Bleeding and Soft Tissue Trauma

1. Bleeding and Soft Tissue Trauma Chapter 28

2. Objectives • Discuss External Bleeding • Discuss Internal Bleeding • Discuss Factors that may Increase bleeding • Cover Hemorrhagic Shock • Learn about Soft Tissue Trauma • Closed and Open • Discuss Bandages and Dressing

3. External Bleeding - Severity Variables that determine severity of blood loss • Amount of blood loss • Rate of blood loss • Other injuries or existing conditions • Patient’s existing medical conditions • Patient’s age The severity and amount is dependent on the patient Uncontrolled or significant bleeding can lead to hemorrhagic shock and possibly death

5. Types of Bleeding • Arterial • Venous • Capillary

6. Arterial Bleeding Bright red, spurting blood from a wound usually indicates severed or damaged artery • Rich in oxygen • Spurts with pulse • Can be more difficult to control due to higher pressure in the arteries • Decreases with patient’s blood pressure

7. Venous Bleeding Dark red blood that flows steadily indicating severed or damaged veins • Depleted of oxygen • Steady flow

8. Capillary Bleeding Dark or intermediate color of red; slowly oozing indicating damaged capillaries • Easily controlled • Clots spontaneously • Can pose a threat of infection

9. Methods of controlling external bleeding • Direct pressure • Tourniquets • Elevation • Splints • Topical hemostatic agents

10. Direct pressure • Place a sterile gauze over the injury site • Applying fingertip pressure directly to the point of bleeding • Remove dressings and apply direct pressure to the point of bleeding if necessary • Apply direct pressure on either side of an impaled object • Pressure points

11. Tourniquets • Use a bandage or device that is 4” wide • Wrap the tourniquet around the extremity proximally to the bleeding • Tighten the tourniquet until bleeding ceases • Secure the tightening rod or device • Write the time on tape and secure it to the tourniquet

12. Tourniquets • Never cover the tourniquet or site of bleeding • Notify the hospital that a tourniquet is in place • Document the use of the tourniquet and time it was applied • Inflated blood pressure cuff may be used as a tourniquet until bleeding stops

13. No evidence shows that elevation is effective for controlling or stopping bleeding No evidence shows its harmful Elevation can only be considered in conjunction with direct pressure Splinting may assist with control of bleeding with a fracture A traction splint serves not only as a splint but also a method of controlling bleeding Apply splints on scene to extremity fractures only if patient is stable without life threatening injuries Elevation and splints

14. Topical hemostatic agents Dressings that promote clotting • Hemostatic • Chitosan Hemostatic agents that pour onto the wound • Celox and Quickclot • TraumaDex

15. Assessment Based approach: External bleeding Scene size-up, primary assessment, secondary assessment • Begin preparing while enroute • BSI • Ensure support resources are notified • Scene safety • Number of patients • General impression • Patent airway • Control bleeding, continue with primary assessment • Perform rapid secondary assessment with patient who has suffered significant bleeding, altered mental status, multiple injuries, or significant MOI • Obtain baseline vitals

16. Emergency Care • BSI • Apply direct pressure • Apply tourniquet if unable to control bleeding • Provide care for shock • Immobilize injured extremities • Reassess by ensuring bleeding is still controlled, wounds that start bleeding again, repeat primary assessment, vital signs every 5 minutes, upgrade to ALS if necessary

17. Bleeding from Nose, ears or mouth Possible causes; • Skull injury • Facial trauma • Digital trauma • Sinusitis or upper respiratory infection • Hypertension • Clotting disorders • Esophageal disease

18. Epistaxis Bleeding from the nose • May result from injury, disease or environment • Place patient in sitting position and have them lean forward • Apply direct pressure by pinching fleshy portion of the nostrils together • Apply ice or cold pack over the bridge of nose • Use of oxymetazoline (Afrin™) helps with vasoconstriction (review Whatcom County Permissive Protocol, page 26)

19. Internal bleeding - Severity Severity depends on the patient’s overall condition, age, other medical conditions, and source of internal bleeding Common sources; • Injured or damaged internal organs • Fractured extremities Hematoma is a contained collection of blood Always suspect internal bleeding in cases of unexplained signs/symptoms of hemorrhagic shock

