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Underneath each rib is a neurovascular bundle consisting of an artery, vein, and nerve. Breaking a rib can cause sharp edges that lacerate blood vessels and lead to bleeding. Signs of hypoperfusion include changes in mental status, weakness, fainting, dizziness, and changes in skin. Decompensation signs include tachycardia, weakness, fainting, dilated pupils, shallow breathing, and dull eyes. Capillary refill time can indicate perfusion or hypoperfusion. In children under three, capillary refill is a better indicator than blood pressure. When dealing with bleeding patients, wear protective gear and prioritize stopping the bleed and ensuring open airways. Control external bleeding with direct pressure and dressings. Use tourniquets for arterial bleeds and hemostatic agents for large wounds. Once a tourniquet is applied, it should not be removed. Underneath each rib is a neurovascular bundle, an artery vein and a nerve. When you break a rib, ribs break sharp edges and they lacerate blood vessels and you can bleed. Bruising over the lower part of the chest, again, it could be spleenic or liver, a rigid distended abdomen, especially if the patient complains of abdominal pain where they kind of winch before you even touch it. Hypoperfusion is going to be indicated by a change in mental status, weakness, fainting, dizziness, and standing changes in skin. Later signs, especially with decompensation, tachycardia, weakness, fainting, dizziness, cold thirst, nausea, cool, moist, clean skin. Shallow rapid bleeds, breathing, dull eyes, dilated pupils, these are all signs of decompensation. Capillary refill more than two seconds. I take your finger, I glance it, and then I let it go. Capillary refill. Still not. Takes about two seconds to say capillary refill. If it delays, that's a sign of pulperfusion. What's actually excellent in children under three, I don't even do a blood pressure. I do capillary refill because if I go to a kid and I glance the skin and I let it go and say capillary refill and it fills in, it pinks up, they have more external surface to internal volume. If they can perfuse that arm, they got good pressure. That's better than a blood pressure. That's better than a measured blood pressure. So capillary refill less than two if you tell that to a doctor. If you go to a doctor and say I have a six-month-old, capillary refill plus two, or capillary refill three, or capillary refill four, he's going to say okay, that's bad, that child is decompensating. And of course, decreased blood pressure and ultramental status, which are both signs of decompensated child. Be alert for potential hazards, don't become a victim yourself. For violent incidents, make sure the police are there. Also stand a precaution, gloves, goggles, mask. Remember they're bleeding, bleeding sprays, especially if somebody's bleeding in the face or the mouth and they're talking to you, or if they're bleeding in their hands and they're very animated, blood's flying everywhere. You'd be surprised the places I found inside the anus that had blood after a bloody patient. It goes everywhere. It hides everywhere. Yeah. I've seen it shoot up front and get on the radio. Remember the mechanism of injury, the need for spinal immobilization, call ALS, especially if there's significant bleeding, we can get IV fluids. And then weather. Remember a cold patient will not bleed until they start warming up. And then they're going to bleed like stuck pigs because cold blood doesn't clot. It'll just keep coming out, and coming out, and coming out. So always bandage a patient before they start warming up. Immediately bandage the patient. Do not be distracted from identifying life threats, right? We've got to focus on ABCs, bleeding ABCs. Don't worry about the degloving or the, you know, the angulated tib-fib fracture. Those aren't going to kill the patient. The bleeding and airway is going to. Determine the age and gender of the patient and be aware of obvious signs of injury. Look for life threats. If the patient has obvious life threats, fix them, assess the skin, and determine the level of consciousness. Airway and breathing, consider the need for spinal stabilization. Make sure the patient has a pain in the airway and adequate breathing. Check for breath sounds. Have suction available. We could use an OPA on an unconscious patient, or if a patient is in and out of consciousness and there's no head trauma, we could use an NPA. The patient's not breathing adequately, bag them. If they're breathing adequately but need oxygenation, put them on an army breather. Determine all of your vital signs, control external bleeding, and treat for shock. Treat early, treat often, treat aggressively. Assess your bleeding ABCs and life threats. Signs that imply rapid transport. Tachycardia, low blood pressure, weak pulse, and cramping skin. Do you see these? High priority. Don't even wait. Call ALS immediately. Look for signs and symptoms of other injuries. Note obvious external bleeding, internal bleeding, or note the contextual coordinate. Set the entire patient. Do your sample history. If the patient's unresponsive, you may have to look for medical alert tags. Ask family members, bystanders, and determine the amount of blood loss. Estimate blood loss the best you can. It's always better when you're new to kind of overestimate. Whatever you come up with, add a little bit more. CTLS, deformities, contusions, abrasions, punctures, perforations, burns, tendons, lacerations, and swelling. Record your vital signs. Get your baseline immediately. Hello sir, my name is Greg, I'm an EMT, my partner's going to do some vital signs. Get the vitals right away, and then every five minutes do subsequent vitals, and you'll know if the patient's getting better or worse. That's how