22: Bleeding
Cognitive Objectives (1 of 2)
5-1.1 List the structure and function of the circulatory
system.
5-1.2 Differentiate between arterial, venous, and
capillary bleeding.
5-1.3 State methods of emergency medical care of
external bleeding.
5-1.4 Establish the relationship between body
substance isolation and bleeding.
5-1.5 Establish the relationship between airway
management and the trauma patient.
Cognitive Objectives (2 of 2)
5-1.6 Establish the relationship between mechanism
of injury and internal bleeding.
5-1.7 List the signs of internal bleeding.
5-1.8 List the steps in the emergency medical care of
the patient with signs and symptoms of internal
bleeding.
Affective Objectives
5-1.11 Explain the sense of urgency to transport
patients who are bleeding and show signs of
shock (hypoperfusion).
Psychomotor Objectives
5-1.12 Demonstrate direct pressure as a method of
emergency medical care of external bleeding.
5-1.13 Demonstrate the use of diffuse pressure as a
method of emergency medical care of
external bleeding.
5-1.14 Demonstrate the use of pressure points and
tourniquets as a method of emergency
medical care of external bleeding.
5-1.15 Demonstrate the care of the patient exhibiting
signs and symptoms of internal bleeding.
Cardiovascular System
Anatomy of the
Cardiovascular System
• The cardiovascular system is responsible for
supplying and maintaining adequate blood supply
flow.
• Consists of three parts:
– Heart (pump)
– Blood vessels (container)
– Blood and body fluids (fluids)
The Heart
Right Side
Left Side
Blood Vessels
•
•
•
•
•
Arteries
Arterioles
Capillaries
Venules
Veins
Blood
• Contains:
– Red blood cells
– White blood cells
– Platelets
– Plasma
Perfusion (1 of 2)
• Circulation within tissues in
adequate amounts to meet
the cells’ needs for oxygen,
nutrients, and waste
removal
• Some tissues and organs
need a constant supply of
blood while others can
survive on very little when
at rest.
Perfusion (2 of 2)
• The heart demands a
constant supply of blood.
• The brain and spinal cord can
survive for 4 to 6 minutes
without perfusion.
• The kidneys may survive 45
minutes.
• The skeletal muscles may last
2 hours.
External Bleeding
• Hemorrhage = bleeding
• Body cannot tolerate greater than 20%
blood loss.
• Blood loss of 1 L can be dangerous in
adults; in children, loss of 100-200 mL is
serious.
The Significance of Bleeding
• The body will not tolerate an acute blood loss of
greater than 20% of the blood volume.
• In the typical adult, 20% is 1 liter or 2 pints.
• A 1-year-old infant typically has 800 mL. A loss of
200 mL is significant.
Conditions With Possible
Serious Bleeding
• Significant mechanism of injury
• Poor general appearance of patient
• Assessment reveals signs of shock
• Significant amount of blood loss noted
• Blood loss is rapid.
• You cannot control external bleeding.
Characteristics of Bleeding (1 of 2)
• Arterial
– Blood is bright red and spurts.
• Venous
– Blood is dark red and does not spurt.
• Capillary
– Blood oozes out and is controlled easily.
Characteristics of Bleeding (2 of 2)
Blood Clotting
•
•
•
•
Bleeding normally stops within 10 minutes.
Some medications interfere with clotting.
Some injuries will be unable to clot.
Patients with hemophilia lack clotting factors.
• You and your EMT-B partner are dispatched to a
cabinet-making shop to a traumatic injury.
• You find a conscious, alert, oriented 27-year-old
man bleeding heavily from his left arm.
• He states that he was working with a band saw
when he slipped and ran into the blade.
• He is holding a red rag against the wound; it is
bright red.
You are the provider
• What precautions must you take in the scene
size-up?
• What type of bleeding is this?
• Should you start oxygen therapy?
• During the initial assessment, when do you
control bleeding?
• How would you control the bleeding?
You are the provider
continued
Scene Size-up
• Follow BSI precautions; bleeding is present.
• Thorough hand washing between patients and after
runs is important.
• Look for hazards.
