Hemorrhage

Paramedic AEMT EMT EMR

Introduction
The recognition and management of hemorrhage in medical and trauma patients are vital for decreasing mobility and
mortality. There is a significant emphasis on hemorrhage management in trauma that should be managed after, or at the
same time if resources allow, airway management is completed.

Anatomy & Physiology

Located inside the thoracic cavity behind the sternum with about two thirds of the heart lying in part of the left aspect of the
mediastinum.

Consisting of the right atrium and ventricle that supplys blood to the lungs and receives the blood from the systemic
vasculature.

Also containing the left atrium and ventricle that supplys blood to the systemic circulation and receives the blood from the
pulmonary circulation.

Blood will pass between the right atrium and right ventricle via the tricuspid valve. Where the right ventricle will pump the
blood up through the pulmonary semilunar valve.

Blood will pass between the left atrium and left ventricle via the mitral valve. Where the left ventricle will pump the blood up
through the aortic semilunar valve.

Blood Flow within the Heart and Lungs

The superior and inferior vena cava return blood from the systemic circulation that is deoxygenated to the right atrium.
From here the blood will pass between the right atrium into the ventricle to be pumped into the pulmonary circulation.

Once the blood is in the pulmonary circulation the blood will offload the carbon dioxide and on load oxygen for perfusion of
the bodies cells.

Blood will be returned to the left side of the heart to then be pumped around to systemic circulation.

The Cardiac Cycle

Is used to describe the continual progressive and repetitive pumping of the heart.

It is important to remember that is is controlled by the SA and AV node. Starting with the depolarization of the right atrium
and left atrium that forces the blood into the prospective ventricles. With the next aspect being the depolarization of the
right ventricle and left ventricle forcing the blood into the prospective section of circulation.
 Preload is at the amount of blood that is returned to the heart to be pumped out. This directly affects the after load.

After load is the pressure in the aorta or peripheral vasculature that the left ventricle must pump against. The greater the
after load the harder it is for the ventricle to eject blood.

Stoke volume is the amount of blood ejected per contraction. This can be reduced in the presence of high after load.

Cardiac Output is the amount of blood pumped through the circulatory system in 1 minute. This is calculated by multiplying
the stroke volume and pulse rate.

Blood

Plasma is the straw colored fluid that counts for more than half of the total blood volume. Consisting of 92% of water and
8% of dissolved chemicals, minerals, and nutrients.

Red Blood Cells (RBCs) make up about 45% of the blood volume. The purpose of the cells are to carry oxygen, glucose,
proteins, fats, and electrolytes to the tissues and then carry away cellular waste products. These cells are also known as
Erythrocytes.

Hemoglobin is contained on the cells and binds to oxygen. Each is able to bind up to four gaseous molecules.

White Blood Cells (WBCs) combined with platelets only makes up about 1% of the blood volume. Help to fight infections.
Also know as Leukocytes. There are several types and they all sever different functions.

Platelets is import for controlling bleeding. These small cells are vital for coagulation to take place. Working with clotting
proteins, calcium, and other proteins in order to stop the hemorrhage.

Hematocrit tests are vital in order to ensure the patient has the appropriate level of RBCs that can indicate disease states
or conditions. Normal range for males of any age is 40.7-50.3% for females of any age it is 36.1-44.3%.

Blood Circulation and Perfusion

It is important to remember that arteries carry blood away from the heart while veins carry blood to the heart.

The vasculature that is spread throughout the body is extensive with varying branches and connection points supplying
vital nutrients to the body that is needed for life.

Perfusion is the actual circulation of blood within an organ or tissue in adequate amounts to meet the cells needs.

The autonomic nervous system monitors the bodies needs and adjust the blood flow accordingly.

Pathophysiology of Hemorrhage
External Hemorrhage

The severity of hemorrhage is linked to the wound type and the types of vascular that have been injured.

Capillary bleeding is typically described as oozing and hemorrhage can be of a significant amount in the present of a large
abrasion and varicose veins.

Arterial bleeding is typically described as spurting (initially), with the progression of loss of blood the bleeding may continue
to a simple continual flow of blood. The blood is typically described as bright red due to being of high concentration of
 oxygen. This type of bleeding changes along with blood pressure.

Arterial incisions directed across or transverse will often recoil in an attempt to slow the bleeding. If the artery is cut
vertically it will continue to bleed and no longer has the mechanism to attempt to self control.

Venous bleeding is typically described as dark red due to the low oxygen concentration and is a steady flow.

Internal Hemorrhage

Internal hemorrhage may occur in any location of the body, with some being contained within a small space and other
being able to freely bleed.

Fractures of the long bones can still lose blood, but is confined into the space surround the bones and between the muscle
tissues. Occupying a limited space.