you tell. We call it trending. With a critically injured patient and a short transport time, there may not be time to conduct a secondary assessment. You may start at the head and then you hear beep, beep, as you're backing up to the ambulance bay. If you don't see your partner, no wait, I'm not done with my assessment. You go in and tell doc, this is as far as I got, the accident happened right down the street. Doctor will love you for that. They like quick transports. Reassess the patient in the areas that show abnormal findings. Vitals every five minutes. Stop bleeding. Do not delay transport to do any assessment. You do your assessment as you're packaging. That's the best way to do it. Communicate, estimate, recognize, estimate the amount of blood loss. All injuries, no matter how minor, communicate all relevant information. What was the mechanism of injury? How did they get injured? Why are they bleeding? How much did they bleed? And the patient's response to any treatments you've done. Let them know if they've been in shock. Wear gloves, eye protection, and possibly a mask or gown. I've never put on a mask. I've never put on a gown for a bleeding patient. You just not. It's like not no time. Oh, stop bleeding for a minute, let me put on my gown. But, that's a personal choice. You want to put on a gown, you have every right to put on a gown. Nobody's ever going to fault you because you put on a gown for an arterial bleed. Make sure the patient has an open patent airway. Again, stop the bleed, airway. You can do it simultaneously. You and I are partners. You know, you're with us. You're a firefighter, a police officer. You grab a C-spine. You stop that bleed right there, put your gloved hand on it, and I can do airway. You can delegate, um, delegate skills. Several methods for, available for controlling external bleeding. Direct, even pressure. Put a gloved hand on it, stop that bleeding. And then you're going to put a pressure dressing on it. Put a bandage on it, wrap it with Curlex, or tie it with a Corvette. Tie it, tie it. If it bleeds through, put another bandage on it. If it bleeds through that, tourniquet. That's what we do. Forget these pressure points, forget elevation and all that stuff. If the tourniquet, and we put a tourniquet on all extremities. If you do not, they have what they call junctional tourniquets. So if I have an area, like a wound here that's bleeding arterially and I can't put a tourniquet on it, I can put a junctional tourniquet on it. They have upper and lower junctional tourniquets. If you don't have those, you take hemostatic roller gauze dressing, and you pack it in the wound until the bleeding stops. You just keep shoving it in. And if the whole roll goes in, the whole roll goes in. And then you bandage, you hold pressure, and you transport that one. You may have your hand on that patient's ear the whole time right into the hospital. Packed full of dressing. If that's the only thing that stops that bleeding, that's what's going to stop it. You must stop the bleeding any way you can. We call it wound packing. Direct pressure is the most common effective way. Put your gloved hand on it, and then put a dressing on it and wrap it. We're going to hold uninterrupted pressure for as long as you can. Like if you have to do something, tell somebody else, hey, put your hand here, I've got to go do something else. You should have enough hands on seam that you can hold it there permanently. Sometimes a finger in a hole does it. Just put your finger right there. Hold it there. Thermally wrapped, sterile, self-adhesive roller gauze around the entire wound. Do it tight. Do not use ACE bandages. You know the elastic bandages we put on splints? Don't do that, because unless you're trying to go for the tourniquet, and that's not a good tourniquet, that will tampen out too much blood flow. So don't use those. Once you put on a dressing, do not remove it. Let the doctor do it. Once you put on a tourniquet, do not remove it. Let the doctor do it. Hemostatic agents. Again, you carry two sets of hemostatic gauze in your ambulance. One in your first bag and one in your ambulance. So four, usually four to six hemostatic gauze packs. And what you do is for big wounds, you can wrap it or you can pack it. You can wrap it around and put pressure on it, and what happens is there's a chemical on it. It's impregnated with a chemical, and that chemical causes rapid clotting of blood. It almost feels like it's burning. So when you put it in, the patient's going to go, oh, that burns, that burns. That's good. That's what it's supposed to feel like. Many of the hemostatic agents that we use come from Oh, excuse me. Tourniquets. Again, if a patient has an arterial bleed, put a tourniquet on it. Don't even wait. If you see spray, glove hands, grab a tourniquet and put it on. Once you get the tourniquet on and the bleeding stops, I don't have to worry about it again. It's done. Once you put on a tourniquet, never take it off. Never cover it. Make sure you note the time that you put it on. And you want to put it about two inches above the wound, not in the joint, because the blood vessel travels through the joint. A tourniquet will never work on a joint. You don't want to use rope, string, or wire. You want to use something thick, like a cravat or a tourniquet, so you don't do tissue damage. Maybe Corman always told me to do high and tight. Like they said, don't do two inches. Like right here, I go up here. Your protocol says to go two inches above. But if you just shoved it on high and tight, nobody's going to say anything. That's fine. If that's what you learned, then that's fine. Junctional tourniquets allow for compression of life-threatening bleeding in areas where a standard tourniquet does not work. Junctional tourniquets go on the upper and lower, right