• Request law enforcement for violent incidents.
• Patient has patent airway; no signs of respiratory
distress.
• You start oxygen therapy via nonrebreathing mask
at 10–15 L/min. Lung sounds are equal bilaterally.
• You quickly dress with wound with a bulky
dressing.
• Radial pulse is rapid and weak. Skin is pale, cool,
and moist.
You are the provider
continued (1 of 2)
• What is your transport decision?
• What should you do with the dressing as it
continues to saturate with blood?
You are the provider continued (2 of 2)
Initial Assessment
• Do not be distracted by bleeding.
• In some cases, significant bleeding may need to be
controlled even before applying oxygen.
• General impression
– Use AVPU. Note any bleeding.
Airway and Breathing
• Ensure clear airway with adequate breathing.
• Check breath sounds.
• Consider high-flow oxygen via nonrebreathing
mask with assisted ventilations.
• Consider spinal stabilization.
Circulation
•
•
•
•
Quickly assess pulse rate and quality.
Determine skin condition, color, and temperature.
Control significant bleeding.
Treat for shock.
Transport Decision
• Transport rapidly if:
– Patient has airway or
breathing problems
– Patient has significant
bleeding
– Patient has signs and
symptoms of internal
bleeding
• Watch for tachycardia,
tachypnea, low blood pressure,
and circulatory collapse.
• You apply additional dressings to the blood-soaked
ones and continue to hold direct pressure.
• Provide rapid transport.
• In the ambulance:
– Respirations of 24 breaths/min
– Slightly dilated and sluggish pupils
– Pale, cool, clammy skin
– Patient states he is going to vomit.
You are the provider continued (1 of
2)
• What do the patient’s signs and symptoms
suggest?
• Describe your continued care of the patient in the
ambulance.
You are the provider
continued (2 of 2)
Focused History and Physical
Exam
• Rapid physical exam versus focused physical
exam
• Treat life-threatening injuries immediately.
• With significant trauma, look for fractures or other
problems.
• Do not delay transport.
• Obtain baseline vital signs.
– Pupillary changes may indicate bleeding inside
the skull.
• Obtain SAMPLE history.
Interventions
• With significant bleeding, provide high-flow oxygen.
• Control bleeding.
• Using multiple methods to control bleeding usually
works best.
• Treat aggressively for shock.
• Provide rapid transport.
Detailed Physical Exam
• Consider once obvious life threats are corrected
and focused history and physical exam has
identified hidden injuries.
• Important in patients with significant trauma
• May be impractical
Ongoing Assessment
• Reassess interventions and treatment.
• With severe bleeding, take vital signs every 5 minutes.
• Communication and documentation
– Recognize, estimate, and report amount of blood
loss and how rapidly and during what time it
occurred.
– Paperwork must reflect all injuries and care you
provided.
Controlling External Bleeding
• Follow BSI precautions.
• Ensure patient has an open
airway and adequate
breathing.
• Provide oxygen if necessary.
• There are several methods to
control bleeding.
Direct Pressure and Elevation
• Direct pressure is the most
common and effective way to
control bleeding.
• Apply pressure with gloved
finger or hand.
• Elevating a bleeding extremity
often stops venous bleeding.
• Use both direct pressure and
elevation whenever possible.
• Apply a pressure dressing.
Pressure Points
• If bleeding continues,
apply pressure on
pressure point.
• Pressure points are
located where a blood
vessel lies near a
bone.
• Be familiar with the
location of pressure
points.
Location of Pressure Points
Splints
• Splints can help
control bleeding
associated with a
fracture.
• Air splints can be
used to control
bleeding of soft-tissue
injuries.
Pneumatic Antishock Garment
(PASG)
• Stabilizes fractures of the pelvis and
proximal femurs
• Controls significant internal bleeding
• Controls massive soft-tissue bleeding of the
lower extremities
• Refer to local protocol.
PASG Contraindications
• Pregnancy
• Pulmonary edema
• Acute heart failure
• Penetrating chest injuries
• Groin injuries
• Major head injuries
• Less than 30 minute transport time
Application of PASG
• Apply the garment so the top is below the lowest rib.
