Haemorrhage Guided Study

Question 1

What examination would you initially make of the casualty

Answer 1

Primary survey of casualty

Question 2

What vital signs would you measure and what other general observations would you make

Answer 2

First I would look for danger on the scene to avoid becoming a casualty. Then I would look for major trauma, check for obstructions to the airway, the breathing of the patient, then the circulation of the patient by checking for a pulse on a carotid artery. I would also look for any obvious disabilities/deformities as well as taking a note on the rough age of the casualty that may effect the application of basic life support

Question 3

Give a definition of shock

Answer 3

Shock is an acute state of insufficient blood flow to tissues due to fall in blood pressure.

Question 4

List the different sub types of shock.

Answer 4

Cardiogenic – When the heart cannot pump enough blood around the body, normally a heart attack.

Hypovolemic – Too little blood circulating around body, normally from trauma but can be internal bleeding from ulcer, haemorrhage or such.

Obstructive – Caused by obstruction, as the name implies, of the heart or the vessels S/I Vena Cava, Pulmonary Artery/Vein and Aorta. Also caused by a pulmonary embolism and cardiac tamponade, where fluid build up in the pericardium compresses the heart, restricting blood flow.

Distributive – Too much vasodilation in the extremities lead to too little blood flowing to the vital organs of the thorax and the brain, leading to a dangerously low BP, which causes shock. Also known as vasodilatory shock due to the mechanisms that cause it.

And some subtypes

Anaphylactic – A distributive shock caused by serious allergic reaction that activates a host of immune cells. This includes histamine which induces vasodilation causing a drop in BP and thus shock.

Septic – A type of distributive shock and most common form in patients admitted to intensive care units. Caused by infection.

Neurogenic – A type of distributive shock caused by disruption to the autonomic pathways of the spinal cord and so the autonomic innervation of the heart. Can be caused by traumatic injury to CNS (predominantly upper thoracic/cervical meninges; anything above T6).

Question 5

Considering her identified injuries, (Obvious deformity of proximal right lower limb. Bone can be seen within the 7 cm wound. Careful palpation around the wound elicits crepitus and increased pain) estimate how much blood this patient could potentially lose as a result of these identified injuries

Answer 5

Considering the wound is open, the paper in the BMJ emergency medical journal “Prehospital management of lower limb fractures” by C Lee, K M Porter, states that the estimated blood loss is between 2000 – 3000ml. A closed fracture would be half this number. This is in addition to the minimal blood loss from the various minor cuts and abrasions sustained.

Question 6

How would you manage the bleeding fracture site in this pre-hospital setting?

Answer 6

a) bleeding management
Cover the wound site in a dressing or clean cloth and apply pressure to stem the bleading, without pressing on the protruding bone. If possible secure the dressing with whatever is at hand, but preferably a bandage from a first aid kit in a local store.
b) fracture management
In my role as a first year medic I would look to the bleeding and wait for trained professionals to arrive. If it is convenient one may attempt an inline immobilisation to put the leg back in its anatomical axis, which reduces pain and lessens chance of muscle spasm forcing bone fragments into blood vessels. Then if a splint is available a traction splint is good for lower limb fractures as it applies a mild traction to keep the leg in line. Or fashion a splint by tying the extended legs together so the healthy leg keeps the fractured leg in line and immobile.