emergency care of the sick and injured - 10/e sample chapter

AAOS Tenth Edition

EmergencySample Chapter

EmergencyCare and Transportation of the Sick and Injured

Series Editor: Andrew N. Pollak, MD, FAAOS

Meetsthe New

National EMSEducation Standards

The Future of EMS Education Has Arrived!The Future of EMS Education Has Arrived!The Future of EMS Education Has Arrived!

Dear Educator,

As you know, the new National EMS Education Standards were approved in January by the National Highway Traffi c Safety Administration. These Standards are part of a larger effort, based on the National EMS Education Agenda for the Future, published in 2000 at the request of National Association of State EMS Offi cials. 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 entry-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 specifi c 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 fl exibility—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 study to online learning resources.

Increased 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. 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. First, the offi cial 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. The requirements are closerto the 1985 National Standard Curriculum than the1999 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 everylevel, such as public health, life span development, pathophysiology, communication, medical terminology,and patients with special challenges.

Tenth Edition Table of Contents Tenth Edition Table of Contents Tenth Edition Table of Contents Correlated to the National EMS Education StandardsCorrelated to the National EMS Education StandardsCorrelated to the National EMS Education StandardsCorrelated to the National EMS Education Standards

Tenth Edition National EMS Education Standards

Section 1. Preparatory

1. EMS Systems EMS SystemsResearchPublic Health

2. Workforce Safety and Wellness Workforce Safety and Wellness

3. Medical, Legal, and Ethical Issues Medical/Legal and Ethics

4. Communication and Documentation DocumentationEMS System CommunicationTherapeutic Communication

5. The Human Body Anatomy and PhysiologyPathophysiology

6. Life Span Development Life Span Development

Section 2. Pharmacology

7. Principles of Pharmacology Principles of PharmacologyMedication AdministrationEmergency Medications

Section 3: Patient Assessment

8. Patient Assessment Scene Size-UpPrimary AssessmentHistory-TakingSecondary AssessmentMonitoring DevicesReassessment

Section 4. Airway

9. Airway Management Airway ManagementRespirationArtifi cial Ventilation

Section 5. Shock and Resuscitation

10. Shock Shock and Resuscitation

11. BLS Resuscitation Shock and Resuscitation

Section 6. Medical

12. Medical Overview Medical OverviewInfectious Diseases

13. Respiratory Emergencies Respiratory

14. Cardiovascular Emergencies Cardiovascular

15. Neurologic Emergencies Neurology

16. Gastrointestinal and Urologic Emergencies Abdominal and Gastrointestinal DisordersGenitourinary/Renal

17. Endocrine and Hematologic Emergencies Endocrine DisordersHematology

18. Immunologic Emergencies Immunology

19. Toxicology Toxicology

20. Psychiatric Emergencies Psychiatric

21. Gynecologic Emergencies Gynecology

Section 7. Trauma

22. Trauma Overview Trauma OverviewMulti-System Trauma

23. Bleeding BleedingDiseases 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 TraumaNervous System Trauma

27. Chest Injuries Chest Trauma

28. Abdominal and Genitourinary Injuries Abdominal and Genitourinary Trauma

29. Orthopaedic InjuriesNon-Traumatic Musculoskeletal DisordersOrthopedic Trauma

30. Environmental Emergencies Environmental Emergencies

Section 8. Special Patient Populations

31. Obstetrics and Neonatal Care ObstetricsNeonatal CareSpecial Considerations in Trauma

32. Pediatric Emergencies PediatricsSpecial Considerations in Trauma

33. Geriatric Emergencies GeriatricsSpecial Considerations in Trauma

34. Patients With Special Challenges Patients With Special ChallengesSpecial Considerations in Trauma

Section 9. EMS Operations

35. Lifting and Moving Patients Workforce Safety and Wellness

36. Transport Operations Principles of Safely Operating a Ground AmbulanceAir Medical

37. Vehicle Extrication and Special Rescue Vehicle Extrication

38. Incident Management Incident ManagementMultiple-Casualty IncidentsHazardous Materials Awareness

39. Terrorism and Disaster Management Mass-Casualty Incidents due toTerrorism and Disaster

Section 10: ALS Techniques

40. ALS Assist

Appendix: Medical Terminology Medical Terminology

Students Will Enjoy

What Steps are the AAOS and J&B Taking to Implement the National EMS Education Standards?What Steps are the AAOS and J&B Taking to Implement the National EMS Education Standards?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 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 and hybrid courses. Now we are taking these tools to the next level for the instructors.

The Tenth Edition of Emergency Care and Transportation of the Sick and Injured offers instructors and students comprehensive coverage of every competency statementin the National EMS Education Standards in an engaging andaccessible format.

A Relaxed, Readable Textbook—When writing EMS textbooks, authors often forget who their audience really is. Some publishers may use “experts” who have little connection to the fi eld. The Tenth Edition creates a learning environment in which students are comfortable with the material presented. That comfort level translates into better understanding and retention, and ultimately leads to better pass rates. This text talks to your students, not at them.

18 Section 1 Preparatory

can quickly be drained of its reserves. This can leave it depleted of key nutrients, weakened, and more suscep-tible 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 potas-sium from the kidneys. Other nutrients that are suscepti-ble to depletion are the vitamins and minerals that are not stored by the body in substantial quantities. These include water-soluble 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 physi-cally prepare your body for stress. Physical conditioning

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, and doctors prescribe muscle relaxants, tranquilizers, and 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 problems described previously.

The term “stress management” refers to the tactics that have been shown to alleviate or eliminate stress reac-tions. 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 defi ned as anything you perceive as a threat to your equilib-rium. 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 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

Table 2-4 Warning Signs of Stress

Irritability toward coworkers, family, and friends �

Inability to concentrate �

Diffi culty sleeping, increased sleeping, or nightmares �

Feelings of sadness, anxiety, or guilt �

Indecisiveness �

Loss of appetite (gastrointestinal disturbances) �

Loss of interest in sexual activities �

Isolation �

Loss of interest in work �

Increased use of alcohol �

Recreational drug use �

Physical symptoms such as chronic pain (headache, �

backache)

Feelings of hopelessness �

Table 2-5 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 –

Periodic stretching –

Slow, deep breathing –

Regular physical exercise –

Progressive muscle relaxation –

Meditation –

Limit intake of caffeine, alcohol, and tobacco use –

78286_CH02_002_049.indd 18 10/9/09 10:26:12 PM

our everyday life. By understanding how it affects you physiologically, physically, and psychologically, you can manage it more



18 Section 1 Preparatory

can quickly be drained of its reserves. This can leave it depleted of key nutrients, weakened, and more suscep-tible 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 potas-sium from the kidneys. Other nutrients that are suscepti-ble to depletion are the vitamins and minerals that are not stored by the body in substantial quantities. These include water-soluble 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 physi-cally prepare your body for stress. Physical conditioning

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, and doctors prescribe muscle relaxants, tranquilizers, and 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 problems described previously.

The term “stress management” refers to the tactics that have been shown to alleviate or eliminate stress reac-tions. 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 defi ned as anything you perceive as a threat to your equilib-rium. 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.



Table 2-4 Warning Signs of Stress

Irritability toward coworkers, family, and friends �

Inability to concentrate �

Diffi culty sleeping, increased sleeping, or nightmares �

Feelings of sadness, anxiety, or guilt �

Indecisiveness �

Loss of appetite (gastrointestinal disturbances) �

Loss of interest in sexual activities �

Isolation �

Loss of interest in work �

Increased use of alcohol �

Recreational drug use �

Physical symptoms such as chronic pain (headache, �

backache)

Feelings of hopelessness �

Table 2-5 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 –

Periodic stretching –

Slow, deep breathing –

Regular physical exercise –

Progressive muscle relaxation –

Meditation –

Limit intake of caffeine, alcohol, and tobacco use –

78286_CH02_002_049.indd 18 10/9/09 10:26:12 PM

Patient Assessment—The 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 fi eld. Recognizing the importance of assessment-based care, each medical and trauma chapter refl ects the patient assessment process, using the same language and visual cues to strengthen students’ command of this process.

12 Section 7 Trauma

Medical identifi cation 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 disfi gure-ment 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 patients may inter-fere with clotting and make bleeding control diffi cult. If the injury was self-infl icted, the patient may also have a behavioral problem.

4 Secondary Assessment The secondary assessment is a more detailed, compre-hensive 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 signifi cant 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 immobiliza-tion device if you have not done so already.

Assessment of the respiratory system should involve looking, listening, and feeling for signs of airway prob-lems. 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 stetho-scope. Breath sounds should be clear and equal bilater-ally, 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 temper-ature; and check the capillary refi ll time.

Assess the neurologic system to gather baseline data on your patient. This examination should include:

level of consciousness—use AVPU �

pupil size and reactivity �

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 signifi cant 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 fi eld 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 signifi cant 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 signifi cant bleeding or signs of signifi cant internal bleeding may quickly become unsta-ble. Treatment must be directed at quickly addressing life threats and providing rapid transportation to the closest appropriate hospital. Signs such as tachycardia, tachyp-nea, 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 prior-ity and transport decision if they develop.

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-specifi c 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 his-tory from other sources, such as friends or family members.

78286_CH23_002_049.indd 12 10/24/09 10:05:01 PM

12 Section 7 Trauma

















Dyspnea �


Shock �

Severe pain �



4History Taking




78286_CH23_002_049.indd 12 10/24/09 10:05:01 PM

If signifi cant 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 immobiliza-

Assessment of the respiratory system should involve looking, listening, and feeling for signs of airway prob-lems. Look at the patient and ask yourself the following

Are there any signs of increased respiratory efforts such as retractions, nasal flaring, pursed lip

Next, listen for air movement at the patient’s mouth and nose. Then listen to breath sounds with a stetho-scope. Breath sounds should be clear and equal bilater-ally, anteriorly, and posteriorly. Determine the patient’s rate and quality of respiration. Finally assess asymmetric

You must be able to quickly assess pulse rate and quality; determine the skin condition, color, and temper-


12 Section 7 Trauma

















Dyspnea �


Shock �

Severe pain �



4History Taking




78286_CH23_002_049.indd 12 10/24/09 10:05:01 PM

Current, State-of-the-Art Medical Content—Medicine is constantly changing and prehospital medicine varies across states and regions. The content of the Tenth Edition refl ects the guidance and recommendations of an extremely experienced, 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). Educators in search of the gold standard in EMS education need look no further than the Tenth Edition.

Constant Reinforcement of Concepts—Health care education can be complicated, and for many students, the EMT class is their fi rst 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 of that content. For example, Chapter 5, The Human Body, provides students with a comprehensive understanding of the entire anatomy, physiology, and pathophysiology of the human body. At the beginning of Chapter 18, Immunologic Emergencies, the text briefl y revisits the relevant anatomy, physiology, and pathophysiology of the immune system, thus solidifying this knowledge in the students’ minds and offering them context when studying specifi c emergencies.

Chapter 9 Airway Management 51

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 signifi cant increase in morbidity and mortality when these patients receive intubation for their condition in the fi eld. 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 benefi t to the patient, CPAP is becoming widely used at the EMT level.

