Chapter 27 – Bleeding and Soft-Tissue Trauma 1

Chapter 27 – Bleeding and Soft-Tissue Trauma

  1. Objectives

Knowledge Objectives /
  1. State the major functions of the skin.
  2. List the layers of the skin.
  3. Define wound and differentiate between an open and closed wound.
  4. Differentiate among arterial, venous, and capillary bleeding.
  5. Establish the relationship between standard precautions and bleeding and soft-tissue injuries.
  6. Describe methods of controlling external bleeding.
  7. Establish the relationship between mechanism of injury and internal bleeding.
  8. List the signs of internal bleeding.
  9. List the steps in the emergency medical care of the patient with signs and symptoms of internal bleeding.
  10. Differentiate between open and closed soft tissue injuries.
  11. List the types of closed soft-tissue injuries.
  12. Describe the emergency care of the patient with a closed soft-tissue injury.
  13. State the types of open soft-tissue injuries.
  14. Describe the emergency medical care of the patient with an open soft-tissue injury.
  15. Discuss the emergency medical care for a patient with a penetrating chest injury.
  16. Describe the emergency medical care of the patient with an evisceration.
  17. Describe the emergency medical care of the patient with an impaled object.
  18. Describe the emergency medical care of the patient with an amputation.
  19. Describe the emergency medical care of the patient with an open neck injury.
  20. Describe the emergency medical care of the patient with an eye injury.
  21. Describe the emergency medical care of the patient with a mouth injury.
  22. Describe the emergency medical care of the patient with an ear laceration.
  23. Identify factors that determine the severity of a burn.
  24. List the classifications of burns.
  25. Define superficial burn.
  26. List the characteristics of a superficial burn.
  27. Define partial-thickness burn.
  28. List the characteristics of a partial-thickness burn.
  29. Define full-thickness burn.
  30. List the characteristics of a full-thickness burn.
  31. Discuss the use of the rule of nines to estimate the total body surface area burned.
  32. Describe the emergency medical care of the patient with a superficial burn.
  33. Describe the emergency medical care of the patient with a partial-thickness burn.
  34. Describe the emergency medical care of the patient with a full-thickness burn.
  35. Describe the emergency care for a chemical burn.
  36. Describe the emergency care for an electrical burn.
  37. List the functions of dressing and bandaging.
  38. Describe the purpose of a bandage.
  39. Describe the steps in applying a pressure dressing.

Attitude Objectives /
  1. Attend to the feelings that the patient with bleeding or soft-tissue trauma might be experiencing.

Skill Objectives /
  1. Demonstrate the care of the patient with signs and symptoms of external bleeding.
  2. Demonstrate the care of the patient with signs and symptoms of internal bleeding.
  3. Demonstrate the care of closed soft-tissue injuries.
  4. Demonstrate the care of open soft-tissue injuries.
  5. Demonstrate the care of a patient with an open chest wound.
  6. Demonstrate the care of a patient with an open abdominal wound.
  7. Demonstrate the care of a patient with an impaled object.
  8. Demonstrate the care of a patient with an amputation.
  9. Demonstrate the care of an amputated part.
  10. Demonstrate the care of a patient with superficial burns.
  11. Demonstrate the care of a patient with partial-thickness burns.
  12. Demonstrate the care of a patient with full-thickness burns.
  13. Demonstrate the steps in the emergency medical care of a patient with a chemical burn.
  14. Demonstrate completing a prehospital care report for patients with bleeding or soft tissue trauma.

  1. Preparation

Corresponding textbook pages: /
  • 449-481

Audiovisual equipment: /
  • Chapter 27 PowerPoint presentation
  • Computer
  • Multimedia projector

EMS equipment: /
  • Personal protective equipment, splints, triangular bandage, stick or rod, air splints, gloves, eye protection, blanket,universal dressings, occlusive dressings, 4 x 4 gauze pads, self-adherent bandages, roller bandages, triangular bandage, burn sheets, sterile water or saline

Course administration materials: /
  • Attendance sign-in sheet

  1. Personnel

Primary instructor qualifications: /
  • One EMR instructor knowledgeable in the physiology of bleeding and soft-tissue trauma.

