Chapter 13 Bleeding Shock and SoftTissue Injuries National

Chapter 13 Bleeding, Shock, and Soft-Tissue Injuries

National EMS Education Standard Competencies (1 of 10) Pathophysiology Uses simple knowledge of shock and respiratory compromise to respond to life threats.

National EMS Education Standard Competencies (2 of 10) Shock and Resuscitation Uses assessment information to recognize shock, respiratory failure or arrest, and cardiac arrest based on assessment findings and manages the emergency while awaiting additional emergency response.

National EMS Education Standard Competencies (3 of 10) Trauma Uses simple knowledge to recognize and manage life threats based on assessment findings for an acutely injured patient while awaiting additional emergency medical response.

National EMS Education Standard Competencies (4 of 10) Bleeding Recognition and management of • Bleeding Head, Facial, Neck, and Spine Trauma Recognition and management of • Life threats

National EMS Education Standard Competencies (5 of 10) Chest Trauma Recognition and management of • Blunt versus penetrating mechanisms • Open chest wound • Impaled object

National EMS Education Standard Competencies (6 of 10) Abdominal and Genitourinary Trauma Recognition and management of • Blunt versus penetrating mechanisms • Evisceration • Impaled object

National EMS Education Standard Competencies (7 of 10) Soft-Tissue Trauma Recognition and management of • Wounds • Burns – Electrical – Chemical – Thermal • Chemicals in the eye and on the skin

National EMS Education Standard Competencies (8 of 10) Multi-system Trauma Recognition and management of • Multi-system trauma

National EMS Education Standard Competencies (9 of 10) Medicine Recognizes and manages life threats based on assessment findings of a patient with a medical emergency while awaiting additional emergency response.

National EMS Education Standard Competencies (10 of 10) Immunology Recognition and management of shock and difficulty breathing related to • Anaphylactic reactions Diseases of the Eyes, Ears, Nose, Throat Recognition and management of • Nosebleed

Introduction • Damage to internal soft tissues and organs can cause life-threatening problems. – Internal bleeding results in shock. – Shock is a state of collapse of the cardiovascular system that results in inadequate delivery of blood to the organs. – More trauma patients die from shock than from any other condition.

Patient Assessment for Bleeding, Shock, and Soft-Tissue Injuries (1 of 3)

Patient Assessment for Bleeding, Shock, and Soft-Tissue Injuries (2 of 3) • Follow the steps of the patient assessment sequence. – The scene size-up needs to ensure safety both for you and your patient. – You may need to halt the primary assessment if the patient is losing too much blood. – During the secondary assessment, be alert for signs and symptoms of shock from internal or external blood loss.

Patient Assessment for Bleeding, Shock, and Soft-Tissue Injuries (3 of 3) • Follow the steps of the patient assessment sequence. (cont’d) – When performing a reassessment, watch the patient for signs and symptoms of shock: • Pale skin • Increasing pulse rate • Decreasing blood pressure

Standard Precautions and Soft. Tissue Injuries • The concept of standard precautions assumes that all body fluids are potentially infectious. • Take appropriate measures to prevent contact with the patient’s body fluids. – Wear gloves. – If appropriate, wear a surgical mask and eye protection.

Parts and Function of the Circulatory System (1 of 9)

Parts and Function of the Circulatory System (2 of 9) • The pump – The heart functions as the human circulatory system’s pump. – The heart consists of four separate chambers. • The two upper chambers on the top of the heart are the left and right atria. • The two lower chambers on the bottom of the heart are the left and right ventricles.

Parts and Function of the Circulatory System (3 of 9)

Parts and Function of the Circulatory System (4 of 9)

Parts and Function of the Circulatory System (5 of 9) • The pipes – The arteries carry blood away from the heart. – The capillaries form a network that distributes blood to all parts of the body. – The veins return the blood from the capillaries to the heart.

Parts and Function of the Circulatory System (6 of 9)

Parts and Function of the Circulatory System (7 of 9) • The fluid – The liquid part of the blood is plasma. – Red blood cells carry oxygen and CO 2. – White blood cells consume bacteria and viruses to combat infections in the body. – Platelets form clots that help stop bleeding.

