EAC Wounds and Bleeding

Question 1

Anatomy of:

The Skin

Answer 1

Epidermis (stratified keratinised squamous epithelium)
Dermis (connective tissue)
Subcutaneous tissue

Question 2

5 categories of wounds

Answer 2

Contusion
Laceration
Incision
Puncture
Gunshot/blast injury

Question 3

define:

Contusion

Answer 3

Usually caused by a blunt instrument

May have associated tissue damage and fractures

Question 4

define:

Laceration

Answer 4

Usually results from snagging or tearing of tissue

Bleeds less freely but healing more prolonged

Question 5

define:

Incision

Answer 5

Usually made by a sharp edged object

Bleeds freely and heals quickly

Question 6

define:

Puncture

Answer 6

Usually caused by a pointed object

Difficult to assess any internal damage done and healing time

Question 7

define:

Gunshot/Blast injury

Answer 7

Usually caused by a bullet, shot or by shrapnel

May have both an entry and exit wound with associated internal injuries

Question 8

types of bleeding

Answer 8

External

Internal

Question 9

define:

External bleeding

Answer 9

This type of bleeding can be seen at source and there are three types:
Arterial - Spurts to the pulse rate
Venous - Constant flow
Capillary - Oozes to wound surface

Question 10

management of:

Bleeding

Answer 10

Bleeding
Apply dressing
Apply pressure direct/indirect
Where possible elevate the bleeding point above heart

Bleed controlled - transfer to further care
Bleed not controlled - Refer to catastrophic haemorrhage management (combat tourniquet)

Question 11

Indications for use of Combat Tourniquet

Answer 11

Life threatening haemorrhage uncontrollable by simple measure

Extreme life threatening haemorrhage or limb amputation/mangled with multiple bleeding points

Point of significant haemorrhage form limb not peripherly accessable due to entrapment

Multiple casualty situation with extremity haemorrhage, lack of resources to maintain simple measures

Question 12

Combat Tourniquet important points

Answer 12

Only use on upper leg or arm

Place as distal as possible to injury - at least 5cm proximal to injury

Place directly on skin surface

Time of application to be documented

• on PRF/triage card
• on Patient

Question 13

indications of:

Internal bleeding

Answer 13

Swelling

Blood may appear via existing orifices

Question 14

where can Internal Bleeding occur

Answer 14

Abdominal Cavity form damage to internal organs

In the brain (seen in eye orbits, ears or nose)

In thoracic cavity from damage to lungs (haemothorax)

Contusions (bruises)

Question 15

Assessing Blood Loss:

Considerations

Answer 15

Its the percentage lost that’s important for developing shock.

Volume lost should be considered relative to pt’s size

consider:
in body tissue (swelling)
On floor (absorption into surface)
In pt's clothing
In wound dressing

Question 16

Assessing Blood Loss:

External - 0.5L blood will cover

Answer 16

Non absorbent e.g. road surface/kitchen floor: 0.4m2

Absorbent e.g. sand/earth/carpet: 0.2m2

Heavy clothing e.g. tweedy material: 0.2m2

Light clothing e.g. cotton/nylon shirt: 0.4m2

Question 17

Assessing Blood Loss

Internal/Closed wounds

Answer 17

ankle with moderate to sever swelling: 0.25-0.5L

Question 18

Factors affecting blood loss

Answer 18

Depth, type, size and position of the wound

Size and type of blood vessel

Duration of bleeding

Age and size of patient

Underlying injuries

Question 19

Normal blood volumes for children

Answer 19

6-12months = 0.5L
1-2years = 0.7L
2-3years = 1L
3-5years = 1.3L
6-9years = 1.7L
10-11years = 2.5L
12-13years = 3.2L

Question 20

Normal blood volumes for adults

Answer 20

by height:
140cm/4ft10in = 2.5L
170cm/5ft8in = 5L
195cm/6ft8in = 6.8L

Question 21

how to assess severity of bleeding:

Answer 21

Pulse: increasing, becoming weaker as condition deteriorates

Respiration: increasing from normal, developing to ‘air hunger’

Pupils: Become larger as the condition worsens

Skin: pallor ashen, cold extremities, cyanosis developing

Blood Pressure: One of the least sensitive, and very late, but most dramatic signs of shock

Faintness, Nausea, thirst, Restlessness, Dizziness, Feeling cold and shivering, Blurred vision

Question 22

pathology of:

Missile Injuries

Answer 22

A missile may be described as any object propelled forwards by an external force.

the force may be a human arm or the ignition and rapid expansion of a chemical mixture.

Question 23

what is kinetic energy transfer

Answer 23

transfer of energy from a moving object to another object.

The principle cause of damage from missiles is the amount of energy transferred to tissue mass. broken into 3 categories low, medium and high energy transfer wounds.

Question 24

types of missile:

Primary Missiles

Answer 24

those that originate from the source of energy, such as bullets, arrows or fragments from an explosive device

Question 25

types of missile: | Secondary missiles

Answer 25

may take form of particles or material picked up by blast waves or the passage of the primary missile i.e. masonry, wood, glass, clothing or bone. Should bone be struck by a missile it may shatter and slivers take up energy and become missiles themselves.