Mechanism CPAP increases pressure in the lungs, opens collapsed alveoli, pushes more oxygen across the alveolar mem-brane, and forces interstitial fl uid back into the pulmo-nary circulation. Studies for this treatment have shown positive results in patients with obstructive pulmonary diseases and those with acute pulmonary edema. The therapy is typically delivered through a face mask that is held to the head with a strapping system. A good seal with minimal leakage between the face and mask is essential.

Many CPAP systems use oxygen as the driving force to deliver the positive ventilatory pressure to the patient. Frequently check the oxygen regulator when administer-ing CPAP; depending on the fl ow and the patient’s respi-ratory rate, some CPAP units will empty a D cylinder in as little as 5 to 10 minutes.

The face mask is fi tted with a pressure-relief valve that determines the amount of pressure delivered to the patient (such as 5 cm H

2 O). The result is similar to hang-

ing your head out the window while driving on the high-way. This results in a high inspiratory fl ow and the need to push a pressure valve open with exhalation. While this may appear to require a great deal of effort on the part of

Providing bag-mask device or mouth-to-mask ven-tilation is usually much easier when dentures can be left in place. Leaving the dentures in place provides more “structure” to the face and will generally assist you in being able to provide a good face-to-mask seal, thus delivering adequate tidal volume. However, loose den-tures make it diffi cult to perform artifi cial ventilation by any method and can easily obstruct the airway. There-fore, dentures and dental appliances that do not stay in place should be removed. Dentures and appliances may become loose or be completely out of place following an accident or as you are providing care. Periodically reas-sess the patient’s airway to make sure these devices are fi rmly in place.

Facial Bleeding Airway problems can be especially challenging in patients with serious facial injuries . Because the blood supply to the face is so rich, injuries to the face can result in severe tissue swelling and bleeding into the airway. Control bleeding with direct pressure and suction as necessary.

Continuous Positive Airway

6 Pressure

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

FPO

78286_CH09_002_063.indd 51 10/7/09 2:14:16 PM

Chapter 17 Immunologic Emergencies 3

6 Introduction

Every year, at least 1,000 Americans die from allergic reactions. When managing allergy-related emergencies, you must be

aware of the possibility of acute airway obstruc-tion and cardiovascular collapse and be prepared to treat these life-threatening complications. You must also be able to distinguish between the body’s usual response to a sting or bite and an allergic reaction, which may require epinephrine. Your ability to recognize and manage the many signs and symptoms of allergic reactions may be the only thing standing between a patient’s life and imminent death.

This chapter describes immunology , the study of the body’s immune system, and the fi ve categories of stimuli that may provoke allergic reactions. You will learn what to look for in assessing patients who may be having an aller-gic reaction and how to care for them, including adminis-tration of epinephrine. The chapter then describes insect bites and stings and their management.

6 Anatomy and Physiology

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. For-tunately, most people have immune systems that are well equipped to detect unauthorized visits or invading attacks by foreign substances. Once a foreign substance

invades the body, the body goes on alert and initiates a series of responses to inactivate the invader.

6 Pathophysiology

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 heard on expiration, usually resulting from bronchos-pasm/bronchoconstriction and increased mucous pro-duction. Also present is widespread urticaria, or hives. Urticaria consists of small areas of generalized itching or burning that appear as multiple, small, raised areas on the skin . You may also note hypotension as a result of hypovolemic shock due to increased capillary permeability.

Given the right person and the right circumstances, almost any substance can trigger the body’s immune system and cause an allergic reaction: animal bites, food, latex gloves, and many other substances can be allergens . The most common allergens, however, fall into the following fi ve general categories:

� Insect bites and stings. When an insect bites you and injects the bite with its venom, the act is called envenomation or, more commonly, a sting. The sting of a honeybee, wasp, ant, yellow jacket, or hornet may cause a severe reaction

You are the Provider: PART 1YYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYooooooooooooooooooooooooooooooooooouuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu aaaaaaaaaaaaaarrrrrrrrrrrrrreeeeeeeeeeeeee tttttttttttttthhhhhhhhhhhhhheeeeeeeeeeeeee PPPPPPPPPPPPPPrrrrrrrrrrrrrroooooooooooooovvvvvvvvvvvvviiiiiiiiiiiiiddddddddddddddeeeeeeeeeeeeeerrrrrrrrrrrrrr::::::::::::: PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAARRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT

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78286_CH17_002_021.indd 3 10/6/09 6:09:43 PM

use of CPAP in the prehospital environment has proven to be an excellent adjunct in the treatment of respiratory

Chapter 9 Airway Management 51

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 signifi cant increase in morbidity and mortality when these patients receive intubation for their condition in the fi eld. 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 benefi t to the patient, CPAP is becoming widely used at the EMT level.

Mechanism CPAP increases pressure in the lungs, opens collapsed alveoli, pushes more oxygen across the alveolar mem-brane, and forces interstitial fl uid back into the pulmo-nary circulation. Studies for this treatment have shown positive results in patients with obstructive pulmonary diseases and those with acute pulmonary edema. The therapy is typically delivered through a face mask that is held to the head with a strapping system. A good seal with minimal leakage between the face and mask is essential.

Many CPAP systems use oxygen as the driving force to deliver the positive ventilatory pressure to the patient. Frequently check the oxygen regulator when administer-ing CPAP; depending on the fl ow and the patient’s respi-ratory rate, some CPAP units will empty a D cylinder in as little as 5 to 10 minutes.

The face mask is fi tted with a pressure-relief valve that determines the amount of pressure delivered to the patient (such as 5 cm H

2 O). The result is similar to hang-

ing your head out the window while driving on the high-way. This results in a high inspiratory fl ow and the need to push a pressure valve open with exhalation. While this may appear to require a great deal of effort on the part of

Providing bag-mask device or mouth-to-mask ven-tilation is usually much easier when dentures can be left in place. Leaving the dentures in place provides more “structure” to the face and will generally assist you in being able to provide a good face-to-mask seal, thus delivering adequate tidal volume. However, loose den-tures make it diffi cult to perform artifi cial ventilation by any method and can easily obstruct the airway. There-fore, dentures and dental appliances that do not stay in place should be removed. Dentures and appliances may become loose or be completely out of place following an accident or as you are providing care. Periodically reas-sess the patient’s airway to make sure these devices are fi rmly in place.

Facial Bleeding Airway problems can be especially challenging in patients with serious facial injuries . Because the blood supply to the face is so rich, injuries to the face can result in severe tissue swelling and bleeding into the airway. Control bleeding with direct pressure and suction as necessary.

Continuous Positive Airway

6 Pressure

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

FPO

78286_CH09_002_063.indd 51 10/7/09 2:14:16 PM

tunately, most people have immune systems that are tunately, most people have immune systems that are well equipped to detect unauthorized visits or invading well equipped to detect unauthorized visits or invading well equipped to detect unauthorized visits or invading attacks by foreign substances. Once a foreign substance

Chapter 17 Immunologic Emergencies 3

6 Introduction

Every year, at least 1,000 Americans die from allergic reactions. When managing allergy-related emergencies, you must be

aware of the possibility of acute airway obstruc-tion and cardiovascular collapse and be prepared to treat these life-threatening complications. You must also be able to distinguish between the body’s usual response to a sting or bite and an allergic reaction, which may require epinephrine. Your ability to recognize and manage the many signs and symptoms of allergic reactions may be the only thing standing between a patient’s life and imminent death.

This chapter describes immunology , the study of the body’s immune system, and the fi ve categories of stimuli that may provoke allergic reactions. You will learn what to look for in assessing patients who may be having an aller-gic reaction and how to care for them, including adminis-tration of epinephrine. The chapter then describes insect bites and stings and their management.

6 Anatomy and Physiology

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. For-tunately, most people have immune systems that are well equipped to detect unauthorized visits or invading attacks by foreign substances. Once a foreign substance

invades the body, the body goes on alert and initiates a series of responses to inactivate the invader.

6 Pathophysiology

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 heard on expiration, usually resulting from bronchos-pasm/bronchoconstriction and increased mucous pro-duction. Also present is widespread urticaria, or hives. Urticaria consists of small areas of generalized itching or burning that appear as multiple, small, raised areas on the skin . You may also note hypotension as a result of hypovolemic shock due to increased capillary permeability.

Given the right person and the right circumstances, almost any substance can trigger the body’s immune system and cause an allergic reaction: animal bites, food, latex gloves, and many other substances can be allergens . The most common allergens, however, fall into the following fi ve general categories:

� Insect bites and stings. When an insect bites you and injects the bite with its venom, the act is called envenomation or, more commonly, a sting. The sting of a honeybee, wasp, ant, yellow jacket, or hornet may cause a severe reaction

You are the Provider: PART 1YYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYooooooooooooooooooooooooooooooooooouuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu aaaaaaaaaaaaaarrrrrrrrrrrrrreeeeeeeeeeeeee tttttttttttttthhhhhhhhhhhhhheeeeeeeeeeeeee PPPPPPPPPPPPPPrrrrrrrrrrrrrroooooooooooooovvvvvvvvvvvvviiiiiiiiiiiiiddddddddddddddeeeeeeeeeeeeeerrrrrrrrrrrrrr::::::::::::: PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAARRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT

FPO

78286_CH17_002_021.indd 3 10/6/09 6:09:43 PM

Clear Application of Material to Real-World EMSSituations —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 fi eld?” 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 fi eld.

8 Section 5 Shock and Resuscitation

infection. In all cases, however, the damage occurs because of insuffi cient 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.

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 thor-oughly. If you understand what causes shock, you will be able to recognize it in many patients before it gets out of control.

Words of WisdomWWWWWWWWWWWooooooooooorrrrrrrrrrrdddddddddddsssssssssss ooooooooooofffffffffff WWWWWWWWWWWiiiiiiiiiiisssssssssssdddddddddddooooooooooommmmmmmmmm

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

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 hor-mones 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 nonessen-tial areas, primarily in the skin and gastrointestinal tract (peripheral vasoconstriction). 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 fl uids to help maintain pressure within the system. However, the response of the autonomic nervous system and hor-mones comes within seconds. It is this response that causes all the signs and symptoms of shock in a patient.

6 Causes of Shock

Shock can result from many conditions, including respi-ratory failure, acute allergic reactions, and overwhelming

You arrive at the clinic and are escorted to the patient by a clinic technician. You fi nd the patient lying supine 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:

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.

3. On the basis of your assessment, does this patient require any changes in the treatment she is currently receiving?

4. How do the patient’s signs and symptoms correlate with the body’s response to inadequate perfusion?

You arrive at the clinic and are escorted to the patient by a clinic technician. You fi nd the patient lying supine on an examination table. She is conscious, but restless, and her skin is notably pale and diaphoretic. She has ablanket 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:

The clinic physician tells you that the patient presented approximately 15 minutes ago complaining of abdominalpain 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.



You arrive at the clinic and are escorted to the patient by a clinic technician You find the patient lying supine

You are the Provider: PART 2YYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYoooooooooooooooooooooooooooooooooouuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu aaaaaaaaaaaaaarrrrrrrrrrrrrreeeeeeeeeeeeee tttttttttttttthhhhhhhhhhhhheeeeeeeeeeeeee PPPPPPPPPPPPPPrrrrrrrrrrrrrroooooooooooooovvvvvvvvvvvvvviiiiiiiiiiiiiiddddddddddddddeeeeeeeeeeeeeerrrrrrrrrrrrrr:::::::::::: PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAARRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT

78286_CH10_002_033.indd 8 10/24/09 4:53:32 PM

The clinic physician tells you that the patient presented approximately 15 minupain and rectal bleeding, which apparently started about 24 hours ago. There is no history of trauma, she haa history of irritable bowel syndrome, she takes lubiprostone (Amitiza) and diand she is allergic to codeine.

