bleeding. blood loss. bleeding compensation in eliminating the consequences of emergencies
TRANSCRIPT
Bleeding. Blood loss. Bleeding compensation in eliminating the consequences of emergencies.
Bleeding
During the Second World War on the battlefield were dying up to 50% of the wounded from bleeding;
36.6% of them dying from limb vessels’ damage.
The arteries of the lower limbs
– 61 %
The arteries of upper limbs – 31 %
The frequency of vascular injury during conducting military operations.
Causes of bleeding
Open
Closed
1. Mechanical damageof the vascular wall.
2. Pathologicalcondition of the vascular wall.
3. Disorders of blood coagulation system
(coagulopathy)
The gradual destructionarrosive bleeding
Violation of permeabilitydiapedetic bleeding
hemophilia
thrombocytopenia
Disseminated intravascular coagulopathy (DIC)
AtherosclerosisTumor.Inflammation.Necrosis.Beriberi.Intoxication.septicemiaaneurysm
Mechanical damages of the vascular wall
Contusion
Повреждение только
адвентиции
Regionalinjury
Damage by half diameter
Almost complete
break
Exit Wounds
complete break
Compression of bone fragments or
foreign bodies
Compression of the brachial artery as a result of dislocation of the forearm.
Compression of the popliteal artery by hematoma (tibia fracture).
Mechanical damages of the vascular wall
hips fracture with damage of the femoral artery.
Regional injury of the femoral artery
Humerus’ fracture with compression of the
brachial artery.
Bleeding
InternalExternalHematoma
(intra-muscular,interfascial,
subcutaneous ...)
haemoperitoneum
haemothorax
hemopericardium
hemarthrosis
intracranial hematoma
Bleeding
deferred bleeding
First time bleeding
Earlier(1-3 days
after injury)
Later(3-10 days or more
from the injury time)
(immediately after injury)
1.Thrombus’ eject out from the vessel by the bloodstream.
2. Vessel’s damage (lack of immobilization,coarse manipulation)3. Ligatures slipping.
1. Necrosis of the vessel wall2. purulent fusion of the thrombusor the vessel wall3. aneurysm rupture.4. ligaturesSlipping5. Infringement blood clotting system
Bleeding
Venous
Arterial
Mixed
Capillary
Classification of bleeding in case
of emergencyMedical classification
small amount of blood
Fountain of blood
A lot of blood
Damages’ symptoms of great vessels of limb
No or weakening of the pulse in the distal parts of limb
Pale skin
Lowering the skin temperature
Lowering the sensitivity
ischemic pain
Contractures (muscles rigidity)
1. Stop the bleeding
Первая
Доврачебная
Первая врачебная
Квалифицированная
Специализированная
Temporarily stopping of
external bleeding
The final stop of all kinds of
bleeding
prehospital
period
hospital
period
Виды медицинской помощи
1.1. Temporarily stopping of external bleeding
Compression of the vessel in the
wound
Stop by the position
Pressing the vessel proximally
Thermal 1.2. Final bleeding’s stopping
Biological
Chemical
Thermal
Mechanical
Temporary artery bypass grafting
1.1. Temporarily stopping of external bleeding
A. Compression of blood vessels
in the wound
Compressive bandage
tamponing
Vessels’ clipping in the wound
Москит Бильрот Кохер
Temporary ligation the
vessel
Anterior nasal packing
(including -predoctor care)
Postnasalpacking
Stop nasalbleedings
1.1. Temporarily stopping of external
bleeding
B. Stop by the position
Elevated limbs position
Immobilisaition
1.1. Temporarily stopping of external
bleeding
C. Pressing the vessel proximally
By the finger
By the roller with a maximum limbs
bending
By the tourniquet
1.1. Temporarily stopping of external
bleeding
C. Pressing the vessel proximally
By the finger
By the tourniquet
By the roller with a maximum limbs
bending
An improvised tourniquet (twisting)
Medical tourniquet
1
32
Regulations concerning tourniquet
1. Lift the limb before applying
2. Put on the clothes or on the gasket.
3. Proximally the location of bleeding
4. As close as possible to the wound.
6. Tighten until the bleeding stops or the
disappearance of the pulse.
5. Each subsequent round covers the
previous for the half of width.
7. Clearly visible
8. Reliably fixed
9.Indicate the date and time.
10. anesthetize
12. In the cold - wrap the limb.11. Immobilize
13. The maximum period of time - 2 hours in warm weather, and 1 hour in cold weather
PREPARATION
CHOOSING A SITE FOR TOURNIQUET
TECHNIQUE OF OVERLAY
CARE AND CONTROL 14. Each subsequent
tourniquet - half time of the previous.
