AAOS
Tenth Edition
Emergency Care and Transportation of the Sick and Injured
Sample Chapter
Meets the New
National EMS Education Standards
The Future of EMS Education Has Arriv Arr ived! ed! Dear Educator Educator,, As you know, the new National EMS Education Standards were approved in January by the National Highway Traffic Traffic Safety Administration. Adminis tration. These Standards are part of a larger effort, based on the National EMS Education Agenda for the Future, Future, published in 2000 at the request of National Association of State EMS Officials. The Agenda was a consensus vision of the future of EMS. It intended to promote quality and consistency among all EMS education programs and establish common entr y-level requirements for the licensure of various levels of EMS providers throughout the country. The National EMS Education Standards document is being used by publishers to develop new instructional materials and should guide EMS educators in designing their programs and in making decisions about the materials to use in their classrooms. You may have noticed that the Standards are less prescriptive than the Department of Transportation’s (DOT) National Standard Curricula that they replace. Instead of specific cognitive, affective, and psychomotor objectives, the National EMS Education Standards identify the depth and breadth of content and provide minimal terminal objectives for each EMS provider level. Ultimately, the new National EMS Education Standards allow for: Increased program flexibility —Educators can now choose to make certain modules in the Standards a prerequisite to their courses, and they may choose to teach the material in whatever order and fashion they choose. Greater creativity in program and material design — Educators have the freedom to be more creative about how they cover content—for example, allowing students to follow a course of independent study for the Medical Terminology module, rather than having the instructor lecture directly out of the training materials. Better alternative delivery methods —Alternative delivery methods will allow many options—from independent independent study to online learning resources. Increased ability ability to respond to changes in medical knowledge—Educators will have a greater ability to adapt their presentations to the latest medical information. Bleeding control and the emphasis on compressions instead of ventilations during CPR are excellent examples of where the National Standard Curricula was less nimble than the new National EMS Education Standards. Standards . As new breakthroughs in medicine occur, this knowledge can easily be incorporated into the classroom.
Many educators are trying to sort out what’s really new in the National EMS Education Standards. Standards . First, the official names of the provider levels have changed: Emergency Medical Responder or EMR— formerly First Responder Emergency Medical Technician or EMT— no longer referred to as “Basic” Advanced Emergency Medical Technician or AEMT— replaces EMT-Intermediate. EMT-Intermediate. The requirements are closer to the 1985 National Standard Curriculum than the 1999 version. Paramedic
New patient assessment terminology is being introduced, although many educators will recognize the terms primary and secondary assessment. Some skills have been added or changed, and there is expanded cognitive material at ever y level, such as public health, life span development, pathophysiology, communication, medical terminology, and patients with special challenges.
Tenth Edition Table Table of o f Contents Conte nts Correlated to the National EMS Education Standards
Tenth Edition
National EMS Education Standards
Section 1. Preparatory
1. EMS Systems
EMS Systems Research Public Health
2. Workforce Safety and Wellness
Workforce Safety and Wellness
3. Medical, Legal, and Ethical Issues
Medical/Legal and Ethics
4. Communication and Documentation
Documentation EMS System Communication Therapeutic Communication
5. The Human Body
Anatomy and Physiology Pathophysiology
6. Life Span Development
Life Span Development
Section 2. Pharmacology
7. Principles of Pharmacology
Principles of Pharmacology Medication Administration Emergency Medications
Section 3: Patient Assessment
8. Patient Assessment
Scene Size-Up Primary Assessment History-Taking Secondary Assessment Monitoring Devices Reassessment
Section 4. Airway
9. Airway Management
Airway Management Respiration Artificial Ventilation
Section 5. Shock and Resuscitation
10. Shock
Shock and Resuscitation
11. BLS Resuscitation
Shock and Resuscitation
Section 6. Medical
12. Medical Overview
Medical Overview Infectious Diseases
13. Respiratory Emergencies
Respiratory
14. Cardiovascular Emergencies
Cardiovascular
15. Neurologic Emergencies
Neurology
16. Gastrointestinal and Urologic Emergencies
Abdominal and Gastrointestinal Disorders Genitourinary/Renal
17. Endocrine and Hematologic Emergencies
Endocrine Disorders Hematology
18. Immunologic Emergencies
Immunology
19. Toxicology
Toxicology
20. Psychiatric Emergencies
Psychiatric
21. Gynecologic Emergencies
Gynecology
Section 7. Trauma
22. Trauma Overview
Trauma Overview Multi-System Trauma
23. Bleeding
Bleeding Diseases of the Eyes, Ears, Nose, and Throat
24. Soft-Tissue Injuries
Soft Tissue Trauma
25. Face and Neck Injuries
Head, Facial, Neck, and Spine Trauma
26. Head and Spine Injuries
Head, Facial, Neck, and Spine Trauma Nervous System Trauma
27. Chest Injuries
Chest Trauma
28. Abdominal an and Ge Geni nitto ur urinary In Injuries
Abdominal an and Ge Genitourinary Tr Trauma
29. Orthopaedic Injuries
Non-Traumatic Musculoskeletal Disorders Orthopedic Trauma
30. En Environmental Em Emergencies
Environmental Em Emergencies
Section 8. Special Patient Populations
31. Obstetrics and Neonatal Care
Obstetrics Neonatal Care Special Considerations in Traum Traumaa
32. Pediatric Emergencies
Pediatrics Special Considerations in Traum Traumaa
33. Geriatric Emergencies
Geriatrics Special Considerations in Traum Traumaa
34. Patients With Special Challenges
Patients With Special Challenges Special Considerations in Traum Traumaa
Section 9. EMS Operations
35. Lifting and Moving Patients
Workforce Safety and Wellness
36. Transport Operations
Principles of Safely Operating a Ground Ambulance Air Medical
37. Ve Vehicle Ex Extrication an and Sp Special Re Rescue
Vehicle Ex Extrication
38. Incident Management
Incident Management Multiple-Casualty Incidents Hazardous Materials Awarenes Awarenesss
39. Terrorism and Disaster Management
Mass-Casualty Incidents due to Terrorism and Disaster
Section 10: ALS Techniques
40. ALS Assist Appendix: Medical Terminology
Medical Terminology
What Steps are the AAOS and J&B Taking to Implement the National EMS Education Standards? Because the Standards are less prescriptive than the DOT objectives, we have gathered a team of outstanding educators from across the country to help develop new materials for the classroom. This consensus approach to content development ensures that we publish only the best practices and nationally accepted training materials. In addition to developing gold standard student textbooks, we are building a wide range of teaching and learning tools that will enable instructors instructors to achieve one of the goals of the new Standards: greater individual creativity in course design.
For the last several years, we have been publishing technology based products and innovative supplementary materials that allow student-directed learning learning and hybrid courses. Now we are taking these tools to the next level for the instructors. The Tenth Edition of of Emergency Emergency Care and Transportation of the Sick and Injured offers instructors and students comprehensive coverage of every competency statement in the National EMS Education Standards in an engaging and accessible format.
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Section 1
Table 2-4 �
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Loss of interest in work Increased use of alcohol Recreational drug use Physical symptoms such as chronic pain (headache, backache) Feelings of hopelessness
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A Relaxed, Readable Textbook —When writing EMS
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textbooks, authors often forget who their audience really is. Some publishers may use “experts” who have little connection to the field. The Tenth Edition creates a learning environment in which students are comfortable with the material presented. That comfort level translates into better understanding understandi ng and retention, and ultimately leads to better pass rates. This text talks to your students, not at them.
, , sedatives more than 90 million times per year to patients in the United States. Although these medications have legitimate uses, they do nothing to combat stress that may cause the medical me dical problems described previously. previously. The term “stress management” refers to the tactics that have been shown to alleviate or eliminate stress reactions. These strategies may involve changing a few habits, . changing your attitude, and perseverance A clue to the management of stress comes from the fact that it is not the event itself but the individual’s reaction to it that determines how much it will strain the body’s resources. Remember that stress is defined as anything you perceive as a threat to your equilibrium. Stress is an undeniable and unavoidable part of our everyday life. By understanding how it affects you physiologically, physically, and psychologically, you can manage it more successfully. successfully. The following sections provide some suggestions for
Warning Signs of Stress
Irritability toward coworkers, family, and friends Inability to concentrate Difficulty sleeping, increased sleeping, or nightmares Feelings of sadness, anxiety, or guilt Indecisiveness Loss of appetite (gastrointestinal disturbances) Loss of interest in sexual activities Isolation
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Students Will Enjoy
Preparatory
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Your job is to remain professional at all times. Try and stay calm. Allow patients to express their feelings, including anger, without becoming angry yourself. There are many methods of handling stress. Some are positive and healthy; others are harmful and destructive. Americans consume more than 20 tons of aspirin per day day,, and doctors prescribe muscle relaxants, tranquilizers, and sedatives more than 90 million times per year t o patients in the United States. Although these medications have legitimate uses, they do nothing to combat stress that may cause the medical problems described previously. The term “stress management” refers to the tactics that have been shown to alleviate or eliminate stress reactions. These strategies may involve changing a few habits, changing your attitude, and perseverance . A clue to the management of stress comes from the fact that it is not the event itself but the individual’s reaction to it that determines how much it will strain the body’s resources. Remember that stress is defined as anything you perceive as a threat to your equilibrium. Stress is an undeniable and unavoidable part of our everyday life. By understanding how it affects you physiologically, physically, and psychologically, you can manage it more successfully. The following sections provide some suggestions for how to prevent the effects of stress from affecting you. Some of them may be useful in helping you prevent problems from developing. Others may help you solve problems should they develop.
Wellness We llness and Stress Management Anyone can respond to sudden physical stress for a short time. However, if stress is prolonged, and especially if physical action is not a permitted response, the body
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Strategies to Manage Stress
Minimize or eliminate stressors Change partners to avoid a negative or hostile personality Change work hours Change the work environment Cut back on overtime Change your attitude about the stressor Talk about your feelings with people you trust Seek professional counseling if needed Do not obsess over frustrating situations such as relapsing alcoholics and nursing home transfers. Focus on delivering high-quality care Try to adopt a more relaxed, philosophical outlook Expand your social support system apart from your coworkers Sustain friends and interests outside emergency services Minimize the physical response to stress by employing various techniques, including: – A deep breath to settle an anger response
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Periodic stretching Slow, deep breathing Regular physical exercise Progressive muscle relaxation Meditation Limit intake of caffeine, alcohol, and tobacco use
can quickly be drained of its reserves. This can leave it depleted of key nutrients, weakened, and more susceptible to illness.
Nutrition Your body’s three sources of fuel—carbohydrates, fat, and protein—are consumed in increased quantities during stress, particularly if physical activity is involved. The quickest source of energy is glucose, taken from stored glycogen in the liver. However, this supply will last less than a day. Protein, drawn primarily from muscle, is a long-term source of fuel. Tissues can use fat for energy. The body also conserves water during periods of stress. To do so, it retains sodium by exchanging and losing potassium from the kidneys. Other nutrients that are susceptible to depletion are the vitamins and minerals that are not stored by the body in substantial quantities. These include water-soluble uble B and C vitamins and most minerals. As an EMT, you have little control of what stressors you will face on any given day. Consequently, stress in one form or another is an unavoidable part of your life. As you would study for a test, dress properly for a day of snow skiing, or train for a sporting event, you should physically prepare your body for stress. Physical conditioning
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4History Taking Investigate Chief Complaint After the life threats have been managed during the primary assessment, investigate the chief complaint or history of present illness. The EMT should obtain a medical history and be alert for injury-specific signs and symptoms as well as any pertinent negatives such as no pain or loss of sensation. Make every attempt to obtain a SAMPLE history from your patient. Using OPQRST may provide some background on isolated extremity injuries. You have the opportunity to interview the patient well in advance of the emergency physician. Any information you receive will be very valuable if the patient loses c onsciousness. If the patient is not responsive, attempt atte mpt to obtain the history from other sources, such as friends or family members.