3. On the basis of your assessment, does this patient require any changreceiving?

4. How do the patient’s signs and symptoms correlate with the body’s res

8 Section 5 Shock and Resuscitation

infection. In all cases, however, the damage occurs because of insuffi cient 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.

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 thor-oughly. 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

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 hor-mones 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 nonessen-tial areas, primarily in the skin and gastrointestinal tract (peripheral vasoconstriction). 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 fl uids to help maintain pressure within the system. However, the response of the autonomic nervous system and hor-mones comes within seconds. It is this response that causes all the signs and symptoms of shock in a patient.

6 Causes of Shock

Shock can result from many conditions, including respi-ratory failure, acute allergic reactions, and overwhelming

You arrive at the clinic and are escorted to the patient by a clinic technician. You fi nd the patient lying supine 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:

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.



You arrive at the clinic and are escorted to the patient by a clinic technician. You fi nd the patient lying supine on an examination table. She is conscious, but restless, and her skin is notably pale and diaphoretic. She has ablanket 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:

The clinic physician tells you that the patient presented approximately 15 minutes ago complaining of abdominalpain 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.



You arrive at the clinic and are escorted to the patient by a clinic technician You find the patient lying supine

You are the Provider: PART 2YYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYoooooooooooooooooooooooooooooooooouuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu aaaaaaaaaaaaaarrrrrrrrrrrrrreeeeeeeeeeeeee tttttttttttttthhhhhhhhhhhhheeeeeeeeeeeeee PPPPPPPPPPPPPPrrrrrrrrrrrrrroooooooooooooovvvvvvvvvvvvvviiiiiiiiiiiiiiddddddddddddddeeeeeeeeeeeeeerrrrrrrrrrrrrr:::::::::::: PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAARRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT

78286_CH10_002_033.indd 8 10/24/09 4:53:32 PM

Emergency Care and Transportation of the Sick and Injured, Tenth Edition sets the standard for quality, clarity, and fl exibility in the delivery of EMT education. To learn more, visit www.jbpub.com.

A Textbook That Refl ects 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 EMSSituations —Instructors will fi nd countless opportunities to place their students “in the fi eld” 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 providers. And isn’t that our goal: to teach students how to be great EMS providers?

Educators Will Enjoy

30 Section 7 Trauma

a lacerated liver or stop bleeding in the brain; thus, their focus on trauma care should be no different from the EMT—to recognize injuries, stabilize the patient, and provide rapid transport.

In many cases, the EMT will be called on to assist the paramedic in performing advanced level skills. Depend-ing on local protocols, EMTs may even be able to perform additional skills as deemed necessary by the EMS system medical director.

a lacerated liver or stop bleeding in the brain; thus, their focus on trauma care should be no different from the EMT—to recognize injuries, stabilize the patient, and provide rapid transport.

In many cases, the EMT will be called on to assist the paramedic in performing advanced level skills. Depend-ing on local protocols, EMTs may even be able to perform additional skills as deemed necessary by the EMS system medical director.

You are the Provider: SUMMARY, continuedYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYooooooooooooooooooooooooooooooouuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu aaaaaaaaaaaaaarrrrrrrrrrrrrreeeeeeeeeeeee ttttttttttttthhhhhhhhhhhhheeeeeeeeeeeeee PPPPPPPPPPPPPPrrrrrrrrrrrrrroooooooooooooovvvvvvvvvvvvviiiiiiiiiiiiiddddddddddddddeeeeeeeeeeeeeerrrrrrrrrrrrrr::::::::::::: SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAARRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYY,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, cccccccccccccccccccccccccccccccccccccccoooooooooooooooooooooooooooooooooooooonnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnttttttttttttttttttttttttttttttttttttttiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiinnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuueeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeddddddddddddddddddddddddddddddddddddd

EMS Patient Care Report (PCR)Date: 9-1-09 Incident No.: 012109 Nature of Call: Motor vehicle crash Location: 2100 Block Hwy 46

Dispatched: 1520 En Route: 1520 At Scene: 1528 Transport: 1538 At Landing Zone: 1540

In Service: 1552

Patient Information

Age: 20Sex: MWeight (in kg [lb]): estimated at 68 (150 lb)

Allergies: UnknownMedications: UnknownPast Medical History: UnknownChief Complaint: Multiple traumatic injuries

Vital Signs

Time: 1533 BP: 84/64 Pulse: 120 Respirations: 28 SaO2: 97%



EMS Treatment(circle all that apply)

Oxygen @ 15 L/min via (circle one): NC NRM

Assisted Ventilation Airway Adjunct CPR

Defi brillation Bleeding Control Bandaging Splinting Other: Thermal management, suction, full spi-nal precautions

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 signifi cant. 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 bleed-ing. 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 fi re-fi ghter 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-fl ow oxygen. Engine 3 EMT drove ambulance to landing zone to meet with air transport helicopter. Continued to reassess patient every 3 to 5 minutes and noted no change in his clinical status. Contacted air medical helicopter via radio and provided patient status update. Con-tinued to assist patient’s ventilations and suctioned his oropharynx as needed to maintain airway patency. Vital signs were also reassessed, as noted above. After a brief wait at the LZ, air transport helicopter arrived. Gave verbal report to fl ight paramedic, and transferred patient care to the fl ight crew. Helicopter departed the LZ at 1550, and EMS 3 returned to service at 1552. **End of report**

78286_CH21_002_033.indd 30 10/9/09 10:42:07 PM

Current, State-of-the-Art Medical Content—EMS has long struggled to prove that the care delivered in the fi eld has real impact on patients’ lives. The Tenth Editionincorporates evidence-based medical concepts to ensure that students are taught assessment and treatment modalities that will help patients today—not simply recycle what has been taught year after year.

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 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 forall students.

Chapter 22 Bleeding 17

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 ban-dage 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 an area only slightly proximal to the bleed-ing to reduce the amount of tissue damage to the extremity.

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 “TK” (for “tourniquet”) and the exact time (hour and minute) that you applied the tourni-quet 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 ambu-lance run report form.

7. As an alternative, you can use a blood pressure cuff as an effective tourniquet. Position the cuff

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 tour-niquet or until bleeding has been controlled.

78286_CH22_002_029.indd 17 9/22/09 7:02:47 PM

Technology Supplements: Interactive CourseeBook/eWorkbookCourseSmartJB Navigate (formerly known as JBCourse Manager)JBTest PrepAudio BookWebsite

Instructor Supplements: Instructor’s ToolKit CD-ROMTest Bank CD-ROMScenario DVD

Student Supplements: Student WorkbookEMT Field Guide

CHAPTER

22

National EMS Education Standard CompetenciesTraumaApplies fundamental knowledge to provide basic emergency care and transportation based on assessment fi ndings for an acutely injured patient.

BleedingRecognition and management of

Bleeding (pp 33–47) �

Pathophysiology, assessment, and management ofBleeding (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)

2. Understand the role of perfusion. (pp 6–7)

3. Know how to determine the signifi cance and characteristics of external bleeding. (pp 7–8)

4. Understand the importance of identifying the mechanism of injury, nature of illness, and signs and symptoms for a patient with suspected internal bleeding. (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)

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n Standard 4. tance of identifying the mechanism of Understand the imports, and signs and symptoms for a patient with injury, nature of illnesseding. (pp 9–10) suspected internal ble

Bleeding

2

78286_CH22_002_029.indd 2 10/19/09 11:13:59 PM

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.

6 Introduction

After managing the airway, recognizing bleeding and understanding how it affects the body are perhaps the most

important skills you will learn as an EMT. Bleed-ing can be external and obvious or internal and hidden. Either way, it is potentially dangerous, fi rst 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.

This chapter will help you understand how the cardiovascular system reacts to blood loss. The chapter begins with a brief review of the anatomy and function of the cardiovascular system. It then describes the signs, symptoms, and emergency medical care of both external and internal bleeding. The chapter concludes with a dis-cussion on the relationship between bleeding and hypo-volemic shock.

Anatomy and Physiology of the

6 Cardiovascular System

The cardiovascular system circulates blood to all of the body’s cells and tissues, delivering oxygen and nutrients and carrying away metabolic waste prod-ucts . 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 skel-etal 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.

Head, arm, and upper trunkVenule

Vein

Lowerbodyand legs

Arteriole

Artery

LungAorta

Heart

Abdominalorgans

At 4:20 PM, you are dispatched to a woodworking shop at 517 East Graham for a 32-year-old man with severe bleeding from the arm. The exact mechanism of injury is unknown. 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?

At 4:20 PM, you are dispatched to a woodworking shop at 517 East Graham for a 32-year-old man with severebleeding from the arm. The exact mechanism of injury is unknown. You and your partner respond to the scene with a response time of approximately 6 minutes.



At 4 20 di t h d t d ki h t 517 E t G h f 32 ld ith

You are the Provider: PART 1YYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYoooooooooooooooooooooooooooooooooouuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu aaaaaaaaaaaaaarrrrrrrrrrrrrreeeeeeeeeeeeee tttttttttttttthhhhhhhhhhhhheeeeeeeeeeeeee PPPPPPPPPPPPPPrrrrrrrrrrrrrroooooooooooooovvvvvvvvvvvvviiiiiiiiiiiiiddddddddddddddeeeeeeeeeeeeeerrrrrrrrrrrrrr::::::::::::: PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAARRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT


78286_CH22_002_029.indd 3 10/19/09 11:14:08 PM

This chapter will help you understand how the This chapter will help you understand how the cardiovascular system reacts to blood loss. The chapter cardiovascular system reacts to blood loss. The chapter cardiovascular system reacts to blood loss. The chapter begins with a brief review of the anatomy and function begins with a brief review of the anatomy and function of the cardiovascular system. It then describes the signs, of the cardiovascular system. It then describes the signs, symptoms, and emergency medical care of both external symptoms, and emergency medical care of both external and internal bleeding. The chapter concludes with a dis-and internal bleeding. The chapter concludes with a dis-cussion on the relationship between bleeding and hypo-cussion on the relationship between bleeding and hypo-

Reinforcement of the

anatomy and physiology

presented in Chapter 5,

The Human Body, occurs

throughout the text.

or a 32-year-old man with severebleeding from the arm. The exact mechanism of injury is unknown. You and your partner respond to the scene bleeding from the arm. The exact mechanism of injury is unknown. You and your partner respond to the scene

di t h d t d ki h t 517 E t G h f 32 ld ith

Progressive case studies

capture the student’s

attention and offer an

authentic context for

students to apply their

knowledge.

4 Section 7 Trauma

The cardiovascular system, the main system responsible for supplying and maintaining adequate blood fl ow, consists of three parts:

The pump (the heart) �

A container (the blood vessels that reach every cell �

in the body)The fl uid (blood and body fl uids) �

The HeartThe heart is a hollow muscular organ about the size of a clenched fi st. 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 disrup-tion 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 backfl ow.

