1. Chapter 23
Bleeding

2. 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.

3. 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

4. Anatomy and Physiology of the Cardiovascular System (2 of 3)

5. Anatomy and Physiology of the Cardiovascular System (3 of 3)
Three parts
Pump (heart)
Container (blood vessels)
Fluid (blood and body fluids)

6. 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)

7. 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

8. The Heart (3 of 4)

9. The Heart (4 of 4)

10. Blood Vessels (1 of 4) Arteries Arterioles
Small blood vessels that carry blood away from the heart
Arterioles
Smaller vessels that connect the arteries and capillaries

11. Blood Vessels (2 of 4) Capillaries Venules Veins
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

12. 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.

13. Blood Vessels (4 of 4)

14. Blood (1 of 3) Red blood cells White 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

15. Blood (2 of 3)
Source: © Phototake/Alamy Images

16. Blood (3 of 3) Platelets Plasma 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

17. 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

18. 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.

19. 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.

20. Pathophysiology and Perfusion (3 of 5)
Some tissues need a constant supply of blood while others can survive with very little.

21. 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.

22. 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.

23. External Bleeding Hemorrhage means bleeding.
Examples include nosebleeds and bleeding from open wounds.
As an EMT, you must understand how to control external bleeding.

24. 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.

25. 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

26. 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.

27. 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

28. 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

29. Characteristics of External Bleeding (2 of 2)
Capillary bleeding
Bleeding from damaged capillary vessels
Dark red, oozes steadily but slowly
Capillary
Venous
Arterial

30. 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.

31. 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

32. Hemophilia Patient lacks blood clotting factors.
Bleeding may occur spontaneously.
All injuries, no matter how trivial, are potentially serious.
Patients should be transported immediately.

33. 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

34. 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

35. 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

36. MOI for Internal Bleeding (2 of 3)
Signs of injury (DCAP-BTLS)
Deformities
Contusions
Abrasions
Punctures/penetrations

37. MOI for Internal Bleeding (3 of 3)
Signs of injury (DCAP-BTLS) (cont’d)
Burns
Tenderness
Lacerations
Swelling

38. 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

39. NOI for Internal Bleeding (2 of 3)
Frequent signs
Abdominal tenderness
Guarding
Rigidity
Pain
Distention

40. 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

41. 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

42. 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

43. 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

44. 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

45. Patient Assessment for External and Internal Bleeding
Patient assessment steps
Scene size-up
Primary assessment
History taking
Secondary assessment
Reassessment

46. 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.

47. 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.

48. 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.

49. 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.

50. 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.

51. 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
Tachycardia

52. 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.

53. History Taking (2 of 3)

54. 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.

55. 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.

56. 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.

57. 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.

58. 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.

59. 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.

60. 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.

61. 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.

62. 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.

63. 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.

64. 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.

65. 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.

66. Direct Pressure (2 of 2) Never remove an impaled object from a wound.
Hold uninterrupted pressure for at least 5 minutes.

67. 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.

68. 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.

69. 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.

70. 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.

71. 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.

72. Tourniquet (3 of 3) Precautions (cont’d):
Never cover a tourniquet with a bandage.
Do not loosen the tourniquet after you have applied it.

73. 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

74. 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.

75. 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.

76. 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.

77. 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

78. 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.

79. 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.

80. 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.

81. 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.

82. 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.

83. Summary (2 of 6) The cardiovascular system has three main components:
Pump (heart)
Container (blood vessels)
Fluid (blood and bodily fluids)

84. 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.

85. Summary (4 of 6) The methods to control bleeding, in order, are:
Direct, even pressure
Elevation
Pressure dressings
Tourniquets
Splinting device

86. 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.

87. Summary (6 of 6) Signs of serious internal bleeding:
Vomiting blood (hematemesis)
Black tarry stools (melena)
Coughing up blood (hemoptysis)
Distended abdomen
Broken ribs