okay this is going to be a quick run through for our uh bleeding chapter for aemt uh most of this is going to be review from your uh EMT uh book but there are a few things that uh will go a little more in depth in uh we know that bleeding can be one of the most time sensitive conditions we have to find it early and control it as best we can and it can cause weakness shock and even death uh we know that uh our body relies on a process called perfusion which is circulation of blood within an organ or tissue inadequate amounts basically what that means is uh that uh enough blood has to circulate to deliver an adequate amount of oxygen and nutrients uh to all the tissues in the body which is in turn called perfusion and you see them some listed there the heart the brain's spinal cord in the nervous system uh the lungs of kidneys these are just some but all tissues are included the cardiac cycle a couple of terms you need to know here obviously it's a repetitive pumping process that uh circulates blood throughout our body but you do need to be familiar with the term preload that is the amount of blood returned to the heart uh waiting to be pumped out or the pressure that of the blood coming back through the inferior and superior vena cava and afterload is the pressure in the aorta or the peripheral vascular resistance so basically um that's what the heart has to pump against so if you had a blood pressure of 120 over 80 or 120 millimeters Mercury over 180 millimeters of mercury that means that the heart has to pull up greater than 80 millimeters of mercury in order to move any blood forward because 80 millimeters of mercury would be the pressure in the vessels or in the aorta uh while it's at rest or while the heart's at rest so that's afterload the pressure that the heart is pumping against whereas preload is the pressure or the amount of blood that's returning to the heart to be pumped and the cardiac cycle is connected to bleeding obviously because the cardiac cycle is what circulates blood throughout our body a delivery of oxygen to our tissues is dependent on our heart working appropriately having adequate stroke volume making sure we have plenty of hemoglobin in place and making sure that we have plenty of uh oxygen available to attach that hemoglobin to be transported and uh dropped off in the tissues so Hemorrhage is a discharge of blood from the blood vessel so anytime we are bleeding or blood is exiting the vascular vasculature then it's not inside the vessels of the heart that's not where it needs to be and that's considered Hemorrhage and some a lot of times we can control it by something as simple as direct pressure more pressure dressing sometimes we have to go all the way the other end to wound packing or tourniquets or using uh hemostatic impregnated dressings so external Hemorrhage comes from uh breaking the skin okay and it's severity is really uh how bad that uh break might be uh could internal hemorrhage can happen in any part of the body uh we usually associate major blood loss uh with our uh thoracic abdominal and pelvic cavities uh also bilateral femur fractures that uh body those compartments can hold um excessive amounts of blood we do know that there's uh we we think of hemorrhage being related to trauma but there are lots of non-traumatic reasons uh you could have gi bleeds or ectopic pregnancies uh even ruptured aneurysms and such things it can cause uh internal bleeding uh could be anything from Falls blast injuries remember because we had in Blast injuries we get a concussion wave that can damage uh internal organs Without Really creating a lot of external damage uh there were that at least not damaged it's not visible to us uh although any kind of automobile crash or whatnot there's a and there are a lot of uh illnesses that can be Associated we just spoke about GI bleeds uh which would you know be related to the whole whole bleeding ulcers or bleeding colon and uh once again the ectopic pregnancies and aneurysms signs and symptoms of internal hemorrhaging are going to be typically pain at the site blood isn't irritant the body doesn't like it being out of the vascular container so whenever it's out outside of the container it uh does irritate and causes pain there can be swelling or bruising in the area there can be a hematoma or also uh hemat emesis which is uh the uh blood in vomit all the way to your first signs of hypovolemic shock usually is going to be a change in mental status feeling like we've all stood up a little too quickly and our blood pressure hasn't uh been able to compensate so we get a little light-headed the same with blood loss uh our body there's not enough pressure there and so our body uh we start getting a little lightheaded or maybe a little altered so substantial changes in Vital Signs can happen uh when just one liter of blood uh is lost uh but our body automatically compensates by increasing our heart rate and our respiratory rate uh in order to try to maintain a blood pressure for as long as possible our body tries to save itself uh tries to maintain that perfusion uh but we know that bleeding is considered serious if there was a significant mechanism of injury uh or possibly the patient just has a poor appearance uh maybe uh there are signs of a shock already present uh that Ultra mental status or uh pale clammy skin whatnot uh or if we actually visibly see rapid blister uh we have some kind of bleeding that we can't control uh through our ordinary means so how does our body respond to hemorrhaging so bleeding usually stops pretty quickly okay platelets uh are on site almost immediately and they start to uh bind together to plug the hole if you will uh there are a lot of medications that interfere with normal clotting if we have patients with any kind of cardiac issues or any history of blood clots they may be on uh Warfarin or um Xarelto or some of the newer ones where uh these blood thinning medications that don't uh that prevent the clotting Factor also patients that are post cardiac uh issue can be on a daily aspirin and we know that aspirin inhibits platelet aggregation and so therefore can make clotting more different or more difficult I should say um and also patients that have blood disorders like hemophilia obviously they would be affected uh by um uh Hemorrhage also at a greater extent trauma Triad of death this is something you do need to know you need to make sure you're aware that the trauma Triad of death is a combination of hypothermia coagulopathy and acidosis okay that is your trauma Triad of death you will see that again uh coagulopathy is the disruption of the body's ability to clot obviously hypothermia is our body's core temperature going down and acidosis is US retaining uh that hydrogen and form of uh carbonic acid or lactic acid or um uh something along those lines we already