Control Bleeding and Control Bleeding and Hypovolemic ShockHypovolemic Shock

Core Skills Control Bleeding 2

IntroductionIntroduction

Review methods of controlling bleedingReview methods of controlling bleeding Hemorrhage control save livesHemorrhage control save lives ABC Measures ABC Measures

– Clear the airway/restoring breathingClear the airway/restoring breathing– Stop the bleedingStop the bleeding– Protect the woundProtect the wound– Treat/prevent shockTreat/prevent shock

A-B-C measures apply to A-B-C measures apply to allall injuries injuries

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Right Ventricle

Left Ventricle

Right Atrium Left Atrium

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FunctionFunction of Bloodof Blood

Transport OTransport O² ² and nutrients to the cells and nutrients to the cells

Removes CORemoves CO² ² and other waste products and other waste products

Detoxification and eliminationDetoxification and elimination

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PlasmaPlasma

Serum, protein and chemical substancesSerum, protein and chemical substances Watery, salty fluid Watery, salty fluid Constitutes over half the volume of Constitutes over half the volume of

bloodblood Transports substances to various Transports substances to various

structures structures Transports waste productsTransports waste products Carries red and white blood cells and plateletsCarries red and white blood cells and platelets

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Red Blood CellsRed Blood Cells

ErythrocytesErythrocytes

Primary functionPrimary function

– Carry oxygen to tissues Carry oxygen to tissues

– Carry carbon dioxide Carry carbon dioxide

away from tissuesaway from tissues

Red color to bloodRed color to blood

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White Blood CellsWhite Blood Cells

LeukocytesLeukocytes

Destroy Destroy

microorganismsmicroorganisms

Produce antibodies Produce antibodies

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PlateletsPlatelets

ThrombocytesThrombocytes

Membrane-enclosed Membrane-enclosed

fragments of specialized fragments of specialized

cellscells

Release chemical factors Release chemical factors

to form blood clotsto form blood clots

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PulsesPulses

Left ventricle contractsLeft ventricle contracts Peripheral pulsePeripheral pulse

– RadialRadial

– Brachial Brachial

– Posterior tibialPosterior tibial

– Dorsalis pedisDorsalis pedis Central pulsesCentral pulses

– CarotidCarotid

– FemoralFemoral

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Blood PressureBlood Pressure Exerts pressure against blood vessels walls Exerts pressure against blood vessels walls SystolicSystolic

– Pressure created in the Pressure created in the

arteriesarteries

– Reported firstReported first DiastolicDiastolic

– Left ventricle relaxed and Left ventricle relaxed and

refillingrefilling

– Reported secondReported second

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BloodBlood

Hemorrhage or bleeding Hemorrhage or bleeding Escape of blood from capillaries, veins, Escape of blood from capillaries, veins,

and arteriesand arteries Adult bodyAdult body::

– Contains approximately 5 to 6 liters of bloodContains approximately 5 to 6 liters of blood– 1 pint of blood without harmful effects1 pint of blood without harmful effects– 2 pints may cause shock2 pints may cause shock

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External BleedingExternal Bleeding

IncisionIncision

Laceration Laceration

Abrasion Abrasion

Puncture woundsPuncture wounds

Amputation Amputation

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LacerationLaceration

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Puncture WoundPuncture Wound

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AmputationAmputation

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AbrasionAbrasion

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IncisionIncision

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Internal BleedingInternal Bleeding

Not always obviousNot always obvious

Suspicion based on mechanism of injurySuspicion based on mechanism of injury

– FallsFalls

– Blast injuriesBlast injuries

– Penetrating traumaPenetrating trauma

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Internal BleedingInternal Bleeding

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Injured Internal OrgansInjured Internal Organs

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Sources of BleedingSources of Bleeding

ArterialArterial

Rapid, profuse and pulsating; bright red Rapid, profuse and pulsating; bright red in colorin color

VenousVenous

Steady flow; dark red or maroon in colorSteady flow; dark red or maroon in color CapillaryCapillary

Slow and oozing; often clots Slow and oozing; often clots spontaneouslyspontaneously

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Hypovolemic ShockHypovolemic Shock

Inadequate tissue perfusionInadequate tissue perfusion CausesCauses

HemorrhageHemorrhage

Severe burnsSevere burns

Severe vomiting and/or diarrheaSevere vomiting and/or diarrhea

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Clinical Signs of Acute HemorrhageClinical Signs of Acute Hemorrhage

