What is your best defense against transmission of infectious disease?
PPE
What variables affect the severity of blood loss?
-amount of blood loss
-rate of blood loss
-other injuries or existing conditions
-patient’s existing medical probelms
-patients age
*not included in the list but patient’s size. a bigger patient may be able to handle more overall blood loss than a smaller one
how much volume of blood does an adult patient have based on their weight in kg?
70 mL/kg
how much blood does an average adult have?
4.9 L
A blood loss greater than what percent is considered significant?
15%
how much volume of blood does an infant or child patient have based on their weight in kg?
80 mL/kg
what is the natural response of the vessels to bleeding?
vessel constriction and clotting, however a series injury bypasses defenses and leads to uncontrolled bleeding
*severe uncontrolled bleeding or severe loss of blood can lead to hemorrhagic shock in a few minutes and possibly death
how does a vessel respond when cut across or perpendicular vs a cut along the length of the vessels?
cut across/perpendicular= retract and clot off
cut along the length=opens wider when it contracts leading to more severe bleeding
What are the steps to applying a tourniquets?
- Wrap the tourniquet around the extremity at a point that is clearly proximal (above) to the site of bleeding. Prehospital Trauma Life Support 9th edition, recommends applying the tourniquet “to the extremity at the level of the groin for the lower extremity or the axilla for the upper extremity.” Do not cover the wound with the tourniquet
- Tighten the tourniquet until the hemorrhage ceases and secure the device in place. There should not be a palpable pulse distal to the wound to which the tourniquet is applied
- Write the time of tourniquet application on tape and secure it to the tourniquet (for example, TK 1332). Never cover the tourniquet or site of bleeding. Continuously reassess the wound for recurrent bleeding.
- If bleeding continues, tighten the tourniquet. If this fails to stop the bleeding, apply a second tourniquet immediately above the first one.
- Notify the receiving medical facility that a tourniquet has been applied. Document the use of the tourniquet and the time it was applied in the prehospital care report.
If a tourniquet is not available, what other methods can we use?
-A bandage that is 4 inches wide and 4-6 layers thick with a spindle
-a bp cuff (this is typically 20 mmhg above a patient’s systolic)
What are some tourniquet considerations?
-If a commercial tourniquet is not available, use a wide bandage 4 inches or greater; never use wire, a belt, or any other material that can cut into the skin or underlying soft tissue
◦ After it is applied, secure the tourniquet tightly. Do not loosen or remove it unless you are directed to do so by medical direction or local protocol. Follow your local protocol.
◦ Apply the tourniquet proximal to the injury as pos- sible, However, never apply a tourniquet directly over any joint, and do not apply the tourniquet over the wound.
◦ Always make sure the tourniquet is in open view
◦ Document the time of application on a piece of tape and affix it to the tourniquet
◦ The tightness needed for a tourniquet to control hemorrhage in a leg is typically greater than that needed to control hemorrhage in an arm
What are some common tourniquet mistakes to avoid?
◦ The tourniquet is not used when it is clearly indicated
- Applying a tourniquet for a wound with no to minimal bleeding that can be easily managed by other measures
◦ Applying the tourniquet over the wound
◦ Removing the tourniquet when not instructed to do so by medical direction
◦ Not making the tourniquet tight enough. The tourniquet should stop the bleeding and eliminate the distal pulse
◦ Failure to apply a second tourniquet proximal to the first if the first tourniquet does not control the bleeding
◦ Waiting too long before applying the tourniquet to control the maior bleeding
◦ Loosening the tourniquet to reduce the patient’s pain associated with the tourniquet or to periodically restore blood flow to the extremity
What are some possible reasons for nose, ear, or mouth bleeding?
• Skull injury
○ Facial trauma
◦ Digital trauma (nose picking)
◦ Sinusitis and other upper respiratory tract infections ◦ Hypertension (high blood pressure)
◦ Clotting disorders
◦ Esophageal disease
Any time you observe bleeding from a patient’s ears or nose, what should you suspect?
A possible skull fracture
If the patient has experienced a head injury, you should not attempt to stop the flow of blood, why?
Trying to stop the flow of blood creates more pressure in the skull, causing more damage. Instead, place a loose dressing around the area to collect the drainage and limit exposure to sources of infection.
What is Epistaxis?