Parts and Function of the Circulatory System (8 of 9)

Parts and Function of the Circulatory System (9 of 9) • Pulse – A pulse is the pressure wave generated by the pumping action of the heart. – In a conscious patient, you can easily find the radial (wrist) pulse at the base of the thumb. – If the patient appears to be in shock or is unconscious, attempt to locate the carotid pulse first.

Shock • Shock is defined as failure of the circulatory system. • Circulatory failure has many possible causes, but the three primary causes are: – Pump failure – Pipe failure – Fluid loss

Pump Failure • Cardiogenic shock occurs if the heart cannot pump enough blood to supply the needs of the body. – Pump failure can result from a heart attack. • Inadequate pumping of the heart can cause blood to back up in the vessels of the lungs, resulting in congestive heart failure (CHF).

Pipe Failure (1 of 4) • Pipe failure is caused by the expansion of the capillaries to as much as three or four times their normal size. – Blood pools in the capillaries. – The rest of the body is deprived of blood. – Blood pressure falls and shock results.

Pipe Failure (2 of 4) • Shock induced by fainting (psychogenic shock) – Fainting is a short-term condition that corrects itself once the patient is placed in a horizontal position.

Pipe Failure (3 of 4) • Anaphylactic shock – Caused by an extreme allergic reaction to a foreign substance – The patient appears flushed, breathing may become difficult, and blood pressure drops rapidly. – Death will result if prompt action is not taken.

Pipe Failure (4 of 4) • Spinal shock – May occur in patients who have sustained a spinal cord injury – The injury allows the capillaries to expand, and blood pools below the level of the injury. – The brain, heart, lungs, and other vital organs are deprived of blood, resulting in shock.

Fluid Loss (1 of 3) • Fluid loss caused by excessive bleeding (hemorrhage) is the most common cause of shock. – Blood escapes from a wound and the system’s total fluid level drops. – The heart begins to pump faster to maintain pressure in the pipes. – The pump eventually stops pumping, resulting in cardiac arrest.

Fluid Loss (2 of 3) • External bleeding is easy to detect. • With internal bleeding, the bleeding cannot be seen, but you may see these signs: – Bruising – Swelling – Rigidity in the affected area – Severe pain in the immediate area

Fluid Loss (3 of 3) • Whether the bleeding is external or internal, if it remains unchecked, the result will be shock, pump failure, and death. • An average adult has about 12 pints (5. 7 L) of blood circulating in the system. – The loss of 2 or more pints can lead to shock.

Signs and Symptoms of Shock (1 of 2) • Shock deprives the body of sufficient blood to function normally. – As shock progresses, the body alters its functions in an attempt to maintain sufficient blood supply. • Signs and symptoms of shock – Confusion, restlessness, or anxiety – Cold, clammy, sweaty, pale skin

Signs and Symptoms of Shock (2 of 2) • Signs and symptoms of shock (cont’d) – Rapid breathing – Rapid, weak pulse – Increased capillary refill time – Nausea and vomiting – Weakness or fainting – Thirst

General Treatment for Shock (1 of 3) • Position the patient correctly. – If the patient has no head injury, extreme discomfort, or difficulty breathing, lay the patient flat on his or her back on a horizontal surface. – Elevate the legs 6" to 12" off the floor.

General Treatment for Shock (2 of 3) • Maintain the patient’s ABCs. • Treat the cause of shock, if possible. • Maintain the patient’s body temperature. • Do not allow the patient to eat or drink. – Eating or drinking may cause vomiting. – Patients in shock may need surgery and should not have anything in their stomachs.

General Treatment for Shock (3 of 3) • Assist with other treatments. – If you are trained in the administration of oxygen, provide it to shock patients. – AEMTs or paramedics can administer intravenous (IV) fluids. • Arrange for transport.

Treatment for Shock Caused by Pump Failure • Pump failure is a serious condition. • Proper treatment and prompt transport by ambulance to an appropriate medical facility will give these patients their best chance for survival.

