EM Lesson 1 Meterials for self preparing

INTERNAL BLEEDING

Internal bleeding (also called internal hemorrhage) is a loss of blood from a blood vessel that collects inside the body. Internal bleeding is usually not visible from the outside. Internal bleeding is usually not visible from the outside. It is a serious medical emergency but the extent of severity depends on bleeding rate and location of the bleeding (e.g. head, torso, extremities). 

Internal bleeding can either be caused by injuries or develop as a result of a variety of illnesses. Trauma. There are two types of trauma: Penetrating trauma and blunt trauma.

Non-traumatic. A number of pathological conditions and diseases can lead to internal bleeding. These include:

Symptoms. At first, there may be no symptoms of internal bleeding. If an organ is damaged and it bleeds, it can be painful. Over time, internal bleeding can cause low blood pressure (hypotension), increased heart rate (tachycardia), increased breathing rate (tachypnea), confusion, drowsiness, and loss of consciousness. Severe internal bleeding into the chestabdomenretroperitoneal spacepelvis, and thighs can cause hemorrhagic shock or death if proper medical treatment is not received quickly.

Some symptoms of internal bleeding depend on the location of the bleed.

Bleeding in the brain is usually associated with decreased mental function which may include vomiting, lethargy, seizure, or coma and unconsciousness. There may be the signs of stroke including slurred speech, loss of vision, and weakness of one side of the body.

Signs and symptoms of bleeding in the eye are decreased or hazy vision, floating objects in the vision, or blindness.

Gastrointestinal bleeding (GI bleed), also known as gastrointestinal hemorrhage, is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. Bleeding is typically divided into two main types: upper gastrointestinal bleeding and lower gastrointestinal bleeding.

Causes of upper GI bleeds include: peptic ulcer disease, esophageal varices due to liver cirrhosis and cancer, among others.

Symptoms of upper GI bleeds include hematemesis (vomiting up blood) and melena (tarry stool containing altered blood).

Causes of lower GI bleeds includehemorrhoids, cancer, and inflammatory bowel disease among others.

Symptoms of lower GI bleeds include passage of fresh red blood rectally, especially in the absence of bloody vomiting. Isolated melena may originate from anywhere between the stomach and the proximal colon.

Pulmonary hemorrhage (or pulmonary haemorrhage) is an acute bleeding from the lung, from the upper respiratory tract and the trachea, and the alveoli. The onset of pulmonary hemorrhage is characterized by cough productive of blood (hemoptysis) and worsening of oxygenation leading to cyanosis.

hemothorax (derived from hemo- [blood] + thorax [chest], plural hemothoraces) is an accumulation of blood within the pleural cavity. Hemothoraces are usually caused by an injury but may occur spontaneously: due to cancer invading the pleural cavity. The symptoms of a hemothorax depend on the quantity of blood that has been lost into the pleural cavity. A small hemothorax usually causes little in the way of symptoms, while larger hemothoraces commonly cause difficulty breathing and chest pain, and occasionally lightheadedness. The clinical signs of a hemothorax include reduced movement of the chest wall on the affected side. Large hemothoraces that interfere with the ability to transfer oxygen may cause a blue tinge to the lips (cyanosis). In these cases the body may try to compensate for the loss of blood, leading to a rapid heart rate (tachycardia), and pale, cool, clammy skin.

PRE-MEDICAL AID FOR INTERNAL BLEEDING

  1. If available put gloves on as bleeding may become apparent.
  2. Examinate the casualty according algorithm CABCE (check conscious, airway, breathing).
  3. Call or get someone to call emergency services. Don’t wait to see if the person improves or deteriorates.
    • If conscious – lie the casualty down and raise or bend legs if injuries permit.
    • If unconscious and breathing – place the person in the recovery position and with legs higher than the heart if possible.
    • If unconscious and not breathing – begin cardiopulmonary resuscitation (CPR).
  4. Put the ice in place for possible bleeding.
  5. Keep casualty warm. This may help delay the onset of shock by minimising the bodies heat loss.
  6. Reassure and stay calm. This helps provide security for the injured person.
  7. Continue to check conscious, breathing and pulse.
  8. Do not give anything to eat or drink as they may require surgery to stop the bleeding.

NOTE: If surgery is needed it is best that the person not consumed anything for minimum of 6 hours prior to having anaesthetic. The reason for this is if the stomach has contents in it they can exit the stomach and be inhaled into the lungs or remain in the throat and cause difficulty breathing during the operation. Neither the patient nor the medical staff need this complication during surgery.

