Chapter 25 Bleeding

Melena

(blood in stool)

Hematemesis

(vomiting of blood)

veins

The blood vessels that carry blood from the tissues to the heart.

Internal bleeding is any bleeding that occurs in a space inside the body.

Mechanism of Injury (MOI) for Internal Bleeding Nature of Illness (NOI) for Internal Bleeding

Issues that affect clotting include:

Movement Disease processes Certain medications (such as blood thinners) Removal of bandages The external environment Body temperature

Bleeding from the nose or ears following a head injury may indicate a skull fracture.

This bleeding may be difficult to control and applying excessive pressure to the injury may force the blood leaking through the ear or nose to collect within the head. This could increase the pressure on the brain and possibly cause permanent damage.

venules

Very small, thin-walled blood vessels.

Reassessment

Reassess an unstable patient every 5 minutes and a stable patient every 15 minutes. Whenever you suspect significant bleeding, either external or internal, provide high-flow oxygen. Control external bleeding. If the patient has signs of hypoperfusion, provide aggressive treatment for shock and rapid transport to the appropriate hospital. If internal bleeding is suspected, apply high-flow oxygen via a nonrebreathing mask and provide rapid transport to the hospital. It is important to recognize, estimate, and report the amount of blood loss that has occurred and how rapidly or over what period of time it occurred. Your transfer report at the hospital should update hospital personnel on how your patient has responded to your care. Be sure your paperwork reflects all of the patient's injuries and the care you have provided.

capillaries

The small blood vessels that connect arterioles and venules; various substances pass through capillary walls, into and out of the interstitial fluid, and then on to the cells.

arterioles

The smallest branches of arteries leading to the vast network of capillaries.

Soon afterward, the cut ends of the blood vessel begin to narrow (vasoconstriction), reducing the amount of bleeding.

Coagulation is the process of clot formation.

_____ occurs when blood volume is significantly diminished and the circulatory system fails to provide sufficient circulation to the body. Hematemesis Hematoma Hemorrhage Hypoperfusion

Correct. Hypoperfusion is a condition in which the circulatory system fails to provide sufficient circulation to maintain normal cellular function.

Whenever you apply a tourniquet, make sure you observe the following precautions:

Do not apply a tourniquet directly over any joint. Always place the tourniquet proximal to the injury (in the axillary region for upper extremity injuries and at the groin for lower extremity injuries). Make sure the tourniquet is tightened securely. Never use wire, rope, a belt, or any other narrow material that could cut into the skin. If it is possible to do so without causing a delay, consider placing padding under the tourniquet as you apply it. This step may protect the skin and help with arterial compression. Never cover a tourniquet with a bandage. Leave it in full view. Do not loosen the tourniquet after you have applied it, unless directed by medical control. Mark the exact time the tourniquet was applied and be sure to communicate the time of application, the site of application, and the rationale for application clearly and specifically to hospital personnel upon arrival.

Hemorrhage =

bleeding.

Infants and children have less blood volume compared with adults.

A 1-year-old has a typical total blood volume of about 27 oz (800 mL); the child will show significant symptoms of blood loss after only 3 to 6 oz (100 to 200 mL) of blood loss, or less than half the volume of liquid in a 12-oz (350-mL) can of soda.

artery

A blood vessel, consisting of three layers of tissue and smooth muscle, that carries blood away from the heart.

contusion

A bruise from an injury that causes bleeding beneath the skin without breaking the skin; also see ecchymosis.

They come in two forms:

A granular powder, which can be inserted into small wounds to create a tight seal (such as a gunshot wound) Gauze impregnated with a clay substance, which speeds blood clot formation Gauze can also be packed into larger wounds to control hemorrhage.

How well a patient's body compensates for blood loss is related to how rapidly the blood loss occurs.

A healthy adult can comfortably donate 1 unit (1 pint [500 mL]) of blood within 15 to 20 minutes and adapt well.

Mechanism of Injury (MOI) for Internal Bleeding

A high-energy MOI should increase your index of suspicion for the possibility of serious, unseen injuries, such as internal bleeding in the abdominal cavity. Internal bleeding is possible whenever the MOI suggests that severe forces affected the body. Internal bleeding commonly occurs as a result of falls, blast injuries, and motor vehicle crashes. Can also result from penetrating trauma As you assess a patient, look for signs of injury using the DCAP-BTLS (Deformities, Contusions, Abrasions, Punctures/penetrations, Burns, Tenderness, Lacerations, Swelling) mnemonic, as well as any other signs of injury. Always suspect internal bleeding in a patient who has sustained a penetrating injury or blunt trauma.