Treatment for Shock Caused by Pipe Failure • Treatment for anaphylactic shock – Transport as soon as possible. – Some patients may carry an epinephrine autoinjector. • Support the patient’s thigh and place the tip of the auto-injector against the outer thigh. • Push the auto-injector firmly against the thigh and hold it in place for several seconds.

Treatment for Shock Caused by Fluid Loss • Shock caused by internal blood loss – Bleeding from stomach ulcers, ruptured blood vessels, or tumors can cause internal bleeding and shock. – Patients with internal bleeding may exhibit: • Coughing or vomiting of blood • Abdominal tenderness, rigidity, bruising, distention • Rectal bleeding • Vaginal bleeding in women

Controlling External Blood Loss (1 of 8)

Controlling External Blood Loss (2 of 8) • Capillary bleeding – Most common type of external blood loss – The blood oozes out. – Apply direct pressure to the site. • Venous bleeding – Second most common type – This bleeding has a steady flow. – Apply direct pressure for at least 5 minutes.

Controlling External Blood Loss (3 of 8) • Arterial bleeding – Most serious type of bleeding – Arterial blood spurts or surges with each heartbeat. – Exert direct pressure and maintain pressure until EMS arrives.

Controlling External Blood Loss (4 of 8) • Direct pressure – Place a dry, sterile dressing directly on the wound and press with a gloved hand. – Wrap the dressing and wound snugly with a roller gauze bandage. Courtesy of Rhonda Beck – Do not remove a dressing after you apply it.

Controlling External Blood Loss (5 of 8) • Elevation – If direct pressure does not stop external bleeding from an extremity, elevate the injured arm or leg as you maintain direct pressure.

Controlling External Blood Loss (6 of 8) • Tourniquets – Indicated only in situations where extremity bleeding cannot be controlled by direct pressure or elevation – Follow the steps in Skill Drill 13 -1 to control bleeding with a tourniquet.

Controlling External Blood Loss (7 of 8) • Pressure points – Used in cases where a wound is too close to the trunk to apply a tourniquet – Prevent blood from flowing into the limb by compressing the artery against the bone – The brachial artery pressure point and the femoral artery pressure point are the most important.

Controlling External Blood Loss (8 of 8)

Standard Precautions and Bleeding Control • Wear nitrile or latex gloves whenever you might come in contact with a patient’s blood or body fluids. – If you do get blood on your hands, wash it off as soon as possible with soap and water. – If you cannot wash your hands, use a waterless hand-cleaning solution that contains an effective germ-killing agent.

Wounds • A wound is an injury caused by any physical means that leads to damage of a body part. – Wounds are classified as open or closed.

Closed Wounds • The skin remains intact. • The only closed wound is the bruise. – Injury of the soft tissue beneath the skin – Small blood vessels are broken. – The area becomes discolored and swells. – A simple bruise heals quickly. • Bruising and swelling may be a sign of an underlying fracture.

Open Wounds (1 of 8) • An open wound results in a break in the skin. • Abrasion – Also called a scrape, road rash, or rug burn – Occurs when the skin is rubbed across a rough surface

Open Wounds (2 of 8)

Open Wounds (3 of 8) • Puncture – Occurs when a sharp object penetrates the skin – May cause deep injury that is not immediately recognized – Puncture wounds do not bleed freely. – An impaled object sticks out of the skin. – A gunshot wound is a special type of puncture wound.

Open Wounds (4 of 8) © E. M. Singletary, M. D. Used with permission.

Open Wounds (5 of 8) • Laceration – Most common type of open wound – Commonly called a cut – Minor lacerations may require little care. – Large lacerations can cause extensive bleeding and even be life threatening.

Open Wounds (6 of 8) © English/Custom Medical Stock Photo

Open Wounds (7 of 8) • Avulsions and amputations – An avulsion is a tearing away of body tissue. – If an entire body part is torn away, the wound is called a traumatic amputation. – Amputated parts should be: • Located • Placed in a clean plastic bag • Kept cool • Taken to the hospital for possible reattachment

Open Wounds (8 of 8)

Principles of Wound Treatment • Very minor bruises need no treatment. • Other closed wounds should be treated by: – Applying ice and gentle compression – Elevating the injured part • Splint all major contusions. • Stop bleeding as quickly as possible using the cleanest dressing available.