• Enclose both legs and the abdomen.
• Open the stopcocks.
• Inflate with the foot pump.
• Check patient’s vital signs.
Applying a Tourniquet
• Fold a triangular bandage into 4˝ cravat.
• Wrap the bandage.
• Use a stick as a handle to twist and secure the
stick.
• Write “TK” and time. Place on patient.
Tourniquet Precautions
• Place as close to injury as possible, but not
over joint.
• Never use narrow material.
• Use wide padding under the tourniquet.
• Never cover a tourniquet with a bandage.
• Do not loosen the tourniquet once applied.
Bleeding from the Nose,
Ears, and Mouth
• Causes:
– Skull fractures
– Facial injuries
– Sinusitis
– High blood pressure
– Coagulation disorders
– Digital trauma
Controlling a Nosebleed
• Follow BSI precautions.
• Help the patient sit and lean
forward.
• Apply direct pressure by
pinching the patient’s nostrils.
– Or place a piece of gauze
bandage under the patient’s
upper lip and gum.
• Apply ice over the nose.
• Provide transport.
Bleeding from Skull Fractures
• Do not attempt to stop the blood flow.
• Loosely cover bleeding site with sterile gauze.
• If cerebrospinal fluid is present, a target (or halo)
sign will be apparent.
Internal Bleeding
• Internal bleeding may not be readily
apparent.
• Assess patient’s:
– Mechanism of injury
– Nature of illness
Signs and Symptoms
of Internal Bleeding (1 of 2)
• Ecchymosis: Bruising
• Hematoma: Bleeding beneath the skin
• Hematemesis: Blood in vomit
• Melena: Black, tarry stool
Signs and Symptoms
of Internal Bleeding (2 of 2)
• Hemoptysis: Coughing up blood
• Pain, tenderness, bruising, guarding, or swelling
• Broken ribs, bruises over the lower chest, or rigid,
distended abdomen
Signs of Hypoperfusion
•
•
•
•
•
•
•
Change in mental status
Tachycardia
Weakness
Thirst
Nausea or vomiting
Cold, moist skin
Shallow, rapid breathing
•
•
•
•
Dull eyes
Dilated pupils
Weak, rapid pulse
Decreased blood
pressure
• Altered level of
consciousness
Scene Size-up
• Be alert for hazards.
• Look for indications of nature of illness
or mechanism of injury.
• Consider spinal stabilization.
• Consider ALS backup.
Initial Assessment
•
•
•
•
•
•
•
•
Form general impression.
Address life threats.
Determine level of consciousness.
Provide high-flow oxygen or assist ventilations with
a BVM device.
Assess pulse and skin.
Treat for shock.
Control bleeding.
Assessment of ABCs and life threats will determine
transport priority.
Focused History and Physical
Exam
• Internal bleeding is found in both medical and
trauma patients.
• Perform a rapid physical exam or focused physical
exam depending on type of patient.
• Obtain vital signs, history.
Detailed Physical Exam
• Perform if:
– Patient is unstable.
– Problems persist.
– Time permits.
Ongoing Assessment
• Reassess vital signs and interventions.
• Signs and symptoms of internal bleeding are often
slow to present.
• Children will compensate well for blood loss, then
crash quickly.
Emergency Medical Care
• Follow BSI precautions.
• Maintain airway and administer oxygen.
• Control external bleeding and care for any internal
bleeding.
• Monitor and record vital signs.
• Elevate legs and keep patient warm.
• Transport immediately.
Review
1. The quickest and MOST effective way to control
external bleeding from an is extremity is:
A. a pressure bandage.
B. direct pressure and elevation.
C. pressure on arterial pulse points.
D. a proximal tourniquet and ice.
Review
Answer: B
Rationale: Direct pressure and elevation are the
quickest, most effective ways to control external
bleeding from an extremity. This combination will
effectively control external bleeding in most cases.
Review
1. The quickest and MOST effective way to control external bleeding
from an is extremity is:
A. a pressure bandage.
Rationale: This is done after direct pressure has controlled the
bleeding and replaces the EMT-B’s hand.