Nose bleed
What is the emergency care steps for Epistaxis?
- Have the patient sit straight up and tip his head slightly forward. Do not have the patient tilt his head back. This can cause him to swallow the blood. Blood is irritating to the stomach and can cause him to vomit. Vomiting can make the bleeding worse or make it recur. Have the patient spit out any blood that collects in the mouth. You can also suction the blood from the mouth for the patient.
- Use your thumb and forefinger to firmly pinch the soft part of the nose shut. Have the patient breathe through his mouth.
- Apply an ice pack to the nose and cheeks. The cold constricts the blood vessels and helps with stopping the bleeding
- Continue pinching the nose shut for 10 minutes. Do not release the pressure every couple of minutes to check for continued bleeding. Maintain the pressure for 10 minutes.
- Tell the patient not to blow his nose for at least 12 hours after the bleeding has stopped. Also, have the patient rest and not return to any aggressive activity
*If the nosebleed can’t be controlled after 10 to 20 minutes of direct pressure and cold application transport the patient to a medical facility for further assessment and treatment
What are the factors that increase bleeding? IMPORTANT!!!!!!
◦ Movement. Movement can disrupt the clotting process and allow bleeding to continue.
• Low body temperature. A low body temperature can make the clotting process slower and less effective. That is one reason why you need to keep the bleeding and shock patient warm.
◦ Medications. Coumadin (warfarin), Eliquis, Xarelto and other anticoagulant drugs, aspirin, ibuprofen, and other nonsteroidal anti-inflammatory drugs (NSAIDs can interfere with the clotting process.)
◦ Intravenous fluids. Intravenous fluids can increase the blood pressure, causing clots to break free, or the water or other properties of the fluid can interfere with the clotting process
-Removal of dressings and bandages. If the bleeding has been controlled, do not remove the dressing to examine the wound. This can disrupt the clotting and cause the bleeding to begin again
A blood loss greater than what percent can affect a patient’s vitals?
15%
Infants and childern compensate for shock well until [answer] of their blood volume is depleted
1/3
Vital signs are affected when what percent of blood loss?
15%
Infants and childern compensate well until what fraction of blood volume is depleted?
Almost 1/3
Treatment for Hypovolemic hemorrhagic shock?
- Maintain Standard Precautions by wearing the appropriate personal protective equipment, including gloves and eye protection
- Control any external bleeding using the techniques described earlier in this chapter.
- Establish and maintain an open airway,
- Establish and maintain adequate breathing, and administer oxygen. If breathing is inadequate begin positive pressure ventilation with supplemental oxygen connected to the ventilation device. If the patient exhibits any signs of major bleeding, poor perfusion, or shock, a high concentration of oxygen should be administered via a non-rebreather mask at 10-15 lpm regardless of the SpO,. If there are no signs of major bleeding, poor perfusion or shock but the SpO, is less than 95 percent on the initial reading or at any time falls below 95 percent in the trauma patient a high concentration of oxygen should be administered to establish and maintain an SpO2 of greater than 95 percent. Oxvgen should be administered via a nonrebreather mask at 10-15 Ipm to achieve and maintain the SpO2 of more than 95 percent in the trauma patient,
- Place the patient in a supine position.
- Use a blanket to cover any patient suspected of suffering hemorrhagic shock to prevent loss of body heat. Because the cells are shifting to anaerobic metabolism, the cells are not producing internal heat adequately. Warm the patient compartment to 85 degrees during transport to prevent body heat loss. Remove any wet or blood-soaked clothes
- Transport the patient immediately.
- Splint suspected bone or joint injuries. In the hemorrhagic shock patient, transport is critical. ‘Thus the fractures will be initially stabilized by stretcher mattress. En route, if time and the patient’s conditior permit, the fractures can be individually splinted
Figure 27-10
Loss of blood volume leads to a decrease in cardiac output and pressure = Decrease in perfusion, o2 delivery and CO2 waste exits = baroreceptors trigger hormone release to compensate and increase cardiac output, bp, n perfusion = hr/contractility/respiratory rate increase and vessels constrict = tachycardia, tachypnea weak peripheral pulses, cool pale clammy skin = volume loss overrides compensary mechanisms = brain becomes ischemic and medulla fails = systems goes down, hr and bp decrease = further decrease in blood loss = repeats cycle