Dressing and Bandaging Wounds (1 of 7) • Dressings and bandaging are applied to: – Control bleeding – Prevent further contamination – Immobilize the injured area – Prevent movement of impaled objects

Dressing and Bandaging Wounds (2 of 7) • Dressings – A dressing is an object placed directly on a wound to control bleeding and prevent further contamination. – Once a dressing is in place, apply firm, direct manual pressure on it to stop any bleeding. – The three most common sizes are 4" gauze squares, 5" 9" heavier pads, and 10" 30" trauma dressings.

Dressing and Bandaging Wounds (3 of 7) • Dressings (cont’d) – If bleeding continues after you have applied a compression dressing, put additional gauze pads over the original dressing.

Dressing and Bandaging Wounds (4 of 7) • Bandaging – A bandage is used to hold the dressing in place. – Roller gauze and triangular bandages are commonly used in the field.

Dressing and Bandaging Wounds (5 of 7) • Principles of bandaging – Ensure that the dressing completely covers the wound and extends beyond all sides of the wound. – Wrap the bandage just tightly enough to control bleeding, but not so tightly that circulation is cut off. – Check circulation regularly. – Secure the bandaging so that it cannot slip.

Dressing and Bandaging Wounds (6 of 7) • Standard precautions techniques for the EMR – Wear gloves to avoid contact with the patient’s blood. – Nitrile or latex medical gloves can be stored on the top of your EMR life support kit or in a pouch on your belt.

Dressing and Bandaging Wounds (7 of 7)

Face and Scalp Wounds (1 of 4) • A relatively small laceration to the face and scalp can result in a large amount of bleeding. • You can control almost all facial or scalp bleeding by applying direct manual pressure. – Direct pressure compresses the blood vessels against the skull and stops the bleeding.

Face and Scalp Wounds (2 of 4)

Face and Scalp Wounds (3 of 4) • For wounds inside the cheek: – Hold a gauze pad inside the mouth. – Always keep the airway open. • Scalp lacerations can be associated with skull fractures or brain injury. – If any brain tissue or bone fragments are visible, do not apply pressure. – Cover the wound loosely.

Face and Scalp Wounds (4 of 4) • With head injuries, the neck and spine may also be injured. – Move the head as little as possible and stabilize the neck. – Monitor the patient’s airway and breathing and protect the spine.

Nosebleeds (1 of 2) • Nosebleeds can result from injury, high blood pressure, or dry air. • A nosebleed with no apparent cause is called a spontaneous nosebleed. • Management – Unless the patient is experiencing shock, have the patient sit down and tilt the head slightly forward.

Nosebleeds (2 of 2) • Management (cont’d) – Pinch both nostrils together for at least 5 minutes. – If the nosebleed persists or is very severe, arrange for transport.

Eye Injuries (1 of 2) • When an eye laceration is suspected, cover the entire eye with a dry gauze pad. – Have the patient lie on his or her back and arrange for transport. • If a small foreign object is lying on the surface of the eye, use a saline solution to flush the object from the eye.

Eye Injuries (2 of 2) • Impaled object – Immediately place the patient on his or her back and cover the injured eye with a dressing and a paper cup so the impaled object cannot move. – Bandage both eyes. – Arrange for transport.

Neck Wounds (1 of 2) • Use direct pressure to control bleeding. • Once bleeding is controlled, dress the neck.

Neck Wounds (2 of 2) • In rare cases, you may have to exert finger pressure above and below the injury site to prevent further neck bleeding. • Major trauma to the neck may be associated with airway problems and with neck fracture or spinal cord injury. – Maintain the patient’s airway. – Stabilize the head and neck.

Chest and Back Wounds (1 of 2) • Place the patient with a chest injury in a comfortable position. • If a lung is punctured, air can escape and the lung will collapse. – The patient may cough up bright red blood. – Cover the open chest wound with an airtight material (occlusive dressing). – Administer oxygen.

Chest and Back Wounds (2 of 2) • Chest wounds may damage the heart. – Seal the wound and monitor the ABCs. – Treat the patient for shock and perform CPR, if necessary. – If the patient’s breathing becomes more labored after you seal the wound, remove the seal briefly to allow excess air to escape, and reseal the wound.

