Transcript Bleeding and Soft Tissue Injuries August 2014

Bleeding, Wounds, and Soft
Tissue Injuries
Presence Regional EMS System
August 2014 C.E.
Objectives
• Describe the characteristics of external
bleeding including differentiation between
arterial, venous, and capillary bleeding
• Identify signs and symptoms of significant
bleeding, including internal bleeding
Objectives
• Explain the use of traditional and new
innovative means of managing external
bleeding
• Describe the management of avulsions and
amputations
• Define a significant crush injury
• Outline the management of patients who
have sustained a significant crush injury
• Maintain Standard Precautions When
Dealing with Body Substances!
Cardiovascular System Overview
• The cardiovascular system is
an organ system that allows for
the circulation of blood to cells
and tissues, the delivery of oxygen
and nutrients, and the removal
of waste products.
Parts of the Cardiovascular System
• Heart: The hollow organ that pumps blood
throughout the body.
– The right side receives deoxygenated blood
from the body and pumps it into the lungs
– The left side receives oxygenated blood from the
lungs and pumps it to the tissues of the body
Parts of the Cardiovascular System
Blood Vessels
• Arteries
– Small blood vessels that carry blood away from
the heart
• Arterioles
– Smaller vessels that connect the arteries and
capillaries
Parts of the Cardiovascular System
Blood Vessels
• Capillaries
– Small tubes that link arterioles and venules
– Capillary beds are where the exchange of nutrients
and wastes take place
• Venules
– Very small, thin-walled vessels that empty into the
veins
• Veins
– Blood vessels that carry blood from the tissues to
the heart
Parts of the Cardiovascular System
Components of Blood
• Red 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
– Cells of the immune system that function to
protect the body from foreign materials and
infectious disease
Parts of the Cardiovascular System
Components of Blood
• Platelets
– 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
– Liquid component of blood that holds the blood
cells in suspension
Why is this important?
• All organs of the body rely on the
cardiovascular system to deliver oxygen and
nutrients
• Bleeding causes hypoperfusion
• The death of an organ system due to lack of
perfusion can lead to the death of
the patient
• Some organ systems can survive without
perfusion for a limited period of time:
– 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.
• The heart requires constant perfusion in
order to survive
External Bleeding
• With serious external bleeding, it may be
difficult to determine 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 it’s blood volume.
Use familiar measurements to
estimate blood loss
• 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
– SHOCK
• 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
Characteristics of External Bleeding
• 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
• Capillary bleeding
– Bleeding from damaged capillary vessels
– Dark red, oozes steadily but slowly
Capillary
Venous
Arterial
Internal Bleeding
• Bleeding in a cavity or space inside the body
• Can be very serious
• Outward signs can be deceiving
– Injury or damage to internal organs can result
in excessive internal bleeding
– Can cause hypovolemic shock even though
there is no fluid loss outside of the body
Internal Bleeding
• Signs of internal bleeding
– High-energy Mechanism of Injury
– Pain
– Swelling in the area of bleeding
– Distention
– Bruising
– Dyspnea, Tachycardia, Hypotension
– Hematoma
– Bleeding from any body opening
Assessing for Bleeding
• Use DCAP-BLS-TIC to assess for traumatic injuries
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Deformities
Contusion
Abrasions
Puncture/Penetrations/Paradoxical Movement
Burns
Lacerations
Swelling
Tenderness
Instability
Crepitus
Identify Bleeding
• Identify life threatening external bleeding
– Assessed during the ‘Circulation phase’ of your
initial assessment
– Identify bleeding that is uncontrolled or
bleeding with significant fluid loss
• Attempt to control life threatening bleeding
as you find it!
Identify Shock
• Hypovolemic Shock is due to fluid loss
outside of the system; results in
hypoperfusion
• Early detection and identification of shock
is paramount to patient survival
• SKINS DO NOT LIE
Signs of Shock
• Compensated Shock (Early Stage)
– Anxiety
– Altered mental status
– Weak, rapid pulse
– Pale, cool, and moist skin
– Shallow, rapid breathing
– Nausea and/or vomiting
Signs of Shock
• Decompensated Shock (Late Stage)
– Systolic Blood Pressure less than 90 in adults
– Labored or irregular breathing
– Ashen, mottled, or cyanotic skin
– Thready or absent peripheral pulses
– Dull eyes with dilated pupils
– Poor skin turgor
How to Control External Bleeding
• Direct Pressure
• Elevation
• Pressure Dressings/Splints
• Tourniquets
Direct Pressure
• 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
• Hold uninterrupted pressure for at least 5
minutes
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.
Pressure Dressing
• 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
• Do not remove without a physician present
Tourniquet
• 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.