Splints

An air splint acts like a pressure dressing applied to an entire extremity rather than to a small, local area. Use only approved, clean, or disposable valve stems when orally inflating air splints. Rigid splints will help immobilize fractures as well as reduce pain and further damage to soft tissues. Once you have applied a splint, monitor pulse and motor and sensory function in the distal extremity.

Common blood thinners include:

Aspirin Warfarin (Coumadin) Rivaroxaban (Xarelto) Dabigatran (Pradaxa) Apixaban (Eliquis) Clopidogrel (Plavix)

Scene Size-up

At vehicle crashes, ensure there are no fluids leaking from the vehicle or energized power lines in the area where you will be working. In incidents involving violence, make sure that police have advised the scene is safe. You may need to stage several blocks away until law enforcement personnel have secured the area. Follow standard precautions. Place several spare pairs of gloves in your pocket for easy access in case your gloves tear or there are multiple patients with bleeding. If you enter a residence, be alert for anxious bystanders, family members, and even pets who may become hostile. Determine the number of patients needing care. Consider early on what additional resources you may need, and verify as you begin your assessment. Determine the NOI by observing signs (such as bloody emesis) or the MOI (such as an upturned step stool). Consider the need for spinal immobilization and/or additional resources, such as an advanced life support (ALS) unit.

Venous bleeding from an open vein is darker than arterial blood because it is oxygen poor. It can flow slowly or rapidly, depending on the size of the vein.

Because it is under less pressure, most venous blood does not spurt and is easier to manage; however, it can be profuse and life threatening.

The heart muscle has several unique features:

Because the heart cannot tolerate a disruption of its blood flow for more than a few minutes, the heart muscle needs a rich and well-distributed blood supply. The heart works as two paired pumps. Each side of the heart has an upper chamber (atrium) and a lower chamber (ventricle), both of which pump blood. Blood leaves each chamber of a normal heart through a one-way valve, which keeps the blood moving in the proper direction by preventing backflow.

There are several forms of hemophilia, most of which are hereditary and some of which are severe.

Because the patient's blood does not clot effectively, all injuries, no matter how trivial, are potentially serious, so you should transport a patient with hemophilia immediately.

Tourniquets

Begin with direct pressure, and move to the next steps if direct pressure does not control the bleeding. If the bleeding oozes slowly through the dressing, reinforce it by applying more dressings on top of it. Do not remove a dressing until a physician has evaluated the patient

In the body, blood clot formation depends on:

Blood stasis Changes in the blood vessel wall (such as a wound) The blood's ability to clot (affected by disease processes or medications)

ecchymosis

Blue or black discoloration associated with a closed wound; signifies bleeding within or under the skin; also see contusion.

Without adequate perfusion:

Cells in the brain and spinal cord start to die after 4 to 6 minutes. Remember that cells of the central nervous system (CNS) do not have the capacity to regenerate. Lungs can survive only 15 to 20 minutes. Kidneys can be damaged after 45 minutes. Skeletal muscle demonstrates evidence of injury after 2 to 3 hours. The gastrointestinal tract can tolerate slightly longer periods. These times are based on a normal core body temperature (98.6°F [37.0°C]).

Blood Vessels and Blood

During an emergency, the autonomic nervous system redirects blood away from other organs to the heart, brain, lungs, and kidneys. If blood volume is significantly diminished and the system fails to provide sufficient circulation for every body part to perform its function, hypoperfusion, or shock, results. Oxygen and nutrients easily pass from the capillaries into the cells, and waste and carbon dioxide diffuse from the cells into the capillaries.

Controlling Epistaxis

Epistaxis is a common emergency. Occasionally, it can cause blood loss great enough to send a patient into shock. You can usually handle this type of bleeding effectively by pinching the nostrils together. Step 1 Position the patient sitting, leaning forward. Apply direct pressure, pinching the fleshy part of the nostrils together. Step 2 Alternative method: Apply pressure with a rolled gauze bandage between the upper lip and gum. Calm the patient. Step 3 Apply ice over the nose. Maintain pressure until bleeding is controlled. Initiate prompt transport while you or the patient applies pressure. Assess and treat for shock, including oxygen, as needed.

Bleeding from the Nose, Ears, and Mouth

If you suspect a skull fracture, loosely cover the bleeding site with a sterile gauze pad to collect the blood and help keep contaminants away from the site. Apply light compression by wrapping the dressing loosely around the head. If blood or drainage contains cerebrospinal fluid, you will see a characteristic staining of the dressing much like a target or halo shape.