Impaled Objects (1 of 2) • Apply a stabilizing dressing. • Arrange for immediate prompt transport. • Sometimes an impaled object is too long to permit the patient to be transported. – Stabilize the impaled object and carefully cut it close to the patient’s body.

Impaled Objects (2 of 2) • If an object is protruding from the abdomen: – Do not attempt to remove it. – Support the object so it cannot move. – Place gauze or towels on either side of the object and secure them with additional gauze.

Closed Abdominal Wounds (1 of 2) • Result of a direct blow from a blunt object • Look for bruises or other marks on the abdomen. • Whenever a patient experiences shock, there may be internal abdominal injuries. – Place these patients on their backs and elevate their legs 6". – Use blankets to conserve their body heat.

Closed Abdominal Wounds (2 of 2) • If the patient is vomiting blood, it may be an indication of bleeding from the esophagus or stomach. – Monitor the airway and vital signs. – Give the patient nothing by mouth. – Arrange for prompt transport.

Open Abdominal Wounds (1 of 2) • Usually result from slashing with a knife or other sharp object • If the intestines are protruding: – Place the patient on his or her back with the knees bent. – Cover the injured area with a sterile dressing. – Do not attempt to replace the intestines inside the abdomen.

Open Abdominal Wounds (2 of 2)

Genital Wounds • Male and female genitals have a rich blood supply, so injury to these areas can result in severe bleeding. • Apply direct pressure with a dry, sterile dressing. • Although it may be embarrassing to examine the patient’s genital area, you must do so if you suspect injuries.

Extremity Wounds (1 of 2) • Apply a dry, sterile compression dressing and bandage it securely in place. • Elevate the injured part to decrease bleeding and swelling. • Splint all injured extremities prior to transport because there may be an underlying fracture.

Extremity Wounds (2 of 2)

Gunshot Wounds (1 of 2) • Most deaths from gunshot wounds result from internal blood loss. • Gunshot wounds to the trunk and neck are a major cause of spinal cord injuries. • Treatment – Open the airway and establish adequate ventilation and circulation.

Gunshot Wounds (2 of 2) • Treatment (cont’d) – Control any external bleeding with dressings and direct pressure. – Examine the patient thoroughly to locate all entrance and exit wounds. – Treat for symptoms of shock. – Arrange for prompt transport. – Perform CPR if the patient’s heart stops.

Bites • All bites carry a high risk of infection. – Patients should seek treatment for all bites. • Minor bites can be washed with soap and water. • With major bite wounds, control the bleeding and apply a dressing and bandage.

Burns • The skin serves as a barrier that prevents foreign substances from entering the body. • It also prevents loss of body fluids. – When the skin is damaged, it can no longer perform these essential functions.

Burn Depth (1 of 3) • Superficial burns (first-degree burns) © Amy Walters/Shutter. Stock, Inc. – Reddened and painful skin – The injury is confined to the outermost layers of the skin. – The patient experiences minor to moderate pain.

Burn Depth (2 of 3) • Partial-thickness burns (second-degree burns) – Do not damage the deepest layers of the skin – Blistering – Fluid loss and moderate to severe pain – Usually heal within 2 to 3 weeks © E. M. Singletary, M. D. Used with permission.

Burn Depth (3 of 3) • Full-thickness burns (third-degree burns) – Damage all layers of the skin – Pain is absent because the nerve endings have been destroyed. – Patients lose large quantities of body fluids and are susceptible to shock and infection.

Extent of Burns (1 of 2) • Rule of nines – Method for determining what percentage of the body has been burned – In an adult, the head and arms each equal 9% of the total body surface. – The front and back of the trunk and each leg are equal to 18% of the total body surface. – This formulation is slightly modified for children.

Extent of Burns (2 of 2)

Cause or Type of Burns (1 of 7) • Thermal burns – Caused by heat – Place the burned area in clean, cold water. – Cover it with a dry, sterile dressing or a burn sheet. – Do not break blisters. – Patients with large burns must be treated for shock and transported to a hospital.