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Section 7
I I I I I I
4HistoryTaking Investigate Chief Complaint After the life threats have been managed during the primary assessment, investigate the chief complaint or history of present illness. The EMT should obtain a medical history and be alert for injury-specific signs and symptoms as well as any pertinent negatives such as no pain or loss of sensation. Make every attempt to obtain a SAMPLE history from your patient. Using OPQRST may provide some background on isolated extremity injuries. You have the opportunity to interview the patient well in advance of the emergency physician. Any information you receive will be very valuable if the patient loses consciousness. If the patient is not responsive, attempt to obtain the history from other sources, such as friends or family members.
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Tenth Edition also applies this unique approach of concept reinforcement to patient assessment. This critical topic is presented in a single, comprehensive chapter, ensuring that students understand patient assessment as a single, integrated process. This also allows instructors to teach patient assessment the way that students will actually practice it in the field. Recognizing the importance of assessment-based care, each medical and trauma chapter reflects the patient assessment process, using the same language and visual cues to strengthen students’ command of this process.
Trauma
consider rapid transport to the hospital for treatment or request ALS support. Whereas treatment performed following the primary assessment is directed at quickly addressing life threats, you should not delay transport of a trauma patient, particularly if the patient has a closed soft-tissue injury that may be a sign of a more serious deeper injury. Patients with a significant MOI may require a secondary assessment to identify these injuries. Although most patients do not require immediate load and go transportation, there are certain conditions for which treatment is limited in the field and therefore immediate transport is the better choice. The following list will help to guide you in recognition of the types of patients that need immediate transportation. Poor initial general impression Altered level of consciousness Dyspnea Irregular vital signs Shock Severe pain It is easy for you to become distracted when a patient has significant soft-tissue injuries, there is a large amount of blood, and the patient is most likely frightened and may be screaming. However, at this point you need to focus on the problems at hand and follow the protocols you have learned. The ABCs are simple enough to remember and treat. Patients who have visible significant bleeding or signs of significant internal bleeding may quickly become unstable. Treatment Treatment must be directed at quickly addressing life threats and providing rapid transportation to the closest appropriate hospital. Signs such as tachycardia, tachypnea, weak pulse, and cool, moist, and pale skin are signs of hypoperfusion and imply the need for rapid transport. You should be alert to these signs and reassess your priority and transport decision if they develop.
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Patient Assessment—The
Medical identification jewelry and cards in wallets may also provide information about the patient’s medical history. Typical signs of an open injury include bleeding, break(s) in the skin, shock, hemorrhage, and disfigurement or loss of a body part. Typically symptoms include pain and/or burning at the injury site. Conditions such as anemia (low quantity of hemoglobin in the blood) and hemophilia (a disorder in which blood has a diminished ability to clot) can complicate open soft-tissue injuries. Medications such as aspirin and other blood-thinning medications frequently taken by older p atients may interfere with clotting and make bleeding control difficult. If the injury was self-inflicted, the patient may also have a behavioralproblem.
4Secondary Assessment The secondary assessment is a more detailed, comprehensive examination of the patient that is used to uncover injuries that may have been missed during the primary assessment. In some instances such as a critically injured patient or a short transport time, the EMT may not have time to conduct a secondary assessment.
Physical Examinations If significant trauma has likely affected multiple systems, start with a rapid full-body scan to be sure that you have found all of the problems and injuries. Begin with the head and neck while manually holding the head in place. When you are done, apply a cervical spine immobilization device if you have not done so already. already. Assessment of the respiratory system should involve looking, listening, and feeling for signs of airway problems. Look at the patient and ask yourself the following questions: 1. Is the patient in a tripod position? 2. Is the patient gasping for air? 3. What is the skin’s color and condition? 4. Are there any signs of increased respiratory efforts such as retractions, nasal flaring, pursed lip breathing, or use of accessory muscles? Next, listen for air movement at the patient’s mouth and nose. Then listen to breath sounds with a stethoscope. Breath sounds should be clear and equal bilaterally, anteriorly, and posteriorly. Determine the patient’s rate and quality of respiration. Finally assess asymmetric chest wall movement. You must be able to quickly assess pulse rate and quality; determine the skin condition, color, and temperature; and check the capillary refill time. Assess the neurologic system to gather baseline data on your patient. This examination should include: level of consciousness—us consciousness—usee AVPU pupil size and reactivity
4Secondary Assessment The secondary assessment is a more detailed, comprehensive examination of the patient that is used to uncover injuries that may have been missed during the primary assessment. In some instances such as a critically injured patient or a short transport time, the EMT may not have time to conduct a secondary assessment.
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Physical Examinations If significant trauma has likely affected multiple systems, start with a rapid full-body scan to be sure that you have found all of the problems and injuries. Begin with the head and neck while manually holding the head in place. When you are done, apply a cervical spine immobilization device if you have not done so already already.. Assessment of the respiratory system should involve looking, listening, and feeling for signs of airway problems. Look at the patient and ask yourself the following questions: 1. Is the patient in a tripod position? 2. Is the patient gasping for air? 3. What is the skin’s color and condition? 4. Are there any signs of increased respiratory efforts such as retractions, nasal flaring, pursed lip 1 /
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Current, State-of-the-Art Medical Content —Medicine is
Continuous Positive Airwa Airway y Pressure 6
constantly changing and prehospital medicine varies across states and regions. The content of the Tenth Edition reflects the guidance and recommendations of an extremely experienced, geographically geographically diverse group of authors. Supporting the efforts of this outstanding group of authors is a team of Medical Editors from the American Academy of Orthopaedic Surgeons (AAOS). (AAOS). Educators in search of the gold standard in EMS education need look no further than the Tenth Edition.
Continuous positive airway pressure (CPAP) is a noninvasive means of providing ventilatory support for patients experiencing respiratory distress. Many people who have been diagnosed with obstructive sleep apnea wear a CPAP unit at night to maintain their airways while they sleep . Over the past several years, the use of CPAP in the prehospital environment has proven to be an excellent adjunct in the treatment of respiratory distress associated with obstructive pulmonary disease and acute pulmonary edema. Typically, many of these patients would be managed with advanced airway devices, such as endotracheal intubation. Research has shown that there is a significant increase in morbidity and mortality when these patients receive intubation for their condition in the field. CPAP offers an alternative means for providing ventilatory assistance to patients, and helps to decrease the overall morbidity and mortality for these patients. Because of the simplicity of the device and its great benefit to the patient, CPAP is becoming widely used at the EMT level.
Anatomy and Physiology 6
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The immune system protects the human body from substances and organisms that are foreign to the body. Without the immune system for protection, life as you know it would not exist. You would be under constant attack from any type of invader, such as a bacterium or virus that wanted to make your body a home. Fortunately, most people have immune systems that are well equipped to detect unauthorized visits or invading er es o respo attacks by foreign substances. Once a foreign substance
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act vate the inva er.
Pathophysiology 6
Constant Reinforcement of Concepts —Health care
education can be complicated, and for many students, the EMT class is their first exposure to anatomy, physiology, medical terminology, and medical care. The Tenth Edition is built on the premise that students need a solid foundation in the basics and then appropriate reinforcement reinforcement of that content. For example, Chapter 5, The Human Body, provides students with a comprehensive understanding understanding of the entire anatomy, physiology, and pathophysiology of the human body. At the beginning of Chapter 18, Immunologic Emergencies,, the text briefly revisits the relevant anatomy, Emergencies physiology,, and pathophysiology of the immune system, physiology thus solidifying this knowledge in the students’ minds and
Contrary to what many people think, an allergic reaction, an exaggerated immune response to any substance, is not caused directly by an outside stimulus, such as a bite or sting. Rather, it is a reaction by the body’s immune system, which releases chemicals to combat the stimulus. Among these chemicals are histamines and leukotrienes. An allergic reaction may be mild and local, involving hives, itching, or tenderness, or it may be severe and systemic, resulting in shock and respiratory failure. Anaphylaxis is an extreme allergic reaction that is life threatening and involves multiple organ systems. In severe cases, anaphylaxis can rapidly result in death. One of the most common signs of anaphylaxis is wheezing, a high-pitched, whistling breath sound that is typically
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Section 5
Shock and Resuscitation
division of the autonomic nervous system that controls involuntary functions by sending signals to the cardiac, smooth, and glandular muscles. This response by the autonomic nervous system causes the release of hormones such as epinephrine and norepinephrine. These hormones cause changes in certain body functions such as an increase in the heart rate and in the strength of cardiac contractions and vasoconstriction in nonessential areas, primarily in the skin and gastrointestinal tract (peripheral vasoconstriction). Together, Together, these actions are designed to maintain pressure in the system and, as a result, sustain perfusion of all vital organs. Eventually, there is also a shifting of body fluids to help maintain pressure within the system. However, the response of the autonomic nervous system and hormones comes within seconds. It is this response that causes all the signs and symptoms of shock in a patient.
Clear Application of Material to Real-World EMS
Situations —Students who want to become EMTs are focused on learning to help people. They need to know why information is important to learn. “How will this help me in the field?” Through evolving patient case studies in each chapter, the Tenth Edition gives students a genuine context for the application of the knowledge presented in the chapter. This approach makes it clear how all of this new information will be used to help their patients in the field.
infection. In all cases, however, the damage occurs because of insufficient perfusion of organs and tissues. As soon as perfusion stops or becomes impaired, tissues start to die, affecting all local body processes. If the conditions causing shock are not promptly arrested and reversed, death soon follows.
Words W ords of ords of Wisdom isd sdom om m Shock is a complex physiologic process that gives subtle signs to its presence before it becomes severe. These early signs relate very closely to the events that lead to more severe shock, so it is even more important than usual for you to know the underlying processes thoroughly. If you understand what causes shock, you will be able to recognize it in many patients before it gets out of control.
Understanding the basic physiologic causes of shock will better prepare you to treat it . There are cardiovascular and noncardiovascular causes of shock. Cardiovascular causes of shock include heart attack, disease, and injury. Noncardiovascular causes include
Causes of Shock 6
Shock can result from many conditions, including respiratory failure, acute allergic reactions, and overwhelming
You are re the Provider: Provider: PART
2
You Y u aarrive rri a at the h clinic lini and an are ar escorted r to the h patient a i n by aa clinic lini technician. hnii iia ian .You Y ufind fin the h patient a ii n lying ll iin supine u iin on an examination table. She is conscious, but restless, and her skin is notably pale and diaphoretic. She has a blanket covering her, her legs are elevated, and she is receiving oxygen via a nasal cannula at 4 L/min. Several attempts at establishing intravenous (IV) access were unsuccessful. Your assessment of the patient reveals the following:
You a are r the Provider: v r: PART
The clinic physician tells you that the patient presented approximately 15 minutes ago complaining of abdominal pain and rectal bleeding, which apparently started about 24 hours ago. There is no history of trauma, she has a history of irritable bowel syndrome, she takes lubiprostone (Amitiza) and dicyclomine hydrochloride (Bentyl), and she is allergic to codeine.
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On the basis of your assessment, does this patient require any changes in the treatment she is currently receiving?
You arrive at the clinic and are escorted to the patient by a clinic technician.. You You You 4.find the patient supine How do the patient’s signslying and symptoms correlate with the body’s response to inadequate perfusion? on an examination table. She is conscious, but restless, and her skin is notably pale and diaphoretic. She has a blanket covering her, her, her legs aare re elevated, and she is receiving oxygen via a nasal cannula at 4 L/min. Several attempts at establishing intravenous (IV) access were unsuccessful. Your Your assessment of the patient reveals the following: _
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The clinic physician tells you that the patient presented approximately 15 minutes ago complaining of abdominal pain and rectal bleeding, which apparently started about 24 hours ago. There is no history of trauma, she has a history of irritable bowel syndrome, she takes lubiprostone (Amitiza) and dicyclomine hydrochloride (Bentyl), and she is alle allergic rgic to to codeine. codeine.
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On the basis of your assessment, does this patient require any changes in the treatment she is currently receiving?
4. 4
How do the patient’ patient’s s signs and symptoms correlate with the body’s response to inadequate perfusion?
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Emergency Care and Transportation of the Sick and Injured,
Tenth Edition Edi tion sets the standard for quality, clarity, and flexibility in the delivery of EMT education. To learn more, visit www.jbpub.com.