Assistant instructor qualifications: /
  • The instructor-to-student ratio should be 1:6 for psychomotor skill practice.
  • Individuals used as assistant instructors should be knowledgeable in bleeding and soft-tissue trauma.

  1. Key Terms Presented in This Lesson
  • Abrasion Damage to the outermost layer of skin (epidermis) by shearing forces (such as rubbing or scraping).
  • Air EmbolismThe entry of air into the circulation through a blood vessel that is torn and exposed to the air.
  • Amputation The separation of a body part from the rest of the body.
  • Anesthesia Without sensation; a loss of feeling.
  • Avulsion A soft-tissue injury in which a flap of skin or tissue is torn loose or pulled completely off.
  • Bandage Material used to secure a dressing in place.
  • Bruise A collection of blood under the skin caused by bleeding capillaries.
  • Blunt Trauma Trauma in which a forceful impact occurs to the body, but there is no break in the skin.
  • Circumferential Burn Swelling from a burn that encircles an extremity.
  • Closed Soft-Tissue Injury A soft-tissue injury that resultswhen the body is struck by a blunt object; there is no break in the skin, but the tissues and vessels beneath the skin surface are crushed or ruptured.
  • Closed Wound An injury that occurs when the soft tissues under the skin are damaged but the surface of the skin is not broken.
  • Crush Injury Trauma caused by a compressing force applied to the body; also called a compression injury.
  • Direct Pressure Firm pressure applied to a bleeding site with gloved hands or bandages to control bleeding.
  • Dressing Absorbent material placed directly over a wound.
  • Evisceration The protrusion of an organ through an open wound.
  • ExternalBleeding Bleeding that can be seen.
  • Fascia A tough sheet of fibrous tissue that covers the skeletal muscles of the body.
  • Fasciotomy A surgical procedure in which a physician cuts the tough sheet of fibrous tissue covering a muscle to relieve pressure.
  • Full-Thickness Burn A burn in which the epidermis and dermis are destroyed; the burn may also involve subcutaneous tissue, muscle, and bone; also called a third-degree burn.
  • Hematoma A localized collection of blood beneath the skin caused by a tear in a blood vessel.
  • Hemophilia A disorder in which the blood does not clot normally.
  • Hemorrhage An extreme loss of blood from a blood vessel; also called major bleeding.
  • Impaled Object An object that remains embedded in an open wound.
  • Internal Bleeding Bleeding that occurs inside body tissues and cavities.
  • Major Bleeding An extreme loss of blood from a blood vessel; also called hemorrhage.
  • Open (Compound) Fracture A broken bone that penetrates the skin.
  • Open Soft-Tissue InjuryA soft-tissue injury in which a break occurs in the skin.
  • Open Wound An injury in which the skin surface is broken.
  • Paresthesias Abnormal sensations such as tingling, burning, numbness, or a “pins-and-needles” feeling.
  • Partial-Thickness Burn A burn that involves the epidermis and dermis; also called a second-degree burn.
  • Penetrating Chest Injury A break in the skin over the chest wall.
  • Puncture Wound Piercing of the skin with a pointed object such as a nail, pencil, ice pick, splinter, piece of glass, bullet, or a knife resulting in little or no external bleeding (internal bleeding may be severe); also called a penetration wound.
  • Rule of Nines A guide used to estimate the affected body surface area of a burn.
  • Soft Tissues Layers of the skin and the fat and muscle beneath them.
  • Splint A device used to limit the movement of an injured arm or leg and reduce bleeding and discomfort.
  • Sucking Chest Wound A chest injury in which air moves into the pleural cavity through an open chest wound, creating a sucking or gurgling sound when air escapes from the wound when the patient breathes in.
  • Superficial Burn A burn that affects only the epidermis; also called a first-degree burn.
  • Tourniquet A tight bandage that surrounds an arm or leg and is used to stop the flow of blood in the extremity.
  • Wound An injury to the soft tissues of the body.

