hello class and welcome to chapter 26 bleeding of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will understand the structure and function of the circulatory system the significance and characteristics of bleeding the importance of personal protective equipment when treating a bleeding patient the characteristics of external versus internal bleeding how to conduct a patient assessment and the methodologies for controlling bleeding okay so let's get started recognizing bleeding and understanding how it affects the body is an important skill bleeding can be external and obvious or internal and hidden so either type of bleeding is potentially dangerous and can cause weakness shock and death uncontrolled bleeding is the most common cause of hypoperfusion following a traumatic injury so the anatomy and physiology of the circulatory system our cardiovascular system so the cardiovascular system circulates blood to all the body's cells and tissues it delivers oxygen and nutrients carries away metabolic waste products and it's responsible for supplying and maintaining adequate blood flow the contents are the pump which is the heart the container which are the blood vessels and the fluid which is the blood and the body fluids so let's talk in depth about those three things so the heart it needs a rich and well distributed blood supply it works as two paired pumps you have the upper chamber which is the atrium and the lower chamber which are the ventricles and blood leaves each chamber through a one-way valve this figure shows the right and left sides of the heart next you have the blood vessels and blood so there are types of blood vessels and those are called arteries arterioles and capillaries and also venules and veins oxygen and nutrients easily pass from capillaries into the cells and waste and carbon dioxide diffuse from the cells back into the keplers blood contains red blood cells and that's responsible for the oxygen transportation and the carbon dioxide you have white blood cells and those are responsible for fighting infection platelets those are the form the blood clots and then the liquid part which is the plasma so blood clot formation depends on several factors the blood stasis changes in the blood vessel walls such as a wound or the blood's ability to clot and that's affected by disease or medication so let's talk about the autonomic nervous system this monitors the body's needs and adjusts blood flow by constricting or dilating blood vessels it automatically redirects blood away from other organs to the heart brain lungs and kidneys in an emergency and it adapts to changing conditions in the body and maintains homeostasis and perfusive if the system fails to provide significant circulation for every body part to perform its function shock results so let's talk about the pathophysiology and perfusion so perfusion is the circulation of blood within an organ or tissue in adequate amounts to meet the cell's current needs for oxygen nutrients and waste removal the speed of blood flow must be fast enough to maintain adequate circulation throughout the body and to avoid clotting and it must be slow enough though to allow cells time to exchange oxygen and nutrients for carbon dioxide and other waste products some tissues need a constant supply blood while others can survive with very little blood all tissues and organs organ systems of the human body depend on adequate perfusion to function properly and some organs cannot tolerate interruption of a blood supply for more than a few minutes without sustaining damage death of an organ system can quickly lead to death of a patient the heart requires a constant flow of blood so let's talk about external bleeding and this is this hemorrhage means bleeding and external bleeding is a visible hemorrhage the significance of external bleeding with serious external bleeding it may be difficult to tell the amount of blood loss blood will look very different on different surfaces so it's important to estimate the amount of external blood loss the body will not tolerate an acute blood loss of greater than 20 percent blood volume so that's about two pints adverse changes and vital signs may occur with significant blood loss so you'll see an increase in heart rate an increase in respiratory rate and a decrease in blood pressure how well people compensate for blood loss is related to how rapidly they bleed so an adult can comfortably donate one unit or about 500 milliliters of blood over a period of about 10 to 20 minutes if a similar blood loss occurs in a much shorter period of time the person may rapidly develop signs of hypovolemic shock the age and pre-existing health of the patient should be also considered so let's talk about some characteristics of external bleeding you should consider bleeding to be serious if the following conditions are present so if you see a poor general appearance and no response to external stimuli signs and symptoms of shock significant blood loss rapid blood loss uncontrolled bleeding or significant mechanism of injury okay so let's talk about the different types of bleeding so you have you could have arterial or venous and so with arterial pressure causes blood to spurt and makes bleeding difficult