Wounds & Bleeding

Question 1

Definition of a Wound

Answer 1

A wound is a break in the continuity of tissue.

It frequently includes a break in the surface of the skin or mucous membrane exposing it to infection.

Question 2

Types of Wounds:

Answer 2

Incision.
Laceration.
Puncture.
Contusion.
Gunshot/Blast.

Question 3

Incision

Answer 3

Usually made by a sharp edged object.

Bleeds freely but heals quickly.

Question 4

Laceration

Answer 4

Usually results from snagging or tearing of tissue.

Bleeds less freely and heals slowly.

Question 5

Puncture

Answer 5

Usually caused by a pointed object.

Difficult to asses if any internal damage done and healing time required.

Question 6

Contusion

Answer 6

Usually caused by a blunt instrument.

May have associated tissue damage and fractures.

Swelling and bruising could be signs of fracture.

Question 7

Gunshot/Blast

Answer 7

Usually caused by a bullet, shot or shrapnel.

May have both an entry and exit wound.

Pressure waves precede bullets so damage can be greater then first appears.

Question 8

2 types of bleeding

Answer 8

External

Internal

Question 9

Arterial bleeding characteristics

Answer 9

Spurts out in time with the pulse rate.

Question 10

Venous bleeding characteristics

Answer 10

Constant flow.

Question 11

Capillary bleeding characteristics

Answer 11

Oozes to the wound surface

Question 12

Internal bleeding diagnosis

Answer 12

Bleeding may not be obvious and difficult to diagnose.

It can sometimes be detected by a swelling (haematoma).

If internal organs are affected blood may appear via body orifices.

Question 13

Areas internal bleeding could be present

Answer 13

Abdominal cavity from damage to internal organs.

Thoracic cavity from damage to the lungs.

In closed fractures.

In contusions.

Question 14

Penetrating injury complications

Answer 14

May be difficult to stop bleeding.

May affect underlying tissues/organs.

Difficult to assess severity of injury.

Increased risk of infection.

Question 15

Complications of bleeding

Answer 15

Depth, type and size of wound.
Size of blood vessel involved.
Duration of bleeding.
Position of injury.
Age/Size of patient
Infection
Emotional distress.

Question 16

Assessing severity of bleeding - signs

Answer 16

Pulse rate increases - weakens with deterioration.
Respiration - increased to air hunger.
Pupils become dilated.
Skin pallor, cold extremities, cyanosis.
Blood pressure lowers - a late stage but a dramatic sign.

Question 17

Management of bleeding

Answer 17

Primary survey: DRABC
Control any serious/obvious haemorrhage.
Administer high % oxygen as appropriate.
Consider paramedic assistance where needed.
Apply direct pressure as required.
Elevate wound if possible.
Raise lower limbs if possible.
Treat for shock.
Reassurance.
If conscious position patient flat with head and shoulders slightly raised.
If unconscious place patient in stable side position.
Treat other injuries and bleeding.
Do not remove foreign bodies.
Check dressings for security and effectiveness.
Consider pressure points if necessary.

Question 18

Arterial tourniquet

Answer 18

Under the direct of paramedic, you may require to apply the Arterial Tourniquet to arrest external haemorrhage.

Question 19

Application of tourniquet - step 1

Answer 19

The tourniquet should be slid into position over the limb.
The tourniquet is not to used on the lower arm or lower leg.
The tourniquet should be placed as distal as possible on either side of the humerus or femur as required, but at least 5cm proximal to the injury, sparing joints as much as possible. It should be placed directly onto skin.

Question 20

Application of tourniquet - step 2

Answer 20

Once in place the tourniquet should be tightened by pulling on the long loose end of the tourniquet.

Question 21

Application of tourniquet - step 3

Answer 21

Once in place the tourniquet can be tightened using the windlass rod. The effective application of the tourniquet is determined by the cessation of external haemorrhage (not the presence or absence of external or distal pulse).

If the cessation of haemorrhage does not occur the tourniquet should be further tightened; if this does not work consideration should be given to repositioning the tourniquet and/or the application of a second tourniquet.

Question 22

Application of tourniquet - step 4

Answer 22

Once control of the haemorrhage has been achieved the windlass rod should be secured using the triangular plastic clip.

Question 23

Application of tourniquet - step 5

Answer 23

The time of application should be noted on the tourniquet.

Question 24

Types of dressing

Answer 24

Standard ambulance minor wound dressings-various.
Various paramedic dressings.
Triangular bandage (support, immobilisation, elevation)

Question 25

Wound dressings should be:

Answer 25

Large enough to completely cover injury.
Sterile and made of soft absorbent material that will not stick to wound.
Applied so as to provide enough pressure to control bleeding.

Question 26

Infection of wounds

Answer 26

Is usually caused by contamination of an open wound by bacteria. The source can be: Clothing/Foreign bodies or other infected material coming into contact with the wound.

Question 27

Infection risk reduction

Answer 27

By good aseptic technique and personal cleanliness of crew.

Universal precautions must be applied when dealing with body fluids.

Question 28

What is a pressure ulcer?

Answer 28

A localised area/s of soft tissue destruction caused by compression of soft tissue over a bony prominence and an external surface for prolonged period of time.

Question 29

Pressure ulcers are caused by:

Answer 29

Pressure
Shear
Friction
Moisture

Question 30

Pressure ulcers - Pressure - definition

Answer 30

created when the external surface against the skin and the persons skeleton compress soft tissue sufficiently to interrupt blood flow. Tissue ischaemia and tissue death occur.
A patient sitting on an ambulance buckle or rumpled blanket for 10-20 minutes is enough!

Question 31

Pressure ulcers - Pressure - pressure points

Answer 31

Elbow
Knees
Back of head
Shoulder
Lower back and buttocks
Heel

Question 32

Pressure ulcers - Shear - definition

Answer 32

Shear occurs when the skeleton moves, but the skin remains fixed to an external surface. Blood vessels are kinked or twisted. (i.e. pulling a patient up in bed, sliding a patient from a bed to a stretcher).

Question 33

Pressure ulcers - Friction ulcers - definition

Answer 33

Friction ulcers are generally superficial and easily reversed unless the cause is not removed.
Common in bed ridden patients who use heels and elbows to aid movement.

Question 34

Pressure ulcers - Moisture - definition

Answer 34

Moisture is a chemical cause of promoting pressure ulcers. It weakens the cell wall of the skin cells. It can change the pH of the skin.

Question 35

Pressure ulcers - Moisture - causes

Answer 35

Faecal & urinary incontinence
Wound drainage
Respiratory secretions
Perspiration

Question 36

Pressure ulcers - Who is vulnerable?

Answer 36

All patients with spinal cord injury, the chronically unwell and the elderly are at high risk of developing pressure damage due to:
Lack of sensation
Lack of movement

Question 37

Pressure ulcers - Intervention

Answer 37

Minimize pressure for all patients.
Encourage weight shifting every 15 minutes.
Handover to staff with pressure sore information.
Use transfer devices.
Position with pillows to elevate pressure points.
Use 2 people minimum & draw sheet to pull patient up bed.
don’t drag a patient.
Keep head of bed <=30degrees incline
Pas skin surfaces - elbows, heels, etc.

Question 38

Pressure ulcers - Consequences

Answer 38

Septicaemia, death
Amputation
Prolonged hospital admission
Loss of independence
Family disruption
Massive financial cost to the NHS