The right side of the heart receives oxygen-poor (deox-ygenated) blood from the veins of the body. Blood enters the right atrium from the vena cava, then fi lls the right ventricle. After the right ventricle contracts, blood fl ows 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 pulmo-nary 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 throughout the body. It is important to remember that the left ventricle is responsible for pro-viding 100% of the body with oxygen-rich blood.

Blood Vessels and BloodThere are fi ve types of blood vessels:

Arteries �

Arterioles �

Capillaries �

Venules �

Veins �

As blood fl ows 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 vessels that connect the arteries and capillaries are called

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 fl ows 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 the body to rid itself of waste products.

Superior vena cava(oxygen-poor blood fromhead and upper body)

Right pulmonaryartery (blood toright lung)

Right atrium

Inferior vena cava(oxygen-poor bloodfrom lower body)

Right ventricle

Left pulmonaryartery (blood

to left lung)

Right pulmonaryveins (oxygen-richblood fromright lung)

Left pulmonary veins(oxygen-rich blood

from left lung)

Oxygen-rich blood to headand upper body

Left atrium

Left ventricle

Oxygen-rich bloodto lower body

78286_CH22_002_029.indd 4 10/19/09 11:14:13 PM


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 (dilate), blood passes into the capillaries in proximity to

each cell of the surrounding tissue; when the muscles are closed (constricted), there is no capillary blood fl ow. The muscles dilate and constrict in response to conditions such as fright, heat, cold, a specifi c need for oxygen, and the need to dispose of metabolic waste. In a healthy indi-vidual, all the vessels are never fully dilated or fully con-stricted at the same time.

The last part of the cardiovascular system is the con-tents of the container, or the blood. Blood contains red 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 as a wound), or the blood’s ability to clot (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 sticky and clump together. As the red blood cells begin to clump, another substance in the body called fi brino-gen reinforces the red blood cells. This is the fi nal step in formation of a blood clot. Blood clots are an important response from the body to control blood loss. Certain medical conditions that interfere with the normal clotting process will be discussed later in this chapter.

The autonomic nervous system monitors the body’s needs from moment to moment and adjusts the blood fl ow by adjusting vascular tone as required. During emergencies, the autonomic nervous system automati-cally redirects blood away from other organs to the heart, brain, lungs, and kidneys. Thus, the cardiovascular system is dynamic and constantly adapting to changing

Lung alveolicapillaries

Pulmonary venule

Pulmonary arteriole

Capillary totissue cells

CO2

O2

O2 and nutrients

CO2 and waste

O2 Lung alveolus

CO2

White blood cells

Platelets

Red blood cells

78286_CH22_002_029.indd 5 10/19/09 11:16:34 PM

formation of a blood clot. Blood clots are an important response from the body to control blood loss. Certain medical conditions that interfere with the normal clotting process will be discussed later in this chapter.

The autonomic nervous system monitors the body’s needs from moment to moment and adjusts the blood fl ow by adjusting vascular tone as required. During fl ow by adjusting vascular tone as required. During flemergencies, the autonomic nervous system automati-cally redirects blood away from other organs to the heart,

Highly descriptive and

detailed illustrations

enable the student to

clearly visualize

human anatomy.

6 Section 7 Trauma

conditions in the body to maintain homeostasis and perfusion. At times, the system fails to provide suffi cient circulation for every body part to perform its function. This condition is called hypoperfusion, or shock.

6 Pathophysiology and Perfusion

Blunt force trauma may cause injury and signifi cant bleeding that is unseen inside a body cavity or region, such as when injury occurs to the liver or the spleen. These injuries cause the patient to lose signifi cant amounts of blood, causing hypoperfusion without visible bleeding. In penetrating trauma, the patient may have only a small amount of bleeding that is visible; however, the patient may have sustained injury to internal organs that will produce signifi cant 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 (or shock) in the trauma patient.

Perfusion is the circulation of blood within an organ or tissue in adequate amounts to meet the cells’ current needs for oxygen, nutrients, and waste removal. Blood enters an organ or tissue fi rst through the arteries, then the arterioles, and fi nally the capillary beds . 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 fi nally 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 at a speed that is fast enough to maintain adequate cir-culation throughout the body and slow enough to allow each cell time to exchange oxygen and nutrients for car-bon dioxide and other waste products. Although some tissues, such as the lungs and kidneys, never rest and require a constant blood supply, most require circulating blood only intermittently, especially when active. Mus-cles are a good example. When you sleep, they are at rest and require a minimal blood supply. However, during exercise, they need a very large blood supply. The gastro-intestinal tract requires a high fl ow of blood after a meal. After digestion is completed, it can do quite well with a small fraction of that fl ow.

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 and do not tolerate interruption of blood supply for very long. If perfusion is interrupted to these organs and dam-age occurs to the organ tissue, dysfunction and failure of that organ system will occur. Death of an organ system

can quickly lead to death of the organism, the human. Emergency medical care is designed to support adequate perfusion to these organs and their systems, listed in

, until the patient arrives at the hospital.

Table 22-1 Organs and Corresponding Organ Systems

Organ Organ System

Heart Cardiovascular system

Brain Central nervous system

Lungs Respiratory system

Kidneys Renal system

The heart requires constant perfusion to function properly. The brain and spinal cord can be injured after 4 to 6 minutes without perfusion. It is important to remember that cells of the central nervous system do not

Artery

Arterioles

Capillaries

Capillaries

Venules

Vein

Organ or tissue

78286_CH22_002_029.indd 6 10/19/09 11:16:51 PM

Blunt force trauma may cause injury and signifi cant Blunt force trauma may cause injury and signifi cant Blunt force trauma may cause injury and signifibleeding that is unseen inside a body cavity or region, such as when injury occurs to the liver or the spleen. These injuries cause the patient to lose signifi cant These injuries cause the patient to lose signifi cant These injuries cause the patient to lose signifiamounts of blood, causing hypoperfusion without visible bleeding. In penetrating trauma, the patient may have only a small amount of bleeding that is visible; however, the patient may have sustained injury to internal organs that will produce signifi cant bleeding that is unseen by you and may cause death quickly. Both of these situations

An in-depth and topic-

specifi c exploration of

the pathophysiology

presented in Chapter 5,

The Human Body, occurs

throughout the medical

and trauma sections.


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 consider-ably colder may be better able to resist damage from hypoperfusion.

6 External Bleeding

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.

The Significance of External Bleeding

When patients have serious external blood loss, it is often diffi cult to determine the amount of blood that is present. This is a diffi cult task because blood will look different on different 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 EMT.

Signs and Symptoms of Hypovolemic ShockRapid, weak pulse �

Low blood pressure (late sign) �

Changes in mental status �

Cool, clammy skin �

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), signifi cant 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. Signifi cant symptoms of blood loss will occur after only 100 to 200 mL of blood loss. To

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 comfort-ably 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, 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 should also be considered.

Remember that a bleeding patient may expose you to potentially infectious body fl uids; 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 fl uids if possible. Take special care if you have an open sore, cut, scratch, or ulcer. Also remember that frequent, thorough handwash-ing 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 assess-ment 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 fl uids and blood between patients you may be caring for.

SafetySSSSSSSSSSSaaaaaaaaaaafffffffffffeeeeeeeeeeetttttttttttyyyyyyyyyyy

78286_CH22_002_029.indd 7 10/19/09 11:14:23 PM

hemorrhage. Examples include nosebleeds and bleeding , you must understand

you when responding to these incidents. This approach to patient care will greatly minimize the chance that you could cause cross-contamination of body flblood between patients you may be caring for. Reinforces safety for both

the EMT and the patient.

8 Section 7 Trauma

You should consider bleeding to be serious if the following conditions are present:

It is associated with a signifi cant mechanism of �

injury (MOI).The patient has a poor general appearance and is �

calm.Assessment reveals signs and symptoms of shock �

(hypoperfusion).You note a signifi cant 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 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 dif-fi cult 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 fl ows 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

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 mecha-nisms and exposure to air. When a person is cut, blood fl ows rapidly from the open vessel. Soon afterward, the cut ends of the vessel begin to narrow (vasoconstriction), reducing the amount of bleeding. Then a clot forms, plugging the hole and sealing the injured portions of the vessel. This process is called coagulation. Bleeding will never stop if a clot does not form, unless the injured ves-sel is completely cut off from the main blood supply.

Despite the effi ciency of this system, it may fail in certain situations. Movement, medications, removal of bandages, and the external environment or body tem-perature commonly affect the blood’s clotting factors. For example, a number of medications, including aspi-rin, interfere with normal clotting. With a severe injury, the damage to the vessel may be so large that a clot can-not 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 clotting factors. This condition is called hemophilia. There are several forms of hemophilia, most of which are hereditary and some of which are severe. Some-times bleeding may occur spontaneously in hemophilia. Because the patient’s blood does not clot, all injuries, no

78286_CH22_002_029.indd 8 10/19/09 11:14:25 PM

Assessment reveals signs and symptoms of shock

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

nisms and exposure to air. When a person is cut, blood fl ows rapidly from the open vessel. Soon afterward, the fl ows rapidly from the open vessel. Soon afterward, the flcut ends of the vessel begin to narrow (reducing the amount of bleeding. Then a clot forms, plugging the hole and sealing the injurvessel. This process is called never stop if a clot does not form, unless the injursel is completely cut off frsel is completely cut off frsel is completely cut of om the main blood supply.

Despite the effi ciency of this system, it may fail in certain situations. Movement, medications, removal of bandages, and the external environment or body tem-

Key terms are easily

identifi ed and defi ned within

the text. A vocabulary list

concludes each chapter,

and a comprehensive

glossary appears at the

end of the textbook.


matter how trivial, are potentially serious. A patient with hemophilia should be transported immediately.

6 Internal Bleeding

Internal bleeding is any bleeding in a cavity or space inside the 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 lacer-ated liver or a ruptured spleen may lose a considerable amount of blood within the abdomen. 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-threatening hemorrhage.

You must always be alert to the possibility of inter-nal bleeding and assess the patient for related signs and symptoms, particularly if the MOI is severe. If you sus-pect that a patient is bleeding internally, you should promptly transport him or her to the hospital.

Mechanism of Injury for Internal Bleeding

A high-energy MOI should increase your index of suspi-cion for the possibility of serious unseen injuries such as internal bleeding in the abdominal cavity. Internal bleed-ing 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 using DCAP-BTLS (Deformities, Contusions, Abrasions,

Punctures/Penetrations, Burns, Tenderness, Lacerations, and Swelling) over the chest or abdomen, including contu-sions, 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.

Nature of Illness for Internal Bleeding

Internal bleeding is not always caused by trauma. Many illnesses can cause internal bleeding. Some of the more common causes of nontraumatic internal bleeding include bleeding ulcers, bleeding from the colon, rup-tured 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 fi rst 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 specifi c 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. Signifi cant internal bleeding will generally cause swell-ing in the area of bleeding. Intra-abdominal bleeding will often cause pain and distention. Bruising is a sign of inter-nal bleeding. It is most common in head, extremity, and pelvic injuries and can be a sign of signifi cant abdomi-nal 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. Bruising or ecchymosis may not be pres-ent initially, and the only sign of severe pelvic or abdomi-nal 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 signifi cant.