Cause or Type of Burns (2 of 7) • Respiratory burns – A burn to any part of the airway – Look for signs and symptoms: • Burns around the face • Singed nose hairs • Soot in the mouth and nose • Difficulty breathing • Pain while breathing • Loss of consciousness as a result of fire

Cause or Type of Burns (3 of 7) • Respiratory burns (cont’d) – Breathing problems can develop rapidly or slowly. – Administer oxygen and be prepared to perform CPR. – Arrange for prompt transport. • Chemical burns – Many strong substances can cause chemical burns.

Cause or Type of Burns (4 of 7) • Chemical burns (cont’d) – The longer the chemical remains in contact with the skin, the more damage it does. – Initial treatment • Remove as much of the chemical as possible. • Brush away any dry chemical. • Flush with water for at least 10 minutes. • Cover the area with a dry, sterile dressing. • Arrange for prompt transport.

Cause or Type of Burns (5 of 7) • Chemical burns (cont’d) – Chemical burns to the eyes cause extreme pain and severe injury. • Flush the eye(s) with water for at least 20 minutes. • Hold the eye open to allow water to flow over its entire surface. • Loosely cover the injured eye(s) with gauze bandages. • Arrange for prompt transport.

Cause or Type of Burns (6 of 7) • Electrical burns – Occur when an electrical current enters the body at one point, travels through the body tissues and organs, and exits at the point of ground contact – Electricity causes major internal damage. – Patients may experience irregularities of cardiac rhythm or full cardiac arrest and death.

Cause or Type of Burns (7 of 7) • Electrical burns (cont’d) – Be certain that a patient is not still in contact with the electrical power source before you touch or treat him or her. – Call for assistance from the power company or from a qualified rescue squad. – Monitor the ABCs of electrical burn patients and arrange for prompt transport.

Multi-system Trauma • Multi-system trauma is an injury that affects more than one system of the body. • You are not expected to diagnose a patient’s injuries. – Several body systems may be injured in situations that involve significant trauma. – Be alert for signs and symptoms of injury.

Summary (1 of 4) • You must take appropriate standard precautions to prevent contact with the patient’s body fluids. • The three parts of the circulatory system are the pump (heart), the pipes (arteries, veins, and capillaries), and the fluid (blood cells and other blood components).

Summary (2 of 4) • The three primary causes of shock are pump failure, pipe failure, and fluid loss. • Three types of external blood loss are possible: capillary (blood oozes out), venous (bleeds at a steady flow), and arterial (blood spurts or surges). Most external bleeding can be controlled by applying direct pressure to the wound.

Summary (3 of 4) • A wound is an injury caused by any physical means that leads to damage of a body part. Wounds are classified as closed (skin remains intact) or open (skin is disrupted). • Open wounds are classified as abrasions, punctures, lacerations, and avulsions or amputations.

Summary (4 of 4) • Control bleeding by applying direct pressure, elevating an extremity, applying a tourniquet, or using pressure points. • Three classes of burns are distinguished based on depth: superficial, partialthickness, and full-thickness. Burns may be caused by heat, chemicals, or electricity.

Review 1. Which of the following statements regarding standard precautions is true? A. Standard precautions assume that all body fluids are potentially infectious. B. Standard precautions assume that some body fluids are potentially infectious. C. Standard precautions apply to paramedics who perform invasive procedures. D. EMRs are only required to wear gloves to comply with standard precautions.

Review Answer: A. Standard precautions assume that all body fluids are potentially infectious.

Review 2. Appropriate management of impaled objects in the eye includes: A. bandaging only the affected eye. B. rinsing the eyes with saline. C. bandaging both eyes. D. removing the object to prevent further damage.

Review Answer: C. bandaging both eyes.

Review 3. Patients with full-thickness burns generally do not complain of pain because: A. blister formation protects the burn. B. the nerve endings have been destroyed. C. deep burns produce a natural pain killer in the patient’s system. D. the patient is generally not conscious.

Review Answer: B. the nerve endings have been destroyed.

Credits • Opener: © Mark C. Ide • Background slide images: © Jones & Bartlett Learning. Courtesy of MIEMSS.