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Educators Will Enjoy
A Textbook That Reflects the Expertise of its Author
Team —The Tenth Edition authors are seasoned EMS providers with decades of experience in both the care of prehospital patients and the education of future EMS providers. This textbook is clearly written by one of us, for all of us.
Clear Application of Material to Real-World EMS
Situations —Instructors will find countless opportunities to place their students “in the field” with progressive case studies that include full patient care reports, video products that show providers in action, and case-based critical thinking examination tools. Opportunities to apply knowledge ultimately make students better-equipped better-equipped providers. And isn’t that our goal: to teach students how to be great EMS providers? , ,
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In many many cases, the EMT will be called on to assist the paramedic in performing advanced level skills. Depending on local protocols, EMTs may even be able to perform additional skill skil ls s as deemed necessary by the EMS system medical director.
EMS Patient Care Report (PCR) Date: 9-1-09
Incident No.: 012109
Dispatched: 1520
En Route: 1520
Nature of Call: Motor vehicle crash
At Scene: 1528
Transport: 1538
Location: 2100 Block Hwy 46 At Landing Zone:
In Service:
1540
1552
Patient Information Age: 20 Sex: M Weight (in kg [lb]): estimated at 68 (150 lb)
Allergies: Unknown Medications: Unknown Past Medical History: Unknown Chief Complaint: Multiple traumatic injuries Vital Signs
Time: 1533
BP: 84/64
Pulse: 120
Respirations: 28
SaO2: 97%
Time: 1538
BP: 80/50
Pulse: 130
Respirations: 34
SaO2: 89%
Time: 1543
BP: 74/50
Pulse: 140
Respirations: 34
SaO2: 95%
EMS Treatment (circle all that apply) Oxygen @ 15 L/min via (circle one): NC NRM
Assisted Ventilation
Airway Ad Adjunct
CPR
Defibrillation
Bandaging
Splinting
Other: Thermal management, suction, full spinal precautions
Bleeding Control
Narrative
Dispatched for a motor vehicle versus tree head-on collision. Engine 3 and law enforcement was dispatched as well. Arrived at the scene and noted that a small passenger vehicle made frontal impact with a large tree. Damage to the front of the vehicle was significant. The driver, a 20-year-old male, was still in the vehicle; however, he was unrestrained. Driver and passenger side airbags both deployed, and patient was not entrapped. Partner accessed patient through backseat and manually stabilized his head. Primary assessment revealed that the patient was responsive only to pain. He had blood in his oropharynx, a large hematoma and laceration with active bleeding to his forehead, and facial bleeding. His respirations were rapid and labored. Suctioned the patient’s oropharynx, controlled the bleeding on his forehead, applied cervical collar, and rapidly extricated him from the vehicle. Due to the MOI and patient’s clinical status, requested air transport. Applied oxygen @ 15 L/min via nonrebreathing mask and performed secondary assessment, which revealed diffuse bruising and crepitus to the chest. Breath sounds were diminished over the left side of the chest. Pelvis and upper and lower extremities were unremarkable for gross injury. Pupils were dilated and sluggish to react. Engine 3 firefighter reported interior damage to the steering wheel and a starburst fracture to the windshield with evidence of human hair. Applied full spinal precautions and a blanket for warmth, and loaded patient into the ambulance. Reassessment revealed that his respiratory rate had increased, his breathing effort was more labored, and his oxygen saturation had decreased. Began assisting his ventilations with a bag-mask device and high-flow oxygen. Engine 3 EMT drove ambulance
Constant Reinforcement of Concepts —EMS educators are
concerned about the National EMS Education Standards and its impact on their classrooms. The Tenth Edition eases any transition to the new National EMS Education Standards. The Tenth Edition is the cornerstone of a complete teaching and learning system consisting of ample resources for both student and faculty. With online resources, students and faculty are able to take practice tests, work on module assignments, and use JBTest Prep Technology Supplements: to ensure competency. Educators will enjoy the updated presentations, test banks, and JB Navigate. This system provides an outstanding platform for a dynamic learning environment for all students.
Interactive Course eBook/eWorkbook CourseSmart JB Navigate (formerly known as JBCourse Manager) JBTest Prep Audio Book Website
Instructor Supplements:
Instructor’s ToolKit CD-ROM Test Bank CD-ROM Scenario DVD
Student Supplements:
Student Workbook EMT Field Guide
Applying a Commercial Tourniquet
Step
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Hold pressure over the bleeding site and place the tourniquet just above the injury.
To release the tourniquet at the hospital, or if otherwise instructed by medical control, push the
Current, State-of-the-Art Medical Content —EMS has
long struggled to prove that the care delivered in the field has real impact on patients’ lives. The Tenth Edition incorporates evidence-based medical concepts to ensure that students are taught assessment and treatment modalities that will help patients today—not simply
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.
“time applied.” Securely fasten the tape to the patient’s forehead. Notify hospital personnel on
CHAPTER
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Bleeding
National EMS Education Standard Competencies Trauma Applies fundamental knowledge to provide basic emergency care and transportation transporta tion based on assessment findings for an acutely injured patient.
Bleeding Recognition and management of I Bleeding (pp 33–47) Pathophysiology, assessment, and management of I Bleeding (pp 29–47)
Knowledge Objectives 1.
Understand the basic anatomy and physiology of the cardiovascular system,, including blood, blood vessels, and the heart. (pp 3–6) system
2.
Understand the role of perfusion. (pp 6–7)
3.
Know how to determine the significance and characteristics of external bleeding. (pp 7–8)
4.
Understand the impor importance ance of identifying identifying the mechanism mechanism of injury, nature of illnes illness, s, and signs and symptoms for a patient with suspected internal ble bleeding. eding. (pp 9–10)
5.
Describe how to assess a patient with external bleeding. (pp 10–14)
6.
Describe how to assess a patient with suspected internal bleeding. (pp 10–14)
7.
Describe the emergency medical care for a patient with external bleeding. (pp 14–20)
8.
Describe the emergency medical care for a patient with suspected internal bleeding. (pp 20–21)
Skills Objectives 1.
Demonstrate how to control external bleeding. (pp 14–20, Skill Drill 22-1)
2.
Demonstrate the application of a tourniquet. (pp 16–17, Skill Drill 22-2)
3.
Demonstrate the control of epistaxis. (pp 19–20, Skill Drill 22-3)
4.
Demonstrate how to control internal bleeding. (pp 20–21, Skill Drill 22-4)
The National EMS Education Standards Competencies along with the chapter’s Knowledge Objectives and Skill Objectives are listed at the beginning of each chapter with corresponding page references.
Chapter 22
Introduction
Bleeding
3
Head, arm, and upper trunk
6
Venule
A
fter managing the airway, recognizing bleeding and understanding how it affects the body are perhaps the most important skills you will learn as an EMT. EMT. Bleeding can be external and obvious or internal and hidden. Either way, it is potentially dangerous, first causing weakness and, if left uncontrolled, eventually shock and death. The most common cause of shock following trauma is bleeding. Generally the shock from trauma is caused at least in part from bleeding.
Vein
Arteriole
Artery
Aorta
This chapter will help you understand how the cardiovascular system reacts to blood loss. The chapter begins with a brief review of the anatomy andcement function Reinforcement Reinfor of the of the cardiovascular system. It then describes anatomythe andsigns, physiology symptoms, and emergency medical care presented of both external in Chapter 5, and internal bleeding. The chapter concludes with a disThe Human Body , occurs cussion on the relationship between bleeding and hypothroughout the text. volemic shock.
Lung
Heart
Abdominal organs
Lower body and legs
Anatomy and Physiology of the Cardiovascular System 6
The cardiovascular system circulates blood to all of the body’s cells and tissues, delivering oxygen and nutrients and carrying away metabolic waste products . Cells in the brain, spinal cord, and heart cannot tolerate a lack of blood for more than a few minutes. Cells in other organs, such as the lungs and kidneys, can survive for almost an hour while skeletal muscle cells may survive for two hours in a state
of inadequate perfusion. After that, their cells begin to die. This can lead to a permanent loss of function or, if enough cells die, death. Progressive case studies capture the student’s
You
are the Provider:: PART 1
attention and offer an authentic context for students to apply their
knowledge. At 4:20 : PM, you you are are dispatched spa c e to oa w woodworking oo wor ng sshop op a at 517 East as Graham ra am for or a 3232-year-old -y year-old ear-o m man an with w severe severe bleeding from the arm. The exact mechanism of injury is unknown. You You and your partner respond to the scene with a response time of approximately 6 minutes. 1. What are the functions of arteries? What major arteries are located in the upper extremity? 2. Why is arterial bleeding more severe than venous bleeding?
4
Section 7
Trauma
The cardiovascular system, the main system responsible for supplying and maintaining adequate blood flow, flow, consists of three parts: The pump (the heart) A container (the blood vessels that reach every cell in the body) The fluid (blood and body fluids)
Superior vena cava (oxygen-poor blood from head and upper body)
Left pulmonary artery (blood to left lung)
I I
I
The Heart
The heart is a hollow muscular organ about the size of a clenched fist. It is an involuntary muscle that is under the control of the autonomic nervous system, but it has its own regulatory system. Thus, it can function even if the nervous system shuts down. The heart is always working; all other organs depend on it to provide a rich blood supply. For this reason, it has a number of special features that other muscles do not. First, because the heart cannot tolerate a disruption of its blood supply for more than a few seconds, the heart muscle needs a rich and well-distributed blood supply. Second, 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. The right side of the heart receives oxygen-poor (deoxygenated) blood from the veins of the body. Blood enters the right atrium from the vena cava, then fills the right ventricle. After the right ventricle contracts, blood flows into the pulmonary artery and the pulmonary circulation. The now oxygen-rich (oxygenated) blood returns to the left side of the heart from the lungs through the pulmonary veins. Blood enters the left atrium, then passes into the left ventricle. This side of the heart is more muscular than the other because it must pump blood into the aorta and on to the arteries art eries throughout the body body.. It is important imp ortant to remember that the left ventricle is responsible for providing 100% of the body with oxygen-rich blood. Blood Vessels and Blood
There are five types of blood vessels: Arteries Arterioles Capillaries Venules Veins As blood flows out of the heart, it passes into the aorta, the largest artery in the body. The arteries become smaller as they move away from the heart. The smaller I I I I I
Right pulmonary artery (blood to right lung)
Right atrium Inferior vena cava (oxygen-poor blood from lower body)
Right ventricle
Right pulmonary veins (oxygen-rich blood from right lung)
Oxygen-rich blood to head and upper body
Left pulmonary veins (oxygen-rich blood from left lung)
Left atrium
Left ventricle
Oxygen-rich blood to lower body
arterioles. 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 vena cava. This is the process that returns blood in the venous side 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 and into the capillaries . This transportation system allows
Chapter 22
Capillary to tissue cells O2 and nutrients
Pulmonary arteriole
CO2 O2
Pulmonary venule
Bleeding
5
each cell of the surrounding tissue; when the muscles are closed (constricted), there is no capillary blood flow. The muscles dilate and constrict in response to conditions such as fright, heat, cold, a specific need for oxygen, and the need to dispose of metabolic waste. In a healthy individual, all the vessels are never fully dilated or fully constricted at the same time. The last part of the cardiovascular system is the contents of the container, or the blood. Blood contains red CO2 and waste cells, white cells, platelets, and a liquid called plasma . As discussed in Chapter 5, The Human Body , red blood cells are responsible for the transportation of oxygen to the cells and for transporting carbon dioxide (a waste product of cellular metabolism) away from the cells to the lungs, where it is exhaled and removed from the body. Platelets are responsible for forming blood clots. In the body, a blood clot forms depending on one of the following principles: blood stasis, changes in the vessel wall (such ( such as a wound), or the blood’ bloo d’s ability to clot cl ot (due to a disease process or medication). When injury occurs to tissues in the body, platelets will begin to collect at the site of injury; this causes red blood cells to become Lung alveoli sticky and clump together. As the red blood cells begin capillaries to clump, another substance in the body called fibrinogen reinforces reinforces the red blood cells. This is the final step in formation of a blood clot. Blood clots are an important response from the body to control blood loss. Certain Highly descriptive andconditions that interfere with the normal clotting medical process will be discussed later in this chapter. chapter. detailed illustrations The enable the student to autonomic nervous system monitors the body’s needs from moment to moment and adjusts the blood clearly visualize flow human anatomy anatomy. . by adjusting vascular tone as required. During emergencies, the autonomic nervous system automatically redirects blood away from other organs to the heart, brain, lungs, and kidneys. Thus, the cardiovascular CO2 system is dynamic and constantly adapting to changing
O2 Lung alveolus
White blood cells Red blood cells
Platelets
At the arterial ends of the capillaries and in the arteries themselves are circular muscular walls, which constrict and dilate automatically under the control of the autonomic nervous system. When these muscles open
6
Section 7
Trauma
conditions in the body to maintain homeostasis and perfusion. At times, the system fails to provide sufficient circulation for every body part to perform its function. This condition is called hypoperfusion hypoperfusion,, or shock shock..