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 that contains digested blood.

If a bandage has already been applied to control bleed-ing before you arrive on the scene, obtain a descrip-tion of the wound and the amount of bleeding from the patient or bystanders.

Words of WisdomWWWWWWWWWWWooooooooooorrrrrrrrrrrdddddddddddsssssssssss ooooooooooofffffffffff WWWWWWWWWWWiiiiiiiiiiisssssssssssdddddddddddooooooooooommmmmmmmmmm

78286_CH22_002_029.indd 9 10/19/09 11:14:27 PM

matter how trivial, are potentially serious. A patient with hemophilia should be transported immediately.

patient who has penetrating injury or blunt trauma.

Internal bleeding is not always caused by trauma. Many illnesses can cause internal bleeding. Some of the more common causes of nontraumatic internal bleeding

Provides real-world

advice from experienced

fi eld providers.

10 Section 7 Trauma

Hemoptysis � . This is bright red blood that is coughed up by the patient.Pain, tenderness, bruising, guarding, or swelling. � These signs and symptoms may mean that a closed frac-ture is bleeding.Broken ribs, bruises over the lower part of the chest, �

or a rigid, distended abdomen. These signs and symptoms may indicate a lacerated spleen or liver. Patients with an injury to either organ may have referred pain in the right shoulder (liver) or left shoulder (spleen). You should suspect inter-nal abdominal bleeding in a patient with referred pain.

The fi rst sign of hypovolemic shock (hypoperfusion) is a change in mental status, such as anxiety, restless-ness, or combativeness. In nontrauma patients, weak-ness, 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 lightCapillary refi ll of more than 2 seconds in infants �

and childrenWeak, rapid (thready) pulse �

Decreasing blood pressure �


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.

Patient Assessment for External

6 and Internal Bleeding

4Scene Size-up

Scene SafetyAs 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 leaking fuel in the area where you will be working and

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 IllnessDetermine the nature of the illness (NOI) (such as bloody emesis or bloody stool), or the MOI (such as a turned-over step stool). Consider the need for manual spinal sta-bilization 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 example, caring for a sick or injured victim of a car crash on a clear, sunny day is a bit different than treating the same victim during a snowstorm. Extreme hot or cold weather can worsen a patient’s overall condition.

In older patients, dizziness, syncope, or weakness may be the fi rst sign of nontraumatic internal hemorrhage.

Special PopulationsSSSSSSSSSSSpppppppppppeeeeeeeeeeeccccccccccciiiiiiiiiiiaaaaaaaaaaalllllllllll PPPPPPPPPPPooooooooooopppppppppppuuuuuuuuuuulllllllllllaaaaaaaaaaatttttttttttiiiiiiiiiiiooooooooooonnnnnnnnnnnsssssssssss

4Primary AssessmentIn patients with suspected signifi cant 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 pro-vide treatment needed to preserve life. The management of life-threatening concerns during the primary assess-ment is determined by asking yourself, “What is going to kill my patient fi rst?” For example, in some situations, signifi cant bleeding may need management before apply-ing oxygen for a person with adequate breathing. The decision on what to treat fi rst will come with experience. Treating according to the ABCs is always a good choice.

Form General ImpressionAs you approach a trauma patient, you must note impor-tant indicators that may alert you to the seriousness of the patient’s condition. For example, patients with exter-nal bleeding may have blood stains on their clothing. Be aware of obvious signs of injury and distress (such

78286_CH22_002_029.indd 10 10/19/09 11:14:27 PM

Patient Assessment for External

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 leaking fuel in the area where you will be working and

signifi cant bleeding may need management before apply-signifi cant bleeding may need management before apply-signifiing oxygen for a person with adequate breathing. The decision on what to treat fi rst will come with experience. decision on what to treat fi rst will come with experience. decision on what to treat fiTreating according to the ABCs is always a good choice.

Form General ImpressionAs you approach a trauma patient, you must note impor-tant indicators that may alert you to the seriousness of the patient’s condition. For example, patients with exter-nal bleeding may have blood stains on their clothing. Be aware of obvious signs of injury and distress (such

Reinforcement of the

patient assessment process

taught in Chapter 8, Patient

Assessment, as it relates

specifi cally to external and

internal bleeding.

an advanced life support unit. Be sure to also consider environmental factors in your decision making. For example, caring for a sick or injured victim of a car crash on a clear, sunny day is a bit different than treating the same victim during a snowstorm. Extreme hot or cold weather can worsen a patient’s overall condition.

Discusses the specifi c

needs and emergency

care of pediatric patients,

geriatric patients, and

special needs patients.


as facial grimace), along with determining gender and age. Assess skin color. Pale or gray, cool, moist skin sug-gests 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 BreathingConsider 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-fl ow oxygen or assist ventilation with a bag-mask device or nonrebreathing mask, depending on the patient’s level of consciousness and rate and quality of breathing. If the patient is unconscious, the airway may be obstructed.

CirculationYou must be able to quickly assess pulse rate and qual-ity; determine the skin condition, color, and tempera-ture; and check the capillary refi ll time to help establish the potential for internal bleeding and shock. When life-threatening 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,

can be bandaged later in your assessment as necessary. Signifi cant bleeding, internal or external, is an immedi-ate life threat. Treat the patient for shock if needed by applying oxygen, improving circulation, and maintaining a normal body temperature.

Transport DecisionThe results of your initial general impression and assess-ment 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 signifi cant 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.

4History Taking

Investigate Chief ComplaintAfter 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 bleed-ing can be found in both medical and trauma patients. If the bleeding is severe, you may have identifi ed it in

You arrive at the scene and fi nd the patient standing outside in front of the shop. He has a towel wrapped around his left wrist; however, 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 slipped and ran into the blade.

3. Is the patient effectively controlling the bleeding from his injury?

4. What should be your initial treatment priority?

You arrive at the scene and fi nd the patient standing outside in front of the shop. He has a towel wrappedaround his left wrist; however, 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 slipped and ran into the blade.



Y i t th d fi d th ti t t di t id i f t f th h H h t l d

You are the Provider: PART 2YYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYoooooooooooooooooooooooooooooooouuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu aaaaaaaaaaaaaarrrrrrrrrrrrrreeeeeeeeeeeeee ttttttttttttthhhhhhhhhhhhheeeeeeeeeeeeee PPPPPPPPPPPPPPrrrrrrrrrrrrrroooooooooooooovvvvvvvvvvvvviiiiiiiiiiiiidddddddddddddeeeeeeeeeeeeeerrrrrrrrrrrrrr::::::::::::: PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAARRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT

78286_CH22_002_029.indd 11 10/20/09 6:27:57 PM

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 previ-ously, 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 signifi cant trauma, you should assess the entire patient, looking for fractures and other problems. Determine if there are any preexisting illnesses.

SAMPLE HistoryObtain a SAMPLE history from your patient. Be sure to ask the patient if he or she takes blood-thinning med-ications. If so, be aware that bleeding will generally be more profuse and more diffi cult 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 AssessmentAs 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 appro-priate 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 ExaminationsWhen performing a secondary assessment, the examina-tion should include a systematic full body scan. Assess the respiratory system. Specifi cally assess the airway for pat-ency 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.

Table 22-2 The Mechanism of Injury: Indicators of Internal Bleeding

Mechanism of Injury Potential Internal Bleeding Sources

Fall from a ladder striking the head Head injury or hematoma

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 thrown or falls from a height Children usually have a head-fi rst impact, causing head injury

Unrestrained driver in head-on collision

Head and neck, chest, abdomen injuriesKnees, femur, hip, and pelvis injuries

Unrestrained front-seat passenger, side impact collision with intrusion into vehicle

Humerus broken exposing the chest wall (possible fl ail chest); pelvis and acetabulum injuries

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 fi ght 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.

78286_CH22_002_029.indd 12 10/19/09 11:14:31 PM

Child thrown or falls from a height Children usually have a head-fi rst impact, causing head injury

Humerus broken exposing the chest wall (possible fl ail chest); pelvis and acetabulum

Chest and abdomen injuries, ruptured spleen, neck trauma

Organizes information

so students can quickly

locate and retain critical

information.


Assess the cardiovascular system, specifi cally 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 inju-ries quickly.

Assess all anatomic regions. When you are exam-ining the head, be alert for raccoon eyes, Battle’s sign, and/or drainage of blood or fl uid 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 SignsYou 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 hypo-perfusion in a patient who may have signifi cant bleed-ing. 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 circula-tory status.

Monitoring DevicesIn addition to hands-on assessment, the EMT should use monitoring devices to quantify oxygenation and cir-culatory status. The EMT may use a noninvasive tech-nique to monitor blood pressure and a pulse oximeter to evaluate the effectiveness of oxygenation. It is recom-mended 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 pres-sure machine.

4ReassessmentThe reassessment is an important tool to see how your patient is doing over time. Reassess the patient, especially in the areas that showed abnormal fi ndings during the primary assessment. The signs and symptoms of internal bleeding are often slow to present because of their covert

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 inter-nally. 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 help-ing the patient to breathe easier? Is your treatment for shock resulting in better perfusion of the vital organs? Is the bandage controlling the bleeding?

InterventionsWhenever you suspect signifi cant bleeding, either exter-nal or internal, provide high-fl ow oxygen. If signifi cant 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 aggres-sive treatment for shock and rapid transport to the appro-priate hospital. If internal bleeding is suspected, apply high-fl ow oxygen via a nonrebreathing 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 com-plete an assessment, particularly when signifi cant bleed-ing is present, even if the bleeding is controlled. The assessment can be started during transport.

Communication and DocumentationIn 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 esti-mate, especially if the surface the patient is on is wet or absorbs fl uids 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, sur-geons, 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 refl ects 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 pre-pare to treat the patient on arrival. Communicate with

78286_CH22_002_029.indd 13 10/19/09 11:14:31 PM

14 Section 7 Trauma

the hospital on your fi ndings 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

6 External Bleeding

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-fl ow oxygen to the patient. You may then concentrate on controlling the bleeding. In some cases, obvious life-threatening bleed-ing may be present and should be addressed as an imme-diate 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 meth-ods. illustrates the basic techniques to control external bleeding that do not require special equipment.

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-fl ow oxygen as necessary. 4. Almost all cases of external bleeding can be con-

trolled simply by applying direct local pressure to the bleeding site. This method is by far the most effective way to control external bleeding. Pres-sure stops the fl ow of blood and permits normal coagulation to occur. You may apply pressure with your gloved fi ngertip 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 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. How-ever, if it does not, you still have several options. Remember to never elevate an open fracture to con-trol bleeding. Fractures can be elevated after splint-ing, and splinting helps control bleeding Step 1 .

6. Once you have applied a dressing to control bleed-ing, create a pressure dressing to maintain the

Bleeding from the patient’s injury has been controlled. While you further assess the patient, your partner applies high-fl ow 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.

5. What are the components of the cardiovascular system? How do they function to perfuse the body’s tissues and cells?

6. What factors determine the severity of external bleeding?

Bleeding from the patient s injury has been controlled. While you further assess the patient, your partner applies high-fl ow oxygen, obtains the patient’s vital signs, and inquires about his past medical history. The patient denieshaving any medical problems and states that he does not take any medications.

