Wounds & Bleeding. Hemorrhage control

1. HEMORRHAGE
CONTROL

2. WOUNDS:
• Wound is caused when any tissue
(Skin, Muscle, Bone, etc. ) is torn or cut
by an injury.
• DEPTH of the wound is more
important than AREA.
TYPES OF WOUND:
• OPEN WOUND
• CLOSED WOUND

3. OPEN WOUND:
• INCISED WOUND
• LACERATED WOUND
• PUNCTURED WOUND
• GRAZE OR ABRASION
• GUN SHOT WOUND
• AVULSION AMPUTATION
CLOSED WOUND:
• CONTUSED WOUND

4. Core Skills Control Bleeding 4
Introduction
• Review types of injuries
• Review Tactical Combat Casualty
Care
• Evaluate and control bleeding
• Take home message:
HEMORRHAGE CONTROL
SAVES LIVES

5. Core Skills Control Bleeding 5
Sources of Bleeding
• Arterial
- Rapid, profuse and pulsating
- Bright red in color
• Venous
- Steady flow, nonpulsating
- Dark red or maroon in color
• Capillary
- Slow and oozing
- Often clots spontaneously, not dangerous

6. BLEEDING:
• BLEEDING RESULTS DUE TO RUPTURE OF
BLOOD VESSELS.
TYPES OF BLEEDING:
• EXTERNAL BLEEDING
• INTERNAL BLEEDING
VARIETIES OF BLEEDING:
ARTERIAL BLEEDING:
• BLOOD COMES FROM AN ARTERY.
• BLOOD IS BRIGHT RED IN COLOUR.
• BLOOD COMES IN JETS & IT CORRESPONDS TO
HEART BEAT.
• BLOOD LOSS IS RAPID & PROFUSE & CAN CAUSE
DEATH QUICKLY.

7. INCISED
LACERATED
PUNCTURED
CONTUSED
BURNS
TYPES OF WOUNDS

8. Core Skills Control Bleeding 8
External Bleeding

9. Core Skills Control Bleeding 9
Types of External Bleeding
• Lacerations
• Abrasions
• Puncture wounds
• Amputations
• Avulsions

10. Core Skills Control Bleeding 10
Laceration

11. Core Skills Control Bleeding 11
Abrasion

12. Core Skills Control Bleeding 12
Puncture Wound

13. Core Skills Control Bleeding 13
Amputations

14. Core Skills Control Bleeding 14
Avulsion

15. MANAGEMENT:
• STOP BLEEDING.
• HANDLE GENTLY.
• WASH YOUR HANDS THOROUGHLY.
• REMOVE ANY FOREIGN BODY, IF POSSIBLE.
• DO NOT REMOVE EMBEDDED OBJECTS.
• DON’T DISTURB BLOOD CLOTS.
• PLACE CLEAN DRESSING & BANDAGE
FIRMLY.
• SHIFT TO HOSPITAL.

16. VENOUS BLEEDING:
• BLOOD COMES FROM A VEIN.
• BLOOD IS DARK RED IN COLOUR.
• BLOOD FLOWS AS A CONTINUOUS
STREAM & MAY BE PROFUSE.
CAPILLARY BLEEDING:
• BLOOD COMES FROM CAPILLARIES.
• BLOOD OOZES.
• COLOUR IS LESS RED THAN ARTERIAL BLOOD.
• NOT SERIOUS.

17. NATURES RESPONSE TO INJURY:
RESTRICTS BLOOD FLOW TO THE AREA BY:
• CONTRACTING THE ENDS OF CUT BLOOD
VESSELS.
• FORMATION OF BLOOD CLOTS WITH THE HELP
OF CLOTTING FACTORS, FIBRINOGEN, ETC.

18. SIGNS & SYMPTOMS OF BLEEDING:
• FAINT & GIDDINESS.
• COLD & CLAMMY SKIN.
• WEAK & RAPID PULSE.
• SHALLOW BREATHING WITH GASPS &
SIGHS.
• PROFUSE SWEATING.
• THIRST.
• BLURRED VISION.
• UNCONSCIOUSNESS.

