Chapter 25 : Bleeding

circulatory system failures

Movement, disease process, certain medications (such as blood thinners), removal of bandages, the external environment, or body temperature commonly affect the blood's clotting factors. Occasionally, blood loss is very rapid. In these cases, the patient might die before clotting

arterial bleeding

from an open artery is bright red (because it is oxygen rich) and spurts in time with the pulse. The pressure that causes the blood to spurt also 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, the arterial spurting.

venous bleeding

from an open vein is darker than arterial blood (because it is oxygen poor) and 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. Capillary bleeding from damaged capillary vessels is dark red and oozes from a wound steadily but slowly. Venous and capillary blood is more likely to clot spontaneously than arterial blood

The autonomic nervous system monitors the body's needs and adjusts......

the blood flow by constricting or dilating blood vessels as required. During an emergency, the autonomic nervous system automatically redirects blood away from other organs to the heart, brain, lungs, and kidneys. Thus, the cardiovascular system adapts to changing conditions in the body to maintain homeostasis and perfusion. As discussed in Chapter 12, Shock, if blood volume is significantly diminished and the system fails to provide sufficient circulation for every body part to perform its function, then hypoperfusion, or shock, results.

If a commercial tourniquet is unavailable, then follow these steps to apply a tourniquet using a triangular bandage and a stick or rod:

1. Fold a triangular bandage until it is 4 inches (101 mm) wide and six to eight layers thick.2. 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).3. Tie one knot in the bandage. Then place a stick or rod on top of the knot, and tie the ends of the bandage over the stick in a square knot.4. Use the stick or rod as a handle, and twist it to tighten the tourniquet until the bleeding has stopped; then stop twisting Figure 25-12 .5. Secure the stick in place, and make the wrapping neat and smooth.6. 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. 7. 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.

how to apply a commercial tourniquet

1. Follow standard precautions.2. Apply direct pressure over the bleeding site.3. Place the tourniquet around the extremity high and tight, proximal to the bleeding site (in the axillary region for upper extremity injuries and at the groin for lower extremity injuries) Step 1 . 4. Click the buckle into place and pull the strap tight. 5. Turn the tightening dial clockwise until pulses are no longer palpable distal to the tourniquet or until bleeding has been controlled Step 2 . 6. Do not release a tourniquet once applied, unless instructed to do so by medical control.

How to control epistaxis

1. Follow standard precautions.2. Help the patient to sit, leaning forward, with the head tilted forward. This position stops the blood from trickling down the throat or being aspirated into the lungs.3. Apply direct pressure for at least 15 minutes by pinching the fleshy part of the nostrils together. This is the preferred method. This technique may also be performed by the patient Step 1 .4. Another option is to place a rolled 4-inch × 4-inch (101-mm × 101-mm) gauze bandage between the upper lip and the gum. Have the patient apply pressure by stretching the upper lip tightly against the rolled bandage and pushing it up into and against the nose. If the patient is unable to do this effectively, use your gloved fingers to press the gauze against the gum Step 2 . 5. Keep the patient calm and quiet, especially if he or she has high blood pressure or is anxious. Anxiety tends to increase blood pressure, which could worsen the nosebleed. 6. Apply ice over the nose. 7. Maintain the pressure until the bleeding is completely controlled, usually no more than 15 minutes if this is the patient's only problem. Most often, failure to stop a nosebleed is the result of releasing the pressure too soon Step 3 . 8. Provide prompt transport. You can initiate transport while having the patient maintain direct pressure or while maintaining pressure yourself. 9. Assess the patient for signs and symptoms of shock and treat appropriately.

how to care for patients with possible internal bleeding

1. Follow standard precautions.2. Maintain the airway with cervical spine immobilization if the MOI suggests the possibility of spinal injury.3. Administer high-flow oxygen and provide artificial ventilation as necessary Step 1 .4. Control all obvious external bleeding.5. Treat suspected internal bleeding in an extremity by applying a splint Step 2 .6. Depending on local protocols, use a pelvic compression device or splint to control suspected internal bleeding from the pelvic area Step 3 .7. Monitor and record the vital signs at least every 5 minutes.8. Keep the patient warm Step 4 .9. Give the patient nothing by mouth, not even small sips of water. 10. Provide prompt transport for all patients with signs and symptoms of hypoperfusion. Report any changes in the patient's condition to emergency department personnel

The typical adult male body contains approximately

70 mL of blood per kilogram of body weight, whereas the adult female body contains approximately 65 mL of blood per kilogram of body weight. Therefore, a typical adult man weighing 175 pounds (79 kg) has a total blood volume of about 10 to 12 pints (6 L). The body cannot tolerate an acute blood loss of greater than 20% of this total blood volume, or more than 2 pints (about 1 liter) in the average adult. With significant blood loss, adverse changes in vital signs will occur, including increased heart and respiratory rates and decreased blood pressure. Because infants and children have less blood volume compared with adults, these effects are seen with smaller amounts of blood loss. For example, 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.

tourniquet

A device used for bleeding control that constricts all blood flow to and from an extremity.