Tourniquet’s Re-imposition
Each subsequent tourniquet - half time
of the previous.
Revision of tourniquet.
Finger pressing the artery proximal to the tourniquet
Loosen tourniquet
Wait until the blood filling the capillaries starts under the nail plate
Overlay tourniquet from 4-5 cm proximal to the previous level.
Remove the bandage
Finger pressing the artery proximal to the tourniquetLoosen tourniquet
Loosen finger pressing and examining the wound at the same time.
Trying to temporarily stop the bleeding without a
tourniquet.
Bleeding resumed Bleeding is not resumed
Protective bandage, and the imposition
of a provisional tourniquet.
(do not remove the bandage!)
Anywhere treatment room
Cloth tourniquet
➢ After removing the tourniquet the bleeding has stopped, but the source of bleeding is not defined.
➢ Bleeding is stopped by a clipping or temporary ligatures.
Накладывание импровизированного провизорного жгута Затягивание жгута
EVERYDAY LIFE:
Many people help to one victim
EMERGENCY SITUATION:
one person is helping to a large number of
victims.
Why tourniquet is especially
dangerous in emergency situations?
1.1. Temporarily stopping of external
bleeding
D. Thermal Local hypothermia
E. Temporary bypass
grafting (drop counter tube)
1.2. The final stop of all kinds of bleeding
А. Mechanical
ligation of the vessel in the
wound
Ligation of the vessel proximal to
the wound
Angiorrhaphy
Plastic or prosthesis of the
vessel
Elevated position
Tamponade of the wound
Сompressive bandage
1.2. The final stop of all kinds of bleeding
B. Thermal
Local hypothermia
Applications of hot
solutions
Electrocoagulation
1.2. The final stop of all kinds of bleeding
C. Chemical
D. Biological
Medicamentous effects on the blood coagulation system
Local impacts
Tamponade by own tissues or biological
graft.
Prehospital period Hospital period
Compressive bandage
Tamponing the wound
Clip on a vessel in the wound
Postnasal packing
Limbs elevated position
Finger pressing
Maximum bending of limbs
Сloth tourniquet
Standard tourniquet
Local hypothermia
Temporary bypass grafting
Ligation of the vessel in a wound
Ligation of the vessel more proximally
Angiorrhaphy
Repair of the vessel or the
vessel prosthesis
Electrocoagulation
Intervention on the blood coagulation system by medicines
Tamponade by own tissues or biological graft
ПЕРВАЯ ВРАЧЕБНАЯ ПОМОЩЬ
КВАЛИФИЦИ-РОВАННАЯ ПОМОЩЬ
СПЕЦИАЛИЗИ-РОВАННАЯ
ПОМОЩЬ
ДОВРА-ЧЕБНАЯ ПОМОЩЬ
Anterior nasal packing
Local application of hemostatic drugs
Возвышенное положение конечностиЛокальная гипотермия
Локальное применение
гемостатических препаратов
Давящая повязка
Пальцевое прижатие
Максимальное сгибание
конечностиИмпровизированный
жгут (закрутка)Табельный
жгут
Наложение зажима на
сосуд в ранеТампонирование
раны
Медикаментозное воздействие на свертывающую систему крови
Передняя тампонада
носовых ходов
Задняя тампонада
носовых ходов
Перевязка сосуда на
протяженииЛигирование сосуда в ране
Временное шунтированиеelectrocoagulation
Tamponade by own tissues or biological
graft
Angiorrhaphy
Repair of the vessel or the vessel
prosthesis
Compensation of blood loss
General weakness
Pale skin
Вizziness
Noise in the ears.
Yawning.
Tachycardia
Excessive thirst.
Symptoms of acute blood lossFlashing "flies" in front of the eyes
Cold clammy sweat.
Frequent weak pulse.
Fast breathing.
Fall of blood pressure
Сlouding or loss of consciousness
Mydriasis.