19. MANAGEMENT:
EXTERNAL BLEEDING CAN BE CONTROLLED BY:
• DIRECT PRESSURE.
• ELEVATION.
• INDIRECT PRESSURE ON PRESSURE POINTS.
• SPLINTING.
• INFLATABLE SPLINTS.
• BLOOD PRESSURE CUFF.
• TOURNIQUET.

20. DIRECT PRESSURE:
CAN BE APPLIED BY:
• FIRST AIDER’S HAND.
• DRESSING & FIRST AIDER’S HAND.
• PRESSURE DRESSING.
• PRESSURE TO BE APPLIED FOR 10 TO 30 MINUTES.
• AFTER CONTROL, APPLY FIRM BANDAGE.
• NEVER REMOVE EXISTING BANDAGE IF BLEEDING
RECURS. APPLY ANOTHER OVER IT.
ELEVATION:
• GRAVITY HELPS TO LOWER BLOOD PRESSURE &
BLEEDING IS SLOWED.
• NOT TO BE USED IN CASES OF FRACTURES & SPINAL
INJURIES.

21. PRESSURE POINTS:
• PRESSURE POINT IS A SITE WHERE MAIN ARTERY LIES
NEAR THE SURFACE OF THE BODY, DIRECTLY OVER A
BONE.
• PULSATION CAN BE FELT IN THESE AREAS.
• THERE ARE 22 PRESSURE POINTS(11 ON EACH SIDE).
• OF THESE 11 ARE USED TO CONTROL PROFUSE
BLEEDING.
• BRACHIALARTERY - FOR BLEEDING FROM UPPER LIMB.
• FEMORALARTERY - FOR BLEEDING FROM LOWER LIMB.
• CAROTID ARTERY - FOR BLEEDING FROM NECK.
• TEMPORALARTERY - FOR BLEEDING FROM SCALP.
• FACIALARTERY - FOR BLEEDING FROM FACE.
• SUB CLAVIAN ARTERY - FOR BLEEDING FROM CHEST
WALL & ARMPIT

22. PRESSURE POINTS

23. Core Skills Control Bleeding 23
Brachial Pressure Point

24. Core Skills Control Bleeding 24
Brachial Pressure Point

25. Core Skills Control Bleeding 25
Femoral Pressure Point
• To control severe
bleeding of thigh
and lower leg
• Located at front,
center part of
crease in the groin

26. APPLICATION OF INDIRECT PRESSURE

27. NOTE:
• PRESSURE POINT TECHNIQUE IS USED ONLY AFTER
DIRECT PRESSURE & ELEVATION FAILS TO CONTROL
BLEEDING.
• RELAX THE MUSCLES OF THAT AREA, WHICH WILL
HELP IN APPLYING PRESSURE BETTER.
• CONTINUE PRESSURE TILL BLEEDING IS CONTROLLED
OR TILL MEDICAL HELPARRIVES.
• RELEASE PRESSURE ONCE IN 15 MINUTES AND
REAPPLY.
• SPLINTING
• INFLATABLE SPLINTS
• BLOOD PRESSURE CUFF
• TOURNIQUET : APPLIED AS A LAST RESORT, AS IN
CASES OF AMPUTATION, ETC.

28. • MINOR BLEEDING:
• CONTROLLED BY ELEVATION & DIRECT PRESSURE.
• MAJOR BLEEDING:
• EXTERNAL BLEEDING:
• BRING SIDES OF WOUND TOGETHER & PRESS FIRMLY.
• POSITION THE PATIENT IN A COMFORTABLE POSITION.
• ELEVATE THE INJURED PART IF POSSIBLE.
• IF DIRECT PRESSURE FAILS, APPLY PRESSURE ON PRESSURE
POINT FOR 10 TO 15 MINUTES.
• APPLY CLEAN PAD, LARGER THAN THE WOUND & PRESS
FIRMLY, TILL BLEEDING IS CONTROLLED.
• IF BLEEDING CONTINUES, DO NOT REMOVE SOAKED PAD, BUT
APPLY MORE PADS.
• BANDAGE FIRMLY.
• TREAT SHOCK.
• SHIFT TO HOSPITALAS A PRIORITY.