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. These forces include blunt and penetrating trauma. Internal bleeding commonly occurs as a result of falls, blast injuries, and motor vehicle crashes. Remember that internal bleeding can result from penetrating trauma as well. As you assess a patient, look for signs of injury using the DCAP-BTLS mnemonic (Deformities, Contusions, Abrasions, Punctures, Burns, Tenderness, Lacerations, and Swelling) as well as any other signs of injury. Always suspect internal bleeding in a patient who has sustained a penetrating injury or blunt trauma.

Hemophilia

A small portion of the population lacks one or more of the blood's clotting factors, a condition called hemophilia. There are several forms of hemophilia, most of which are hereditary and some of which are severe. Sometimes bleeding occurs spontaneously in patients with hemophilia. Because the patient's blood does not clot effectively, all injuries, no matter how trivial, are potentially serious. Transport a patient with hemophilia immediately.

History Taking: Bleeding

After the primary assessment is complete, investigate the chief complaint and be alert for signs or symptoms of other injuries due to the MOI and/or NOI. Remember, internal bleeding can be found in both medical and trauma patients. For example, ectopic pregnancy, gastrointestinal bleeding, bleeding from a dialysis shunt, and severe nosebleed are medical causes of potential internal bleeding. If signs and symptoms of internal bleeding are not obvious, look more carefully during the patient assessment process. 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. When you encounter a patient who is bleeding, avoid focusing solely on the bleeding. With significant trauma, assess the entire patient, looking for the source of the problem, any preexisting illnesses, and other issues. If the patient is responsive, obtain a SAMPLE history (Signs and symptoms, Allergies, Medications, Pertinent past medical history, Last oral intake, Events leading up to the illness or injury). It is important to 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. Common blood thinners include aspirin, warfarin (Coumadin), rivaroxaban (Xarelto), dabigatran (Pradaxa), apixaban (Eliquis), and clopidogrel (Plavix) 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.

splints

Air splints (commonly known as soft splints or pressure splints) can control internal or external bleeding associated with severe extremity injuries, such as fractures Figure 25-13 . They also immobilize the fracture itself. 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, be sure to monitor pulse and motor and sensory function in the distal extremity.

blood loss and broken bones

Broken bones, especially broken ribs, also may cause serious internal blood loss. Sometimes this bleeding extends into the chest cavity and the soft tissues of the chest wall. 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. Always be alert to the possibility of internal bleeding. Assess the patient for related signs and symptoms, particularly if the MOI is significant. If you suspect that a patient is bleeding internally, treat for shock and promptly transport him or her to the hospital.

scene size up: bleeding

As you approach the patient, be alert to potential hazards to yourself and the crew, bystanders, and the patient. 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, such as assaults or patients with gunshot wounds, 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 Patient Assessment for External and Internal Bleeding pets, as they may become hostile. Determine the number of patients needing care. Consider early on what you additional resources you may need, and verify as you begin your assessment. Determine the nature of the illness (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 unit. Be sure to also consider environmental factors in your decision making. For example, caring for a sick or injured victim of a motor vehicle crash on a clear, sunny day is different from treating the same victim during a snowstorm. Extremely hot or cold weather can worsen a patient's overall condition

Reassessment: Bleeding

Because the signs and symptoms of internal bleeding are often slow to develop, it is important to reassess the patient frequently. Children especially will compensate well for blood loss and then "crash" quickly. The reassessment is your best opportunity to determine whether your patient's condition is improving or getting worse and to determine the effectiveness of any interventions and treatments. 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. If significant bleeding is visible, control external bleeding as shown in Skill Drill 25-1. Using multiple methods to control external bleeding usually works best. 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. See Skill Drill 25-4 for additional steps. Do not delay transport of a patient to complete an assessment, particularly when significant bleeding is present, even if the bleeding is controlled. The assessment can be started during transport. In patients with severe external bleeding, 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. For example, you may report that approximately 2 pints (about 1 liter) of blood loss occurred or that the bleeding soaked through three trauma dressings. Report this information to hospital personnel during transport to allow the hospital to evaluate needed resources, such as the availability of surgical suites, surgeons, and other specialty providers. 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.

what kind of bleeding indicates a skull fractures?