• Never use a tourniquet over a joint
• Pad below the tourniquet
• Use only proper equipment; i.e. a commercial
tourniquet
• Document the date/time the tourniquet was placed
Hemostatic Agents
• Hemostatic agents are used to promote the
body’s natural clotting abilities
• For uncontrollable bleeding
– Unable to use tourniquet (groin, axilla, neck)
• Used in conjunction with direct pressure and
pressure dressings
• Be mindful of local protocols
regarding their use
Internal Bleeding
• Identify internal bleeding and initiate rapid
transport
• Control cervical spine through use of Spinal
Motion Restriction
• Control fractures with splinting
• Internal bleeding requires surgery – Do not
delay transport!
Avulsions
• An injury that separates various layers of
soft tissue
• Treat by placing partially separated piece
back into original location and covering
with sterile gauze
– Be careful to make sure the site is free of debris
• Wrap pieces that have been completely
removed in sterile gauze and transport with
patient
Avulsions
• Avulsions involving large areas of tissue
may cause large amounts of bleeding
• Never remove an avulsion skin flap,
regardless of size!
Amputations
• An injury in which part of the body is
completely severed
• Includes both incomplete and complete
amputations
– A complete amputation involves an extremity
that has been completely removed from the
body
– An incomplete amputation involves an
extremity that is still attached to the body by a
small amount of tissue
Amputations
• Attempt to control bleeding via direct
pressure over the stump
• If bleeding cannot be controlled by direct
pressure, apply a commercial tourniquet
proximal to the amputation
• Amputation extremities can possibly be
saved by a surgical team
Amputation
• Note incomplete
amputation to the right
leg on image
• Note complete
amputation to the left
leg on image
Amputation
• DO NOT delay care in order to retrieve entrapped or lost part
• DO NOT complete an incomplete amputation
FR/BLS TREATMENT:
• INITIAL TRAUMA CARE.
• Treat for shock if indicated.
• Tissue Preservation:
– Rinse part gently with normal saline if gross contamination (DO
NOT SCRUB)
– Wrap part in moist sterile gauze (part should never be immersed in
water).
– Place wrapped part in water tight bag and seal.
– Label bag with name, date and time.
– Place sealed bag into container filled with water and ice and
transport with patient.(DO NOT PLACE DIRECTLY ON ICE)
Amputation
Call for intercept per INTERCEPT CRITERIA.
• ALS may administer pain medications following
Region 6 protocols.
Crush Injury
• Pressure on extremities for extended time
– Disrupts blood flow
– Promotes anaerobic metabolism
• Pressure released
– Blood flow to crushed tissue reinstated
– Toxins distributed throughout entire body
– May induce cardiac dysrhythmia and severe
kidney damage
• “Crush or Compression Syndrome”
Examples of Crush Injuries
• Hand trapped in an
industrial roller
• Foot caught in
railroad tracks
• Lower extremities
caught between a
car and a wall
• Arm caught
between two large
rocks
Management of Crush Injuries
– Perform frequent ongoing exams
– Alkalizing the blood
• Fluid resuscitation – large volumes
• NaCO3 infusion
• Osmotic diuretics
– If administration of fluids or medications prior
to releasing the entrapped body area is not
possible, consider application of a tourniquet
proximal to the injury site.
– Contact Medical Control early; follow local
protocols regarding treatment of crush injuries
Case Study 1
• Dispatch: 1100 to farm outside of town for a 19
y/o male patient with a bandsaw related injury
Scene Size Up
• Scene Safety: Upon arrival directed to barn
out back; no safety hazards noted
• BSI: Gloves
• Nature of Illness: Sick
• Number of Patients: 1
• Additional Resources: ALS Intercept possible
(If Applicable)
Primary Assessment
• General Impression: The patient is sitting on a chair with his
hand wrapped with a shirt; appears very anxious
• Level of Consciousness: Awake, alert and obeys commands.