ClassClass % Blood % Blood LossLoss

Clinical SignsClinical Signs

II Up to 750 Up to 750 ml (15%)ml (15%)

Slight increase in HR; no change in Slight increase in HR; no change in BP or respirationsBP or respirations

IIII 750-1500 750-1500 ml (15-ml (15-30%)30%)

Increased HR and respirations; Increased HR and respirations; increased diastolic BP; anxiety, increased diastolic BP; anxiety, fright or hostilityfright or hostility

IIIIII 1500-2000 1500-2000 ml (30-ml (30-40%)40%)

Increased HR and respirations; fall Increased HR and respirations; fall in systolic BP; significantin systolic BP; significant AMSAMS

IVIV >2000 >2000 (>40%)(>40%)

Severe tachycardia; severe Severe tachycardia; severe lowering of BP; cold, pale skin; lowering of BP; cold, pale skin; severe AMSsevere AMS

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Other Common Signs of Other Common Signs of Hypovolemic ShockHypovolemic Shock

Cold, clammy skinCold, clammy skin Cyanosis- nail beds, lips and ear lobesCyanosis- nail beds, lips and ear lobes Weak, thready, rapid pulseWeak, thready, rapid pulse Shallow respirationsShallow respirations OliguriaOliguria Listlessness, stupor, LOCListlessness, stupor, LOC Excessive thirstExcessive thirst

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Internal Signs of HemorrhageInternal Signs of Hemorrhage

Soft tissue bruisingSoft tissue bruising Abdominal tendernessAbdominal tenderness HemoptysisHemoptysis HematemesisHematemesis MelenaMelena

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Treatment-Direct PressureTreatment-Direct Pressure

First, expose the wound!!!First, expose the wound!!! Place a sterile dressing Place a sterile dressing

over the wound and over the wound and apply pressure apply pressure

Use a bandage or Use a bandage or cravat to tie a knot over the cravat to tie a knot over the dressing covering the wounddressing covering the wound

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Treatment-ElevationTreatment-Elevation

Raise injured extremity above the Raise injured extremity above the heartheart

Used together with direct pressureUsed together with direct pressure Use an object to maintain Use an object to maintain

elevationelevation Utilize bystandersUtilize bystanders

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Treatment-Pressure DressingTreatment-Pressure Dressing

Use a pressure dressing if bleeding Use a pressure dressing if bleeding is NOT controlled with direct is NOT controlled with direct pressurepressure

Place Kerlex, ace wrap or cravat Place Kerlex, ace wrap or cravat over previous dressingover previous dressing

Wrap this dressing over Wrap this dressing over the wound and previous the wound and previous dressing dressing

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Pressure PointsPressure Points

Severe bleedingSevere bleeding Bleeding not controlled by direct pressure Bleeding not controlled by direct pressure

and elevation and elevation Apply pressure to appropriate pressure Apply pressure to appropriate pressure

pointpoint

(

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Pressure PointsPressure Points

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Pressure PointsPressure Points TemporalTemporal

CarotidCarotid

BrachialBrachial

RadialRadial

FemoralFemoral

Posterior/ Posterior/ Anterior Anterior tibialastibialas

(

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Brachial Pressure PointBrachial Pressure Point

Lower part of the upper arm Lower part of the upper arm Above the elbow in the groove between Above the elbow in the groove between

musclesmuscles Using fingers or thumbUsing fingers or thumb Apply pressure to the inside of the arm Apply pressure to the inside of the arm

over the boneover the bone

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Brachial Pressure PointBrachial Pressure Point

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Femoral Pressure PointFemoral Pressure Point

Control severe Control severe bleeding of thigh and bleeding of thigh and lower leglower leg

Front, center part of Front, center part of crease crease in the groin the groin

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Application of Pressure Application of Pressure PointsPoints

Position the casualty on his or her backPosition the casualty on his or her back Kneel on opposite side from woundKneel on opposite side from wound Place heel of hand directly on pressure pointPlace heel of hand directly on pressure point Lean forward to apply pressureLean forward to apply pressure If bleeding is not controlledIf bleeding is not controlled

– Press directly over artery Press directly over artery

– Press heel of other handPress heel of other hand on fingertips on fingertips

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SplintingSplinting

Immobilization is one of the best ways to Immobilization is one of the best ways to stop bleedingstop bleeding

Broken bone fragments may grate on Broken bone fragments may grate on blood vesselsblood vessels

Muscular activity can increase rate of Muscular activity can increase rate of blood flow blood flow

Air splints used to apply direct pressureAir splints used to apply direct pressure

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Air Splints

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TourniquetTourniquet

Direct pressure, elevation, pressure Direct pressure, elevation, pressure dressings or pressure points will not stop dressings or pressure points will not stop some bleedingsome bleeding

In these cases, a In these cases, a tourniquet may be tourniquet may be lifesavinglifesaving

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TourniquetTourniquet

Forceful, arterial bleeding Forceful, arterial bleeding (amputation) may require early (amputation) may require early use of a tourniquet.use of a tourniquet.

