Hemorrhage Control PDF - PARA 1004 Fall 2021

Hemorrhage Control PARA 1004 - Fall 2021 Dan Aitken Hemorrhage Control Intro The average adult has approximately 6L of blood circulating through their body at any given time (65-70mL/kg) Obviously, most of us want it to stay there When there’s an opening in that circulation, either in...

Hemorrhage Control PARA 1004 - Fall 2021 Dan Aitken Hemorrhage Control Intro The average adult has approximately 6L of blood circulating through their body at any given time (65-70mL/kg) Obviously, most of us want it to stay there When there’s an opening in that circulation, either internally or externally, all body systems become affected Acute blood loss will produce significant changes in vital signs Increase HR and RR and decreasing BP Without adequate blood supply, all the tissues and organs in our body will quickly become starved for oxygen and other essential nutrients Hemorrhage Terms A few terms that will help your understanding: Stroke Volume (SV) - amount of blood ejected per contraction Cardiac Output (CO) - amount of blood pumped through the circulatory system in 1 minute. HR x SV. Blood - consists of Plasma, Red Blood Cells (RBC), White Blood Cells (WBC), Platelets Systemic Vascular Resistance - resistance to blood flow in the vasculature Perfusion - the delivery of oxygen and nutrients to the cells, organs, and tissues of the body. Hypovolemia - low blood volume You guessed it…Basic Anatomy!! Basic Anatomy Don’t be alarmed, there’s not a lot… To understand hemorrhage and the dangers it can possess, we must have a basic understanding of blood and what causes it to flow We all know that the heart is responsible for circulating oxygenated blood throughout the body As we learned last week, when the left ventricle contracts it pumps blood through the many arteries in the body and returns to the heart through the vena cava (inferior or superior) Obviously its a bit more complex then that…but that’s good enough for now Physiologic Response to Blood Loss Compensation Typically, arterial blood is bright red (high oxygen content) and spurts from a wound - often in time with the pulse Arteries are under much higher pressure then veins making these bleeds very difficult to manage Venous bleeds are much darker red (low oxygen content) and tend to flow steadily Much easier to manage then arterial, but can still be life threatening if not treated promptly Physiologic Response to Blood Loss Compensation When a vessel is lacerated, the open end of the vessel begins to narrow (vasoconstriction) to reduce the amount of blood loss Hemostasis occurs - Platelets aggregate at the site, plugging the hole This process, while efficient, does not occur quick enough or effectively enough to stop all bleeding before it is too late External aid will help reduce blood loss while the body does its work Some hemorrhages will require surgical intervention Physiologic Response to Blood Loss Compensation When we lose blood, our body has certain compensatory mechanisms to help maintain perfusion until normal blood volume can be restored Increased HR - to circulate more oxygen to tissues Vasoconstriction - to maintain BP while fluid volume drops Increased RR - to increase gas exchange in combination with increased HR Our body’s ability to compensate is directly related to how fast it is losing volume as well as several other coexisting factors Illness, other injuries, age, fitness level Physiologic Response to Blood Loss Compensation Hypovolemic Shock Shock refers to a state of collapse and failure of the cardiovascular system that leads to inadequate circulation, creating inadequate tissue perfusion Will be discussed in greater detail at a later date Hypovolemic shock is caused by decreased fluid volume (most often blood) Hemorrhage External vs Internal External hemorrhage is bleeding that has broken through the skin and is typically easier to recognize and manage in the prehospital setting This will be our main focus as it is essentially the only type of hemorrhage we can manage Internal hemorrhage is bleeding in a portion of the body that has not broken through the skin. This is typically far more difficult to recognize and can require surgical intervention. In the prehospital environment, there is practically nothing we can do about internal hemorrhage However, early recognition and rapid transport can make the difference between life and death Hemorrhage External vs Internal Internal Hemorrhage Some body cavities can contain a massive amount of blood Each thigh can hold up to 1.5L Pain is typically the only early symptom associated - pay careful attention to any pain that seems to be worse then what you would expect for any injury* Any tenderness, rigidity or hematoma that may develop are often late signs Have a high index of suspicion with any significant MOI and pay close attention to the patients compensation mechanisms Diaphoresis, pallor, tachycardia, changes in BP Hemorrhage External vs Internal External Hemorrhage While it may be easy to recognize external hemorrhage, it is quite difficult to estimate blood loss Blood looks different on different surfaces (saturated clothing/hair, diluted with water, pooling on flat surface, absorbed into dirt/snow/sand, etc) Do your best to estimate blood loss and pass the information on to the ER - but don’t delay patient care or rapid transport External Hemorrhage Patient Assessment and Management Just like any call, a good scene assessment helps set us up for success Severity and type of bleeding may require additional PPE requirements Eye protection, gowns, face shield, procedural mask, extra gloves ABCs are still our first priority in patient management MAJOR hemorrhage is a part of Circulation and needs to be managed immediately If the hemorrhage cannot be managed with basic maneuvers, you must initiate rapid transport and put all your efforts