5. What are the components of the cardiovascular system? How do they function to perfuse the body’stissues and cells?


Bleeding from the patient’s injury has been controlled While you further assess the patient your partner applies

You are the Provider: PART 3YYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYoooooooooooooooooooooooooooooooooooouuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu aaaaaaaaaaaaaarrrrrrrrrrrrrreeeeeeeeeeeee ttttttttttttthhhhhhhhhhhhheeeeeeeeeeeeee PPPPPPPPPPPPPPrrrrrrrrrrrrrroooooooooooooovvvvvvvvvvvvviiiiiiiiiiiiiddddddddddddddeeeeeeeeeeeeeerrrrrrrrrrrrrr::::::::::::: PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAARRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT

78286_CH22_002_029.indd 14 10/19/09 11:14:31 PM

Administer high-fl ow oxygen as necessary. Administer high-fl ow oxygen as necessary. Administer high-fl Almost all cases of external bleeding can be con-trolled simply by applying direct local pressure to the bleeding site. This method is by far the most effective way to control external bleeding. Pres-sure stops the fl ow of blood and permits normal coagulation to occur. You may apply pressure with your gloved fi ngertip or hand over the top of a sterile dressing if one is immediately available.

Provides written step-

by-step explanations of

important psychomotor

skills and procedures.

on oxygen

14 Section 7 Trauma

the hospital on your fi ndings 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.


6 External Bleeding

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-fl ow oxygen to the patient. You may then concentrate on controlling the bleeding. In some cases, obvious life-threatening bleed-ing may be present and should be addressed as an imme-diate 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 meth-ods. illustrates the basic techniques to control external bleeding that do not require special equipment.

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-fl ow oxygen as necessary. 4. Almost all cases of external bleeding can be con-

trolled simply by applying direct local pressure to the bleeding site. This method is by far the most effective way to control external bleeding. Pres-sure stops the fl ow of blood and permits normal coagulation to occur. You may apply pressure with your gloved fi ngertip 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 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. How-ever, if it does not, you still have several options. Remember to never elevate an open fracture to con-trol bleeding. Fractures can be elevated after splint-ing, and splinting helps control bleeding Step 1 .

6. Once you have applied a dressing to control bleed-ing, create a pressure dressing to maintain the

Bleeding from the patient’s injury has been controlled. While you further assess the patient, your partner applies high-fl ow 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.



Bleeding from the patient s injury has been controlled. While you further assess the patient, your partner applies high-fl ow oxygen, obtains the patient’s vital signs, and inquires about his past medical history. The patient denieshaving any medical problems and states that he does not take any medications.



Bleeding from the patient’s injury has been controlled While you further assess the patient your partner applies

You are the Provider: PART 3YYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYoooooooooooooooooooooooooooooooooooouuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu aaaaaaaaaaaaaarrrrrrrrrrrrrreeeeeeeeeeeee ttttttttttttthhhhhhhhhhhhheeeeeeeeeeeeee PPPPPPPPPPPPPPrrrrrrrrrrrrrroooooooooooooovvvvvvvvvvvvviiiiiiiiiiiiiddddddddddddddeeeeeeeeeeeeeerrrrrrrrrrrrrr::::::::::::: PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAARRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT

78286_CH22_002_029.indd 14 10/19/09 11:14:31 PM


pressure by fi rmly 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 extrem-ity after applying the pressure dressing. If bleed-ing continues, the dressing is probably not tight enough. Do not remove a dressing until a physician has evaluated the patient. Instead, apply additional

manual pressure through the dressing. Then add more gauze pads over the fi rst 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 other tissues. As long as a fracture remains unstable, the bone ends will move and continue to injure partially

p pp y and other tissues. As long as a fracture remains unstable, the bone ends will move and continue to injure partially

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.

Step 2 Apply a pressure dressing.

78286_CH22_002_029.indd 15 10/19/09 11:14:34 PM

Much of the bleeding associated with broken bones occurs because the sharp ends of the bones cut muscles and other tissues. As long as a fracture remains the bone ends will move and continue to injure and other tissues. As long as a fracture remainsthe bone ends will move and continue to in

Provides a visual summary

of important psychomotor

skills and procedures.

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 effec-tiveness of using pressure points in severe external hemorrhage. It is preferable, if allowed by local proto-col and policy, to move to the use of a tourniquet with-out attempting pressure point control. If a tourniquet is deemed necessary, it should be applied quickly and not released until a physician is present.

TourniquetsThe tourniquet is especially useful if a patient has sub-stantial bleeding from an extremity injury below the axilla or groin. Follow the steps in to apply a commercial tourniquet.

Superficial temporal

External maxillary

Ulnar

Radial

Carotid

Brachial

Femoral

Posteriortibial

Dorsalis pedis

Historically, if direct pressure and elevation proved inef-fective, 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 tech-nique 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. 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, there is no real evidence that this is an effec-tive or safe method to control potentially fatal hemor-rhage. If the patient has an open fracture of an 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 effective. Remember that uncontrolled bleeding results in shock and then death. Patients can and do bleed to death from extremity injuries. It is imperative that you use effec-tive techniques to stop bleeding when you encounter it.


Hemostatic agents such as Celox, HemCon, and Quik-Clot, are primarily utilized in the military to promote hemostasis or, in other words, to stop profuse bleed-ing. 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 coagula-tion cascade. Some of these agents have an exothermic affect that can damage the surrounding tissue.


78286_CH22_002_029.indd 16 10/19/09 11:14:38 PM

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 effective. Remember that uncontrolled bleeding results in shock and then death. Patients can and do bleed to death from extremity injuries. It is imperative that you use effec-tive techniques to stop bleeding when you encounter it.

Current, state-of-the-

art medical content is

presented in an engaging

and comprehensive

writing style.


1. 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 ban-dage 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 an area only slightly proximal to the

bleeding to reduce the amount of tissue damage to the extremity.

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 “TK” (for “tourniquet”) and the exact time (hour and minute) that you applied the tourniquet

Choose an area only slightly proximal to the 5. Secure the stick in place, and make the wrapping neat and smooth.

6. Write “TK” (for “tourniquet”) and the exact time (hour and minute) that you applied the tourniquet


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 tour-niquet or until bleeding has been controlled.

78286_CH22_002_029.indd 17 10/19/09 11:14:44 PM

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 infl ate it just enough to stop the bleeding. Leave the cuff infl ated. If you use a blood pressure cuff, monitor 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 infl ating 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.

SplintsAir splints can control internal or external bleeding associated with severe soft-tissue injuries, such as mas-sive 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 infl ating 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 frac-tures. When the EMT pulls traction to the ankle, counter-traction is applied to the ischium and groin. This reduces the thigh muscle spasms and prevents one end of the

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.

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?

The patient is placed onto the stretcher and loaded into the ambulance. He remains conscious and alert, but isstill anxious. You place him in a supine position, elevate his legs, and cover him with a blanket. Shortly beforedeparting the scene, you reassess him and obtain another set of vital signs.



The patient is placed onto the stretcher and loaded into the ambulance He remains conscious and alert but is

You are the Provider: PART 4YYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYoooooooooooooooooooooooooooooooooooouuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu aaaaaaaaaaaaaarrrrrrrrrrrrrreeeeeeeeeeeeee tttttttttttttthhhhhhhhhhhhhheeeeeeeeeeeeee PPPPPPPPPPPPPPrrrrrrrrrrrrrroooooooooooooovvvvvvvvvvvvviiiiiiiiiiiiiddddddddddddddeeeeeeeeeeeeeerrrrrrrrrrrrrr::::::::::::: PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAARRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT

Research indicates that a pelvic compression device is an effective method to reduce the width of pelvic ring fractures. Overcompression has not been identifi ed as an issue to date. The decrease in the width of the frac-ture will assist in the control of internal bleeding result-ing from the fracture, specifi cally an open book fracture of the pelvis.


78286_CH22_002_029.indd 18 10/19/09 11:15:02 PM

is internal rather than external? is internal rather than external?


introduce patients and

follow their progress from

dispatch to delivery at the

emergency department.

The cases become

progressively more detailed

as new medical information

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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 noseSinusitis, infections, nose drop use and abuse, dried �

or cracked nasal mucosa, or other abnormalitiesHigh blood pressure �

Coagulation disorders �

Digital trauma (nose picking) �

Epistaxis, or nosebleed, is a common emergency. Occasionally, it can cause enough of a blood loss to send 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 vom-iting the blood, which is sometimes confused with inter-nal 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.

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 fl eshy part of the nostrils together. This is the preferred 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 fi ngers 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. Anxi-ety 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 signifi cant amount of blood loss, transport the patient immediately. Assess the patient for signs and symptoms of shock. Treat appropriately for shock, and administer oxygen via mask, if nec-essary.

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 fl ow. This bleeding may be diffi cult 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

78286_CH22_002_029.indd 19 10/19/09 11:15:06 PM

20 Section 7 Trauma

the head . If blood or drainage contains cerebrospinal fl uid, a characteristic staining of the dress-ing, much like a target or halo, will occur .


6 Internal Bleeding

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 assists the body’s clotting process. Next, if spinal injury is not suspected, place the patient in the shock position. Provide high-fl ow oxygen; also maintain body temperature. You can usually control internal bleeding into the extremities quite well in the fi eld simply by splinting the extrem-ity, usually most effectively with an air splint, and you should never use a tourniquet to control the bleeding from closed, internal, soft-tissue injuries. Follow the steps in to care for patients with possible internal bleeding.

from closed, internal, soft-tissue injuries. Follow the steps in to care for patients with possibleinternal bleeding.

Controlling Epistaxis

Step 1 Position the patient sitting, leaning forward. Apply direct pressure, pinching the fl eshy part of the nostrils together.

Step 3 Apply ice over the nose. Maintain pressure until bleeding is con-trolled. Provide prompt transport after bleeding stops. Transport immediately if indicated. Assess and treat for shock, including oxy-gen, as needed.

Step 2 Alternative method: Use pres-sure with a rolled gauze bandage between the upper lip and gum. Calm the patient.

78286_CH22_002_029.indd 20 10/19/09 11:15:07 PM


6. 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.

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.

The patient is delivered to the hospital and you give your report to the attending physician. An intravenous line is started, the patient is given normal saline to improve his perfusion status, and he is admitted for observation.

9. How does the body typically respond to blood loss?

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.

The patient is delivered to the hospital and you give your report to the attending physician. An intravenous line is started, the patient is given normal saline to improve his perfusion status, and he is admitted for observation.


You continue to monitor the patient en route to the hospital and reassess his condition as appropriate After

You are the Provider: PART 5YYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYoooooooooooooooooooooooooooooooouuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu aaaaaaaaaaaaaarrrrrrrrrrrrrreeeeeeeeeeeeee tttttttttttttthhhhhhhhhhhhhheeeeeeeeeeeeee PPPPPPPPPPPPPPrrrrrrrrrrrrrroooooooooooooovvvvvvvvvvvvviiiiiiiiiiiiiddddddddddddddeeeeeeeeeeeeeerrrrrrrrrrrrrr::::::::::::: PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAARRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT

1. Follow standard precautions. 2. Maintain the airway with cervical spine immobili-

zation if a mechanism of injury suggests the pos-sibility of spinal injury.