to control it's typically brighter red and spurts in time with the pulse okay then you have venus and that's dark red it does not spurt it's easy to manage and more likely to clot spontaneously than arterial bleeding it can be profuse and life-threatening however and then you have capillary bleeding so this is dark red and oozes from a wound steady but slowly more likely to clot spontaneously than arterial bleeding so let's talk about the clotting process okay so bleeding tends to stop rather quickly within about 10 minutes in response to internal mechanisms and exposure to air so when the skin is broken blood flows rapidly from the open vessel the cut ends of the vessel begin to narrow and this is called vasoconstriction it reduces the amount of bleeding then a clot forms bleeding will never stop if the clot does not form unless the injured vessel is completely cut off from the main blood supply by direct pressure or a tourniquet with hemophilia the patient lacks one or more of the blood clotting factors and so bleeding may occur spontaneously and all injuries no matter how trivial are potentially serious so patients should be transported immediately if they're hemophiliac let's talk about internal bleeding and this can be very serious because it is not easy to detect immediately injury or damage to internal organs commonly result in extensive internal bleeding it can cause hypovolemic shock possible conditions causing internal bleeding include you could have a stomach ulcer or a lacerated liver a ruptured spleen perhaps broken bones often the signs of internal bleeding are contusions or echomosis a mechanism for injury for internal bleeding so a high speed mechanism of injury should increase your index of suspicion for the possibility of a serious unseen injury blood trauma and penetrating trauma so we use the pneumonic d-cap btls to assess for signs of injuries and this is deformities contusions abrasions punctures penetrations burns lat tenderness laceration swelling and any other signs of injury okay nature of illness for internal bleeding and so internal bleeding is not always caused by trauma possible non-traumatic causes can be ulcers or bleeding in the colon maybe a ruptured atopic pregnancy or perhaps aneurysms it is not important for you to know the specific organ involved as it is to recognize a patient who is in shock and respond appropriately so signs and symptoms of internal bleeding occur include pain and that's the most common okay so you can have swelling in the area of the bleeding distension leading into the chest cavity or lung you could have a hematoma or bruising so bleeding from any body opening so if it's bright red bleeding from the mouth or rectum you could have hematuria or non-menstrual vaginal bleeding in hemiamesis and that's vomiting blood so if it's bright red or dark red coffee ground appearance malena and that's black foul smelling tarry stool and it's digested blood basically or pain tenderness bruising gardening or swelling and that could be possible close fractures or broken ribs which and you'll might see bruising over the lower part of the chest or a rigid distant abdomen okay so hypoperfusion is hypovolemic shock and change in mental status such as anxiety restlessness or combativeness you could have weakness faintness or dizziness on standing change in the skin later signs of hypoperfusion suggesting internal bleeding include tachycardia weakness fainting or dizziness thirst nausea and vomiting cool moist clammy skin or shallow rapid breathing could have dull eyes slightly dilated pupils that are slow to respond to light kept refill of more than two seconds in infants and children weak rapid pulse decreasing blood pressures altered mental status or patients with these signs and symptoms require prompt transport so let's do the patient assessment okay so we're going to do the scene size up and we're going to be alert for potential hazards in a violent incident make sure the police are on scene and we want to follow standard precautions so we're going to consider the mechanism of injury and the need for spinal immobilization and additional resources okay next is our primary assessment we do not want to be distracted from life threats so we need to form our general impression and we need to know important indicators that alert us for the seriousness of the patient's condition we are going to perform a rapid exam so if the patient has obvious life threatening external bleeding address it first and assess skin color determine the level of consciousness using the avpoo scale okay next we're going to do the abcs and our d but first the airway and breathing so we have to ensure that patent airway of course high flow too and we're going to assist with ventilations via bag valve mass device or a non-rebreather and we're going to insert an oral pharyngeal to secure the airway if the patient is unconscious then circulation we're going to assess the pulse rate and quality determine skin condition color and temperature cap refill time and we're going to control external bleeding and treat for shock next is the d so we're going to do that transport decision we're going to assess the abcs and life threats to determine rapid transport patients