B. direct pressure and elevation.
Rationale: Correct answer
C. pressure on arterial pulse points.
Rationale: This is done after direct pressure is attempted.
D. a proximal tourniquet and ice.
Rationale: A tourniquet is the last method of controlling external
bleeding.
Review
2. Which of the following sets of vital signs is LEAST
indicative of internal bleeding?
A. BP, 140/90 mm Hg; pulse rate, 58 beats/min;
respirations, 8 breaths/min
B. BP, 100/50 mm Hg; pulse rate, 120 beats/min;
respirations, 24 breaths/min
C. BP, 98/60 mm Hg; pulse rate, 110 beats/min;
respirations, 28 breaths/min
D. BP, 102/48 mm Hg; pulse rate, 100 beats/min;
respirations, 22 breaths/min
Review
Answer: A
Rationale: Internal hemorrhage typically reveals vital
signs that are consistent with shock: hypotension,
tachycardia, and tachypnea. Hypertension,
bradycardia, and bradypnea (choice “A”) is
consistent with a closed head injury, not internal
bleeding.
Review
2. Which of the following sets of vital signs is LEAST indicative of
internal bleeding?
A. BP, 140/90 mm Hg; pulse rate, 58 beats/min; respirations, 8
breaths/min
Rationale: Correct answer
B. BP, 100/50 mm Hg; pulse rate, 120 beats/min; respirations, 24
breaths/min
Rationale: This is indicative of a progression to decompensated shock.
C. BP, 98/60 mm Hg; pulse rate, 110 beats/min; respirations, 28
breaths/min
Rationale: This is indicative of a progression to decompensated shock.
D. BP, 102/48 mm Hg; pulse rate, 100 beats/min; respirations, 22
breaths/min
Rationale: This is indicative of a progression to decompensated shock.
Review
3. A man involved in a motorcycle crash has multiple
abrasions and lacerations. Which of the following
injuries has the HIGHEST treatment priority?
A. Widespread abrasions to the back with pinkish
ooze
B. 3” laceration to the forehead with dark red, flowing
blood
C. Laceration to the forearm with obvious debris in
the wound
D. 1” laceration to the thigh with spurting, bright red
blood
Review
Answer: D
Rationale: Bleeding from an artery produces bright
red bleeding that spurts with the pulse. The
pressure that causes the blood to spurt also makes
this type of bleeding difficult to control. Blood loss
from an arterial wound is more severe—and thus,
more life-threatening—than from a venous wound.
Review
3. A man involved in a motorcycle crash has multiple abrasions
and lacerations. Which of the following injuries has the
HIGHEST treatment priority?
A. Widespread abrasions to the back with pinkish ooze
Rationale: Abrasions are painful, but not an immediate life threat.
B. 3” laceration to the forehead with dark red, flowing blood
Rationale: Venous bleeding is controlled after arterial bleeding is
controlled.
C. Laceration to the forearm with obvious debris in the wound
Rationale: There is no indication that this wound is actively
bleeding.
D. 1” laceration to the thigh with spurting, bright red blood
Rationale: Correct answer
Review
4. When caring for a patient with severe epistaxis, the
MOST effective way to prevent aspiration of blood
is to:
A. insert a nasopharyngeal airway and lean the
patient back.
B. tilt the patient's head forward while he or she is
leaning forward.
C. place the patient supine with his or her head in the
flexed position.
D. tilt the patient's head forward while he or she is
leaning backward.
Review
Answer: B
Rationale: Leaning forward, with the head tilted
forward, will stop blood from trickling down the
throat. This decreases the risk that the patient will
swallow the blood, which may cause vomiting, or
aspirating the blood into the lungs.
Review
4. When caring for a patient with severe epistaxis, the MOST effective
way to prevent aspiration of blood is to:
A. insert a nasopharyngeal airway and lean the patient back.
Rationale: Never insert a nasopharyngeal airway into actively bleeding
nares.
B. tilt the patient's head forward while he or she is leaning forward.
Rationale: Correct answer
C. place the patient supine with his or her head in the flexed position.
Rationale: Lying a patient supine with epistaxis will cause blood to be
swallowed and may cause vomiting.