 

BLOOD LOSS

 

Recognizing the degree of blood loss via vital sign and mental status abnormalities is important. The American College of Surgeons Advanced Trauma Life Support (ATLS) hemorrhagic shock classification links the amount of blood loss to expected physiologic responses in a healthy 70 kg patient.

Class 1: Volume loss up to 15% of total blood volume, approximately 750 mL. Heart rate is minimally elevated or normal. Typically, there is no change in blood pressure, pulse pressure, or respiratory rate.

Class 2: Volume loss from 15% to 30% of total blood volume, from 750 mL to 1500 mL. Heart rate and respiratory rate become elevated (100 BPM to 120 BPM, 20 RR to 24 RR). Pulse pressure begins to narrow, but systolic blood pressure may be unchanged to slightly decreased.

Class 3: Volume loss from 30% to 40% of total blood volume, from 1500 mL to 2000 mL. A significant drop in blood pressure and changes in mental status occur. Heart rate and respiratory rate are significantly elevated (more than 120 BPM). Urine output declines. Capillary refill is delayed.

Class 4: Volume loss over 40% of total blood volume. Hypotension with narrow pulse pressure (less than 25 mmHg). Tachycardia becomes more pronounced (more than 120 BPM), and mental status becomes increasingly altered. Urine output is minimal or absent. Capillary refill is delayed.

 

HYPOVOLEMIC SHOCK

Severe internal bleeding into the chestabdomenretroperitoneal spacepelvis, and thighs can cause hemorrhagic shock or death if proper medical treatment is not received quickly. Hypovolemic shock is a life-threatening condition that results when you lose more than 20 percent (one-fifth) of your body’s blood or fluid supply. This severe fluid loss makes it impossible for the heart to pump a sufficient amount of blood to your body. More specifically, hypovolemic shock occurs when there is decreased intravascular volume to the point of cardiovascular compromise. The hypovolemic shock could be due to severe dehydration through a variety of mechanisms or from blood loss. Hypovolemic shock can lead to organ failure. This condition requires immediate emergency medical attention.

Hypovolemic shock results from significant and sudden blood or fluid losses within your body. Blood loss of this magnitude can occur because of:

In addition to actual blood loss, the loss of body fluids can cause a decrease in blood volume. This can occur in cases of:

The symptoms of hypovolemic shock vary with the severity of the fluid or blood loss. Internal bleeding symptoms may be hard to recognize until the symptoms of shock appear, but external bleeding will be visible. Symptoms of hemorrhagic shock may not appear immediately.

Mild symptoms can include:

  • headache
  • fatigue
  • nausea
  • profuse sweating
  • dizziness

Severe symptoms, which must be taken seriously and warrant emergency medical attention, include:

  • cold or clammy skin
  • pale skin
  • rapid, shallow breathing
  • rapid heart rate
  • little or no urine output
  • confusion
  • weakness
  • weak pulse
  • blue lips and fingernails
  • lightheadedness
  • loss of consciousness

 

PRE-MEDICAL AID FOR HYPOVOLEMIC SHOCK

  1. Put gloves on as bleeding may become apparent.
  2. Examinate the casualty according algorithm CABCE (check conscious, airway, breathing).
  3. Call or get someone to call emergency services. Don’t wait to see if the person improves or deteriorates.
  • If conscious – lie the casualty down and raise or bend legs if injuries permit.
  • If unconscious and breathing – place the person in the recovery position and with legs higher than the heart if possible.
  • If unconscious and not breathing – begin cardiopulmonary resuscitation (CPR).
  1. Stop external bleeding with tourniquet or apply direct pressure to the area.
  2. Apply bandaging. Remove any visible dirt or debris from the injury site. Do not remove embedded glass, a knife, stick, arrow, or any other object stuck in the wound. If the area is clear of debris and no visible object protrudes from it, tie fabric, such as a shirt, towel, or blanket, around the site of injury to minimize blood loss. If you can, tie or tape the fabric to the injury.
  3. Have the person lie flat with their feet elevated about 12 inches. Refrain from moving the person if you suspect a head, neck, or back injury. Don’t elevate their head.
  4. Keep the person warm to avoid hypothermia.

Don’t give the person fluids by mouth!

  1. Prepare the victim for transport to the hospital or for evacuation.

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