know how to size up a scene and do a primary survey we're going to jump through that pretty quickly just remember that our primary assessment uh starts off with a full body scan follow the X ABC that's X for a single nation or X to make sure that we control Hemorrhage first as quickly as possible internal bleeding must be treated promptly but remember you have to be aware of the signs and symptoms of internal bleeding because you're not seeing it externally there's nothing in the pre-hospital setting that we can do to stop internal bleeding however uh we were treating for shock and Rapid transport is going to be their best option because getting the surgery is going to provide the highest possibility of a positive outcome we know how to take histories we know how to do secondary assessments we know how to reassess critical patients every five minutes uh in route to the hospital and uh we know that a reassessment involves a repeat of an entire primary assessment plus um vital signs Plus reevaluation of any Hemorrhage control uh measures we may have taken external hemorrhaging can usually be managed with direct pressure or sometimes we have to add a pressure dressing to it maybe we even add a splint on top of that air splints uh are uh pre-packaged pressure dressings in themselves and we'll talk about those in just a second uh but we would provide high flow oxygen assist ventilations if necessary any bulky dressings remember once we start applying dressings to uh an external Hemorrhage we don't remove those dressings if the Hemorrhage isn't controlled uh to put on more we just continue to pile more and more on because we don't want to uh any we don't want to disrupt any clotting that may have taken place with the initial dressings that we applied tourniquets be familiar with how to use whatever your agency uses are there a lot of different options out there there's a cat tourniquet the soft d uh the SWAT tee there's the rat tourniquet there's several different ones uh that you made this Israeli the ratcheting medical tourniquet lots of different ones out there so just be familiar with what your agency uses and how to apply it as quickly as possible there's some there's some examples of those there's a cat trying to get up there in the top left the ratchet uh tourniquet there on the right hand side it was actually designed uh by someone who basically took a uh tourniquet or webbing and attached a inline skate uh ratchet um to it to create that it's really good for one-handed applications so turn you typically are not going to um release a tourniquet before you get to the hospital it's going to be released at the hospital uh if you don't have a commercial tourniquet available you can use a triangular bandage you see there how they tied a bandage around uh the arm above the side of the injury uh tied a stick or windlass in place and you're going to twist that and twist that and twist that until there's no set number of times you're going to continue to turn it until the Hemorrhage has subsided there's those air splints or splints that we talked about earlier uh rigid splints can help stabilize fractures with those air Slims uh they inflate and they can actually apply pressure to addressing and slow uh circulation in the extremity to help with external hemorrhage excuse me we have um hemostatic agents out there and basically what they do is they adhere to uh damaged tissue or um dehydrate uh blood causing it to uh clot um more easily uh they are usually pretty easy to remove from the wound and they usually don't put anything uh into the rest of the body systems uh as smaller particles on wound packing is one of the last uh efforts we make but if we have injuries uh to um the Torso or even the upper part of the lower extremity that we cannot control with the tourniquet uh we might have to uh do some wound packing and that's basically where uh we continue to apply Galls inside them until we're able to apply pressure to the bottom of the wound where the Hemorrhage is originating pneumatic anti-shot garments or pasgs uh you also see them written as mass trousers military anti-shock trousers are um basically velcro pants they have two leg compartments in an abdominal compartment and you they're inflated uh with pressure to uh push blood they're originally designed to uh squeeze blood out of an extremity back into the Torso to raise blood pressure but when inflated to a certain amount they can help with external Hemorrhage as well anybody who's hemorrhaging from the nose ears or mouth uh there are lots of different causes for this could be from a traumatic incident where they have a skull fracture uh facial injuries uh chronic sinus infections resulting or even the overuse of nasal spray uh or um extremely dry sinuses uh high blood pressure can cause nosebleeds as a some of the thinnest vessels in our body are located in our nose and we can have coagulation disorders uh digital trauma is actually uh we can cause nosebleeds by uh picking our nose or a patient can't uh excessively epistaxis is the actual name for nosebleed that's epistaxis be familiar with that because that's how it will be referred to from here on out and it can cause enough blood loss to send a patient in the shock however maybe uh remembrance uh these are difficult leads to control because there's not ex there's not external Hemorrhage the humor just coming from from somewhere inside so basically what we'll have to do is compress uh apply compress or press down on the bridge of the nose having our patient lean forward we don't want them swallowing a lot of blood and the another alternative would be to roll calls and place it under the patient's upper lip creating pressure in that nasal cavity uh to stop um the uh Hemorrhage from taking place internal hemorrhage not really a lot we can do that other than rapid transport uh you may um we're not going to give the patient anything in my mouth but we're going to do our standard treatment for shock we're going to keep a monitor on our Vital Signs make sure we keep our patient warm uh I will apply or obtain IV access in traumatic injuries uh part of phtls you'll see is that we're going to maintain blood pressures not we think of 90 being a normal blood pressure and we think that we want to run fluid to get above that but between 80 and 90 uh is adequate in traumatic events because it takes 80 millimeters of mercury in order to perfuse the brain and that's our ultimate goal is to make sure that our brain and vital organs are being perfused we don't want to raise the blood pressure to a point that we actually increase Hemorrhage or blow out clots that have already formed in our body or our patient's body I should say continually homologous level of Consciousness pulse and blood pressure constantly reassessing and that's going to be the end of our bleeding lecture