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Flashcards in EAC Wounds and Bleeding Deck (43):
1

Anatomy of:
The Skin

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

2

5 categories of wounds

Contusion
Laceration
Incision
Puncture
Gunshot/blast injury

3

define:
Contusion

Usually caused by a blunt instrument

May have associated tissue damage and fractures

4

define:
Laceration

Usually results from snagging or tearing of tissue

Bleeds less freely but healing more prolonged

5

define:
Incision

Usually made by a sharp edged object

Bleeds freely and heals quickly

6

define:
Puncture

Usually caused by a pointed object

Difficult to assess any internal damage done and healing time

7

define:
Gunshot/Blast injury

Usually caused by a bullet, shot or by shrapnel

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

8

types of bleeding

External

Internal

9

define:
External bleeding

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

10

management of:
Bleeding

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)

11

Indications for use of Combat Tourniquet

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

12

Combat Tourniquet important points

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

13

indications of:
Internal bleeding

Swelling

Blood may appear via existing orifices

14

where can Internal Bleeding occur

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)

15

Assessing Blood Loss:
Considerations

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

16

Assessing Blood Loss:
External - 0.5L blood will cover

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

17

Assessing Blood Loss
Internal/Closed wounds

#ankle with moderate to sever swelling: 0.25-0.5L

#femur with moderate swelling: 0.5-1L

#femur with sever swelling: up to 4L

#lower leg with moderate swelling: 0.5-1L

#forearm with moderate swelling: 0.5-1L

#pelvis: up to 5L

18

Factors affecting blood loss

Depth, type, size and position of the wound

Size and type of blood vessel

Duration of bleeding

Age and size of patient

Underlying injuries

19

Normal blood volumes for children

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

20

Normal blood volumes for adults

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

21

how to assess severity of bleeding:

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

22

pathology of:
Missile Injuries

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.

23

what is kinetic energy transfer

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.

24

types of missile:
Primary Missiles

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

25

types of missile:
Secondary missiles


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.

26

factors affecting missile flight

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.

27

define:
Low Energy Transfer Wounds

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

28

define:
Medium Energy Transfer Wounds

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.

29

define:
High Energy Transfer Wounds

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

30

define:
Temporary Cavitation

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.

31

management of:
Ballistic Injuries

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

32

management of:
Amputation and De-Gloving

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

33

pathology of:
pressure ulcer

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.

34

who is at risk of:
Pressure Ulcers

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

35

bodies risk areas for developing:
pressure ulcers

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

36

development stages of:
Pressure Ulcers

Stage 1
Stage 2
Stage 3
Stage 4

37

development stages of Pressure Ulcers:
Stage 1

Non-blanchable erythema (redness) of intact skin

May present as discolouration, warmth, oedema, hardness in dark skinned people

38

development stages of Pressure Ulcers:
Stage 2

Partial thickness skin loss involving epidermis, dermis or both

superficial, looks like a blister

39

development stages of Pressure Ulcers:
Stage 3

Full thickness skin loss involving subcutaneous tissue down to but not through fascia

Involves necrosis (death of tissue)

40

development stages of Pressure Ulcers:
Stage 4

Extensive tissue destruction and necrosis

Damage to muscle, bone and supporting structures

Full-thickness skin loss

41

pathway of care for:
pressure ulcers

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

42

define:
Haematoma

a swelling of blood within the tissues

43

define:
Hyphema

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