VI.Skills Presented In This Lesson

  • Skill 1 – Bleeding and Shock Management
  • Skill 2 – Amputation
  • Skill 3 – Abdominal Evisceration
  • Skill 4 – Impaled Object (Cheek)
  • Skill 5 – Impaled Object (Eye)
  • Skill 6 – Open Neck Wound

VII. Lesson Outline

Slide # / Instructor Notes
1 / A.Bleeding and Soft-Tissue Trauma
2 / B.Objectives
3
Objective 1 / C.Anatomy of the Skin
1.Skin protects the body from the environment, bacteria, and other organisms.
2.Blood vessels and sweat glands in the skin help control and maintain body temperature.
3.Skin acts as a sense organ detecting sensations such as heat, cold, touch, pressure, and pain and relaying the information to the brain and spinal cord.
4.The skin is the site where vitamin D is produced.
5.Sweat glands in the skin excrete excess water and some wastes.
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Objective 2 / D.Layers of the Skin
1.Skin has multiple layers that lie over muscle and bone.
2.Epidermis
a.Outer portion of the skin
b.Does not contain blood vessels
c.Thickest on the palms of the hands and soles of the feet
3.Dermis
a.Thick layer of skin below the epidermis
b.Contains hair follicles, sweat and oil glands, small nerve endings, and blood vessels
4.Subcutaneous layer
a.Thick layer that lies below the dermis
b.Contains fat
c.Insulates body from changes in temperature
d.Loosely attached to muscles and bones of musculoskeletal system
5 / E.Bleeding
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Objective 3 / 1.Wound
a.Injury to the soft tissues
2.Closed wound
a.Soft tissues under the skin are damaged.
b.Skin surface is not broken.
c.Example: bruise
7
Objective 3 / 3.Open wound
a.Skin surface is broken.
b.Examples: cuts and scrapes
8 / 4.Bleeding
a.Can occur from capillaries, veins, or arteries
5.The larger the blood vessel, the greater the bleeding and blood loss
6.Hemorrhage
a.Excessive loss of blood from a blood vessel
b.Also called major bleeding
9 / 7.Blood clotting
a.If a blood vessel is cut or torn:
1)Blood vessel wall contracts immediately.
2)Platelets rush to plug the torn vessel.
3)Clot begins to form at the site of the torn vessel.
4)Clotting is usually complete within 6-10 minutes.
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Objective 4 / 8.Types of bleeding
a.Arterial bleeding
1)Life-threatening
2)Bright red, oxygen-rich blood
3)Spurts from the wound
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Objective 4 / b.Venous bleeding
1)Flows as a steady stream
2)Dark red or maroon
3)Oxygen-poor blood
4)Usually easier to control than arterial bleeding
 Bleeding from deep veins (such as those in the thigh) can cause significant bleeding that is hard to control.
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Objective 4 / c.Capillary bleeding
1)Oozes slowly from the wound
2)Dark red blood
3)Usually not serious
4)Often clots and stops by itself in a few minutes
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Objective 4 / Arterial / Venous / Capillary
Color / Bright red / Dark red, maroon / Dark red
Blood Flow / Spurts with each heart beat / Flows steadily / Oozes slowly
Bleeding Control / Difficult to control / Usually easier to control than arterial bleeding; bleeding from deep veins may be hard to control / Often clots and stops by itself
14 / 9.External bleeding
a.External bleeding is bleeding that you can see.
1)Blood flows through an open wound.
b.Control bleeding manually until bleeding stops.
15 / 10.Emergency care of external bleeding
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Objective 5, 6 / a.Scene size-up
1)Make sure the scene is safe to enter.
2)Evaluate the mechanism of injury or the nature of the illness.
3)Personal protective equipment (PPE)
 PPE must be worn when an exposure to blood or other potentially infectious material can be reasonably anticipated. HIV and the hepatitis virus are examples of diseases to which you may be exposed that can be transmitted by exposure to blood. Additional PPE, such as eye protection, mask, and gown, should be worn if there is a large amount of blood or when the splashing of blood or body fluids into your face or eyes is likely.
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Objective 5 / b.Remember:
1)NEVER touch blood or body fluids with your bare hands.
2)ALWAYS wear PPE during every patient contact.
3)Wash your hands immediately after exposure to blood and/or body fluids and after removing disposable gloves.
a)If you were not wearing gloves and had contact with blood or body fluids, wash your hands with soap and water for at least 2 minutes.