into External Hemorrhage Patient Assessment and Management Patient may have multiple injuries that all would classify as major hemorrhage Do your best at managing what you can and using the resources available to you (tourniquets, hemostatic dressings, direct pressure, FD/PD, additional ambulances) You may have to ignore other major injuries (fractured extremities, evisceration, amputations, burns, etc) until bleeding can be controlled Continually monitor patient condition and VSS enroute to ER without interrupting hemorrhage control External Hemorrhage Management Standard first aid treatment still stands as basic treatment for external hemorrhage Follow the RED pneumonic (Rest Elevate Direct pressure) For simple, minor hemorrhages, moderate direct pressure and simple dressings will often suffice (to be discussed later in the presentation) Major hemorrhage must be controlled more aggressively Different techniques can be used depending on the location of the injury Tourniquets, Hemostatic dressings, Direct pressure External Hemorrhage Dressings and Equipment There are many different types of dressings and equipment at our disposal, and many of them can be used in multiple injury types Consider specific treatment requirements when deciding between moist or dry sterile dressings and occlusive vs non-occlusive dressings Occlusive - non-permeable to moisture and air Non-occlusive - permeable to moisture and air Dressings and wound care will be taught, in detail, in lab Remember that paramedics are FAR from wound care experts - our field of expertise is EMERGENCY wound management External Hemorrhage Dressings and Equipment Gauze Pads Used as a dressing for minor wounds and hemorrhage 2x2, 4x4, etc. Pressure Dressing Used for minor to moderate wounds and hemorrhage Large and Small sizes External Hemorrhage Dressings and Equipment Abdominal Pad Very absorbent, used for major hemorrhage 8x10 Kling Dressing (rolled gauze) 6” or 4” Typically used for wrapping and securing dressings External Hemorrhage Dressings and Equipment Tourniquet (arterial) Used for major extremity hemorrhage that cannot be controlled with direct pressure Different brands with subtle difference all do the safe task Applied proximal to the injury and tightened to occlude arterial blood flow distal to the device Tissue and nerve damage is possible if the tourniquet is left on for too long - it is important to document the time of application both on the ACR and the tourniquet itself External Hemorrhage Dressings and Equipment Hemostatic Dressing Saturated in a chemical agent that aids in the clotting process Typically contact with the blood plasma causes the chemical to form a gel like substance Used when regular dressings/pressure are ineffective and tourniquet use is contraindicated or ineffective Internal Hemorrhage Dressings and Equipment Pelvic Binder Essentially the only form of internal hemorrhage we can apply “direct pressure” to is a pelvic fracture using a binder Pelvic wounds, especially open book, can be a significant source of internal hemorrhage that isn’t easily identifiable in the field All significant MOI traumas should have a pelvic binder applied External Hemorrhage Dressings and Equipment Trauma Shears Used for cutting clothing, bandages, or anything else Service provided ones are typically cheap - most medics provide their own Medical Tape Several types depending on the surface to adhere to Used for securing dressings, IV lines, advanced airways, etc. External Hemorrhage Dressings and Equipment MAST Pants (PASG) Military AntiShock Trousers (Pneumatic AntiShock Garment) Not currently used in Ontario Inflatable garment that surrounds the legs and abdomen Very controversial equipment Hemorrhage Management BLS PCS Pg 111 Hemorrhage Management BLS PCS Pg 111 Hemorrhage Management BLS PCS Pg 111 Hemorrhage Management BLS PCS Pg 111 Hemorrhage Management Breakdown Extremities Junctional Location 1. Direct digital pressure Head, neck, shoulders, armpit, groin, pelvis 2. Tourniquet (can apply a second if needed) 1. Direct digital pressure 3. Hemostatic dressing (Pack) 2. Hemostatic dressing (Pack) Hollow Spaces Skull, chest abdomen Direct pressure with flat palm and hemostatic dressing DO NOT PACK DO NOT INSERT FINGERS Hemorrhage Management Methods Direct Pressure Expose the wound and attempt to visualize the source of bleeding Clear away blood and debris to improve visualization (use sterile water if necessary) Be firm, and aggressive Use as small a surface are as possible (i.e. digital for small wounds) Hemorrhage Management Methods Tourniquet Application When possible, apply the tourniquet over a large muscle group DO NOT apply to a joint Turn windlass until tight, then turn again (manufacturer specific instructions) Can use a second if the first isn’t cutting it DOCUMENT application time DO NOT cover the tourniquet Hemorrhage Management Methods Hemorrhage Management Methods Hemostatic Dressing Maintain pressure on bleeding site while firmly packing the wound Cover and hold pressure for 3-5 minutes after wound is packed DO NOT pack hollow spaces (head, neck abdomen) DO NOT apply over open skull fracture Hemorrhage Management Methods IV Fluid Therapy IV initiation can be helpful but should not delay transport or distract you from other, more pressing tasks Fluid can only be administered to hypotensive patients under our directives and does not take precedence over stopping the bleeding Normal Saline fluid to hypovolemic patients?? Diluted blood volume - these patients need BLOOD not saline Hemorrhage Control Conclusion Remember that ABCs are our primary priority Treatment of major hemorrhage cannot be delayed (can’t progress past “C” until we correct it) Most sources of major hemorrhage require time sensitive hospital management so don’t delay transport! Maintain high index of suspicion for internal bleeding with significant MOI