Artery
Pathophysiology and Perfusion 6
Arterioles Blunt force trauma may cause injury and significant An in-depth and topicbleeding that is unseen inside a body cavity or region, Capillaries specific exploration of such as when injury occurs to the liver or the spleen. These injuries cause the patient to lose significant the pathophysiology Organ or tissue amounts of blood, causing hypoperfusion without visible presented in Chapter 5, bleeding. In penetrating trauma, the patient may have The Human Body , occurs only a small amount of bleeding that is visible; however, however , throughout the medical the patient may have sustained injury to internal organs and trauma sections. that will produce significant bleeding that is unseen by you and may cause death quickly. Both of these situations are examples of serious internal bleeding, in which blood volume and supply have been interrupted to the cells of the body; this interruption is the cause of hypoperfusion Capillaries (or shock) in the trauma patient. Perfusion is the circulation of blood within an organ Venules 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 . Vein While passing through the capillaries, the blood delivers nutrients and oxygen to the surrounding cells and picks up the wastes they have generated. Then the blood leaves the capillary beds through the venules and finally reaches the veins, which take the blood back to the heart. Oxygen and carbon dioxide exchange takes place in the lungs. Blood must pass through the cardiovascular system can quickly lead to death of the organism, the human. at a speed that is fast enough to maintain adequate cirEmergency medical care is designed to support adequate culation throughout the body and slow enough to allow perfusion to these organs and their systems, listed in each cell time to exchange oxygen and nutrients for car, until the patient arrives at the hospital. bon dioxide and other waste products. Although some tissues, such as the lungs and kidneys, never rest and Organs and Correspo Corresponding nding require a constant blood supply, most require circulating Table 22-1 Organ Systems blood only intermittently, especially when active. Muscles are a good example. When you sleep, they are at rest Organ Organ System and require a minimal blood supply. However, during Heart Cardiovascular system exercise, they need a very large blood supply. The gastrointestinal tract requires a high flow of blood after a meal. Brain Central nervous system After digestion is completed, it can do quite well with a Lungs Respiratory system small fraction of that flow. Kidneys Renal system All organs and organ systems of the human body are dependent on adequate perfusion to function properly. Some of these organs receive a very rich supply of blood The heart requires constant perfusion to function and do not tolerate interruption of blood supply for very properly. The brain and spinal cord can be injured after long. If perfusion is interrupted to these organs and dam4 to 6 minutes without perfusion. It is important to age occurs to the organ tissue, dysfunction and failure of
Chapter 22
have the capacity to regenerate. Kidneys can be damaged after 45 minutes of inadequate perfusion. Skeletal muscle demonstrates evidence of injury after 2 hours of inadequate perfusion. The gastrointestinal tract can tolerate slightly longer periods of inadequate perfusion. These times are based on a normal body temperature (98.6°F [37.0°C]). An organ or tissue that is considerably colder may be better able to resist damage from hypoperfusion.
External Bleeding 6
Hemorrhage means bleeding. External bleeding is visible hemorrhage. Examples include nosebleeds and bleeding from open wounds. As an EMT, you must understand how to control external bleeding.
Bleeding
7
Safety e Remember that a bleeding patient may expose you to potentially infectious body fluids; therefore, you must always follow standard precautions when treating patients with external bleeding. Wear gloves and eye protection in all situations, and wear a gown and mask if there is a risk of blood splatter . Avoid direct contact with body fluids if possible. Take special care if you have an open sore, cut, scratch, or ulcer. Also remember that frequent, thorough handwashing between patients and after every run is a simple yet important protective measure. You will be called to respond to emergencies involving more than one patient who needs emergency care. As you complete the assessment and care for each patient, remember to place clean gloves on your hands. Always keep spare gloves with you when responding to these incidents. This approach to patient care will greatly minimize the chance that you could cause cross-contamination of body fluids and blood between patients Reinforces Reinfor ces safety for both you may be caring for.
the EMT and the patient.
The Significance of External Bleeding When patients have serious external blood loss, it is often difficult to determine the amount of blood that is present. This is a difficult task because blood will look differe different nt on different surfaces, surfaces, such as when it is absorbed in clothing or when it has been diluted when mixed in water. Always attempt to determine the amount of external blood loss, but the presentation and assessment of the patient will direct the care and treatment the patient will receive from you as an a n EMT.
Words r oof Wisdom m Signs and Symptoms of Hypovolemic Shock I Rapid, weak pulse I Low blood pressure (late sign) I Changes in mental status I Cool, clammy skin I Cyanosis (lips, oral membranes, nail beds)
The body will not tolerate an acute blood loss of greater than 20% of blood volume. The typical adult has approximately 70 mL of blood per kilogram of body weight, or 6 L (10 to 12 pints) in a body weighing 80 kg (175 lb). If the typical adult loses more than 1 L of blood (about 2 pints), significant changes in vital signs will occur, including increasing heart and respiratory rates and decreasing blood pressure. Because infants and children have less blood volume to begin with, the same effect is seen with smaller amounts of blood loss. For example, a 1-year-old infant has a total blood volume of about 800 mL. Significant symptoms of blood loss
put this in perspective, a soft drink can holds roughly 355 mL of liquid. How well people compensate for blood loss is related to how rapidly they bleed. A healthy adult can comfortably donate 1 unit (500 mL) of blood during a period of 15 to 20 minutes and adapts well to this decrease in blood volume. However, However, if a similar blood loss occurs in a much shorter period, the person may rapidly develop hypovolemic shock, a condition in which low blood volume results in inadequate perfusion and even death. The body simply cannot compensate for such a rapid blood loss. The age and preexisting health of the patient
8
Section 7
Trauma
You should consider bleeding to be serious if the following conditions are present: I
I
I
I I I
It is associated with a significant mechanism of injury (MOI). The patient has a poor general appearance and is calm. Assessment reveals signs and symptoms of shock (hypoperfusion). You Y ou note a significant amount of blood loss. The blood loss is rapid. You cannot control the bleeding.
In any situation, blood loss is an extremely serious problem. It demands your immediate attention as soon as you have cleared the airway and managed the patient’s breathing.
Characteristics of External Characteristics Bleeding Injuries and some illnesses can disrupt blood vessels and cause bleeding. Typically, bleeding from an open artery (arterial bleeding) is brighter red (high in oxygen) 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. Blood from an open vein (venous bleeding) is darker (low in oxygen) and flows slowly or severely, 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 however
blood (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 . On its own, bleeding tends to stop rather quickly, within about 10 minutes, in response to internal mechanisms and exposure to air. When a person is cut, blood flows rapidly from the open vessel. Soon afterward, the Key cutterms endsare of easily the vessel begin to narrow ( vasoconstriction), identified and defined within of bleeding. Then a clot forms, reducing the amount the text. A vocabulary plugging the hole list and sealing the injured portions of the concludes each chapter, vessel. This process is called coagulation. Bleeding will and a comprehensive never stop if a clot does not form, unless the injured vessel is completely cut off from the main blood supply. glossary appears at the the efficiency of this system, it may fail in end of Despite the textbook. certain situations. Movement, medications, removal of bandages, and the external environment or body temperature commonly affect the blood’s clotting factors. For example, a number of medications, including aspirin, interfere with normal clotting. With a severe injury, the damage to the vessel may be so large that a clot cannot completely block the hole. Sometimes only part of the vessel wall is cut, preventing it from constricting. In these cases, bleeding will continue unless it is stopped by external means. Occasionally, blood loss occurs very rapidly. In these cases, the patient might die before the body’s defenses, such as clotting, could help. A very small portion of the population lacks one or more of the blood’s blood’s clotting factors. This condition is called call ed hemophilia. There are several forms of hemophilia, most of which are hereditary and some of which are severe. Sometimes bleeding may occur spontaneously in hemophilia. Because the patient’s blood does not clot, all injuries, no
Chapter 22
Words of Wisdom If a bandage has already been applied to control bleeding before you arrive on the scene, obtain a description of the wound and the amount of bleeding from the patient or bystanders.
Nature of Illness for Internal Bleeding
advice from experienced
Internal Bleeding 6
Internal bleeding is any bleeding in a cavity or space inside the body. body. It can be very serious, especially because you might not be aware that it is happening. 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 lose a large amount of blood very quickly. Similarly, a person who has a lacerated liver or a ruptured spleen may lose a considerable amount of blood within the abdomen. Yet Yet the patient has no outward signs of bleeding. 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 1 L or more of blood into the soft tissues of the thigh. Often the only signs of such bleeding are local swelling and bruising due to the accumulation of blood around the ends of the broken bone. Severe pelvic fractures may result in life-threatenin life-threateningg hemorrhage. You must always be alert to the possibility of internal bleeding and assess the patient for related signs and symptoms, particularly if the MOI is severe. If you suspect that a patient is bleeding internally, you should promptly transport him or her to the hospital.
Mechanism of Injury Mechanism Injur y 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 automobile or motorcycle crashes. Remember that internal bleeding can result from penetrating trauma as well. As you assess a patient, look for signs of injury
9
Punctures/Penetrations, Burns, Tenderness, Lacerations, and Swelling) over the chest or abdomen, including contusions, abrasions, lacerations, and other signs of injury or deformity. You should always suspect internal bleeding in a patient who has penetrating injury or blunt trauma.
Provides real-world
matter how trivial, are potentiallyfield serious. A patient with providers. hemophilia should be transported immediately immediately..
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 nontraumatic internal bleeding. Ulcers or other gastrointestinal problems may cause vomiting of blood or bloody diarrhea or urine. It is not as important for you to know the specific organ involved as it is to recognize that the patient is in shock and respond appropriately.
Signs and Symptoms of Internal Bleeding The most common symptom of internal bleeding is pain. Significant internal bleeding will generally cause swelling in the area of bleeding. Intra-abdominal bleeding will often cause pain and distention. distent ion. Bruising is a sign of internal bleeding. It is most common in head, extremity, and pelvic injuries and can be a sign of significant abdominal trauma. Bleeding into the chest may cause dyspnea in addition to tachycardia and hypotension. A bruise is also called a contusion, or ecchymosis . A hematoma, a mass of blood in the soft tissues beneath the skin, indicates bleeding into soft tissues and may be the result of a minor or a severe injury. injury. Bruising or ecchymosis ecchymos is may not be present initially, and the only sign of severe pelvic or abdominal trauma may be redness, skin abrasions, or pain. Bleeding, however slight, from any body opening is serious. It usually indicates internal bleeding that is not easy to see or control. 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. Other signs and symptoms of internal bleeding in both trauma and medical patients include the following: Hematemesis . This is vomited blood. It may be bright red or dark red, or, if the blood has been partially digested, it may look like coffee-grounds vomitus. Melena This is a black, foul-smelling, tarry stool I
I
10
Section 7
I
Trauma
Hemoptysis. This is bright red blood that is
coughed up by the patient. I
Pain, tenderness, bruising, guarding, or swelling. These
signs and symptoms may mean that a closed fracture is bleeding. I
Broken ribs, bruises over the lower part of the chest,
These signs and symptoms may indicate a lacerated spleen or liver. Patients with an injury to either organ may have referred pain in the right shoulder (liver) or left shoulder (spleen). You should suspect internal abdominal bleeding in a patient with referred pain. The first sign of hypovolemic shock (hypoperfusion) 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. Changes in skin color or pallor (pale skin) are seen often in both trauma and medical patients. Later signs of hypoperfusion 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 of more than 2 seconds in infants and children Weak, rapid (thready) pulse Decreasing blood pressure Altered level of consciousness Patients with these signs and symptoms are at risk. Some may be in danger. Even if their bleeding stops, it could begin again at any moment. Therefore, prompt transport is necessary. or a rigid, distended abdomen.