D. tilt the patient's head forward while he or she is leaning backward.
Rationale: Tilt the patient’s head forward, but the patient’s body must
lean forward.
Review
5. A 50-year-old man was involved in a motor vehicle
crash and has an unstable pelvis and bilateral femur
deformities. His BP is 70/40 mm Hg, pulse rate is 130
beats/min, and respirations are 28 breaths/min. He
has a history of congestive heart failure and
hypertension. Which of the following is the BEST
method of stabilizing his injuries?
A. Apply and inflate the entire PASG
B. Secure the patient to a long spineboard.
C. Apply and inflate only the legs of the PASG.
D. Apply two traction splints to the patient's legs.
Review
Answer: B
Rationale: The PASG can be used to stabilize pelvic
and bilateral femur fractures; however, they are
contraindicated in patients with pulmonary edema
or those prone to pulmonary edema (ie, CHF). The
pressure from the garment would only cause more
blood to backup into the lungs. Applying two
traction splints is not practical; he is in shock and
his pelvis is unstable. The quickest and most
effective way to stabilize his injuries is to secure
him to a long spineboard.
Review (1 of 2)
5. A 50-year-old man was involved in a motor vehicle crash and has
an unstable pelvis and bilateral femur deformities. His BP is
70/40 mm Hg, pulse rate is 130 beats/min, and respirations are
28 breaths/min. He has a history of congestive heart failure and
hypertension. Which of the following is the BEST method of
stabilizing his injuries?
A. Apply and inflate the entire PASG
Rationale: This is contraindicated in patients prone to pulmonary
edema.
B. Secure the patient to a long spineboard.
Rationale: Correct answer
Review (2 of 2)
5. A 50-year-old man was involved in a motor vehicle crash and has
an unstable pelvis and bilateral femur deformities. His BP is
70/40 mm Hg, pulse rate is 130 beats/min, and respirations are
28 breaths/min. He has a history of congestive heart failure and
hypertension. Which of the following is the BEST method of
stabilizing his injuries?
C. Apply and inflate only the legs of the PASG.
Rationale: This is contraindicated in patients prone to pulmonary
edema.
D. Apply two traction splints to the patient's legs.
Rationale: This is not practical in patients with an unstable pelvis.
Review
6. When caring for a patient with internal bleeding, the
EMT-B must:
A. ensure a patent airway.
B. obtain baseline vital signs.
C. control any external bleeding.
D. take appropriate BSI precautions.
Review
Answer: D
Rationale: All of the interventions in this question
must be performed. However, before providing
patient care—whether the patient is bleeding or
not—the EMT-B must first ensure that he or she
has taken the appropriate BSI precautions.
Review
6. When caring for a patient with internal bleeding, the EMT-B
must:
A. ensure a patent airway.
Rationale: This would be the first step after BSI.
B. obtain baseline vital signs.
Rationale: This would be the third step after BSI, airway, and
bleeding control.
C. control any external bleeding.
Rationale: This would be the second step after BSI and airway.
D. take appropriate BSI precautions.
Rationale: Correct answer
Review
7. Perfusion is MOST accurately defined as:
A. the removal of adequate amounts of carbon
dioxide during exhalation.
B. the intake of adequate amounts of oxygen during
the inhalation phase.
C. circulation of blood within an organ with sufficient
amounts of oxygen.
D. the production of carbon dioxide, which
accumulates at the cellular level.
Review
Answer: C
Rationale: Perfusion is the circulation of blood within
an organ and tissues with sufficient amounts of
oxygen and other nutrients. Carbon dioxide is the
byproduct of normal cellular metabolism; it should
be returned to the lungs for removal from the body,
not accumulate at the cellular level.
Review
7. Perfusion is MOST accurately defined as:
A. the removal of adequate amounts of carbon dioxide during
exhalation.
Rationale: Removal of carbon dioxide is a part of exhalation, and not
perfusion.
B. the intake of adequate amounts of oxygen during the inhalation
phase.
Rationale: This is a function of respirations, and not perfusion.