3. Administer high-fl ow oxygen and provide artifi -cial ventilation as necessary.

4. Control all obvious external bleeding. 5. Treat suspected internal bleeding in an extremity

by applying a splint.

78286_CH22_002_029.indd 21 10/19/09 11:15:11 PM

Photos of real emergencies

prepare students for

the fi eld.

on oxygen

22 Section 7 Trauma


Arteries are high-pressure blood vessels that distribute oxygenated blood throughout the body. The largest artery in the body, the aorta, arises from the left ventricle and branches into smaller arteries 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 pulmonary 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, 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 the arm, just proximal to the elbow.


Blood fl ow through the arteries is driven by contraction of the powerful left ventricle. Pressure in the arter-ies is much higher than pressure in the veins (high capacitance, low-pressure blood vessels that return deoxygenated blood to the heart).

Because blood fl ow through the arteries is much higher, blood loss is generally more rapid and severe. Arte-rial bleeding is also more diffi cult to control than venous bleeding. Oxygen loss is more severe from arterial bleeding than it is from venous bleeding; this is because arterial blood carries a higher concentration of oxygen than do the veins.

The color of blood and characteristic of the bleeding are often clues to the type of blood vessel that is injured. Venous blood is dark red and fl ows from the injury site, whereas arterial blood is bright red and spurts from the wound each time the left ventricle contracts.


As evidenced by the blood-soaked towel and large amount of blood on the ground, it is clear that the patient is not effectively controlling the bleeding from his injury. Furthermore, 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 signifi cant external blood loss.


You must take immediate 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-fl ow oxygen.

In most cases, direct pressure will control both venous and arterial bleeding. However, if direct 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, application of pressure to a proximal arterial pressure point has been the next step in controlling severe 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, this treatment is largely governed by local protocol. Regardless of the method used to control severe external bleeding, it must be quick and effective.


The cardiovascular system—the system responsible for supplying and maintaining adequate blood fl ow to the body’s tissues and cells—consists of three components: the heart (pump), the container (the blood


Arteries are high-pressure blood vessels that distribute oxygenated blood throughout the body. The largest artery in the body, the aorta, arises from the left ventricle and branches into smaller arteries and arteriolesthat deliver oxygen to the body’s tissues and cells. In general, arteries carry highly oxygenated blood awayfrom the heart; an exception to this is the pulmonary artery, which carries deoxygenated blood from theright ventricle to the lungs where it is reoxygenated.

Two major arteries are located in the upper extremity, the radial 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 the arm, just proximal to the elbow.


Blood fl ow through the arteries is driven by contraction of the powerful left ventricle. Pressure in the arter-ies is much higher than pressure in the veins (high capacitance, low-pressure blood vessels that return deoxygenated blood to the heart).

Because blood fl ow through the arteries is much higher, blood loss is generally more rapid and severe. Arte-rial bleeding is also more diffi cult to control than venous bleeding. Oxygen loss is more severe from arterial bleeding than it is from venous bleeding; this is because arterial blood carries a higher concentration ofoxygen than do the veins.

The color of blood and characteristic of the bleeding are often clues to the type of blood vessel that is injured. Venous blood is dark red and fl ows from the injury site, whereas arterial blood is bright red andspurts from the wound each time the left ventricle contracts.


As evidenced by the blood-soaked towel and large amount of blood on the ground, it is clear that the patient is not effectively controlling the bleeding from his injury. Furthermore, you do not know how muchblood he has lost because he is standing outside—not in the area where the injury occurred. The fact that heis anxious and has cool, pale skin suggests signifi cant external blood loss.


You must take immediate action to control the patient’s bleeding. His airway is patent, as evidenced by thefact that he is conscious, alert, and talking. One EMT can attempt to control the patient’s bleeding as the other applies high-fl ow oxygen.

In most cases, direct pressure will control both venous and arterial bleeding. However, if direct 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, application of pressure to a proximal arterial pressure point has been the next step in controlling severe 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, this treatment is largely governed by local protocol. Regardless of the method used to control severe external bleeding, it must be quick and effective.

5. What are the components of the cardiovascular system? How do they function to perfuse the body’stissues and cells?

The cardiovascular system—the system responsible for supplying and maintaining adequate blood fl ow tothe body’s tissues and cells—consists of three components: the heart (pump), the container (the blood

You are the Provider: SUMMARYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYoooooooooooooooooooooooooooooooouuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu aaaaaaaaaaaaaarrrrrrrrrrrrrreeeeeeeeeeeee ttttttttttttthhhhhhhhhhhhheeeeeeeeeeeeee PPPPPPPPPPPPPPrrrrrrrrrrrrrroooooooooooooovvvvvvvvvvvvviiiiiiiiiiiiiddddddddddddddeeeeeeeeeeeeeerrrrrrrrrrrrrr::::::::::::: SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAARRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYY

78286_CH22_002_029.indd 22 10/19/09 11:15:18 PM

Blood fl ow through the arteries is driven by contraction of the powerful left ventricle. Pressure in the arter-pressure blood vessels that return

generally more rapid and severe. Arte-rial bleeding is also more diffi cult to control than venous bleeding. Oxygen loss is more severe from arterial

ood carries a higher concentration of

often clues to the type of blood vessel that is ereas arterial blood is bright red and

Progressive case studies are followed

by a summary of answers to the

critical-thinking questions, as well as:

• Additional signs and symptoms

commonly associated with the

patient’s injury or condition

• Additional pathophysiologic

information regarding the

patient’s injury or condition

• Information and justifi cation

for each treatment modality


vessels), and the fl uid (blood and body fl uids). These components of the cardiovascular system are interdependent—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.


Several factors determine the severity of external bleeding. The single most infl uential 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 diffi culty 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 diffi cult 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 (ie, warfarin [Coumadin]) or those with a bleeding disor-der (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.


Compared to external bleeding, which you can see and control, internal bleeding is hidden and cannot be controlled in the prehospital setting. Many patients with internal bleeding do not present with signs or symptoms of shock until a signifi cant amount of blood has been lost.

Overall, patients with internal bleeding have a higher mortality rate than those with external bleed-ing. Most of these deaths are the result of intrathoracic or intra-abdominal bleeding in which surgical intervention 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, particularly if the mechanism of injury is signifi cant. Remember this: if a trauma patient is in shock but does not have any obvious external signs of injury, suspect internal bleeding!


Since internal bleeding cannot be seen outright, you must rely on your assessment skills and careful evalu-ation of the mechanism of injury. Signs and symptoms of internal bleeding are essentially those of shock: restlessness or anxiety; cool, pale, clammy skin; tachycardia; rapid, shallow breathing; thirst; and as a late sign, hypotension.

External indicators of internal bleeding in both medical and trauma patients include hematemesis (vomiting blood), melena (dark, tarry stools), and hemoptysis (coughing up blood).

Other indicators of internal bleeding, which are more common in trauma patients, include redness or bruising, swelling, or tenderness over the injured area.

vessels), and the fl uid (blood and body fl uids). These components of the cardiovascular system are interdependent—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 bloodvessels to adequately perfuse the body’s tissues and cells. Failure of any one of these components will resultin inadequate perfusion of the body, a condition known as shock.


Several factors determine the severity of external bleeding. The single most infl uential factor is the typeand size of the blood vessel that is injured. A lacerated brachial artery, for example, will bleed more severelythan 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 diffi culty 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 diffi cult to control than a transverse laceration—one that isdirectly 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 bleedmore 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 (ie, warfarin [Coumadin]) or those with a bleeding disor-der (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.


Compared to external bleeding, which you can see and control, internal bleeding is hidden and cannot becontrolled in the prehospital setting. Many patients with internal bleeding do not present with signs or symptoms of shock until a signifi cant amount of blood has been lost.

Overall, patients with internal bleeding have a higher mortality rate than those with external bleed-ing. Most of these deaths are the result of intrathoracic or intra-abdominal bleeding in which surgical intervention 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 andsymptoms, particularly if the mechanism of injury is signifi cant. Remember this: if a trauma patient is inshock but does not have any obvious external signs of injury, suspect internal bleeding!


Since internal bleeding cannot be seen outright, you must rely on your assessment skills and careful evalu-ation of the mechanism of injury. Signs and symptoms of internal bleeding are essentially those of shock: restlessness or anxiety; cool, pale, clammy skin; tachycardia; rapid, shallow breathing; thirst; and as a late sign, hypotension.

External indicators of internal bleeding in both medical and trauma patients include hematemesis (vomiting blood), melena (dark, tarry stools), and hemoptysis (coughing up blood).

Other indicators of internal bleeding, which are more common in trauma patients, include redness orbruising, swelling, or tenderness over the injured area.

You are the Provider: SUMMARY, continuedYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYoooooooooooooooooooooooooooooooouuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu aaaaaaaaaaaaaarrrrrrrrrrrrrreeeeeeeeeeeee ttttttttttttthhhhhhhhhhhhheeeeeeeeeeeeee PPPPPPPPPPPPPPrrrrrrrrrrrrrroooooooooooooovvvvvvvvvvvvviiiiiiiiiiiiiddddddddddddddeeeeeeeeeeeeeerrrrrrrrrrrrrr::::::::::::: SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAARRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYY,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ccccccccccccccccccccccccccccccccccccccccoooooooooooooooooooooooooooooooooooooooonnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnntttttttttttttttttttttttttttttttttttttttiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiinnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuueeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeedddddddddddddddddddddddddddddddddddddd

78286_CH22_002_029.indd 23 10/20/09 6:29:40 PM

24 Section 7 Trauma


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; 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), signifi cant changes in vital signs will occur, including increasing heart and respiratory rates, and as a later sign, a decreasing blood pressure.

A loss of circulating blood volume is sensed by receptors in the body, which send messages to the nervous system. The nervous system, specifi cally, the sympathetic nervous system, releases epinephrine and nor-epinephrine. Norepinephrine constricts the peripheral blood vessels (vasoconstriction), thus shunting blood 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. The net effect is to maintain adequate perfusion of the body’s vital organs. If blood loss continues, however, the body’s compensatory mechanisms will eventually fail, the patient’s blood pressure will fall, and he or she will die.


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; 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), signifi cant changes in vital signs will occur,including increasing heart and respiratory rates, and as a later sign, a decreasing blood pressure.

A loss of circulating blood volume is sensed by receptors in the body, which send messages to the nervoussystem. The nervous system, specifi cally, the sympathetic nervous system, releases epinephrine and nor-epinephrine. Norepinephrine constricts the peripheral blood vessels (vasoconstriction), thus shunting blood 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. The net effect is to maintain adequate perfusion of the body’s vital organs. If blood loss continues, however, the body’s compensatory mechanisms will eventually fail, the patient’s blood pressure will fall, and he or she will die.