I I I I
that energized electrical lines are not close to where you will be working. In incidents involving violence, such as assaults or gunshot wounds, make sure that police are on scene. At times you may need to stage several blocks away until law enforcement personnel have secured the area. Follow standard precautions. Place several pairs of gloves in your pocket for easy access in case your gloves tear or there are multiple patients with bleeding. If you are entering a residence, be alert for anxious bystanders and family members because they may become hostile. Ensure that you are only going to have to provide care for one patient. Consider early on what you may need, and verify as you begin your assessment.
Mechanism of Injury/Nature of Illness Determine the nature of the illness (NOI) (such as bloody emesis or bloody stool), or the MOI (such as a turnedover step stool). Consider the need for manual spinal stabilization and the need for additional resources, such as an advanced life support unit. Be sure to also consider environmental factors in your decision making. For Discusses the specific example, caring for a sick or injured victim of a car crash needs and emergency on a clear, sunny day is a bit different than treating the care of pediatric same victim during a snowstorm. Extreme hotpatients, or cold geriatric patients, and weather can worsen a patient’s overall condition. special needs patients.
I I I
Special Populations
I
In older patients, dizziness, syncope, or weakness may be the first sign of nontraumatic internal hemorrhage.
I
I I I
6
Patient Assessment for External and Internal Bleeding
4Scene Size-up Scene Safety As you approach the patient, be alert to potential hazards to yourself and the crew, bystanders, and the patient(s). At vehicle crashes, ensure that there is no
4Primary Assessment In patients with suspected significant blood loss from a visible wound or from unseen internal bleeding, you must not be distracted from identifying life threats. The EMT should treat the patient according to the ABCs and provide treatment needed to preserve life. The management of life-threatening concerns during the primary assessment is determined by asking yourself, “What is going to kill my patient first?” For example, in some situations, significant bleeding may need management before applying oxygen for a person with adequate breathing. The Reinforcement Reinfor cement of the decision on what to treat first will come with experience. patient assessment process Treating according to the ABCs is always a good choice. taught in Chapter 8, Patient
Form General Assessment Assessment, , as it relatesImpression As you approach trauma patient, you must note imporspecifically to externala and tant indicators internal bleeding. that may alert you to the seriousness of the patient’s condition. For example, patients with external bleeding may have blood stains on their clothing.
Chapter 22
as facial grimace), along with determining gender and age. Assess skin color. Pale or gray, cool, moist skin suggests a perfusion problem. Determine the patient’s level of consciousness using the AVPU scale (Awake and alert; responsive to Verbal stimuli or Pain; Unresponsive). Is the patient able to speak? This will indicate whether or not the airway is patent. What is the mental status of the patient? These indicators will help you determine whether the patient is sick or not so sick; this assists you in developing an index of suspicion for serious illness or injuries related to internal bleeding.
Airway and Breathing Consider the need for spinal stabilization. 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-mask device or nonrebrea nonrebreathing thing 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. Circulation You must be able to quickly assess pulse rate and quality; determine the skin condition, color, and temperature; and check the capillary refill time to help establish the potential for internal bleeding and shock. When lifethreatening external bleeding is seen, you must begin the steps necessary to control the external bleeding and treatment of shock should begin as quickly as possible. Non–life-threatening bleeding, such as with abrasions,
You
Bleeding
can be bandaged later in your assessment as necessary. Significant bleeding, internal or external, is an immediate life threat. Treat the patient for shock if needed by applying oxygen, improving circulation, and maintaining a normal body temperature.
Transport Decision The results of your initial general impression and assessment of the ABCs will help you develop a sense of urgency for the patient and guide you in your transport decision to manage the patient on scene or manage the patient on the way to the hospital. For example, if the patient has signs and symptoms of internal bleeding or airway or breathing problems, you must transport quickly to the appropriate hospital for treatment by a physician. The condition of patients who may have 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 imply the need for rapid transport.
Taking ng 4History Taki Investigate Chief Complaint 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. Internal bleeding can be found in both medical and trauma patients. If the bleeding is severe, you may have identified it in
are the Provider: PART 2
Yo ou u arrive arr ve at a the e scene scene and an find n the ep patient a en standing s an n g o outside u s e in n front ron of ro o the e shop. s op. He e has as a towel owe w ow wrapped rappe around his left wrist; howev however er,, it is soaked in blood and you can see a large amount of blood on the ground. He is conscious and alert, but anxious, and tells you that he cut his wrist on a table saw when his arm s lipped and ran into the blade.
3. Is the patient effectively controlling the bleeding from hi s injury? 4. What should be your initial treatment priority?
11
12
Section 7
Trauma
the primary assessment and begun treatment and rapid transport to the hospital. If the signs and symptoms of internal bleeding are not as obvious as described previously, you will need to look more carefully in this step of the patient assessment process . In a responsive trauma patient who has an isolated injury with a limited MOI, consider a focused assessment before assessing vital signs and obtaining a history. When you encounter a patient who is bleeding, it is important to avoid focusing only on the bleeding. With significant trauma, you should assess the entire patient, looking for fractures and other problems. Determine if there are any preexisting illnesses. SAMPLE History
Obtain a SAMPLE history from your patient. Be sure to ask the patient if he or she takes blood-thinning medications. If so, be aware that bleeding will generally be more profuse and more difficult to control. If the patient is unresponsive, obtain history information from medical alert tags or ask bystanders if they have any information.
Look for signs and symptoms of shock (hypoperfusion) and determine how much blood has been lost.
4Secondary Assessment As described earlier, the secondary assessment is a detailed, comprehensive examination of the patient to uncover injuries that may have been missed during the primary assessment. The EMT should record vital signs, complete a focused assessment of pain, and attach appropriate monitoring devices. In some instances, such as a critically injured patient or a short transport time, there may not be time to conduct a secondary assessment.
Physical Examinations When performing a secondary assessment, the examination should include a systematic full body scan. Assess the respiratory system. Specifically assess the airway for patency and determine the rate and quality of respirations. In the neck, look for distended neck veins and a deviated trachea. In the chest, check for paradoxical movement of the chest wall and bilateral breath sounds.
Inju ry: Indicators of Internal Bleeding Table 22-2 The Mechanism of Injury: Mechanism of Injury
Potential Internal Bleeding Sources
Fal alll from from a lad ladde derr stri striki king ng the the hea head d
Head He ad inj injur ury y or hem hemat atom oma a
Fall from a ladder striking the extremities
Possible fractures; consider chest injury
Child struck by a car
Head trauma, chest and abdominal injuries, leg fractures
Fall on an outstretched arm
Possible broken bone or joint injury
Child Chi ld thro thrown wn or fall falls s from from a height height
Childr Chi ldren en usual usually ly have have a head head-fi -firs rstt impact impact,, causin causing g head head injury injury
Unrestrained driver in head-on collision
Head and neck, chest, abdomen injuries Knees, femur, hip, and pelvis injuries
Unrestrained front-seat passenger, side impact collision with intrusion into vehicle
locate andand retain critical Humerus broken exposing the chest wall (possible flail chest); pelvis acetabulum injuries information.
Unrestrained driver crushed against steering column
Chest and abdomen injuries, ruptured spleen, neck trauma
Road bike or mountain bike (over the handlebars)
Fractured clavicle, road rash, head trauma if no helmet
Abrupt motorcycle stop, causing rider to catapult over the handlebars
Fractured femurs, head and neck injuries
Diving into the shallow end of a swimming pool
Head and neck injuries
Assault or fight
Punching or kicking injury to chest, abdomen, and the face
Blast or explosion
Injury from direct strike with debris; indirect and pressure wave in enclosed space. External injuries are dependent upon the anatomic area of the body injured. Internally, air-containing organs such as the middle of the ears and lungs are the most susceptible to injury.
Organizes information so students can quickly
Chapter 22
Assess the cardiovascular system, specifically the rate and quality of pulses. Assess the neurologic system to formulate baseline data to guide further decisions. This examination should include level of consciousness, pupil size and reactivity, motor response, and sensory response. Assess the musculoskeletal system. Perform a detailed full body examination. Look for DCAP-BTLS to be sure that you have found all of the problems and injuries quickly quickly.. Assess all anatomic regions. When you are examining the head, be alert for raccoon eyes, Battle’s sign, and/or drainage of blood or fluid from the ears or nose. In the abdomen, feel all four quadrants for tenderness or rigidity. In the extremities, record pulse, motor, and sensory function.
Vital Signs You must assess baseline vital signs to observe the changes that may occur during treatment. A systolic blood pressure of less than 100 mm Hg with a weak, rapid pulse should suggest to you the presence of hypoperfusion in a patient who may have significant bleeding. Cool, moist skin that is pale or gray is an important sign that the patient is experiencing a perfusion problem. Because infants and children have less blood volume to begin with, the same effect is seen with smaller amounts of blood loss. In geriatric patients, the pulse rate may not increase with early shock; therefore, if possible, try to determine the patient’s normal baseline blood pressure and circulatory status. Monitoring Devices
In addition to hands-on assessment, the EMT should use monitoring devices to quantify oxygenation and cir culatory status. The EMT may use a noninvasive technique to monitor blood pressure and a pulse oximeter to evaluate the effectiveness of oxygenation. It is recommended that the EMT always assess the patient’s blood pressure with a sphygmomanometer and stethoscope (manually) before using a noninvasive blood pressure monitor to establish a baseline blood pressure and to determine the accuracy of the noninvasive blood pressure machine.
4Reassessment The reassessment is an important tool to see how your patient is doing over time. Reassess the patient, especially in the areas that showed abnormal findings during the primary assessment. The signs and symptoms of internal bleeding are often slow to present because of their covert
Bleeding
13
nature. 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. Assess the effectiveness of any interventions and treatments provided to the patient. Vital signs show how well your patient is doing internally. In all cases of severe bleeding, obtain the patient’s vital signs every 5 minutes. Is the patient’s airway still patent and breathing still adequate? Is the oxygen helping the patient to breathe easier? Is your treatment for shock resulting in better perfusion of the vital organs? Is the bandage controlling the bleeding?
Interventions Whenever you suspect significant bleeding, either external or internal, provide high-flow oxygen. If significant bleeding is visible, begin the steps to control external bleeding, as shown in Skill Drill 22-1. 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 nonrebreath nonrebreathing ing mask and provide rapid transport to the hospital. See Skill Drill 22-4 for additional steps to take. You should 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. Communication and Documentation 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. This can be a challenge to estimate, especially if the surface the patient is on is wet or absorbs fluids or if the environment is dark. For example, you may report that approximately one quart of blood was lost 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. With internal bleeding, describe the MOI/NOI and the signs and symptoms that make you think internal bleeding is occurring. Report this information to the emergency department personnel to allow them to prepare to treat the patient on arrival. Communicate with
14
Section 7
Trauma
the hospital on your findings and the interventions used to improve the patient’s condition. Be sure to document all of the patient’s injuries, the care provided, and the patient’s response to the care. Give the information to emergency department personnel.