29. CMAST 29

30. Core Skills Control Bleeding 30
Splints
• Immobilization of the injured extremity is one of the
best ways to stop bleeding
• Broken bone fragments may lacerate blood vessels
• Muscular activity will increase rate of blood flow

31. Core Skills Control Bleeding 31
Tourniquets
• Early use of a tourniquet in the
setting of forceful arterial bleeding,
such as an amputation, may be life-
saving
• STOP THE BLEEDING!

32. Core Skills Control Bleeding 32
Amputations

33. Core Skills Control Bleeding 33
Tourniquets
• Use a commercial tourniquet, such as the Combat
Application Tourniquet, if available
• If not available, then use..
– Cravat
– Belt
– Rope
– Strap from LBE
– Any available material

34. CMAST 34
Combat Application Tourniquet
WINDLASS
SELF ADHERING BAND
WINDLASS STRAP
▪ The C-A-T was selected as the primary tourniquet
for every soldier.

35. C-A-T Step 1
Place the wounded
extremity through
the loop of the
Self-adhering
Band

36. C-A-T Step 2
Place tourniquet
above the injury
site

37. C-A-T Step 3
Pull the free-
running end of the
Self-adhering
Band tight and
securely fasten it
back on itself.

38. Hemorrhage Control
COMBAT MEDIC ADVANCED SKILLS TRAINING (CMAST)

39. CMAST 39
Improvised Tourniquet

40. Core Skills Control Bleeding 40
Tourniquet Application
• Place tourniquet between the heart
and wound
• Wrap tourniquet around extremity
• Tighten UNTIL BLEEDING
STOPS

41. INTERNAL BLEEDING:
THIS IS SUSPECTED WHEN YOU DETECT:
• WOUNDS THAT HAVE PENETRATED THE SKULL.
• BLOOD IN EARS & NOSE.
• PATIENT VOMITING OR COUGHING BLOOD.
• PENETRATING WOUND OF CHEST & ABDOMEN.
LARGE AREA OF BRUISED ABDOMEN.
• ABDOMINAL TENDERNESS, RIGIDITY OR SPASM.
• BLOOD IN URINE.
• RECTAL OR VAGINAL BLEEDING.
• FRACTURES.

42. DIAGNOSIS:
• HISTORY OF SUFFICIENT INJURY TO CAUSE INTERNAL
BLEEDING.
• HISTORY OF MEDICAL CONDITION WHICH CAN CAUSE
INTERNAL BLEEDING. (PEPTIC ULCER, ETC.)
• PAIN & TENDERNESS OVER THE AFFECTED AREA.
• SIGNS & SYMPTOMS OF SHOCK.
• BLEEDING FROM BODY ORIFICES.

43. MANAGEMENT:
• LAY THE CASUALTY DOWN, WITH HEAD LOW & TO ONE SIDE, SO
AS TO ENSURE GOOD BLOOD SUPPLY TO THE BRAIN.
• RAISE THE LEGS IF THERE IS NO FRACTURE.
• CONTROLALL SERIOUS EXTERNAL BLEEDING.
• LOOSEN CONSTRICTIVE CLOTHING.
• REASSURE.
• CHECK VITAL SIGNS & RESPONSIVENESS AT 10 MINUTES
INTERVALS & RECORD.
• IF UNCONSCIOUS, ENSURE OPEN AIRWAY & RESUSCITATE IF
NEEDED.
• AFTER RECOVERY PUT IN RECOVERY POSITION.
• KEEP CASUALTY COVERED.
• KEEP RECORD OF ANY SPECIMEN PASSED OR VOMITED & SEND
THE SAMPLES TO HOSPITAL.
• SHIFT TO HOSPITAL ON PRIORITY.
• DON’T GIVE ANYTHING TO EAT OR DRINK.

44. Life Saving &
Life Threatening Process

45. BLOOD
TRANSFUSION
Prof. M.C.Bansal
MBBS., MS., FICOG., MICOG.
Founder Principal & Controller,
Jhalawar Medical College & Hospital Jjalawar.
MGMC & Hospital , sitapura ., Jaipur.