who may have significant pleading will quickly become unstable okay so signs that imply the need for rapid transporting clues include tachycardia tachypnea low blood pressure weak pulse or clammy skin so next let's do the history taking and of course we're going to investigate that chief complaint we're going to look for signs and symptoms of other injuries due to the mechanism of injury or the nature of illness then we're going to do the sample history so we want to ask the patient if they're taking blood thinning medications so if the patient is unresponsive obtain history information from medical alert tags or bystanders and look for signs and symptoms of shock determine how much blood loss estimated and then of course our secondary assessment we're going to assess all areas using looking for d-cap etls the head we're looking for uncontrolled bleeding from a large scalp laceration the abdomen we want to feel all four quadrants for tenderness or rigidity the extremities we're going to record pulse motor and sensory functions and we're going to record vital signs with a critically injured patient or a short transport time there may not be time to conduct a secondary assessment then we're going to do that reassessment so the patient frequently especially in the areas that show abnormal findings during the primary assessment and we're going to reassess any unstable every five and stable every 15 minutes some of the interventions we're going to provide are high flow o2 we're going to control external bleeding we're going to provide treatment for shock and transport rapidly and if internal bleeding is suspected we're going to put on high flow 2 via non-rebreather mask and provide rapid transport we do not want to delay transport of any patient to complete any assessments and of course we have to communicate and document so we have to recognize estimate and report the amount of blood loss and how rapidly or over what period of time it occurred we want to communicate all relevant information to the staff at the receiving hospital including all injuries the care provided and the patient's response so emergency care for external bleeding now we need to follow standard precautions and what we need to do is wear a mask gloves eye protection and sometimes a gown we want to make sure that the patient has an open airway and is breathing adequately we want to provide high flow oxygen and if obvious life-threatening bleeding is present we have to control it as quickly as possible there are several methods to control this external bleeding first we're going to use direct pressure then pressure dressings or splits we could use tourniquets or hemostatic dressing or wound packing so let's talk about direct pressure the most common ineffective way to control external bleeding the pressure stops the flow of blood and permits normal coagulation to occur we want to apply pressure with our glove fingertip or hand over the top of sterile dressing for an object protruding from the wound apply bulky dressing to stabilize that object in place and apply pressure the best you can hold uninterrupted pressure for at least five minutes then there's the pressure dressing so firmly wrap a sterile self-adhering roller bandage around the entire room wound stretch the bandage tight enough to control the bleeding you should still be able to palpate a distal pulse on the in injured extremity after applying the dressing do not remove the dressing until the physician has evaluated the patient apply additional manual pressure through the dressing if necessary just add more dressings over the first if it bleeds through and the tourniquet is a useful is useful if the patient has substantial bleeding from the injury and it cannot be controlled with direct pressure so you could apply the tourniquet above the level of bleeding if this is not possible consider additional tourniquet or wound packing with the hemostatic dressing if available so we want to follow the skill drill 26-1 to demonstrate the basic techniques to control external bleeding next we're going to talk about wound packing and hemostatic dressing so this is gauze and it can be packed into larger wounds to control hemorrhaging when direct pressure is not adequate or application of a tourniquet is not possible so a hemostatic dressing is impregnated with a chemical compound that slows or stops bleeding by promoting clot formation it can be used together with wound packing and direct pressure when direct pressure alone is ineffective or when a tourniquet placement is otherwise impossible so we're going to follow the skill drill on 26 desk 2 to demonstrate the basic techniques for wound packing okay and tourniquets of course if direct pressure does not control that extremity bleeding then use a tourniquet a tourniquet is only useful if the patient has substantial bleeding from that extremity injury and we're going to follow the skill drill uh skill drill in our book on 22 26-3 to demonstrate applying a commercial tourniquet and then there's junctional tourniquets and allow for a proximal compression of life-threatening bleeding in areas where a standard tourniquet application is not possible such as the groin or axilla area it may be indicated for severe