Hemorrhage into the trunk of the body can be considerable and develop rapidly. Leading too severe and uncontrollable
bleeding in the out of hospital setting.

Non trauma induced hemorrhage usually occurs in the GI system. But can also occur in the pelvic cavity or abdominal
cavity due to ectopic pregnancy, abdominal cavity and thoracic cavity or inside the cranium due to ruptured aneurysms.

It is vital treat these patients quickly and signs of discoloration and hematoma do not always develop quickly, meaning that
you must rely on other signs and symptoms. This is even more so in trauma patients.

The Significance of Hemorrhage

The adult male has approximately 70mL of blood per kg of body weight, adult females contain approximately 65mL of
blood per kg.

The body cannot tolerate more than 20% of the total blood volume. If the body loses more than 20% of blood, vital signs
will change leading to increased heart rate, respiratory rate, and a decrease in blood pressure.

With pediatrics, they have a significantly less blood volume meaning that with even a small amount of blood loss could
lead to significant changes.

A patients ability to compensate for blood loss is related to how rapidly they are bleeding and health.

One must consider bleeding to be serious in the presence of a significant MOI, poor general appearance of the patient,
signs and symptoms of shock, significant amount of blood loss, rapid blood loss, and uncontrollable hemorrhage.

Physiologic Response to Hemorrhage

With arterial bleeding it can be difficult to control due to the pressure that cause the bleeding to spurt. As the bleeding
continues the amount of blood available decreases causing the patient blood pressure to drop. This can be seen when the
spurting diminishes.

Venous bleeding is easier to manage due to having less pressure.

Capillary bleeding is typically relatively easy to slow and stop.

Venous and capillary bleeding is more likely to clot spontaneously while arterial bleeding is not.

Venous and capillary bleeding, and some minor arterial bleeding can on its own typically can stop bleeding in about 10
 minutes due to clotting mechanisms and being exposed to the air.

Hemostasis occurs when vasoconstriction and platelet aggregation occurs and the bleeding is stopped. If the clot does not
occur the bleeding will continue.

Clotting typically occurs due to direct contact with body tissues and fluids or the external environment.

Anticoagulants prevent the normal process of clotting from occurring. It is also important to remember that blood clotting
disorders can have spontaneous bleeding and are not able to produce clots.

Beta Blockers can prevent vasoconstriction.

With large every injuries the clot could not be able to completely form or the vascular wall injury could prevent
vasoconstriction from occurring.

It is important to remember that in the presence of a cold environment or hypothermia the enzymes that assist in clot
formation can be stopped. Leading to clotting not occurring.

Hemorrhagic Shock

There is significant risk of developing hemorrhagic shock in patients with both external and internal hemorrhage. With an
increased risk of development in patients with trauma and internal hemorrhage.

Penetrating injuries to the heart, thoracic vascular system, abdominal vascular system, venous system, and liver have a
high potential for development of hemorrhagic shock.

The American College of Surgeons Committee on Trauma has created four classes in order to identify the characteristics
and treatments needed.

Class I - Compensated Shock

Vital signs seen include a heart rate less than 100, systolic blood pressure that is within normal limits, pulse pressure
that is within normal limits, capillary refill time that is within normal limits, respiratory rate between 14-20, patient may
be slightly anxious, and the skin may be cool and pink.

The patient should still have a urine output of greater than 30mL/hr.

Fluid replacement of crystalloid is approved for this class.

Class II - Compensated Shock

Vital signs seen include heart rate more than 100, systolic blood pressure this is normal, pulse pressure that is
narrow, delayed capillary refill, respiratory rate between 20-30 breast a minute, patient may be mildly anxious, and
the skin may appear cool and pale.

The patient may have a urine output between 20-30mL/hr.

Fluid replacement of crystalloid is approved for this class.

Vital signs seen include heart rate more than 120, systolic blood pressure that is low, narrow pulse pressure,
respiratory rate between 30-40, delayed capillary refill, patient may be anxious and confused, and skin may appear
cold/pale/moist.

The patient may have urine output between 5-15mL/hr.

Fluid replacement of crystalloid and blood product are approved for this class.

Class IV - Irreversible Shock

Vital signs seen include heart rate above 140, systolic blood pressure that is now, very narrow pulse pressure,
absent capillary refill, the patient may be confused and lethargic, and skin may appear cold and cyanotic.

The patient may have only a little or no urine output.

Fluid replacement of crystalloid and blood products are approved for this class.

As the body attempts to compensate for the bleeding, decreased venous return will develop. Leading too decreased stroke
volume, low cardiac output, tachycardia, hypotension, and hypopurfusion.