down here. Usually, it's the brachial artery and the femoral artery that it puts pressure on. This would be the iliac artery. The iliac, femoral, and the brachial, it puts pressure on those and stops the bleeding. If you can't put on a tourniquet and you have junctional, use those. If you can't, don't try and make one with a strap. You can make one with a strap and a BP cuff. I know how to do it, but they're not stable. They slide around a lot, so I don't recommend it. Just pack it. Air splints. We don't use them in Massachusetts, but you put them on, you blow them up, and that can help control bleeding because it constricts the tissues. Pelvic binder. LayerDol and More Medical make a binder. It goes around the pelvis and clamps, and you pull it tight, and it keeps an unstable pelvis stable so it doesn't cause further damage. Where was this? What's that? Where was this when I needed it? But they have them. If you don't have one, you can do a couple things. Take a sheet, tie it around the waist, and tie it tight, or you can take two or three straps, your sacro straps, wrap them around the pelvis and pull them tight. All you're doing is stabilizing the pelvis by holding it in place. It would hurt, but it helps to control that, because you don't want those bones, because you can lacerate those blood vessels. Bleeding from the nose, ears, and mouth. Things like skull fractures, facial injuries, sinusitis infections, nose, breath, dry speech, nasal mucosa, digital trauma. I was just scratching. Stop picking your nose. High blood pressure, coagulation disorders, and cancer. We talked about epistaxis. We talked about how to fix it. Pinch the nose, held your head up forward, ice pack or cold pack on the forehead, stick something under the bottom lip, whether it be a pen, roll of gauze, and just kind of stimulate underneath the lip, the upper lip. That will stop 90% of nosebleeds. If necessary, take 4x4, roll it up, and shove it up the nose. Tampons work great for that. Bleeding from the nose following head trauma may be the indication of a skull fracture. Do we necessarily want to stop that? Well, not always. Right. Maybe we want some of that to come out. So we don't want to necessarily stop it, but we want to keep a root from bacterial infection. So we want to bandage it. And we want to slow it down, but allow it, you know, I'm not really going to put pressure on it to stop it from bleeding. Just light pressure dressing. That's the halo test. Remember we talked about the halo test? That's what it would look like. This is cerebral spinal fluid. That's a drop of blood coming out of the ear or the nose. And that's a classic, that is a telltale positive skull fracture indication. Phasal skull fracture indication. Emergency care for external bleeding requires surgery. It's a surgical disease. We can't do this in the field, so don't even try. Keep the patient calm. Immobilize them. High flow oxygen. Transport and splint any extremity. Backboard is a full body splint if necessary. Which of the following is not a component of the cardiovascular system? Which one? P, right? That's the cardiopulmonary system, but not the cardiovascular. Perfusion is most accurately defined as? Circulation of blood within an organ with sufficient amounts of oxygen. Does everybody agree with that? Sounds good to me. A man involved in a motor vehicle, motorcycle crashes, multiple abrasions and lacerations. Which of these injuries has the highest treatment priority? A? You see that spurting blood? What does that mean? Arterial. Arterial. Stop that right away. It's not the size of the wound, it's the amount of blood coming out. Which of the following sets of vials is least indicative of internal bleeding? Yes. How do you know? Can you guys go through this with me? Because this is something that I need help with. Normal blood pressure is about 120 over 80, right? So anything there or up would be okay. Anything low would be questionable. Pulse, 60 to 100. So around 60 is good, 60 to 100 is good. Anything above 100 is considered tachycardia, that's a sign of bleeding. Respiratory rate of 8. So that's kind of slow, that's a person that might be sleeping. So they're 8 breaths per minute? Correct. So that could be somebody breathing, sleeping. So this would be hypertension person sleeping. So that's not bad. This wouldn't indicate hypotension or bleeding because there's no 140 over 90. Unless that patient is normally 170. That's the thing to remember. If you have an elderly patient who is hypotensive and they don't take their meds. So you walk up to them, they're bleeding, you take their blood pressure, it's like 130 over 90. I'm like, dude, your blood pressure is pretty good, you're like mine. Well he normally is at 190. So technically, what is he? Hypovolemic. Because he's normally at 190 because he doesn't take his meds. Now he's 130 because he's so hypovolemic. So he's decompensating at 130. So that's why with elderly patients you really have to do more. You have to check mental status and all kinds of stuff. So you see now, with the difference, you see how these would be hypovolemic? And you see how the heart rate goes up and the respirations go up. Because the body is compensating with epinephrine for that loss of fluid. When caring for a patient with internal bleeding, the EMT must first... First things first. When it's that answer, it's always that answer. A. Scene safety BSI. D. Standard precautions. Always going to be D. Especially with these patients because they're bleeding. If it's more sticky and it's not mine, I don't want to touch you without gloves. What the hell? It was D. The quickest and most effective way to control external bleeding from an extremity is... The quickest and most effective way. B. Direct pressure and elevation. And don't worry about elevation but direct pressure.