C. circulation of blood within an organ with sufficient amounts of
oxygen.
Rationale: Correct answer
D. the production of carbon dioxide, which accumulates at the cellular
level.
Rationale: Carbon dioxide is a normal by-product of cellular
metabolism and should not accumulate in the cells.
Review
8. A 70-year-old man is experiencing a severe
nosebleed. When you arrive, you find him leaning over
a basin, which contains an impressive amount of
blood. He has a history of coronary artery disease,
diabetes, and migraine headaches. His BP is 180/100
and his heart rate is 100 beats/min. Which of the
following is the MOST likely contributing factor to his
nosebleed?
A. His blood pressure
B. His history of diabetes
C. The fact that he is elderly
D. His heart rate of 100 beats/min
Review
Answer: A
Rationale: Several conditions can cause a nosebleed
(epistaxis), including skull fractures, facial injuries,
sinusitis (inflamed sinuses), high blood pressure,
coagulation disorders (ie, hemophilia), and digital
trauma (ie, nose-picking). A BP of 180/100
indicates a significant amount of pressure on the
arteries, which is no doubt the main contributing
factor to this patient’s nosebleed.
Review (1 of 2)
8. A 70-year-old man is experiencing a severe nosebleed. When
you arrive, you find him leaning over a basin, which contains an
impressive amount of blood. He has a history of coronary artery
disease, diabetes, and migraine headaches. His BP is 180/100
and his heart rate is 100 beats/min. Which of the following is the
MOST likely contributing factor to his nosebleed?
A. His blood pressure
Rationale: Correct answer
B. His history of diabetes
Rationale: Diabetes can be a cause of hypertension, CAD, and
vascular problems, but typically is not a condition that will cause
epistaxis.
Review (2 of 2)
8. A 70-year-old man is experiencing a severe nosebleed. When
you arrive, you find him leaning over a basin, which contains an
impressive amount of blood. He has a history of coronary artery
disease, diabetes, and migraine headaches. His BP is 180/100
and his heart rate is 100 beats/min. Which of the following is the
MOST likely contributing factor to his nosebleed?
C. The fact that he is elderly
Rationale: Elderly patients are prone to hypertension, which can
cause epistaxis, but age is not a factor.
D. His heart rate of 100 beats/min
Rationale: His heart rate may be a result of his age or a
compensatory mechanism dealing with blood loss.
Review
9. Which of the following is NOT a component of the
cardiovascular system?
A. Heart
B. Lungs
C. Venules
D. Plasma
Review
Answer: B
Rationale: Components of the cardiovascular system
include the heart, blood vessels (arteries,
arterioles, capillaries, venules, veins), and blood
(plasma and blood cells). The lungs are a
component of the respiratory system.
Review
9. Which of the following is NOT a component of the
cardiovascular system?
A. Heart
Rationale: This is part of the cardiovascular system.
B. Lungs
Rationale: Correct answer
C. Venules
Rationale: This is part of the cardiovascular system.
D. Plasma
Rationale: This is part of the cardiovascular system.
Review
10. When applying a tourniquet to an amputated arm,
the EMT-B should:
A. use the narrowest bandage possible.
B. avoid applying the tourniquet over a joint.
C. cover the tourniquet with a sterile bandage.
D. use rope to ensure that the tourniquet is tight.
Review
Answer: B
Rationale: If you must apply a tourniquet, never apply
it directly over a joint. You should use the widest
bandage possible and make sure it is secured
tightly. Never use wire, rope, a belt, or any other
narrow material, as it could cut the skin. The
tourniquet should never be covered with a
bandage. Leave it open and in full view.
Review
10. When applying a tourniquet to an amputated arm, the EMT-B
should:
A. use the narrowest bandage possible.
Rationale: You should use the widest bandage possible.
B. avoid applying the tourniquet over a joint.
Rationale: Correct answer
C. cover the tourniquet with a sterile bandage.
Rationale: You should leave a tourniquet open and in plane view.
D. use rope to ensure that the tourniquet is tight.
Rationale: Never use a wire, rope, belt, or any other narrow material,
as it may cut or damage the extremity.