Emergency Medical Care for External Bleeding 6
As you begin to care for a patient with obvious external bleeding, remember to follow standard precautions. This includes, at a minimum, gloves and eye protection and often a mask and possibly a gown. As with all patient care, make sure that the patient has an open airway and is breathing adequately. Provide high-flow oxygen to the patient. You may then concentrate on controlling the bleeding. In some cases, obvious life-threatening bleeding may be present and should be addressed as an immediate life threat and controlled as quickly as possible. Several methods are available to control external bleeding. Start with the most commonly used; these include the following: Direct, even pressure and elevation Pressure dressings Pressure points (for upper and lower extremities) Tourniquets Splints It will often be useful to combine these methods. illustrates the basic techniques to control external bleeding that do not require special equipment. I I I I I
You
1. Follow standard precautions. 2. Maintain the airway with cervical spine immobi-
lization if the mechanism of injury suggests the possibility of spinal injury. 3. Administer high-flow oxygen as necessary. 4. Almost all cases of external bleeding can be controlled simply by applying directwritten local pressure to Provides stepthe bleeding site. This method is by far theofmost by-step explanations effective way to controlimportant externalpsychomotor bleeding. Pressure stops the flow of blood andprocedure permitss.normal skills and procedures. 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, apply bulky dressings to stabilize the object in place, and apply pressure as best you can. Never remove an impaled object from a wound. Hold uninterrupted pressure pressure for at least 5 minutes. 5. Elevate a bleeding extremity by as little as 6 . This often stops venous bleeding. Whenever possible, use both techniques: direct pressure and elevation. In most cases, this will stop the bleeding. However, if it does not, you still have several options. Remember to never elevate an open fracture to control bleeding. Fractures can be elevated after splintStep11 .. ing, and splinting helps control bleeding Step 6. Once you have applied a dressing to control bleeding, create a pressure dressing to maintain the "
are the Provider:: PART 3
Bleeding ee ng from rom the e patient’s pa en ’s injury n ury has as been een controlled. con ro e . While ey you ou further ur er assess assess the e patient, pa en , your your p partner ar ner appli app ees s high-flow igh-flow oxygen, obtains the patient’s vital signs, and inquires about his past medical history. The patient denies having any medical problems and states that he does not take any medications.
on oxygen
system? ? How do they function to perfuse the body’s 5. What are the components of the cardiovascular system tissues and cells? bl eeding? ng? 6. What factors determine the severity of external bleedi
Chapter 22
pressure by firmly wrapping a sterile, self-adhering roller bandage around the entire wound. Use 4 × 4 sterile gauze pads for small wounds and sterile universal dressings for larger wounds. Cover the entire dressing above and below the wound. 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. If bleeding continues, the dressing is probably not tight enough. Do not remove a dressing until a physician has evaluated the patient. Instead, apply additional "
"
Bleeding
manual pressure through the dressing. Then add more gauze pads over the first dressing, and secure them both with a second, tighter roller bandage. Bleeding will almost always stop when the pressure of the dressing exceeds arterial pressure. This will assist in controlling bleeding and helping blood to clot Step 2 . 7. If a wound continues to bleed despite use of direct pressure, elevate the extremity and move to the use of a tourniquet Step 3 . Much of the bleeding associated with broken bones occurs because the sharp ends of the bones cut muscles and otherProvides tissues..aAs longsummary as a fracture remains unstable,, visual the bone ends will move and continue to injure partially of important psychomotor skills and procedure procedures. s.
Controlling External Bleeding
Step 1
Apply direct pressure over the wound. Elevate the injury above the level of the heart if no fracture is suspected.
Step 3
If the wound continues to bleed, elevate the extremity and move to the use of a tourniquet.
15
Step 2
Apply a pressure dressing.
16
Section 7
Trauma
clotted vessels. Therefore, stabilizing a fracture and decreasing movement is a high priority in the prompt control of bleeding. Often, simple splints will quickly control bleeding associated with a fracture . If not, you may need to use another splinting device, such as an air splint or a tourniquet, discussed next. Recent studies have brought into question the effectiveness of using pressure points in severe external hemorrhage. It is preferable, if allowed by local protocol and policy, to move to the use of a tourniquet without attempting pressure point control. If a tourniquet is deemed necessary, it should be applied quickly and not released until a physician is present.
Tourniquets The tourniquet is especially useful if a patient has substantial bleeding from an extremity injury below the axilla or groin. Follow the steps in to apply a commercial tourniquet.
Words o of of Wisdom i o Historically, if direct pressure and elevation proved ineffective, EMS providers were advised to apply pressure to a proximal arterial pressure point. A pressure point is a spot where a blood vessel lies near a bone. This technique should be considered interesting from a historic perspective only. Because a wound usually draws blood from more than one major artery, proximal compression of a major artery rarely stops bleeding completely. completely. In rare cases, it may help to slow the loss of blood. You would need to be thoroughly familiar with the location of the pressure points for this to work . Even if you are familiar, familiar, there is no real evidence that this is an effective or safe method to control potentially fatal hemorrhage. If the patient has an open fracture of an extremity extremity,, bleeding can be substantial. Consider a tourniquet early if bleeding is not easily controlled with direct pressure or if pressure results in excessive pain. The method used to control severe external bleeding may be governed by local protocol; regardless of the method, it must be quick and Current, state-of-theeffective. Remember that uncontrolled bleeding results in shock and then death. Patients can do bleed to death artand medical content is from extremity injuries. It is imperative thatin you effecpresented anuse engaging tive techniques to stop bleeding when you encounter it.
Superficial temporal
External maxillary Carotid Brachial
Femoral
Ulnar Radial
and comprehensive writing style.
Words of Wisdom Hemostatic agents such as Celox, HemCon, and QuikClot, are primarily utilized in the military to promote hemostasis or, in other words, to stop profuse bleeding. The agent may be granules poured into a wound or contained in a dressing. The agent absorbs the water component of blood thereby concentrating the clotting factors, activating platelets, and enhancing the coagulation cascade. Some of these agents have an exothermic affect that can damage the surrounding tissue.
Posterior tibial
Dorsalis pedis
Chapter 22
Follow standard precautions. 2. Hold direct pressure over the bleeding site. 3. Place the tourniquet around the extremity just above the bleeding site 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. To release the tourniquet at the hospital, or if otherwise instructed by medical control, push the release button and pull the strap back. Be aware that bleeding may rapidly return upon tourniquet release and that you should be prepared to reapply it immediately if necessary. If a commercial tourniquet is not available, 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 wide and six to eight layers thick. 2. Wrap the bandage around the extremity twice. Choose oose an an area area only on y slightly s g t y proximal prox ma to to the t e
Bleeding
17
1.
"
bleeding to reduce the amount of tissue damage to the extremity e xtremity.. 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 . 5.. Secure the stick in place,, and make the wrapping neat and smooth. 6. Write Write “TK” (for “tourniquet”) and the exact time (hour and minute) that you applied the tourniquet
Applying a Commercial Tourniquet
Step 1
Hold pressure over the bleeding site and place the tourniquet just above the injury.
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.
18
Section 7
Trauma
on a piece of adhesive tape. Use the phrase “time applied.” Securely fasten the tape to the patient’s forehead. 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 an alternative, you can use a blood pressure cuff as an effective tourniquet. Position the cuff proximal to the bleeding point, and inflate it just enough to stop the bleeding. Leave the cuff inflated. If you use a blood pressure cuff, monitor moni tor the gauge continuously to make sure that the pressure is not gradually dropping. You may have to clamp the tube with a hemostat leading from the cuff to the inflating bulb to prevent loss of pressure. Whenever you apply a tourniquet, make sure you observe the following precautions: Do not apply a tourniquet directly over any joint. Keep it as close to the injury as possible. Make sure the tourniquet is tightened securely. Never use wire, rope, a belt, or any other narrow material. It could cut into the skin. Use wide padding under the tourniquet if possible. This will protect the tissues and help with arterial compression. Never cover a tourniquet with a bandage. Leave it open and in full view. Do not loosen the tourniquet after you have applied it. Hospital personnel will loosen it once they are prepared to manage the bleeding. I
I
Splints Air splints can control internal or external bleeding associated with severe soft-tissue injuries, such as massive or complex lacerations, or fractures . They also stabilize the fracture itself. An air splint acts like a pressure dressing applied to an entire extremity rather than to a small, local area. Air splints are also commonly referred to as soft splints or pressure splints. Once you have applied an air splint, be sure to monitor circulation in the distal extremity. Use only approved, clean, or disposable valve stems when orally inflating air splints. Rigid splints can help stabilize fractures as well as reduce pain and prevent further damage to soft-tissue injuries. Once you have applied a rigid splint, be sure to monitor circulation in the distal extremity. Traction splints are designed to stabilize femur fractures. When the EMT pulls traction to the ankle, counter counter-traction is applied to the ischium and groin. This reduces the thigh muscle spasms and prevents one end of the
I
Words of Wisdom m
I
I
I
You are the Provider: PART
Research indicates that a pelvic compression device is an effective method to reduce the width of pelvic ring fractures. Overcompression has not been identified as an issue to date. The decrease in the width of the fracture will assist in the control of internal bleeding resulting from the fracture, specifically an open book fracture of the pelvis.
4
The patient is placed onto the stretcher and loaded into the ambulance.. He remains conscious and alert,, but is still anxious. You place him in a supine position, elevate his legs, and cover him with a blanket. Shortly before departing the scene, you reassess him and obtain another set of vital signs. Progressive case studies introduce patients and follow their progress from dispatch to delivery at the emergency department. The cases become progressively more detailed on oxygen
as new medical information is presented.
7.
How might a patient’s outcome be affected if bleeding is internal rather than external?
8.
What are the signs and symptoms of internal bleeding?
Chapter 22
Bleeding
19
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 preferre preferred d method. This technique may also be self-administered by the patient Step 1 . 4. Placing a rolled 4 × 4 gauze bandage between the upper lip and the gum is another option. 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 (assuming that 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 once the bleeding has stopped. 9. If you cannot control the bleeding, if the patient has a history of frequent nosebleeds, or if there is a significant amount of blood loss, transport the patient immediately. immediately. Assess the patient for signs and symptoms of shock. Treat Treat appropriately for shock, and administer oxygen via mask, if necessary. Bleeding from the nose or ears following a head injury may indicate a skull fracture. In these cases, you should not attempt to stop the blood flow. 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. There is always a risk of infection to the brain. Apply light compression by wrapping the dressing loosely around "
fracture from impacting or overriding the other. Be sure to pad these areas well to prevent applying excessive pressure to the soft tissue of the pelvis. Once you have applied a traction splint, be sure to monitor circulation in the distal extremity.
Bleeding From the Nose, Ears, and Mouth 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, or other abnormalities High blood pressure Coagulation disorders Digital trauma (nose picking) Epistaxis, or nosebleed, is a common emergency. Occasionallyy, it can cause enough of a blood loss to send Occasionall s end a patient into shock. Keep in mind that the blood you see 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 wit h 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. illustrates the basic techniques to control epistaxis. I I
I
I I I
"
20
Section 7
Trauma
the head . If blood or drainage contains cerebrospinal cerebrosp inal fluid, a characteristic staining of the dressing, much like a target or halo, will occur .
Emergency Medical Care for Internal Bleeding 6
Controlling internal bleeding or bleeding from major organs usually requires surgery or other procedures
that must be done in the hospital. It is important for you to remain calm and reassure the patient. Keeping the patient as still and quiet as possible possib le assists the body’s clotting process. Next, if spinal injury is not suspected, place the patient in the shock position. Provide highflow oxygen; also maintain body temperature. You can usually control internal bleeding into the extremities quite well in the field simply by splinting the extremity, usually most effectively with an air splint, and you should never use a tourniquet to control the bleeding from rom cclosed, ose , internal, nterna , ssoft-tissue nt o t-t ssue injuries. n ur es. Follow o ow the t e steps in to care for patients with possible internal bleeding.
Controlling Epistaxis
Step
1
Position the patient sitting, leaning forward. Apply direct pressure, pinching the fleshy part of the nostrils together.
Step
3
Apply ice over the nose. Maintain pressure until bleeding is controlled. Provide prompt transport after bleeding stops. Transport immediately if indicated. Assess and treat for shock, including oxygen, as needed.
Step
2
Alternative method: Use pressure with a rolled gauze bandage between the upper lip and gum. Calm the patient.
Chapter 22
Bleeding
21
Photos of real emergencies prepare students for the field.
Monitor and record the vital signs at least every 5 minutes. 7. Give the patient nothing (not even small sips of water) by mouth. 8. Elevate the legs 6 to 12 in nontrauma patients to help the blood return to the vital organs. 9. Keep the patient warm. 10. Provide immediate transport for all patients with signs and symptoms of shock (hypoperfusion). Report any changes in the patient’s condition to emergency department personnel. 6.
