fall sharply, and his or her heart rate may increase

29. 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?

30. Activity Choose your partner and each choose an injury
Bandage your partner’s injury (page )
Practice splinting
Practice applying tourniquet

31. Amputations Read Link on Web Site
Write one paragraph summarizing article and put in notebook.
A paragraph is one topic sentence with 5-7 supporting sentences and a closing sentence.