• Airway: Open, clear
• Breathing: Respirations slightly fast and non-labored
• Circulation
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Skins: pale, warm, and diaphoretic
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Pulses: Radial pulse weak and rapid
•
Bleeding: Note bleeding from left hand
• Rapid Head to Toe: Note amputation of thumb on the left
hand; no further findings
• Priority: Stable but sick
Focused History
• Signs and Symptoms: Was cutting a board when
he got distracted and felt his thumb go through the
saw
• Allergies: Bees
• Medications: None
• Past Medical History: None
• Last Oral Intake: Breakfast around 0700
• Events: No complaints prior to accident;
amputated thumb with saw
Detailed Physical Exam
• Clean amputation distal to the first joint of the thumb
• Thumb has been retrieved by coworker; appears to be
in good condition
Vital Signs
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Blood Pressure: 102/60
Pulse: 140
Respirations: 24
O2 Saturation: 99%
Blood Sugar: 79
Management
• Oxygen to keep patient’s O2 saturation above
94%
• Control bleeding with direct pressure
• Wrap thumb in moist sterile gauze; place in
watertight bag and seal with patient’s name, date,
and time on outside of bag
• ALS: IV access with 500cc fluid bolus of 0.9NS
• ALS: Pain management per Regional 6 protocol
Ongoing Assessment
• Bleeding controlled with direct pressure;
Patient voices little to no discomfort
Repeat Vital Signs:
• Blood Pressure: 110/72
• Pulse: 108
• Respirations: 20
• O2 saturation: 100% on Oxygen at 4lpm
Case Study 2
• Dispatch: 2345 to industrial site for a 25 y/o patient
pinned against the wall by a forklift
Scene Size Up
• Scene Safety: Directed into warehouse upon
arrival; met by coworkers who have shut down
operations in the area
• BSI: Gloves
• Nature of Illness: Sick
• Number of Patients: 1
• Additional Resources: ALS Intercept possible (If
Applicable), Consider need for Aeromedical Services
Primary Assessment
• General Impression: The patient is trapped against the wall with a
stand up forklift; his right leg appears to be pinned by the edge of
the drivers compartment
• Level of Consciousness: Awake, alert and obeys commands.
• Airway: Open, clear
• Breathing: Respirations normal
• Circulation
– Skins: Pink, warm, and dry
– Pulses: Radial pulse strong and regular
– Bleeding: None
• Rapid Head to Toe: Note right leg cyanotic and
pulseless distal to the area that is pinned
• Priority: Stable but sick
Focused History
• Signs and Symptoms: Was coming around a corner
near the wall when he lost control; leg went out of the
forklift and became trapped against the wall when the
machine lost power. Complains of severe pain to his
right leg with loss of sensation below the injury
• Allergies: None
• Medications: None
• Past Medical History: None
• Last Oral Intake: Hamburgers at 1700
• Events: No complaints prior to accident; Machine has
been acting weird all night
Detailed Physical Exam
• Note right leg cyanotic distal to point of entrapment; approximately
mid-femur; no pedal pulse
• Patient unable to move leg
• Machine is not operating; will have to be pushed off of patient
Vital Signs
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Blood Pressure: 134/76
Pulse: 110
Respirations: 20
O2 Saturation: 98% on room air
Blood Sugar: 102
Management
• Oxygen to keep patient O2 Saturation above
94%
• Contact Medical Control with information
regarding patient and injury
• Place tourniquet proximal to trapped area
• Carefully remove vehicle from position on
patient; do not cause harm to patient
• ALS: IV access with 500cc bolus of 0.9NS
• Pain management per Regional 6 protocol
Ongoing Assessment
• Carefully monitor patient for any changes in
mental status or vital signs
• Expedited transport to closest appropriate
facility
Repeat Vital Signs:
• Blood Pressure: 124/68
• Pulse: 114
• Respirations: 20
• O2 saturation: 100% on Oxygen at 4lpm
Review
• If doing this CE individually, please e-mail
your answers to:
• [email protected]
• Use “August 2014 CE” in subject box.
• IDPH site code: 06-7100-E-1214
• You will receive an e-mail confirmation.
Print this confirmation for your records and
document in your PREMSS CE record
book.
Short Answer
1) Describe the differences between arterial
and venous bleeding.
2) Give 3 signs of compensated shock
3) List the 4 primary methods used to control
external hemorrhage
4) What does DCAP-BLS-TIC stand for?
5) Give 2 examples of crush injuries
True or False
1) A partial amputation should be fully
removed prior to transport
2) Splinting can be used to control bleeding
3) There is no blood loss associated with
internal bleeding
4) The brain may survive 4-6 minutes without
perfusion
5) The body is able to tolerate losing 40% of
it’s blood volume
Answers – Short Answer questions
1. Arterial bleeding is bright red, under pressure and is
difficult to control. Venous bleeding is dark red, slow
flowing and easier to manage.
2. Anxiety, altered mental status, weak, rapid pulse, pale,
cool, and moist skin, shallow and rapid breathing, nausea
and/or vomiting.
3. Direct pressure, elevation, pressure dressing, tourniquet
4. Deformities, contusions, abrasions,
punctures/penetrations, burns, lacerations, swelling,
tenderness, instability, crepitus
5. Hand trapped in an industrial roller, foot caught in
railroad tracks, lower extremities caught between a car
and a wall, arm caught between two large rocks
Answers – True or False questions
1.
2.
3.
4.
5.
False
True
False
True
False