Follow standard precautions. 2. Maintain the airway with cervical spine immobilization if a mechanism of injury suggests the possibility of spinal spin al injury. injury. 3. Administer high-flow oxygen and provide artificial ventilation as necessary. necessary. 4. Control all obvious external bleeding. 5. Treat suspected internal bleeding in an extremity by applying a splint. 1.
You are the Provider: PART
"
"
5
You continue to monitor the patient en route to the hospital and reassess his condition as appropriate.. After reassessing the patient and his vital signs, you call your radio report into the receiving facility.
on oxygen
The patient is delivered to the hospital and you give your report to the attending physician. An intravenous line is started, the patient is gi ven normal saline to improve his perfusion status, and he is admitted for observation.
22
Section 7
Trauma
You are the Provider: SUMMARY 1.
What are the functions of arteries? What major arteries are located in the upper extremity? Arteries are high-pressure blood vessels that distrib dist ribute ute oxygenated blood throughout the body. The largest artery in the body, the aorta, arises from the left ventricle and branches into smaller ar teries and arterioles that deliver oxygen to the body’s tissues and cells. In general, arteries carry highly oxygenated blood away from the heart; an exception to this is the pulm onary artery, artery, which carries deoxygenated blood from the right ventricle to the lungs where it is reoxygenated. Two major arteries are located in the upper extremity, the radial artery, artery, which is located on the thumb-side (lateral) aspect of the wrist, proximal to the hand, and the brachial artery, which is located on the inner (medial) aspect of t he arm, just proximal to the elbow.
2.
Why is arterial bleeding more severe than venous bleeding?
Progressive case studies are followed
by a summary of answers to the Blood flow through the arteries is driven by contraction of t he powerful left ventricle. Pressure in the arterar tercritical-thinking questions, as ies is much m uch higher than pressure in the veins (high capacitance, capacitance, low-pressure low-pressure blood vessels that returnwell as: low-pressure • Additional signs and symptoms deoxygenated blood to the heart). commonly associated with the Because blood flow through the arteries is much higher higher,, blood loss is generally more rapid and severe. Arteor from condition rial bleeding is also more difficult to control than venous bleeding. Oxygen losspatient’s is more injury severe arterial • Additional pathophysiologic bleeding than it i s from venous bleeding; this is because arterial blood carries a higher concentration of information regarding the oxygen than do the veins. injury or condition The color of blood and characteristic of the bleeding are are often often clues clues to to the the type typepatient’s of of bl blood ood vessel that is • Information and justification injured. Venous Venous blood is dark red and flows from the injury site, whereas arterial blood is bright red and for each treatment modality spurts from the wound each time the left ventricle contracts. 3.
Is the patient effectively controlling the bleeding from his injury? As evidenced by the blood-soaked towel and large amount of blood on the ground, it is cl ear that the patient is not effectively controlling the bleeding f rom his injury. Furthermore, Furthermore, Furthermor e, you do not know how much blood he has lost because he is standing outside—not in the area where the injury occurred. The fact that he is anxious and has cool, pale skin suggests significant external blood loss.
4.
What should be your initial treatment priority? You must take immediate mmediate action to control the patient’s bleeding. His airway is patent, as evidenced by the fact that he is conscious, alert, and talking. One EMT can attempt to control the patient’s bleeding as the other applies high-flow oxygen. In most cases, direct pressure will control both venous and arterial b bleeding. leeding. However, However, if di rect pressure alone is ineffective, continued direct pressure and elevation of the extremity above the level of the heart typically controls the bleeding. Historically, if direct pressure and elevation are ineffective, ineffective, application of pressure to a proximal arterial pressure point has been the next step in controlling severe external external bleeding. Recent evidence exists that supports the application of a proximal tourniquet, instead of pressure point control, if direct pressure and elevation are ineffective in controlling severe external bleeding. However, However, this treatment is largely governed by local protocol. Regardless Regardless of the method m ethod used to control severe external bleeding, it must be quick and effective.
5.
What are the components of the cardiovascular cardiovascular system? system? How do they function to perfuse the body’s tissues and cells? The cardiovascular system—the system—the system responsible for supplying and maintaining adequate blood flow to the body’s tissues and cells—consists of three components: the heart (pump), the container (the blood
Chapter 22
You
are the Provider: SUMMARY,
Bleeding
continued
vessels), and the fluid (blood and body fluids). These components of the cardiovascular system are interdependent—that interdepen dent—that is, they rely on each other mutually to perform a common function. The heart must be able to contract forcefully and fast enough to move oxygenated blood through the blood vessels to adequately perfuse the body’s tissues and cells. Failure of any one of these components will result in inadequate perfusion of the body, a condition known as shock. 6. What factors determine the severity of external bleeding?
Several factors determine the severity of external bleeding. The single most influential factor is the type and size of the blood vessel that is injured. A lacerated brachial artery, for example, will bleed more severely than a small vein in the leg. As previously discussed, arteries are under high pressure, while veins are under low pressure. How the vessel is injured is also a determining factor in the severity of the bleeding and the difficulty in controlling it. A longitudinal laceration—one that extends in the direction of the length of the blood vessel— usually bleeds more profusely and is more difficult to control than a transverse laceration—one that is directly across the blood vessel. The patient’s blood pressure and heart rate can also affect the severity of external bleeding. For example, a patient with a blood pressure of 190/90 mm Hg and a heart rate of 120 beats/min would likely bleed more profusely than a patient with a blood pressure of 70/40 mm Hg and a heart rate of 50 beats/min. The greater the pressure on the arterial wall and the faster the heart rate, the more rapid the bleeding tends to be. Certain aspects of a patient’s medical history also can impact the severity of external bleeding. For example, patients who take blood-thinning medications medications (ie, (ie, warfarin warfarin [Coumadin]) [Coumadin]) or those [Coumadin]) those with with a bleeding bleeding disordisorder (ie, hemophilia) tend to bleed faster because it takes longer for their blood to clot. For this and other reasons, it is important to obtain an accurate medical history from the patient. 7. How might a patient’s outcome be affected if bleeding is internal rather than external?
Compared to external external bleeding, which you can see and control control,, internal bleeding is hidden and cannot be controlled control led in the prehospita prehospital prehospitall setting. Many patients with internal bleeding do not present with signs or symptomss of shock until a significant amount of blood has been lost. symptom Overall, patients with internal bleeding have a higher mortality Overall, mortality rate rate than those with external bleeding. Most of these deaths are the result of intrathoracic or intra-abdominal bleeding in which surgical intervention interven tion is delayed. Internal bleeding can also be caused by multiple long bone fractures and pelvic fractures. You must always be alert to the possibility of internal bleeding and assess the patient for related signs and symptoms, symptom s, particularly if the mechanism of injury is significant. Remember this: if a trauma patient is in shock but does not have any obvious external external signs signs of injury, suspect suspect internal internal bleeding! bleeding! 8. What are the signs and symptoms of internal bleeding?
Since internal bleeding cannot be seen outright, you must rely on your assessment skills and careful evaluation of the mechanism mechanism of injury. injury. Signs and symptoms symptoms of of internal internal bleeding bleeding are are essentially essentially those essentially those of of shock: shock: restlessness or anxiety; cool, pale, clammy skin; tachycardia; rapid, shallow breathing; thirst; and as a late sign, hypotensi hypotension. on. External indicators of internal bleeding in both medical and trauma patients include hematemesis (vomiting blood), melena (dark, tarry stools), stools), and hemoptys hemoptysiiss (coughing up blood). hemoptysis Other indicators of internal bleeding, which are more common in trauma patients, include redness or bruising, swelling, or tenderness over the injured area.
23
24
Section 7
You
Trauma
are the Provider: SUMMARY,
continued
oss? ? 9. How does the body typically respond to blood l oss The body will not tolerate an acute blood loss of greater than 20% of blood volume. The typical adult has approximately 70 70 mL of blood per kilogram of body weight; in a person who weighs 80 kg (175 lb), this equals 6 L (10 to 12 pints). If the typical adult loses more than 1 L of blood (about 2 pints), significant changes in vital sig ns will occur, occur, including increasing heart and respiratory rates, rates, and as a later sign, a decreasing blood pressure. A loss of circulating blood volume i s sensed by receptors in the body, body, which send messages to the nervous system. The nervous system, specifically, specifically, the sympathetic nervous system, releases releases epinephrine and norepinephrine. Norepinephrine constricts the peripheral peripheral blood blood vessels (vasoconstriction), (vasoconstriction (vasoconstriction), ), thus shunting bl blood ood from areas of lesser need (ie, skin and muscles) to areas of greater need (ie, heart, brain, kidneys, liver). Epinephrine causes increases in heart rate and cardiac contractility. contractility. The net effect is to maintain adequate perfusion of the body’s vital organs. If blood loss continues, however however,, the body’s compensatory mechanisms will eventually fail, the patient’s blood pressure will fall, and he or she will die.
EMS Patient Care Report (PCR) Date: 6-30-09
Incident No.: 220109
Dispatched: 1620
En Route: 1621
Nature of Call: Laceration
At Scene: 1627
Location: 517 E. Graham
Transport: 1642
At Hospital: 1655
In Service:
1704
Patient Information Age: 32 Sex: M Weight (in kg [lb]): 82 kg (180 lb)
Time: 1637
BP: 104/60
Time: 1642
BP: 112/70
Allergies: No known drug allergies Medications: None Past Medical History: None Progressive case studies Chief Complaint: Lacerat Laceration ion to left wrist conclude with a complete Vital Signs Patient Care Report to Pulse: 120 Respirations: 24 SaO2: 95% teach students how to Pulse: 116 Respirations: 24 properly SaOdocument : 98% 2 patient
Time: 1649
BP: 114/68
Pulse: 110
Respirations: 20 assessment SaO2: 97% and care.
EMS Treatment (circle all that apply) Oxygen @ 15 L/min via (circle one): NC NRM
Assisted Ventilation
Airway Adjunct
CPR
Defibrillation
Bandaging
Splinting
Other Shock treatment
Bleeding Control
Narrative
Dispatched for a patient with severe bleeding from the arm. Arrived on scene to find the patient, a 32-year-old male, standing in front of his place of employment, a woodworking shop. He was conscious and alert, but notably anxious. His airway was patent and his breathing, although increased, was producing adequate tidal volume. Patient had bloodsoaked towel wrapped around his left wrist and an impressive amount of blood was on the ground where he was standing. Patient stated that his hand slipped while he was working with a table saw and his left wrist ran across the blade. Immediately applied direct pressure to patient’s wrist with sterile dressing and elevated his left arm. This intervention successfully controlled the bleeding; a pressure dressing was then applied to maintain bleeding control. Applied oxygen at 15 L/min via nonrebreathing mask and obtained vital signs, as noted above. Further assessment revealed that patient’s skin was cool, pale, and dry. Patient denied significant past medical history and further denied taking any medications. Placed patient onto stretcher, covered him with a blanket, elevated his lower extremities, and placed him into the ambulance. Reassessed patient’s vital signs and began transport to the hospital. Continued to monitor patient’s condition en route; he remained conscious and alert, although anxious, and his vital signs remained stable. Reassessed bandaged wound and noted that the bleeding remained controlled. Called report to receiving facility to inform them of our arrival. Delivered patient to hospital without incident. Verbal report given to charge nurse. **End of report**
Chapter 22
Bleeding
External Bleeding
Internal Bleeding
Scene Safety
Ensure scene safety. If incident involved violence, ensure that police are on scene. Consider if additional resources are needed. Wear a minimum of gloves and eye protection to protect from bleeding.
Ensure scene safety. Consider if additional resources are needed. Follow standard precautions.
Mechanism of Injury/Nature of Illness
Determine the MOI/NOI.
High-energy MOI should increase your index of suspicion for possible internal bleeding.
Scene Size-up
Primary Assessmen Assessmentt Form General Ge neral Impression
Check for responsiveness and look for blood stains or other obvious signs of external bleeding. Assess skin color. Manage significant visible bleeding.
Suspect internal bleeding after blunt or penetrating trauma. Determine level of consciousness using AVPU and check the patient’s mental status. Assess skin color. Consider the need for manual spinal immobilization.
Airway and Breathing
Ensure a patent airway, look for adequate breathing, and check for breath sounds. If necessary, provide high-flow oxygen or assist ventilation.