hemorrhage at the junction of the torso with the arms and the legs so some junctional tourniquets may be used as such as a pelvic binder okay and then you have air splints so you can control internal and external bleeding associated with severe extremity injuries you could immobilize fractures or it could also act like a pressure dressing applied to an extreme an entire extremity with um rather than to a small local area okay and then you have the pelvic binder this is a type of splint that may be indicated for a suspected closed unstable pelvic fracture it helps to control internal bleeding specifically bleeding associated with a life-threatening open-book pelvic fracture then there's bleeding from the nose ears or mouth so several conditions can result in bleeding from the nose ears mouth and they include the following so you could have a skull fracture or facial injury have some type of sinusitis or an infection or use and abusive nose drops dried or cracked nasal mucosa or some other abnormality um perhaps high blood pressure coagulation disorder disorders or digital trauma or cancer so epistasis that's a nosebleed okay it's common emergency occasionally can cause enough blood loss to lead the shock the blood you see may only be a small part of the blood loss because much the blood may pass down the patient's throat into the stomach as the patient swallows a person who swallows a large amount of blood may become nauseated and start vomiting and um so most nontraumatic nosebleed occur from sites in the septum and that's the tissue dividing the nostrils so you can usually handle this type of bleeding effectively by pinching the nostrils together and there's a skill drill showing you how to do that on 20-26-4 in your book okay so bleeding from the nose or ears following a head injury so this may indicate a skull fracture and it may be difficult to control do not attempt to stop that blood flow to supply uh applying excessive pressure to the injury may force the the blood leaking through the ear or nose to collect in the head so loosely cover the bleeding site with a sterile gauze pad to collect the blood and keep contaminants away from the site apply light compression by wrapping the bulky dressing around the head a target or halo shaped stain may occur on a dressing if the blood or drainage contains cerebral spinal fluid and you can see the photo of that halo on the slide so emergency care for internal bleeding controlling internal bleeding or bleeding from a major organ usually requires surgery or other hospital procedures so try to keep the patient calm reassure and still and as quiet as possible you can give them high flow too maintain body temperature splint the injured extremity usually with an air splint never use a tourniquet to control bleeding from a closed internal or soft tissue injury and follow the skill drill on 26-5 to care for patients with internal bleeding okay so that concludes chapter 26 bleeding chapter and let's see what we've learned so which of the following is not a component of the cardiovascular system okay and right away we know lungs lungs that's the respiratory system perfusion is most accurately defined as i think it's c circulation of enough oxygen and nutrients as significant amounts a man involved in a motorcycle crash has multiple abrasions and lacerations which of the following injuries is the highest treatment priority hmm widespread abrasion three inch laceration dark flowing blood laceration the form with obvious debris or one inch lacerations thigh squirting okay so we know that's that arterial so d perfect which of the following sets of vital signs least indicative of internal bleeding least well i would think it would be a yes a um and uh okay when caring for a patient with internal bleeding the emt must first okay we know we want to control the bleeding so that's an obvious life threat but we also have to ensure there's an airway but very first we have to take the appropriate standard precautions so all of the interventions must be her form however we have to take standard precautions first the quickest and most effective way to control external bleeding from an extremity is direct pressure that's right direct pressure when applying a tourniquet to an amputated arm the emt should let's see the emt should apply the tourniquet over the joint avoid applying it yes okay we have a 70 year old man who's experiencing a nosebleed when we arrive we find him leaning over basin which contains an impressive amount of blood he has a history of coronary artery disease diabetes migraine headaches oh his blood pressure's high his heart rate's a little elevated which of the following is the most likely the contributing factor i'm going to say it's going to be the high blood pressure yes okay when caring for a patient with um epistasis the most effective way to prevent aspiration of blood is too [Music] i think it's going to be b yep lean forward tilt them forward okay and controlling internal bleeding requires surgery usually right yes internal bleeding controlling is a surgical intervention okay so that concludes chapter 26 the bleeding chapter um if you like this lecture go ahead and subscribe to the channel all right have a great night