DO NOT WASTE TIME attempting a DO NOT WASTE TIME attempting a pressure dressing in these casespressure dressing in these cases

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Tourniquet Tourniquet

Use a cravat, if available. If not, use:Use a cravat, if available. If not, use:

a belta belt

a ropea rope

a BP cuffa BP cuff

roperope

strap from LBEstrap from LBE

or any other material availableor any other material available

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Apply a TourniquetApply a Tourniquet Place tourniquet between heart and woundPlace tourniquet between heart and wound Place pad over artery to be compressedPlace pad over artery to be compressed Wrap tourniquet around extremity Wrap tourniquet around extremity Tie half-knot on upper surfaceTie half-knot on upper surface Place short stick on half-knotPlace short stick on half-knot Tie a square knotTie a square knot Twist stick to tightenTwist stick to tighten UNTIL BLEEDING STOPSUNTIL BLEEDING STOPS

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Apply a TourniquetApply a Tourniquet

Never cover a tourniquetNever cover a tourniquet 'T" on casualty's forehead'T" on casualty's forehead Never loosen or remove a Never loosen or remove a

tourniquettourniquet

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AmputationAmputation

Apply dressing to cover end of the stumpApply dressing to cover end of the stump Control BleedingControl Bleeding

– Blood vessels collapse, retract Blood vessels collapse, retract or curl closed to limit bleedingor curl closed to limit bleeding

– Direct pressure, pressure Direct pressure, pressure dressing or tourniquetdressing or tourniquet

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Preservation of Amputation Preservation of Amputation PartsParts

Rinse amputated part free of debris Rinse amputated part free of debris Wrap loosely in saline-moistened sterile gauzeWrap loosely in saline-moistened sterile gauze Seal amputated part in a plastic bag or cravatSeal amputated part in a plastic bag or cravat Place in a cool container, do not freeze Place in a cool container, do not freeze NeverNever place amputated part in water place amputated part in water NeverNever place amputated part directly on ice place amputated part directly on ice NeverNever use dry ice to cool an amputated part use dry ice to cool an amputated part

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Hemostatic AgentsHemostatic Agents

QuickclotQuickclot hemostatic powder hemostatic powder

ChitosanChitosan hemostatic dressing hemostatic dressing

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Treatment GoalsTreatment Goals

Directed at adequate oxygenation Directed at adequate oxygenation and ventilationand ventilation

STOP THE BLEEDINGSTOP THE BLEEDING Maintain circulation with fluid Maintain circulation with fluid

replacementreplacement

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TreatmentTreatment

ABCsABCs Circulation and hemorrhage controlCirculation and hemorrhage control -IV access-IV access -Control external bleeding -Control external bleeding Baseline vitalsBaseline vitals Brief neuro examBrief neuro exam Position casualty and expose Position casualty and expose

hemorrhage siteshemorrhage sites

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TreatmentTreatment

Maintain body temperatureMaintain body temperature IV fluid administration- 2 large IV fluid administration- 2 large

bore IVsbore IVs Perform serial neurological exams Perform serial neurological exams

every 5 minutesevery 5 minutes Perform vital signs every 5 minutesPerform vital signs every 5 minutes Transport to medical facility ASAPTransport to medical facility ASAP

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HextendHextend

Superficial (> 50% of injuredSuperficial (> 50% of injured

Significant extremity or truncalSignificant extremity or truncal

Significant blood lossSignificant blood loss

• IncoherentIncoherent

• Loss of radial pulse Loss of radial pulse

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Summary Summary

A&P of Circulatory SystemA&P of Circulatory System Identify Hemorrhage and Hypovolemic Identify Hemorrhage and Hypovolemic

ShockShock Provide Treatment for HemorrhageProvide Treatment for Hemorrhage Provide Treatment for Hypovolemic Provide Treatment for Hypovolemic

ShockShock

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QUESTIONS ??QUESTIONS ??