Ensure a patent airway, look for adequate breathing, and check for breath sounds. If necessary, provide high-flow oxygen or assist ventilation.
Cirrcu Ci cula lati tion on
Ass sse ess pul pulse se rat ate e and qua uallit ity y, sk skin col olor or and temperature, and check capillary refill time. Control external bleeding with direct pressure, elevation, or use of a tourniquet. Treat for shock if needed by applying oxygen, improving circulation, and maintaining normal temperature.
Assess pulse rate and quality, skin color and temperature, and check capillary refill time. Treat the patient for shock if needed by applying oxygen, improving circulation, and maintaining normal temperature.
Transport Decision
Transport quickly if breathing problem or significant bleeding exists.
If you suspect internal bleeding or signs of shock are present, promptly transport to the hospital.
Ask the patient about the chief complaint, if responsive. Attempt to determine the amount of blood loss.
Ask the patient what happened.
History Taking Investigate Chief Complaint
Summarizes and review reviewss the patient assessment process and the specific findings presented in the chapter.
25
26
Section 7
Trauma
External Bleeding
Internal Bleeding
Secondary Assessme Assessment nt Physical Examinations
Perform a systematic full-body scan. Assess respiratory, cardiovascular, neurologic, musculoskeletal (using DCAP-BTLS), and anatomic regions.
Perform a systematic full-body scan. Assess respiratory, cardiovascular, neurologic, musculoskeletal (using DCAP-BTLS), and anatomic regions. Look for bruising, pain, abdominal distention, and guarding.
Vital Si Signs
Assess vi vital si signs. Lo Look fo for si signs of of sh shock: systolic blood pressure less than 100 mm Hg with weak, rapid pulse. Pale or gray, cool, moist skin suggests a perfusion problem.
Assess vital signs. Look for signs of shock: systolic blood pressure less than 100 mm Hg with weak, rapid pulse. Pale or gray, cool, moist skin suggests a perfusion problem.
Interventions
Repeat the primary assessment and reassess interventions performed. Reassess Reassess vital signs and the chief complaint. In cases of severe bleeding, obtain vital signs at least every 5 minutes while providing high-flow oxygen. Control significant significant bleeding and if signs of shock are present, treat aggressively. Determine whether patient’s condition is improving or deteriorating.
Repeat the primary assessment and reassess interventions interventi ons performed. Internal bleeding is often slow to present. Reassess vital signs and the chief complaint. Provide high-flow oxygen. Determine whether patient’s condition is improving or deteriorating.
Communication and Documentation
Report approximate amount of blood lost, how rapidly, and over what period of time. Communicate interventions performed, and how patient has responded to care.
Describe the MOI/NOI and signs and symptoms that make you suspect internal bleeding is occurring. Communicate interventions performed, and how patient has responded to care.
Reassessment
NOTE: Although the steps below are widely accepted, be sure to consult and follow your local protocol.
External Bleeding
Internal Bleeding
Emergency Care Steps to Caring for Patient With External Bleeding 1.
Follow standard precautions—minimum of gloves and eye protection. stabilization if MOI Summarizes and revie reviews ws 2. Maintain cervical stabilization suggests possible spinal injury. the emergency care skills 3. Administer high-flow oxygen as necessary. for the illnesses and 4. Control external bleeding using one of the injuries presented in following methods: • Direct pressure and elevation the chapter. • Pressure dressings • Tourniquets • Splints
Steps to Caring for Patient With Internal Bleeding 1. 2.
3. 4. 5. 6.
Follow standard precautions. Maintain the airway with cervical immobilization if MOI suggests possible spinal injury. Administer high-flow oxygen and provide artificial ventilation as necessary. Control all obvious external bleeding. Apply a splint splint to an extremity where internal bleeding is suspected. Monitor and record vital signs at least every 5 minutes.
Chapter 22
External Bleeding
Bleeding
Internal Bleeding
Emergency Care 5. 6. 7. 8.
Apply direct local pressure to bleeding site. Elevate the bleeding extremity. Create a pressure dressing. If the wound continues to bleed, consider the use of a tourniquet. Follow local protocol for approved methods of bleeding control.
Applying a Commercial Tourniquet 1. Follow standard precautions. 2. Hold direct pressure over the bleeding site. 3. Place the tourniquet around the extremity just above the bleeding site. 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 is controlled. Treating Epistaxis 1. Follow standard precautions. 2. Help the patient patient to sit, leaning forward, with the head tilted forward. 3. Apply direct pressure for at least 15 minutes by pinching nostrils together. 4. Keep the patient calm and quiet. 5. Apply ice over the nose. 6. Maintain the pressure until bleeding is completely controlled. 7. Provide prompt transport. 8. If bleeding cannot be controlled, transport patient immediately. Treat for shock and administer oxygen via mask if necessary.
7. Give the patient nothing by mouth. 8. Elevate the legs 6” to 12” in nontrauma patients. 9. Keep the patient warm. 10. Provide immediate transport for patients with signs and symptoms of shock. Report changes in condition to hospital personnel.
27
CHAPTER
Title Goes Prep KitHere and I need 22 the longest title Ready for Review Vital Vocabular Vocabulary y
6
Perfusion is the circulation of blood in adequate amounts to meet each cell’s current needs for oxygen, nutrients, and waste removal. The three arms of the perfusion triad must be functioning to meet this demand: a working pump (heart), a set of intact pipes (blood vessels), and fluid volume (enough oxygen-carrying Summarizes chapter blood). Hypoperfusion, or shock, occurs when one or more of content in a comprehensive these three arms is not working properly and the cardiobulleted list. vascular system fails to provide adequate perfusion. Both internal and external bleeding can cause shock. You must know how to recognize and control both. The methods to control bleeding, in order, are: – Direct local pressure – Elevation – Pressure dressing – Tourniquet – Splinting device Bleeding from the nose, ears, and/or mouth may result from a skull fracture. Other causes include high blood pressure and sinus infection. Evaluate the MOI and consider the more serious problem of skull fracture. Bleeding around the face always presents a risk for airway obstruction or aspiration. Maintain a clear airway by positioning the patient appropriately and using suction when indicated. If bleeding is present at the nose and a skull fracture is suspected, place a gauze pad loosely under the nose. If bleeding from the nose is present and a skull fracture frac ture is not suspected, pinch both nostrils together for 15 minutes. If the patient is awake and has a patent airway, place a gauze pad inside the upper lip against the gum. Any patient you suspect of having internal bleeding or significant external bleeding should be transported promptly. If the mechanism of injury is significant, be alert to sig ns of unseen bleeding in the chest or abdomen—signs such as serious bruising or symptoms such as complaints of difficulty breathing or abdominal pain. Signs of serious internal bleeding include the following: Vomiting omiting blood (hematemesis) – V – Black tarry stools (melena) – Coughing up blood (hemoptysis) – Distended abdomen – Broken ribs I
I
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I
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6
aorta The main artery that receives blood from the left ventricle and delivers it to all the other arteries that carry blood to the tissues of the body. Provides a list of key arterioles The smallest branches of arteries leading to the vast terms and definitions network of capillaries. chapter. threethe layers of tissue and artery A blood vessel, consisting offrom smooth muscle that carries blood away from the heart. 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. coagulation The formation of clots to plug openings in injured blood vessels and stop blood flow. contusion A bruise, or ecchymosis. ecchymosis Discoloration of the skin associated with a closed wound; bruising. epistaxis A nosebleed. hematemesis Vomited blood. hematoma A mass of blood in the soft tissues beneath the skin. hemophilia A congenital condition in which the patient lacks one or more of the blood’s normal clotting factors. hemoptysis Coughing up blood. hemorrhage Bleeding. hypoperfusion A condition that occurs when the level of tissue perfusion decreases below that needed to maintain normal cellular functions; also called shock. hypovolemic shock A condition in which low blood volume, due to massive internal or external bleeding or extensive loss of body water, results in inadequate perfusion. melena Black, foul-smelling, tarry stool containing digested blood. perfusion Circulation of blood within an organ or tissue in adequate amounts to meet the current needs of the cells. pressure point A point where a blood vessel lies near a bone. shock A condition in which the circulatory system fails to provide sufficient circulation so that every body part can perform its function; also called hypoperfusion. tourniquet The bleeding control method used when a wound continues to bleed despite the use of direct pressure and elevation; useful if a patient is bleeding severely from a partial or complete amputation. vasoconstriction Narrowing of a blood vessel, such as with hypoperfusion or cold extremeties. veins The blood vessels that carry blood from the tissues to the heart. venules Very small, thin-walled vessels.
Assessment in Action Y
our unit is dispatched to a roadside construction site for a blast-related injury. The fire department arrives before you and radios to tell you that the scene is safe. On your arrival, you are informed that your patient is a 46-year-old man who had been blasting rock and had set the fuse too short. As he was leaving the area to seek cover from the explosion, he was blown forward onto a gravel area. He tells you that he remembers everything and he did not lose consciousness. He also indicates that the entire front of his body A short case study withhurts and he can’t hear very well. He denies having any past medical history or allergies and does both critical-thinking andnot take any medications. examination, you find minor bleeding from his ears and some cuts and bruises to his multiple-choice On questions arms. As you remove his clothing, you find that his chest and abdomen are bruised. He complains allows students to of increasing pain and experiences severe trouble breathing. As you begin your transport, you notice that he is now synthesize and apply presenting with hematemesis, cool and clammy skin, tachycardia, and hypotension. what they have learned in the chapter.
1.
Does the mechanism of injury create the suspicion of serious injury prior to your arrival?
7.
Is your patient’s pain likely to be a result of internal or external injuries? Explain your answer. answer.
2.
What is the first important factor to consider in this scenario? A. Scene safety B. Mechanism of injury C. Level of consciousness D. Apparent injuries
8.
What condition is likely when signs of hypotension, tachycardia,, and cool, clammy skin are found? tachycardia A. Internal bleeding B. Shock C. Central nervous system depression D. Intracranial bleeding
3.
After considering this, what factor should you next consider? A. Scene safety B. Mechanism of injury C. Level of consciousness D. Apparent injuries
9.
Effective primary treatment of this patient should consist of: A. tourniquet use. B. direct pressure. C. rapid transport. D. Trendelenburg positioning.
4.
Is your patient’s complaint of frontal body pain significant on your primary assessment?
10.
5.
The minor bleeding from his ears is most likely an indication of: A. a skull fracture. B. internal hemorrhagin hemorrhaging. g. C. cardiac distress. D. an ocular cavity cavity..
6.
You determine that your patient is experiencing internal bleeding. What should you do first? A. Apply pressure dressings B. Immobilize the injury C. Apply oxygen D. Apply cold packs
Trendelenburg positioning is effective because it: A. moves waste from the legs to the core. B. moves blood from the legs to the core. C. allows a more comfortable transport position. D. creates a platform for fluid diffusion.
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AAOS
Tenth Edition
Emergency Care and Transportation of the Sick and Injured
Sample Chapter Forty years ago, the American Academy of Orthopaedic Surgeons (AAOS) ushered in the new era of cutting-edge prehospital care with the publication of Emergency Care and Transportation of the Sick and Injured —the first edition of the “Orange Book.” This revolutionary training program set the standard for EMT-Basic education. Now, as the EMS community is about to embark on a new chapter in its histor y with the implementation of the new National EMS Education Standards,, the AAOS celebrates this industry milestone and Standards the 40th anniversary of their entrance into EMS education with the publication of Emergency Care and Transportation of the Sick and Injured, Tenth Edition.
Meets the New
National EMS Education Standards
The Tenth Edition is the cornerstone in an advanced training program. Authored by a team of experienced and respected leaders in the field, Emergency Care and Transportation of the Sick and Injured combines the new National EMS Education Standards with a practical and concise patient assessment process and current treatment modalities. The training program is supported with instructional instructional,, assessment, and learning-performance learning-perf ormance management solutions for educators and students. These student and instructor resources offer the most up-to-date and cutting-edge digital platforms available. The AAOS has built a reputation as the most authoritative national medical organization in EMS. There’s only one training program that carries the AAOS name — “Orange Book.”