46. History of Transfusions
• Blood transfused in humans since mid-
1600’s
• 1828 – First successful transfusion
• 1900 – Landsteiner described ABO
groups
• 1916 – First use of blood storage
• 1939 – Levine described the Rh factor

47. Philip (1825)
First human blood transfusion

48. Landsteiner
(1900))
Discovery of ABO type

49. Successful blood transfusion is relatively recent
• Crossmatching
• Anticoagulation
• Plastic storage container
Blood Transfusion

50. Cross matching
1. Matching blood components between a Pt & a D
is a direct compatibility test.
2. The red cells & Plasma are cross matched thru
Major and Minor cross match, defined as to an
amount of Antibody react with Antigen
A. Major‘: the patient's serum & the donor's
RBCs.
–large amount of Antibody has greater impact
B. Minor’: the patient's RBCs & the donor's
serum.

51. BLOOD TYPES

53. WHAT IS ANTIGENS ?
An antigens is a substance that causing
the formation of antibodies
WHAT IS ANTIBODYS ?
Antibodies is a protein substance
develop in the body in response to the
presence of an antigen that has entered
the body

54. TRANSFUSION
THERAPY
* REPLACEMENT
* THERAPEUTIC
1.To restore intravascular volume with
whole blood or albumin.
2. To restore the oxygen capacity of
blood by replacing red blood cells.
3. To replace clotting factor and
correction of anemia
PURPOSE OFBLOOD

55. Type of Transfusion ：
■ Whole Blood ；
■ Blood Component ；
RBC PLT FFP Leukocyte concentrate
■ Plasma Substitutes ；
Use of whole blood is considered to be a waste of
resources
Blood Transfusion

56. DEFINITIONS
BLOOD PRODUCT = Any therapeutic substance prepared from
human blood
WHOLE BLOOD = Unseparated blood collected into an
approved container containing an anticoagulant preservative
solution
BLOOD COMPONENT = 1. A constituent of blood , separated
from whole blood such as
• Red cell concentrate
• Plasma
• Platelet concentrates
2. Plasma or platelets collected by apheresis
3. Cryoprecipitate prepared from fresh frozen plasma

57. Differential Centrifugation
First Centrifugation
Whole Blood
Main Bag
Satellite
Bag
1
Satellite Bag
2
RBC’s
Platelet-
rich
Plasma
Firs
t
Closed System

58. Differential Centrifugation
Second Centrifugation
Platelet-rich
Plasma
RBC’s
Platelet
Concentrat
e
RBC’s
Plasma
Second

59. Whole Blood
• Storage
– 4° for up to 35 days
• Indications
– Massive Blood Loss/Trauma/Exchange Transfusion
• Considerations
– Use filter as platelets and coagulation factors will not
be active after 3-5 days
– Donor and recipient must be ABO identical

60. Blood Components
THE PRBC
Storage
- 2 – 6 O C
Unit of issue
- 1 donation ( unit or pack )
Administration
- ABO & Rh compatible
- Never add medication to a unit
- Complete transfusion within 4 hrs of
commencement
1M
e
m

61. Indications
- Acute blood loss with > 20% loss of
blood volume
Trauma
Surgery - Trigger – 10gm% - 8gm%
Rate of development of anemia,
General condition and type of
surgery
Radiotherapy

62. Platelets
• The platelets are separated from the plasma by
centrifugation.
• Platelets are supplied either as single donor units or as a
combination of multiple donors.
• One unit of platelets will increase the platelet count of a 70
kg adult by 5 to 10,000/mm³.
• Platelet viability is optimal at 22° C but storage is limited to
4-5 days.
• Platelets have both the ABO and HLA antigens. ABO
compatibility is ideal but not required. (incompatibility will
shorten the life span of the platelet)

63. Platelets• Storage
– Up to 5 days at 20-24°
• Indications
– Thrombocytopenia, Plt <15,000
– Bleeding and Plt <50,000
– Invasive procedure and Plt <50,000
• Considerations
– Contain Leukocytes and cytokines
– 1 unit/10 kg of body weight increases Plt count by 50,000
– Donor and Recipient must be ABO identical

64. • Thrombocytopenia
(< 50,000)
• Platelet dysfunction
• Each unit increase 5,000
PLTs after 1 H
Platelets