Question 26

factors affecting missile flight

Answer 26

Size: The larger the missile the more quickly it is slowed or retarded Shape: The more irregular the shape the more it will be slowed as it travels through the air Weight: The forces of gravity act upon missiles, therefore the more they weigh the more they are slowed Velocity: The greater the driving energy the greater the range of flight Stability: e.g. bullets are heavier at their base causing momentum to carry base forward when they strike a target. The centre of gravity (base) becomes the leading point causing an 'end over end' motion. This tumble effect produces a far greater energy exchange and therefore greater tissue damage. Oscillation: bullets are prone to oscillate on the long axis of flight. guns barrels are rifled to spin bullets as they leave, reducing the angle of yaw in flight, increasing stability and range.

Question 27

define: | Low Energy Transfer Wounds

Answer 27

These may be describes as penetrating injuries that involve the disruption of tissue. Causes of injury may be: Hand held instruments such as knives and tools Falls that result in the Pt being impaled on a sharp thin object As these are low velocity injuries there is usually less secondary trauma and damage usually being confined to the path of the missile and underlying structures

Question 28

define: | Medium Energy Transfer Wounds

Answer 28

Energy transferred to tissues will be relatively minor, therefore damage will be minimal and confined to the permanent wound track. Unless vital organs or structures have been damaged, infection will be the primary concern.

Question 29

define: | High Energy Transfer Wounds

Answer 29

The effects of a large amount of energy being transferred can be devastating. The density of tissue involved will be a significant factor. The more dense the tissue, the greater the degree of retardation and thus the greater the damage caused by the increased transfer of energy. 3 factors involved in the damage and destruction of tissue: Direct laceration and crushing of tissue by the missile on its passage The shockwave that precedes the missile The formation of a temporary cavity

Question 30

define: | Temporary Cavitation

Answer 30

in the case of a bullet, high energy transfer wounds may form temporary cavity ten times its diameter. Sucks in debris due to a brief initial fluctuating positive and negative pressure, causing severe destruction to tissue/blood vessels. Longitudinal fractures may also cause nerve damage.

Question 31

management of: | Ballistic Injuries

Answer 31

``` DrABCDE High % O2 Be prepared to ventilate Seal any thoracic wounds if present If an extremity injury, immobilise Minimise time on scene to ```

Question 32

management of: | Amputation and De-Gloving

Answer 32

Injured area: Irrigate grossly contaminated wounds with saline Immobilise partially amputated limb in normal anatomical alignment Apply moist dressing to cover injured area ``` amputated part: Remove any gross contamination Cover the part/s with moist dressing Place part/s in sealed bag Place bag on ice ```

Question 33

pathology of: | pressure ulcer

Answer 33

A localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear.

Question 34

who is at risk of: | Pressure Ulcers

Answer 34

``` Seriously Ill Neurologically compromised Impaired mobility or immobile Impaired nutrition obesity Poor posture or use of bed/seating Spinal cord injured patients Elderly Pregnant mothers are at risk ```

Question 35

bodies risk areas for developing: | pressure ulcers

Answer 35

``` Back of head Shoulder Base of spine Buttocks Heels Toes Elbow Hip Leg Rib cage Thigh Knees ```

Question 36

development stages of: | Pressure Ulcers

Answer 36

Stage 1 Stage 2 Stage 3 Stage 4

Question 37

development stages of Pressure Ulcers: | Stage 1

Answer 37

Non-blanchable erythema (redness) of intact skin May present as discolouration, warmth, oedema, hardness in dark skinned people

Question 38

development stages of Pressure Ulcers: | Stage 2

Answer 38

Partial thickness skin loss involving epidermis, dermis or both superficial, looks like a blister

Question 39

development stages of Pressure Ulcers: | Stage 3

Answer 39

Full thickness skin loss involving subcutaneous tissue down to but not through fascia Involves necrosis (death of tissue)

Question 40

development stages of Pressure Ulcers: | Stage 4

Answer 40

Extensive tissue destruction and necrosis Damage to muscle, bone and supporting structures Full-thickness skin loss

Question 41

pathway of care for: | pressure ulcers

Answer 41

be alert to risk of pressure damage when positioning/ moving Pt's When identified in a Pt THI MUST be handed over to ED staff and recorded on PRF High grade 3-4 ulcers should be reported through safe guarding regardless of destination High grade should be conveyed unless Pt declines and has capacity Low grade or at risk - ensure robust follow up with GP or CTT if Pt declines hospital If attending an elderly faller who is not conveyed but has more then 2 risk factors: note risk or pressure ulcer on falls referral and PRF If transporting Pt with pressure ulcer try to position them off the area to avoid further damage if possible Ensure fully documented on PRF and handed over to ED staff

Question 42

define: | Haematoma

Answer 42

a swelling of blood within the tissues

Question 43

define: | Hyphema

Answer 43

is blood in the front (anterior) chamber of the eye.