SEVERITY OF BLOOD LOSS
Shock index of about 0.8
Shock index of about 1.5 and more
Shock index of about 1,3-1,4
Shock index of about: 0,9-1,2
Ориентировочный объем кровопотери при переломах (мл)
Если кровопотеря не превышает 1/3 ОЦК,самопроизвольное восполнение занимает:
Объем плазмы – 24-48 часКонцентрация белков плазмы – 72-94 часМасса эритроцитов – 20-25 сут
ОТКРЫТЫЕ ТРАВМЫ
ЗАКРЫТЫЕ ТРАВМЫ
ТРАВМАТИ-ЧЕСКИЕ
ОТРЫВЫ (АМПУТАЦИИ)
ПЕРЕЛОМЫ КОСТЕЙ
черепа – до 0,5 л
таза (изолированные переломы) – 0,5 -1,0 л
живота – 1,5-3,0 л
груди – 1,5-1,8 л
черепа – 1,5 л и более
груди – 2,0 л
и более
живота – 1,5-3,0 л и более
разрушения таза с повреждением внутренностей –
3,5 л и более
ключицы – 0,1-0,3 л
ребер– 0,5-0,6 л
плеча – 0,3-0,5 л
таза (заднее полукольцо) –
1,5-1,8 л
предплечья – 0,3 -0,4 л
таза (переднееполукольцо) –
0,3-0,6 л
бедра– 0,5-1,2 л
голени – 0,3-0,75 л
голеностопного сустава – 0,35-0,45 л
плеча – 1,5 л
предплечья – 1,0 л
кисти– 0,75 л
бедра – 2,0 л
голени – 1,8 л
стопы– 0,8 л
Decrease CBV
Decrease inflow of venous blood to the heart
Decrease in stroke volume and minute ejection.
Decrease in arterial pressure
Decrease in perfusion pressure in the vessels
Microcirculatory disorders
Tissue hypoperfusion
The capillary-trophic insufficiency
Hypoxia, toxemia, acidosis, dystonia
Multiorgan failure
Disorders of vital activity
The severity of blood loss
Volume Speed
✓The spasm of small blood vessels and increase the tone of the sympathetic part of the autonomic nervous system (maintaining blood pressure)✓ Tachycardia
(maintenance of minute volume)✓ Disclosure of arteriovenous shunts, it facilitates the return blood to the heart
(CENTRALIZATION OF CIRCULATION) –compensates up to 10% of the deficit CBV
✓ Interstitial fluid begins replenish the the bloodstream
(Replenishing CBV)tHE WHOLE PROCESS IS DIRECTED
TOWARDS THE TRANSITION INTO THE CIRCULATORY HYPOXIA TO ANEMIC HYPOXIA.
Compensatory mechanisms
Crystalloid solutions
Infusion-transfusion fluids.They remain in the
bloodstream for about
25 % of the injected volume
Colloidal solutions(blood substitutes)
They increase the CBV
1,2-1,3times more self-
administered volume.
Blood and blood products
If life-threatening conditions, we start with crystalloid infusion solutions, then - blood substitutes
Blood - optimal fluid transfusion
BUT:compatibility problems
the risk of infection
приказ Минздрава РФ от 25 ноября 2002 г. N 363
Transfusion of blood components is accompanied some consequences to the recipient, both positive and negative:
1. Acute hemolysis.2. Deferred hemolytic reactions.3. Bacterial shock.4. Responses resulting from the anti-leukocyte antibodies.5. Anaphylaxis.6. Acute volemic overload.7. Transmissible Infection
Transmission of human immunodeficiency virus by transfusion is about 2% of all AIDS cases.
A LONG PERIOD OF PRODUCTION OF SPECIFIC ANTIBODIES AFTER INFECTION (6 - 12 WEEKS) MAKES COMPLETE ELIMINATION OF
RISK OF HIV TRANSMISSION ALMOST IMPOSSIBLE
INDICATIONS FOR TRANSFUSION OF WHOLE BLOOD CANNED DOES NOT EXIST. except in cases of acute massive blood loss, when there is no blood substitutes or fresh frozen plasma, packed red blood cells or a slurry.
The indications for transfusion of blood gas carriers in acute anemia due to massive blood loss is the loss of 25 - 30% of circulating blood volume, accompanied by a decrease hemoglobin level below 70 - 80 g / l and a hematocrit below 25% and the occurrence of circulatory disorders.The use of intraoperative blood reinfusion indications only in those circumstances where the anticipated blood loss exceeds 20% of circulating blood volume.Transfusions fresh frozen plasma to replenish blood volume is not recommended (we have a safer and more economical medications)
BLOOD TRANSFUSIONS ARE USED ONLY FOR THE LIFE-SAVING
INTRAVENOUSLY:
Puncture a peripheral vein
Puncturecentral vein
(subclavian)
Preparation a peripheral vein
INTRAARTERIALLY
INTRAOSSEOUS
The routes of entry of infusion fluids.
Basic rules for infusion therapy in critical conditions1. The main thing is not composition of the infusion solution, but
- the timeliness of infusion’s start,
- the volume;
- the rate of introduction
2. Are beginning to infusion with a quick introduction of crystalloid solution
3. The proportion of colloid and crystalloid solutions – 2:14. Volume infusion must be greater than deficit CBV by 1,5-2,0 times
5. Blood transfusions are used only for the life-saving.
6. Percentage of blood products should not exceed the volume of blood loss
Thank you for attention!