65. Plasma
• Contents—Coagulation Factors (1 unit/ml)
• Storage
– FFP--12 months at –18 degrees or colder
• Indications
– Coagulation Factor deficiency, fibrinogen replacement, DIC,
liver disease, exchange transfusion, massive transfusion
• Considerations
– Plasma should be recipient RBC ABO compatible
– In children, should also be Rh compatible
– Account for time to thaw
– Usual dose is 20 cc/kg to raise coagulation factors approx 20%

66. • Coagulation factor deficiencies
• 1 ml increases 1% clotting
factors
• Being used as soon as possible
• Albumin, hetastarch,
crystalliods are equally
effective volume expander but
safer than FFP
• After use of 5 U of RBCs,
matching 2 U of FFP
Fresh Frozen Plasma (FFP)

67. Dosage & Administration for
FFP
Dosage - 10-15 ml/Kg(Approx 2-3
bags for an adult)
Administration - Thawed at +37o C
before transfusion
ABO compatible
Group AB plasma can be used for all
patient

68. --Volume Expander
Dextran
• Most widely used
• Low/Middle M.W. (40,000-70,000)
• Massive transfusion could impair coagulation
• Occasional ALLERGIC reaction
Hydroxyethyl Starch Formulation (HES)
• More stable
• Containing essential electrolytes
• No allergic reaction
Plasma Substitutes

69. Cryoprecipitate
• Description
– Precipitate formed/collected when FFP is thawed at 4°
• Storage
– After collection, refrozen and stored up to 1 year at -18°
• Indication
– Fibrinogen deficiency or dysfibrinogenemia
– vonWillebrands Disease
– Factor VIII or XIII deficiency
– DIC (not used alone)(Disseminated intravascular
coagulation)
• Considerations
– ABO compatible preferred (but not limiting)
– Usual dose is 1 unit/5-10 kg of recipient body weight

70. • Although blood transfusions can be
life-saving, they are not without risks.
The most serious risks are
transfusion reactions and infections.

71. Transfusion Complications
• Acute Transfusion Reactions (ATR’s)
• Chronic Transfusion Reactions
• Transfusion related infections

72. Acute Transfusion Reactions
• Hemolytic Reactions (AHTR)
• Febrile Reactions (FNHTR)
• Allergic Reactions
• TRALI(Transfusion related acute lung
injury)
• Coagulopathy with Massive transfusions
• Bacteremia
Can be fatal

73. Symptoms of AHTR
• High fever/chills
• Hypotension
• Back/abdominal pain
• Oliguria
• Dyspnea
• Dark urine
• Pallor

74. What to do?
If an AHTR occurs
• STOP TRANSFUSION
• ABC’s
• Maintain IV access and run IVF (NS or LR)
• Monitor and maintain BP/pulse
• Give diuretic
• Obtain blood and urine for transfusion reaction
workup
• Send remaining blood back to Blood Bank

75. Febrile Nonhemolytic Transfusion
Reactions (FNHTR)
• Definition--Rise in patient temperature >1°C (associated
with transfusion without other fever precipitating
factors)
• Occurs with approx 1% of PRBC transfusions and
approx 20% of Plt transfusions
• FNHTR caused by alloantibodies directed against HLA
antigens
• Need to evaluate for AHTR and infection

76. Allergic Nonhemolytic Transfusion
Reactions
• Etiology
– May be due to plasma proteins or blood
preservative/anticoagulant
– Best characterized with IgA given to an IgA deficient
patients with anti-IgA antibodies
• Presents with urticaria and wheezing
• Treatment
– Mild reactions—Can be continued after Benadryl
– Severe reactions—Must STOP transfusion and may require
steroids or epinephrine
• Prevention—Premedication (Antihistamines)

77. TRALI
Transfusion Related Acute Lung Injury
• Clinical syndrome similar to ARDS
• Occurs 1-6 hours after receiving plasma-
containing blood products
• Caused by WBC antibodies present in
donor blood that result in pulmonary
leukostasis
• Treatment is supportive
• High mortality

78. Transfusion Associated
Infections
• Hepatitis C
• Hepatitis B
• HIV
• CMV
– CMV can be diminished by leukoreduction,
which is indicated for immunocompromised
patients

79. ThAnk You!
Hope you learned
something!