Applying a Tourniquet Using a Triangular Bandage

Fold a triangular bandage until it is 4-inches (101-mm) wide and six to eight layers thick. Wrap the bandage around the extremity twice. Place the bandage high and tight, proximal to the injury (in the axillary region for upper extremity injuries and at the groin for lower extremity injuries). Tie one knot in the bandage. Place a stick or rod on top of the knot and tie the ends of the bandage over the stick in a square knot. Using the stick or rod as a handle, twist it to tighten the tourniquet until the bleeding has stopped, then stop twisting. Secure the stick in place and make the wrapping neat and smooth. Write "TK" (for "tourniquet") and the exact time (hour and minute) that you applied the tourniquet on a piece of adhesive tape. Securely fasten the tape to the patient's forehead or write the time directly on the forehead with a marker. Notify hospital personnel on your arrival that your patient has a tourniquet in place. Record this same information on the ambulance run report form.

Signs and symptoms of internal bleeding in trauma and medical patients include:

Hematemesis (vomiting of blood) The vomitus may be bright red or dark red. If the blood has been partially digested, the vomitus may look like coffee grounds. Melena (blood in stool) Pain, tenderness, bruising, guarding, or swelling These signs and symptoms may mean that a closed fracture is bleeding. Broken ribs; bruises over the lower part of the chest; or a rigid, distended abdomen These signs and symptoms may indicate a lacerated spleen or liver. Patients with an injury to one of these organs may have referred pain in the right shoulder (indicating the liver is injured) or left shoulder (indicating the spleen is injured).

The Significance of External Bleeding

If this volume of blood loss occurs during a much shorter period, symptoms of hypovolemic shock and even death might develop. In any situation, severe blood loss presents an immediate life threat. Your priority is to quickly control major external bleeding, even before you address airway and breathing concerns. With significant blood loss, adverse changes in vital signs occur, including increased heart and respiratory rates and decreased blood pressure.

History Taking

In a responsive trauma patient with an isolated injury and a limited MOI, consider a detailed physical examination of the specific area before you assess vital signs and obtain a history. If the patient is responsive, obtain a SAMPLE history. Ask the patient if he or she takes blood-thinning medications because bleeding is generally more profuse and difficult to control in patients who take blood thinners. Blood thinners are often prescribed for patients with a history of stroke, pulmonary embolism, or heart attack. If the patient is unresponsive, obtain medical history information from medical alert tags or ask family members or bystanders if they have any information. Look for signs and symptoms of hypoperfusion and determine how much blood loss has occurred.

The first sign of hypovolemic shock is a change in mental status, such as anxiety, restlessness, or combativeness.

In nontrauma patients, weakness, faintness, or dizziness on standing is another early sign.

Signs and Symptoms of Internal Bleeding

Intra-abdominal bleeding will often cause pain and distention. Bleeding into the chest cavity or lung may cause dyspnea, tachycardia, hemoptysis, and hypotension. A hematoma indicates bleeding into soft tissues and may be the result of a minor or a severe injury. Bruising or ecchymosis may not be present initially, and the only sign of severe pelvic or abdominal trauma may be redness, skin abrasions, or pain. Bright-red bleeding from the mouth or rectum or hematuria (blood in the urine) suggests serious internal injury or disease. Nonmenstrual vaginal bleeding is always significant. Patients with these signs and symptoms, particularly in the setting of significant MOI, require prompt transport, preferably to a trauma center.

Primary Assessment

Perform a rapid exam, look for life threats, and treat them as you find them. If the patient has obvious, life-threatening external bleeding, address it first (even before airway and breathing) by controlling it quickly. Assess the ABCs and provide treatment. If direct pressure is ineffective in controlling massive hemorrhage from an extremity, the patient may require a tourniquet before the airway is opened. Assess skin color: cool, moist skin that is pale or gray suggests a perfusion problem. Determine the patient's level of consciousness using the AVPU scale. Develop an index of suspicion for serious illness or injuries related to internal bleeding. Consider the need for spinal immobilization. At the same time, ensure a patent airway, look for adequate breathing, and check for breath sounds. If necessary, provide the patient with high-flow oxygen or assist ventilation with a bag-valve mask (BVM) or nonrebreathing mask, depending on the patient's level of consciousness and rate and quality of breathing. If the patient is unconscious and the airway is obstructed, insert an oropharyngeal airway. Quickly assess pulse rate and quality. Determine the condition, color, and temperature of the skin and check capillary refill time. Treat the patient for shock, if needed, by applying oxygen, improving circulation, and maintaining a normal body temperature. If the patient has signs and symptoms of internal bleeding or airway or breathing problems, provide rapid transport to the most appropriate facility. The condition of patients with significant bleeding will quickly become unstable. Signs such as tachycardia, tachypnea, low blood pressure, weak pulse, and clammy skin are signs of impending circulatory collapse and indicate the need for rapid transport.