20. Assessment based approach Internal bleeding Scene size-up/primary assessment • Look for and evaluate potential MOI • Look for any obvious major external bleeding • If a major bleed is found, control immediately with direct pressure • Assess mental status • Asses airway • Assess pulses, skin, and capillary refill

21. Assessment based approach Internal bleeding Secondary Assessment • Internal bleeding suspected, do a rapid secondary assessment • Evidence of contusions, abrasions, deformity, impact marks, swelling, or other trauma, treat for internal bleeding

22. Assessment based approach Internal bleeding Signs/Symptoms of internal bleeding • Pain, tenderness, swelling, or discoloration at site of injury • Bleeding from mouth, rectum, vagina or other orifice • Vomiting bright red blood or blood the color of dark coffee grounds • Dark, tarry stools with bright red blood • Tender, rigid, and/or distended abdomen

23. Assessment based approach Internal bleeding Signs/Symptoms of internal bleeding that also indicates hemorrhagic shock; • Anxiety, restlessness, combativeness, or altered mental status • Weakness, faintness, or dizziness • Thirst • Shallow, rapid breathing • Rapid, thready pulse • Pale, cool, clammy skin • Delayed capillary refill • Dropping blood pressure (late sign) • Narrow pulse pressure • Dilated pupils that are sluggish in responding to light • Nausea and vomiting

24. Emergency Care • BSI • Maintain open airway, ensure adequate breathing • Oxygen via NRB • Control external bleeding with direct pressure or tourniquet if unable to control • Provide immediate transport • Provide care for shock • Reassess vital signs every 5 minutes

25. Factors that may increase internal bleeding Several factors may interfere with the clotting process • Movement • Low body temperature • Medications • Intravenous fluids • Removal of dressings and bandages

26. Hemorrhagic Shock Scene size-up/Primary assessment • Note MOI • Ensure scene safety and police presence • Assess mental status and ABC’s • Note abnormalities or signs of shock • Oxygen via NRB • Ventilation with supplemental oxygen, if needed

27. Perform rapid secondary Assess for signs of hemorrhagic shock Signs/Symptoms Mental Status – Restlessness, anxiety, altered mental status Peripheral perfusion and perfusion to the skin – Pale, cool, clammy skin; Weak, thready, or absent peripheral pulses; delayed capillary refill Vital Signs – Increased pulse rate (early sign) with weak, thready pulse (early sign); Increased respiratory rate; decreased BP (late sign); Narrow pulse pressure Other signs/symptoms – Dilated pupils, Marked thirst, Nausea/vomiting, Pallor with cyanosis to the lips Hemorrhagic Shock Secondary Assessment

28. Emergency Care • BSI • Maintain open airway • Control external bleeding • Apply and inflate PASG if symptoms warrant (Refer to Whatcom Co. protocols, page 17) • Place in supine position • Splint suspected bone or joint injuries • Keep patient warm • Transport immediately • Reassess mental status and vital signs every 5 minutes

29. Figure 28-8 Continuous cycle of shock.

30. Pneumatic Antishock garment (PASG) aka MAST pneumatic antishock garment (PASG). Per Whatcom County Protocol page 17: PASG/MAST is no longer recommended in Whatcom county. However, the rest of the country still has these in use Indications; • Suspected pelvic fractures with hypotension • Profound hypotension • Suspected intraperitoneal hemorrhage with hypotension • Suspected retroperitoneal hemorrhage with hypotension Contraindications; • Penetrating thoracic trauma • Splinting of lower extremities • Evisceration of abdominal organs • Impaled object in abdomen • Pregnancy • Cardiopulmonary arrest

31. Hemophilia • A congenital disease that prevents activation of the normal clotting mechanisms found in the blood • Bleeding in this patient is always considered to be significant • Transport immediately

33. Soft Tissue Trauma – The Skin • One of the most durable and largest organs of the body • Composed of 3 layers – Epidermis, Dermis, and subcutaneous layer • Protects the body • Serves as a receptor organ • Wounds • Open • Closed • Single • Multiple