Bleeding from the nose or ears following a head injury may indicate a skull fracture. In these cases, do not attempt to stop the blood flow. This bleeding may be difficult to control. 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. 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 Figure 25-15 . If blood or drainage contains cerebrospinal fluid, you will see a characteristic staining of the dressing much like a target or halo shape bleeding from the ear after head injury indicates a skull fracture. Loosely cover the bleeding site with a sterile gauze pad and apply light compression by wrapping the dressing loosely around the head

how fast does the blood pass through the cardiovascular system?

Blood must pass through the cardiovascular system fast enough to maintain adequate circulation throughout the body and to avoid clotting, yet slow enough to allow each cell time to exchange oxygen and nutrients for carbon dioxide and other waste products. Although some tissues never rest and require a constant blood supply, most require a large volume of circulating blood only intermittently, with less required when at rest. For example, skeletal muscles require a minimal blood supply during sleep, as opposed to a large blood supply during exercise. Another example is the gastrointestinal tract, which requires a high flow of blood after a meal. After digestion is completed, however, the gastrointestinal tract functions well with only a small fraction of that blood flow.

hematuria

Bright red bleeding from the mouth or rectum or blood in the urine (hematuria) may suggest serious internal injury or disease. Nonmenstrual vaginal bleeding is always significant.

functions of the heart

First, 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. Second, the heart works as two paired pumps Figure 25-2 . 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.

How to control external bleeding

Follow standard precautions. Maintain the airway with cervical spine immobilization if the MOI suggests the possibility of spinal injury. Apply direct pressure over the wound with a dry, sterile dressing Step 1 . Apply a pressure dressing Step 2 If direct pressure and a pressure dressing are not immediately effective, apply a tourniquet to an extremity above the level of the bleeding Step 3 . Tighten the tourniquet until pulses are no longer palpable distal to the tourniquet Step 4 . Position the patient supine unless there is a reason not to; for example, underlying respiratory issues.

Nature of illness for internal bleeding

Internal bleeding is not always caused by trauma. Many illnesses can cause 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 non-traumatic internal bleeding. Ulcers or other gastrointestinal problems may cause vomiting of blood or bloody diarrhea. It is not as important for you to know the specific organ involved as it is to recognize the patient is in shock. When combined with prompt transport decisions and limited time spent at the scene, the rapid recognition of a patient in shock should result in the rapid administration of potentially life-saving treatments.

signs and symptoms of internal bleedings

The most common symptom of internal bleeding is pain. Significant internal bleeding will generally cause swelling in the area of bleeding, but swelling is often undetected until massive blood loss has occurred. Internal bleeding is most common in head, extremity, and pelvic injuries and is often associated with significant abdominal trauma. Intra-abdominal bleeding will often cause pain and distention. Bleeding into the chest cavity or lung may cause dyspnea, tachycardia, hemoptysis (the coughing up of bright red blood), and hypotension. A hematoma, a mass of blood that has collected in the soft tissues beneath the skin, 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.

The first sign of hypovolemic shock is....

change in mental status, such as anxiety, restlessness, or combativeness. In nontrauma patients, weakness, faintness, or dizziness on standing is another early sign. Changes in skin color or pallor (pale skin) are often seen in both trauma and medical patients.

Secondary Assessment : Bleeding

Unless you discover a life-threatening condition during the primary assessment, next conduct a secondary assessment, which is a detailed, comprehensive examination of the patient to uncover injuries or illness that may have been missed during the primary assessment. Record vital signs, complete an assessment of pain, and attach appropriate monitoring devices to quantify oxygenation and circulatory status. In some instances, such as a critically injured patient or a short transport time, there may not be time to conduct a secondary assessment. Assess all areas for DCAP-BTLS to identify underlying or secondary injuries. For isolated injuries such as pain in the ankle, 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; this allows you to more easily 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. In geriatric patients and patients who take certain blood pressure medications, the pulse rate may not increase with early shock; therefore, try to determine the patient's baseline blood pressure and quickly obtain a medical history and list of medications to help you better assess the patient's condition.