4)Remember to throw away contaminated gloves and other PPE in clearly labeled biohazard bags or containers.
5)Report all exposures to your supervisor or Risk Management Department immediately.
18 / c.Primary survey
1)Form a general impression.
2)Then, assess
a)Airway
b)Breathing
c)Circulation
i)Look for major (severe) bleeding.
ii)Control bleeding if present.
19 / d.An average adult man has a normal blood volume of about 5-6 liters (5000-6000 mL).
1)In a previously healthy patient, a sudden episode of blood loss will usually not produce vital sign changes until the patient has lost 15-30% of his blood volume.
2)Estimate the severity of blood loss on the basis of patient’s signs and symptoms. If the patient shows signs and symptoms of shock, consider the bleeding severe.
Severity of Blood Loss
Normal Blood Volume / Severe Blood Loss
Adult / 5000-6000 mL / Loss of 1000 mL or more
Child / 2000 mL / Loss of 500 mL or more
Infant / 800 mL / Loss of 100-200 mL or more
 If bleeding is present, look at the area around the patient to get an idea of how much blood the patient may have lost before arriving on the scene. Consider less obvious signs such as the loss of blood into the ground, blood that is washed away by running water or rain, and blood that may have soaked into the patient’s clothing. Sometimes blood loss is difficult to estimate. For example, blood mixed with vomit or urine can appear to be a greater volume than it is. When it is dark, or if the patient is wearing dark clothing, the volume of blood loss will be harder to gauge.
20
Objective 6 / 11.Three methods may be used to control external bleeding:
a.Applying direct pressure to the wound
b.Applying a splint
c.Applying a tourniquet (if the bleeding is severe and cannot be controlled with direct pressure)
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Objective 6 / d.Direct pressure
1)Applying direct pressure to the bleeding site slows blood flow and allows clotting to take place.
2)Place a sterile dressing (such as a gauze pad) or a clean cloth (such as a towel or washcloth) over the wound.
a)If you do not have a dressing or clean cloth available, use your gloved hand to apply firm pressure to the bleeding site until a dressing can be applied.
3)Use your gloved fingertips if the bleeding site is small. If the patient has a large, open wound, you may need to apply direct pressure to the site with the palm of your gloved hand.
4)Hold continuous, firm pressure to the bleeding site while the body works to plug the wound with a clot.
5)If the bleeding does not stop within 10 minutes, press more firmly over a wider area.
22
Objective 6 / 6)If the bleeding site is on an extremity, continue direct pressure by applying a pressure bandage. A pressure bandage is a bandage with which enough pressure is applied over a wound site to control bleeding.
a)Wrap roller gauze snugly over the dressings to hold them in place on the wound.
b)Make sure that the pressure bandage is not so tight that there is no blood flow past the dressing.
i)For example, if you applied a pressure bandage to a wound on a patient’s lower arm, you should be able to feel a pulse at the wrist if the bandage has been applied properly.
 If blood soaks through the dressings, do not remove them. Removing the original dressings could disturb any blood clots that may be forming and cause more bleeding. Add another dressing on top of the first and continue to apply direct pressure.
23
Objective 6 / 12.Splints
1)The sharp ends of broken bones can pierce the skin and cause major bleeding. Unless a broken bone is immobilized, movement of bone ends or bone fragments can damage soft tissues and blood vessels, resulting in more bleeding.
2)Dress and bandage the wound and then apply a splint. A splint is a device used to limit movement of an injured arm or leg to reduce pain and further injury.
3)Pressure splint
a)Also called an air or pneumatic splint
i)Can help control bleeding associated with soft-tissue injuries or broken bones
ii)Also helps to stabilize the broken bone
b)Acts as a pressure bandage, applying even pressure to the entire arm or leg
c)After applying any splint, be sure to check the fingers (or toes) often for color, warmth, and feeling.
d)Direct pressure can be applied with an air splint in place.
i)May be necessary when controlling arterial bleeding from an arm or leg
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Objective 6 / 4)Pneumatic antishock garment (PASG)