As a last resort, you can use a blood pressure cuff as a tourniquet.

Position the cuff proximal to the bleeding point and inflate it just enough to stop the bleeding. Leave the cuff inflated. Monitor the gauge continuously to make sure that the pressure is not gradually dropping, which could allow the bleeding to restart. You may have to clamp the tube leading from the cuff to the inflating bulb with a hemostat to prevent loss of pressure. Consider wrapping the cuff with tape to prevent the Velcro from loosening under continuous high pressure.

Secondary Assessment

Record vital signs. Complete an assessment of pain. Attach appropriate monitoring devices to quantify oxygenation and circulatory status. Assess all areas for DCAP-BTLS to identify underlying or secondary injuries. For isolated injuries, assess that area only (detailed physical examination). When examining the head, be alert for uncontrolled bleeding from large scalp lacerations. In the abdomen, feel all four quadrants for tenderness or rigidity. In the extremities, record pulse, motor, and sensory function. Obtain baseline vital signs to identify any changes that may occur during treatment. In an adult patient, a systolic blood pressure of less than 100 mm Hg with a weak, rapid pulse and cool, moist skin that is pale or gray are signs of hypoperfusion that require immediate attention.

Blood contains:

Red cells Transport oxygen to the cells and transport carbon dioxide away from the cells to the lungs, where it is removed from the body during exhalation White cells Platelets Key to formation of blood clots Plasma

Several conditions can result in bleeding from the nose, ears, and/or mouth, including:

Skull fracture Facial injuries, including those caused by a direct blow to the nose Sinusitis, infections Nose drop use and abuse Dried or cracked nasal mucosa Intranasal use of street drugs (snorting) Other abnormalities High blood pressure Coagulation disorders Digital trauma (nose picking)

Nature of Illness (NOI) for Internal Bleeding

Some of the more common causes of nontraumatic internal bleeding include bleeding ulcers, bleeding from the colon, ruptured ectopic pregnancy, and aneurysms. Abdominal tenderness, guarding, rigidity, pain, and distention are frequent in these situations but are not always present. In older patients, dizziness, faintness, or weakness may be the first sign of nontraumatic internal bleeding. Ulcers or other gastrointestinal problems may cause vomiting of blood or bloody diarrhea. Injury or damage to internal organs commonly results in extensive internal bleeding, which can cause hypovolemic shock before you realize the extent of blood loss. A broken femur can easily result in the loss of 2 pints (about 1 liter) or more of blood into the soft tissues of the thigh. Often the only signs of such bleeding are local swelling and bruising (called a contusion, or ecchymosis) caused by the accumulation of blood around the ends of the broken bone. Severe pelvic fractures may result in life-threatening hemorrhage. If you suspect that a patient is bleeding internally, treat for shock and promptly transport him or her to the hospital

Applying a MAT Commercial Tourniquet

Step 1 Apply pressure over the bleeding site and place the tourniquet proximal to the injury (in the axillary region for upper extremity injuries and at the groin for lower extremity injuries). Step 2 Click the buckle into place, pull the strap tight, and turn the tightening dial clockwise until pulses are no longer palpable distal to the tourniquet or until bleeding has been controlled.

Controlling Internal Bleeding

Step 1 Follow standard precautions. Maintain the airway and be alert for cervical spine injury. Administer oxygen and provide ventilation as necessary. Step 2 Control obvious external bleeding and treat suspected internal bleeding using a splint. Apply a tourniquet for severe bleeding that cannot be controlled with direct pressure. Step 3 Depending on local protocols, use a pelvic compression device or splint to control suspected internal bleeding in the pelvic region. Step 4 Monitor vital signs and keep the patient warm.

Controlling External Bleeding

Step 1 Take standard precautions. Apply direct pressure over the wound with a dry, sterile dressing. Step 2 Apply a pressure dressing. Step 3 If direct pressure with a pressure dressing does not control bleeding, apply a tourniquet above the level of the bleeding. Step 4 Tighten the tourniquet until distal pulses are no longer palpable. Properly position the patient. Apply high-flow oxygen as necessary. Keep the patient warm. Transport promptly.

Which of the following should you do when applying a tourniquet? Place the tourniquet proximal to the injury (in the axillary region for upper extremity injuries and at the groin for lower extremity injuries). Cover a tourniquet with a bandage to prevent contamination of the injury site. Loosen the tourniquet after you have applied it to check for changes in circulation at the injury site. Make sure the tourniquet is tightened securely.

Submit Correct. You should place the tourniquet proximal to the injury and be sure it is tightened securely.