primary assessment: bleeding

When you treat a patient with significant blood loss from a visible wound or with suspected internal bleeding, do not be distracted from identifying and managing life threats, which is the focus of your primary assessment. As you approach a trauma patient, note important indicators that may signal the seriousness of the patient's condition. For example, a patient with external bleeding may have bloodstains on his or her clothing. Be aware of obvious signs of injury and distress, such as facial grimace. Determine the patient's gender and age. Perform a rapid exam of the patient, look for life threats, and treat them as you find them. If the patient has obvious, life- threatening external bleeding, remember to address it first (even before airway and breathing) by controlling it quickly; then assess the ABCs and provide treatment. If direct pressure is ineffective in controlling massive hemorrhage from an arm or leg, the patient may require a tourniquet before the airway is opened. Next, 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 (Awake and Alert, Responsive to Verbal Stimuli, Responsive to Pain, Unresponsive). Does the patient have a patent (open) airway? If the patient is able to speak, then this indicates the airway is patent. What is the mental status of the patient? These indicators will help you assess how sick the patient is, which will help you 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, the airway may be obstructed. Insert an oropharyngeal (oral) airway to secure the airway. Quickly assess pulse rate and quality; determine the condition, color, and temperature of the skin; and check the capillary refill time to help establish the potential for internal bleeding and shock. Treat the patient for shock, if needed, by applying oxygen, improving circulation, and maintaining a normal body temperature. The results of your initial general impression and your assessment of the ABCs will help you decide whether to manage the patient on scene or transport immediately and manage the patient en route to the hospital. 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.

the significance of external bleeding

With serious external bleeding, it is often difficult to determine the amount of blood loss because blood will look different on different surfaces, such as when it is absorbed in clothing, when it has been diluted in water, or when the environment is dark. It is important to estimate the amount of external blood loss; however, treatment should be based on the patient's presentation and MOI.

when a wound is located on a part of the body where tourniquet placement is impossible....

a hemostatic agent may be applied to increase clotting

Capillaries

are small tubes, with the diameter of a single red blood cell, that pass among all the cells in the body, linking the arterioles and the venules. Blood leaving the distal side of the capillaries flows into the venules. These small, thin-walled vessels empty into the veins, and the veins then empty into the inferior and superior venae cavae. This is the process that returns blood in the venous portion of the circulatory system to the heart. Oxygen and nutrients easily pass from the capillaries into the cells, and waste and carbon dioxide diffuse from the cells into the capillaries Figure 25-3 . This transportation system allows the body to rid itself of waste products.

air splints can also be used to control bleeding because

because they act as pressure bandage for the entire extremity. they are not as effective as tourniquet, however, and should never be used when a tourniquet is an option

arteries

become smaller the farther they are from the heart. The smaller blood vessels that connect the arteries and capillaries are arterioles

what does blood contain

contains red cells, white cells, platelets, and plasma Figure 25-4 . Red blood cells transport oxygen to the cells and transport carbon dioxide (a waste product of cellular metabolism) away from the cells to the lungs, where it is removed from the body during exhalation. Platelets are the key to formation of blood clots. Blood clots are an important response from the body to control blood loss. In the body, blood clot formation depends on several factors: blood stasis, changes in the blood vessel wall (such as a wound), and the blood's ability to clot (affected by disease processes or medications). When tissues are injured, platelets begin to collect at the site of injury; this causes red blood cells to become sticky and clump together. As the red blood cells begin to clump, a protein in plasma reinforces the developing clot by converting to a threadlike mesh that forms a clot

venous bleeding is .....

darker than arterial bleeding and flows steadily

internal bleeding

is any bleeding that occurs in a cavity or space inside the body. Internal bleeding can be very serious, especially because it is not easy to detect immediately. 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 person with a bleeding stomach ulcer may sustain a large amount of blood loss very quickly. Similarly, a person who has a lacerated liver or a ruptured spleen may sustain a considerable amount of blood loss within the abdomen, yet the patient may have no outward signs of bleeding

hemostatic agent

is any chemical compound that slows or stops bleeding by assisting with clot formation. Hemostatic agents are primarily utilized in military medicine to stop profuse bleeding. 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), and gauze impregnated with a clay substance, which speeds blood clot formation. Gauze can also be packed into larger wounds to control hemorrhage. 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 Figure 25-10 . These agents have the potential to improve prehospital bleeding control, especially when transport time to definitive care is prolonged. However, the use of hemostatic agents in EMS remains largely experimental. Because of the lack of scientific evidence demonstrating an effect on survival in civilian settings, most local protocols do not allow for their use. Be aware of and follow your local protocols.

arterial bleeding...

is characteristically bright red and spurts in time with the pulse

bleeding from capillary vessels ...

is dark red and oozes from the wound slowly but steadily

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. Blood enters an organ or tissue first through the arteries, then the arterioles, and finally the capillary beds Figure 25-5 . As it passes through the capillaries, the blood delivers nutrients and oxygen to the surrounding cells and picks up the wastes they have generated.