You are the Provider: SUMMARY, continuedYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYoooooooooooooooooooooooooooooooouuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu aaaaaaaaaaaaaarrrrrrrrrrrrrreeeeeeeeeeeee ttttttttttttthhhhhhhhhhhhheeeeeeeeeeeeee PPPPPPPPPPPPPPrrrrrrrrrrrrrroooooooooooooovvvvvvvvvvvvviiiiiiiiiiiiiddddddddddddddeeeeeeeeeeeeeerrrrrrrrrrrrrr::::::::::::: SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAARRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYY,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ccccccccccccccccccccccccccccccccccccccccooooooooooooooooooooooooooooooooooooooonnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnntttttttttttttttttttttttttttttttttttttttiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiinnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuueeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeedddddddddddddddddddddddddddddddddddddd

EMS Patient Care Report (PCR)Date: 6-30-09 Incident No.: 220109 Nature of Call: Laceration Location: 517 E. Graham

Dispatched: 1620 En Route: 1621 At Scene: 1627 Transport: 1642 At Hospital: 1655 In Service: 1704

Patient Information

Age: 32Sex: MWeight (in kg [lb]): 82 kg (180 lb)

Allergies: No known drug allergiesMedications: NonePast Medical History: NoneChief Complaint: Laceration to left wrist

Vital Signs




EMS Treatment(circle all that apply)

Oxygen @ 15 L/min via (circle one): NC NRM

Assisted Ventilation Airway Adjunct CPR

Defi brillation Bleeding Control Bandaging Splinting Other Shock treatment

Narrative

Dispatched for a patient with severe bleeding from the arm. Arrived on scene to fi nd 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 blood-soaked towel wrapped around his left wrist and an impressive amount of blood was on the ground where he was stand-ing. 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 signifi cant 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 ambu-lance. 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**

78286_CH22_002_029.indd 24 10/19/09 11:15:28 PM

No known drug allergies

None Laceration to left wrist

Respirations: 24 SaO2: 95%




conclude with a complete

Patient Care Report to

teach students how to

properly document patient

assessment and care.


Scene Size-up

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 pre-cautions.

External Bleeding Internal Bleeding

Primary Assessment

Form General Impression

Check for responsiveness and look for blood stains or other obvious signs of external bleeding. Assess skin color. Manage signifi -cant visible bleeding.

Suspect internal bleeding after blunt or pene-trating trauma. Determine level of conscious-ness 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-fl ow oxygen or assist ventilation.

Ensure a patent airway, look for adequate breathing, and check for breath sounds. If necessary, provide high-fl ow oxygen or assist ventilation.

Circulation Assess pulse rate and quality, skin color and temperature, and check capillary refi ll time. Control external bleeding with direct pressure, elevation, or use of a tourniquet. Treat for shock if needed by applying oxygen, improving circu-lation, and maintaining normal temperature.

Assess pulse rate and quality, skin color and temperature, and check capillary refi ll 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 signifi cant bleeding exists.

If you suspect internal bleeding or signs of shock are present, promptly transport to the hospital.

History Taking

Investigate Chief Complaint

Ask the patient about the chief complaint, if responsive. Attempt to determine the amount of blood loss.

Ask the patient what happened.

Mechanism of Injury/Nature of Illness

Determine the MOI/NOI. High-energy MOI should increase your index of suspicion for possible internal bleeding.

78286_CH22_002_029.indd 25 10/19/09 11:15:32 PM

Chief Complaint responsive. Attempt to determine the amount of blood loss.

Summarizes and reviews

the patient assessment

process and the specifi c

fi ndings presented in

the chapter.

26 Section 7 Trauma

Interventions

Communica-tion and Documentation

Repeat the primary assessment and reassess interventions performed. Reassess vital signs and the chief complaint. In cases of severe bleeding, obtain vital signs at least every 5 minutes while providing high-fl ow oxygen. Control signifi cant bleeding and if signs of shock are present, treat aggressively. Deter-mine whether patient’s condition is improving or deteriorating.

Report approximate amount of blood lost, how rapidly, and over what period of time. Communicate interventions performed, and how patient has responded to care.

Repeat the primary assessment and reassess interventions performed. Internal bleeding is often slow to present. Reassess vital signs and the chief complaint. Provide high-fl ow oxygen. Determine whether patient’s condi-tion is improving or deteriorating.

Describe the MOI/NOI and signs and symp-toms that make you suspect internal bleed-ing 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.

Emergency Care

Steps to Caring for Patient With External Bleeding

1. Follow standard precautions—minimum of gloves and eye protection.

2. Maintain cervical stabilization if MOI suggests possible spinal injury.

3. Administer high-fl ow oxygen as necessary. 4. Control external bleeding using one of the

following methods:Direct pressure and elevation• Pressure dressings• Tourniquets• Splints•

Steps to Caring for Patient With Internal Bleeding

1. Follow standard precautions. 2. Maintain the airway with cervical immo-

bilization if MOI suggests possible spinal injury.

3. Administer high-fl ow oxygen and provide artifi cial ventilation as necessary.

4. Control all obvious external bleeding. 5. Apply a splint to an extremity where

internal bleeding is suspected. 6. Monitor and record vital signs at least

every 5 minutes.

re


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 Signs 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.

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.

Secondary Assessmentessment


78286_CH22_002_029.indd 26 10/19/09 11:15:36 PM

1. Follow standard precautions—minimum of gloves and eye protection.

2. Maintain cervical stabilization if MOI sugge

3. Administer high-fl 4. Control external bleeding using one of the

following methods:Direct pressure and elevation• Pressure dressings• Tourniquets•

Summarizes and reviews

the emergency care skills

for the illnesses and

injuries presented in

the chapter.


Emergency Care

5. Apply direct local pressure to bleeding site. 6. Elevate the bleeding extremity. 7. Create a pressure dressing. 8. If the wound continues to bleed, consider

the use of a tourniquet. Follow local pro-tocol for approved methods of bleeding control.


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 to sit, leaning forward,

with the head tilted forward. 3. Apply direct pressure for at least 15 min-

utes 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.

re


78286_CH22_002_029.indd 27 10/19/09 11:15:41 PM

Title Goes Here and I need the longest title

CHAPTER

22Prep Kit6

Ready for Review

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 function- �

ing to meet this demand: a working pump (heart), a set of intact pipes (blood vessels), and fl uid volume (enough oxygen-carrying blood).

Hypoperfusion, or shock, occurs when one or more of �

these three arms is not working properly and the cardio-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 con-sider the more serious problem of skull fracture.

Bleeding around the face always presents a risk for air- �

way 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 frac ture �

is not suspected, pinch both nostrils together for 15 min-utes. 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 signifi cant external bleeding should be transported promptly.

If the mechanism of injury is signifi cant, be alert to signs �

of unseen bleeding in the chest or abdomen—signs such as serious bruising or symptoms such as complaints of diffi culty breathing or abdominal pain.

Signs of serious internal bleeding include the following: �

Vomiting blood (hematemesis) –Black tarry stools (melena) –Coughing up blood (hemoptysis) –Distended abdomen –Broken ribs –

6 Vital Vocabulary

aorta The main artery that receives blood from the left ventri-cle and delivers it to all the other arteries that carry blood to the tissues of the body.

arterioles The smallest branches of arteries leading to the vast network of capillaries.

artery A blood vessel, consisting of three layers of tissue and 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 fl uid, and then on to the cells.

coagulation The formation of clots to plug openings in injured blood vessels and stop blood fl ow.

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 tis-sue 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 pro-vide suffi cient circulation so that every body part can per-form 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.

78286_CH22_002_029.indd 28 10/19/09 11:15:44 PM

The main artery that receives blood from the left ventri- The main artery that receives blood from the left ventri-cle and delivers it to all the other arteries that carry blood cle and delivers it to all the other arteries that carry blood to the tissues of the body.

The smallest branches of arteries leading to the vast The smallest branches of arteries leading to the vast

A blood vessel, consisting of three layers of tissue and A blood vessel, consisting of three layers of tissue and smooth muscle that carries blood away from the heart.smooth muscle that carries blood away from the heart.

The small blood vessels that connect arterioles and The small blood vessels that connect arterioles and

Provides a list of key

terms and defi nitions

from the chapter.ing to meet this demand: a working pump (heart), a set of intact pipes (blood vessels), and fl uid volume (enough oxygen-carrying blood).

Hypoperfusion, or shock, occurs when one or more of �

these three arms is not working properly and the cardio-vascular system fails to provide adequate perfusion.

Both internal and external bleeding can cause shock. You �

must know how to recognize and control both.

Summarizes chapter

content in a comprehensive

bulleted list.

Assessmentin Action

Your unit is dispatched to a roadside construction site for a blast-related injury. The fi re 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 hurts and he can’t hear very well. He denies having any past medical history or allergies and does not take any medications.

On examination, you fi nd minor bleeding from his ears and some cuts and bruises to his arms. As you remove his clothing, you fi nd that his chest and abdomen are bruised. He complains

of increasing pain and experiences severe trouble breathing. As you begin your transport, you notice that he is now presenting with hematemesis, cool and clammy skin, tachycardia, and hypotension.

1. Does the mechanism of injury create the suspicion of serious injury prior to your arrival?

2. What is the fi rst important factor to consider in this scenario?A. Scene safetyB. Mechanism of injuryC. Level of consciousnessD. Apparent injuries

3. After considering this, what factor should you next consider?A. Scene safetyB. Mechanism of injuryC. Level of consciousnessD. Apparent injuries

4. Is your patient’s complaint of frontal body pain sig-nifi cant on your primary assessment?

5. The minor bleeding from his ears is most likely an indication of:A. a skull fracture.

B. internal hemorrhaging.C. cardiac distress.

D. an ocular cavity.

6. You determine that your patient is experiencing internal bleeding. What should you do fi rst?

A. Apply pressure dressings B. Immobilize the injury C. Apply oxygen D. Apply cold packs

7. Is your patient’s pain likely to be a result of internal or external injuries? Explain your answer.

8. What condition is likely when signs of hypotension, tachycardia, and cool, clammy skin are found?A. Internal bleedingB. ShockC. Central nervous system depressionD. Intracranial bleeding

9. Effective primary treatment of this patient should consist of:A. tourniquet use.B. direct pressure.C. rapid transport.D. Trendelenburg positioning.

10. 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 fl uid diffusion.

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the explosion, he was blown forward onto a gravel area. He tells you that he remembers 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 everything and he did not lose consciousness. He also indicates that the entire front of his

body hurts and he can’t hear very well. He denies having any past medical history or allergies body hurts and he can’t hear very well. He denies having any past medical history or allergies and does not take any medications. and does not take any medications.

On examination, you fi nd minor bleeding from his ears and some cuts and bruises to his arms. As you remove his clothing, you fi nd that his chest and abdomen are bruised. He complains

of increasing pain and experiences severe trouble breathing. As you begin your transport, you notice that he is now presenting with hematemesis, cool and clammy skin, tachycardia, and hypotension.

Does the mechanism of injury create the suspicion of serious injury prior to your arrival?

A short case study with

both critical-thinking and

multiple-choice questions

allows students to

synthesize and apply

what they have learned

in the chapter.

Source Code: EBSC09

PRSRT STDU.S. Postage

PAIDPermit No. 6Hudson, MA

AAOS Tenth Edition

EmergencySample Chapter

EmergencyCare and Transportation of the Sick and Injured

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 fi rst 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 history with the implementation of the new National EMS Education Standards, the AAOS celebrates this industry milestone and the 40th anniversary of their entrance into EMS education with the publication of Emergency Care and Transportation of the Sick and Injured, Tenth Edition.

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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.”

Meetsthe New

National EMSEducation Standards

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emergency care of the sick and injured - 10/e sample chapter

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