Later signs of hypovolemic shock suggesting internal bleeding include:

Tachycardia Weakness, fainting, or dizziness at rest Thirst Nausea and vomiting Cold, moist (clammy) skin Shallow, rapid breathing Dull eyes Slightly dilated pupils that are slow to respond to light Capillary refill time longer than 2 seconds in infants and children Weak, rapid (thready) pulse Decreasing blood pressure Altered level of consciousness

aorta

The main artery leaving the left side of the heart, which receives blood from the left ventricle and delivers it to all the other arteries that carry blood to the tissues of the body.

Several different types of commercial tourniquets are on the market, including:

The mechanical advantage tourniquet (MAT) The combat application tourniquet (CAT) The ratcheting medical tourniquet (RMT) The special weapons and tactics tourniquet (SWAT-T)

Direct, even pressure

The most effective way to control external bleeding Previously, elevation of the extremity was also recommended, but there is no evidence it helps control bleeding and it may aggravate other injuries. Apply pressure with your gloved fingertip or hand over the top of a sterile dressing if one is immediately available. If there is an object protruding from the wound, never remove it unless it is in the cheek and blocking the patient's airway. Apply bulky dressings to stabilize the impaled object in place, and apply pressure as best you can for at least 5 minutes without interruption.

vasoconstriction

The narrowing of a blood vessel, such as with hypoperfusion or cold extremities.

You should consider bleeding to be severe if:

The patient has a poor general appearance and has no response to external stimuli. Assessment reveals signs and symptoms of shock (hypoperfusion). You note a significant amount of blood loss. The blood loss is rapid and ongoing. You cannot control the bleeding. It is associated with a significant MOI.

The cardiovascular system is the main system responsible for supplying and maintaining adequate blood flow. It consists of three parts:

The pump (the heart) A container (the blood vessels that reach the cells of the body) The fluid (blood and body fluids)

Treatment of hemorrhage should be based on the patient's presentation and mechanism of injury (MOI).

The typical adult male body contains approximately 70 mL of blood per kilogram of body weight. The adult female body contains approximately 65 mL of blood per kilogram of body weight. The body cannot tolerate an acute blood loss of greater than 20% of total blood volume, or more than 2 pints (about 1 liter) in the average adult.

Blood leaving the distal side of the capillaries flows into the venules.

These empty into the veins. The veins then empty into the inferior and superior venae cavae.

Arterial bleeding from an open artery is bright red (because it is oxygen rich) and spurts in time with the pulse.

This pressure makes this type of bleeding difficult to control. As the amount of blood circulating in the body drops, so does the patient's blood pressure and, eventually, arterial spurting.

Pressure dressings and/or splints

Use 4-inch × 4-inch (101-mm × 101-mm) sterile gauze pads for small wounds and sterile universal dressings for larger wounds. Cover the entire dressing with the bandage above and below the wound, and stretch the bandage tight enough to control bleeding. If you were able to palpate a distal pulse before applying the dressing, you should still be able to palpate a distal pulse on the injured extremity after applying the pressure dressing.

You are treating a patient with significant external bleeding. Rearrange the steps into the correct order in which they should be addressed. Treat for shock Address ABCs Control bleeding Assess for DCAP-BLTS

You are treating a patient with significant external bleeding. Rearrange the steps into the correct order in which they should be addressed. Control bleeding Correct. Your priority is to quickly control major external bleeding, even before you address airway and breathing concerns. Then you will need to treat for shock and assess areas for DCAP-BLTS to identify underlying secondary injuries. Address ABCs Correct. Your priority is to quickly control major external bleeding, even before you address airway and breathing concerns. Then you will need to treat for shock and assess areas for DCAP-BLTS to identify underlying secondary injuries. Treat for shock Correct. Your priority is to quickly control major external bleeding, even before you address airway and breathing concerns. Then you will need to treat for shock and assess areas for DCAP-BLTS to identify underlying secondary injuries. Assess for DCAP-BLTS Correct. Your priority is to quickly control major external bleeding, even before you address airway and breathing concerns. Then you will need to treat for shock and assess areas for DCAP-BLTS to identify underlying secondary injuries. Submit

A hemostatic agent

is any chemical compound that slows or stops bleeding by assisting with clot formation. Hemostatic agents can be used together with direct pressure when direct pressure alone is ineffective, such as with massive chest injuries, or when tourniquet placement is impossible.

The tourniquet

is especially useful if a patient has substantial bleeding from an extremity injury.

Perfusion

is the circulation of blood within an organ or tissue in adequate amounts to meet the cells' current needs for oxygen, nutrients, and waste removal.