34. Closed injury - Contusions Closed injury – a wound in which there is no break in the skin • Contusion – injury to the tissue and blood vessels contained with in the dermis • Will cause localized swelling and pain • Discoloration may occur due to blood leaking from damaged vessels • Black and blue call Ecchymosis

35. Closed injury - Hematomas • Usually involves damage to a larger blood vessel and a larger amount of tissue • Characterized by a large lump with bluish discoloration • The size of the patient’s fist can be equal to 10% blood loss

36. Closed injury – Crush injuries • Force great enough to cause injury has been applied to the body • Severe blunt trauma or crushing force may result in internal bleeding an hemorrhagic shock • Internal organs may actually rupture

37. Assessment based approachClosed soft-tissue injuries Scene size-up/primary assessment • Scan for MOI • BSI • Conduct primary assessment • Establish in-line stabilization of the cervical spine if spinal injury suspected • Assess mental status • Ensure adequate airway • Check and treat signs of severe bleeding and shock • Oxygen • Ventilation with supplemental oxygen if needed

38. Secondary Assessment • Check for evidence of trauma • Assess baseline vitals • Obtain history • Signs/symptoms • Swelling, pain, and discoloration at injury site • Signs/symptoms of internal bleeding and hemorrhagic shock

39. Emergency Care • BSI • Ensure open airway and adequate breathing • Treat for shock • Splint suspected fractures • Reassess by repeating primary assessment, vital signs every 5 – 10 minutes

40. Open Soft-tissue injuries

41. Open injury - Abrasion An open injury is a wound in which the skin is broken • Abrasion – scraping, rubbing, or shearing away of the epidermis • Often is extremely painful due to exposed nerve endings • Capillary bleeding controlled with direct pressure • Abrasions to large areas of body surface may be cause for concern due to threat of contamination, infection, and underlying injuries

42. Open injury - Lacerations A break in the skin of varying depth • Linear • Stellate • May bleed more than other types of open soft-tissue injuries

43. Open injury - Avulsions Partial avulsion – loose flap of skin and underlying soft tissue that has been torn loose Total avulsion – loose flap of skin and underlying soft-tissue that has been pulled completely off Bleeding may be severe due to blood vessel injury Healing will be prolonged, scarring may be extensive

44. Open injury - Amputations Disruption in the continuity of an extremity or other body part • Bleeding may be massive, often very little bleeding occurs • Always consider shock

45. Open injury – Penetrations/Punctures Results of a sharp, pointed object being pushed or driven into the soft tissues • Entry wound may appear small and cause little bleeding • Injuries may be deep and cause severe internal bleeding • Severity factors; • Location • Size of object • Depth of penetration • Forces involved • Structures in pathway • Always assess for underlying internal injuries and hemorrhagic shock

46. Open injury – Crush injuries • May not appear to be serious • Only external sign may be an injury site that is painful, swollen, an deformed • External bleeding may be absent or minimal • Always suspect internal bleeding • Patients may deteriorate rapidly into shock

47. Open injury – Bites & Clamping Bites – Complications; • Infection • Cellulitis • Septicemia • Rabies • Tetanus • Hepatitis • Bite should be evaluated • Always ensure scene safety • Arrange for containment/isolate animal Clamping injuries • Body part caught or strangled by a piece of machinery • Longer clamped, more damage • Edema makes removal difficult • Apply lubricant • Transport immediately • Call for specialized help to cut away parts of the clamping object

48. Assessment base approach Open soft-tissue injuries Scene size-up/primary assessment • Ensure scene is safe • Note potential MOI • Be prepared to stabilize cervical spine • General impression • Assess mental status, ensure open airway • Oxygen via NRB • Ventilation with supplemental oxygen if needed • Bring any severe bleeding under control using direct pressure

49. Secondary Assessment • Baseline vitals • Obtain history • Signs/symptoms • Break in skin & external bleeding • Localized swelling • Pain • Discoloration at injury site • Possible signs/symptoms of internal bleeding and hemorrhagic shock

50. BSI Ensure open airway, adequate breathing Expose wound Control bleeding Prevent further contamination Dress and bandage Keep patient calm and quiet Treat for shock Transport Reassess with repeat primary assessment, vital signs, check dressings Special considerations; Chest injuries Abdominal injuries Impaled objects Amputations Large open neck wounds Emergency Care