Compensated hypopurfusion presentation includes agitation, anxiety, restlessness; sees of impending doom; weak, rapid
(thready pulse; pallor with cyanosis of the lips; SOB; nausea and vomiting; delayed capillary refill in pediatrics; thirst; and
normal systolic blood pressure.

Decompensated hypopurfusion presentation includes altered mental status; decreased level of consciousness;
hypotension; labored or irregular breathing; thready or absent peripheral pulses; ashen, mottled, or cyanotic skin; dilated
pupils; diminished urine output; and impending cardiac arrest.

Management for Hemorrhage and Hemorrhagic Shock

Initially management includes applying direct pressure over the site of bleeding and maintaining said pressure. It is
important to recognize the need for a secondary method of hemorrhage control included below.

Rapid transport is recommended for patients who are presenting with hypopurfusion with shock management.

Do NOT attempt stop hemorrhage from the nose or ears following head trauma, it may indicate a skull fracture. If done it
may result in blood collecting inside the head increasing ICP and potentially leading to permanent damage.

Wound packing for large gaping wounds with sterile dressing and applying pressure has been show to be fairly effective in
slowing hemorrhage.

It is vital to keep the patient warm and in the appropriate position.

Utilized for sever hemorrhage from and extremity below the axilla or groin.

Direct pleasure should be applied to the wound while applying a tourniquet.

Place above the injury site, about 2-3 inches.

Tighten until bleeding is controlled or the loss of pulse is noted.

The goal is to stop the bleeding.

A secondary tourniquet may need to be applied above the first in some situations.

The time of tourniquet needs to be placed as well and is vital, also know that there is no contraindication for the use in an
emergency situation.

Splints

Typically when bleeding occurs due to fractures, it is from the sharp ends of the bones lacerates the nearby vasculature
and tissues. This movement can also lead to clots that have started to be formed to become broken away that can lead to
increased hemorrhage.

Air splints can control venous hemorrhage via stabilizing the broke bones. It works by turning into a pressure dressing that
covers the entire extremity. It is important to continually monitor circulation in the distal aspect of the extremity. It is
important to note that the air splint cannot control an arterial hemorrhage.

Rigid splints can stabilize fractures, reduce pain, and prevent further damage to soft tissues. It is important that we monitor
distal vital signs as well.

Traction splints are used to stabilize femur fractures. Due to the counetrtraction at the ischium and goin along with the
traction at the ankle prevents the fractured ends of the femur from causing further injuries and decreased the overall space
available for hemorrhage. Make sure that you continue to monitor circulatory status distal to the extremity.

Hemostatic Agents

The use of hemostatic agents has ben field tested and shown to be an affective hemorrhage control tool by the military.

Are used for severe hemorrhage in areas where a tourniquet is not practical.

Cause vasoconstriction to the vasculature that the agent comes into contact with.

With hemostatic agents that come in powder form it is a risk of an emboli as well as the introduction of contaminates into
the vasculature where as impregnated bandages have been shown to bypass these risks.

Internal Hemorrhage

For management of internal hemorrhage, we focus more on the treatment of shock, minimizing movement of the injured or
bleeding par, and providing rapid transport.

Patients with internal hemorrhaging ultimately needs surgical procedures in order to stop the hemorrhaging in the hospital
setting.
 We need to maintain airway and cervical spinal immobilization, supply oxygen when needed and indicated, and control
obvious external bleeding.

Treat suspected internal bleeding in an extremity with the use of splints.

Monitor vital signs every 5 minutes and ensure the patient is NPO.

Establish large bore vascular access and supply fluid bolus after ensuring that the patient shows no signs of fluid overload
with pulmonary edema. Consider establishing a secondary large bore IV access.

Keep the patient warm.

Consider pain management following your agencies protocol.

Hemorrhagic Shock

For treatment of shock we will follow the same patient management with controlling and stabilizing the patients ABCs while
providing rapid transport to the ED.

Spinal immobilization may be needed and ensure the the patient does not vomit, or if the patient does that you are able
manage them as such.

Control external bleeding and ally splints as needed.

Administer supplemental oxygen and assisted ventilations as indicated.

Establish large bore vascular access during transport. If indicated in your policy you may need to draw blood for lab work.

Apply warm fluid resuscitation as indicated per protocol to keep mean arterial pressure (MAP) with in recommended range.

Blood products and surgical intervention is needed in the clinical setting and needs to go into effect as quickly as possible.

Ensure that the patient is NPO as this increases the risk of vomiting leading to complications.

Resources

1. Nancy Carolines Emergency Care in the Street. 7th Edition. Jones & Bartlett Learning. Volume 2. 2013. ISBN 978-1-4496-
4586-1.