Hemorrhage

means bleeding. External bleeding is visible hemorrhage. Examples include nosebleeds and bleeding from open wounds.

epistaxis

or nosebleed, is a common emergency. Occasionally, it can cause blood loss great enough to send a patient into shock. Keep in mind that the blood that is visible may be only a small part of the total blood loss. Much of the blood may pass down the throat into the stomach as the patient swallows. A person who swallows a large amount of blood may become nauseated and start vomiting the blood, which is sometimes confused with internal bleeding. Most nontraumatic nosebleeds occur from sites in the septum (the tissue dividing the nostrils). You can usually handle this type of bleeding effectively by pinching the nostrils together. Skill Drill 25-3 illustrates the basic techniques to control epistaxis.

Most cases of external bleeding can be controlled by:

pplying direct, local pressure to the bleeding site. This method is by far 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.) Pressure stops the flow of blood and permits normal coagulation to occur. You may 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. In most cases, direct pressure will stop the bleeding. Once you have applied a dressing to control bleeding, create a pressure dressing to maintain the pressure by firmly wrapping a sterile, self-adhering roller bandage around the entire wound. 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, then you should still be able to palpate a distal pulse on the injured extremity after applying the pressure dressing. If bleeding continues, then the dressing is insufficient. If the bleeding oozes slowly through the dressing, then reinforce it by applying more dressings on top of it. Do not remove a dressing until a physician has evaluated the patient.

All organs and organ systems of the human body depend on adequate perfusion to function properly. Some organs require a.....

rich supply of blood and do not tolerate interruption of blood supply for even a few minutes without sustaining damage. If perfusion to these organs is interrupted, then dysfunction and failure of that organ system will occur. The death of an organ system can quickly lead to the death of the patient. Emergency medical care is designed to support adequate perfusion of these critical organs and organ systems, listed in Table 25-1 , until the patient arrives at the hospital. The heart requires constant perfusion to function optimally; without it, cells in the brain and spinal cord start to die after 4 to 6 minutes. (Remember that cells of the central nervous system do not have the capacity to regenerate.) Without adequate perfusion, the lungs can survive only 15 to 20 minutes and kidneys can be damaged after 45 minutes. Skeletal muscle demonstrates evidence of injury after 2 to 3 hours of inadequate perfusion, while the gastrointestinal tract can tolerate slightly longer periods. These times are based on a normal core body temperature (98.6°F [37.0°C]). An organ or tissue that is kept at a considerably lower temperature may be better able to resist damage from hypoperfusion.

how well a patient's body can compensate for blood loss depends....

s related to how rapidly the blood loss occurs. A healthy adult can comfortably donate 1 unit, or roughly 1 pint (500 mL) of blood within 15 to 20 minutes and adapt well to this decrease in blood volume. If this volume of blood loss occurs during a much shorter period, however, symptoms of hypovolemic shock, a condition in which low blood volume results in inadequate perfusion and even death, might develop. The age and preexisting health of the patient should also be considered. 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.

what will halo shape stain appear?

when cerebrospinal fluid is present in blood or drainage, a stain in the shape of target or halo will appear

use of simple splint...

will often quickly control bleeding associated with a fracture. If a fracture is not immobilized, then the bone ends are free to move and may continue to injure partially clotted blood vessels

how does bleeding tends to stop ?

within about 10 minutes, in response to internal mechanisms and exposure to air. When a person's skin is broken, blood flows rapidly from the open blood vessel. Soon afterward, the cut ends of the blood vessel begin to narrow (vasoconstriction), reducing the amount of bleeding. Then a clot forms, plugging the hole and sealing the injured portions of the blood vessel. This process is called coagulation. With a severe injury, the damage to the blood vessel may be so great that a clot cannot completely block the hole. Bleeding will never stop if an effective clot does not form, unless the injured blood vessel is completely cut off from the main blood supply by direct pressure or a tourniquet.

Several methods are available to control external bleeding. The most commonly used include:

▪ Direct, even pressure▪ Pressure dressings and/or splints ▪ Tourniquets

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. Hospital personnel will loosen it once they are prepared to manage the bleeding.

Other signs and symptoms of internal bleeding in trauma and medical patients include the following:

▪ Hematemesis. The 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. Black, foul-smelling, tarry stool that contains digested blood.▪ 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). Suspect internal abdominal bleeding in a patient with referred pain.

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

▪ 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), or other abnormalities▪ High blood pressure▪ Coagulation disorders▪ Digital trauma (nose picking)

Later signs of hypovolemic shock suggesting internal bleeding include the following:

▪ 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

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)