Monograph 3 ~ FIRST-AID CONSIDERATIONS

Monograph 3

First-Aid Considerations in
Postraumatic Bleeding and Shock
By R. C. Schafer, DC, PhD, FICC
Manuscript Prepublication Copyright 1997
Copied with permission from ACAPress

Bleeding
  Hemorrhage
    Thrombophlebitis and Embolism
    Controlling Hemorrhage
    Pressure Points
    Pressure Dressing
    Hygiene
    Elevation of a Wounded Limb
    Use of a Tourniquet
  Reactionary Hemorrhage
  Lacerations
  Hematoma Formation
Shock
  Typical Causes in Sports and Manual Labor
  Clinical Features
  Preventive Measures
  Emergency Care
  Weeping Contusions

References and Bibliography

In aiding a person after injury, the first priority is to seek and correct when possible any life-threatening condition. Most common would be situations of bleeding (and/or arterial entrapment) and/or shock. The next priority would be to ease pain and discomfort.

BLEEDING

Hemorrhage

Acute hemorrhage is defined as the sudden or rapid loss of blood from the circulatory system within a few minutes or hours as a result of an opening or openings in the system. Life is threatened if blood loss reaches 25%-50% of total volume. Concealed bleeding is difficult to estimate. Williams/Sperryn point out that over a quart of blood may be lost into the tissues in a closed fracture of the tibia, yet this is minor compared to be what may be lost within pleural or peritoneal cavities in chest or abdominal injuries. The seriousness of hemorrhage lies in both the rate and the quantity of blood volume reduction, which are related to the number, type, and location of the opened vessels.

Whenever an artery or vein is opened, the injured vessel reflexively constricts and, if severed, retracts into the tissue, thereby reducing the size of the opening and facilitating clot formation (scalp vessels are an exception). In addition, other blood vessels temporarily constrict as a part of the general reaction to injury. This generalized vasoconstriction helps maintain blood pressure by reducing the capacity of the circulatory system.

The body in general and the cardiovascular system in particular react to stress of injury to the circulatory system by shock that is apparent after sudden loss of 15% or more of the circulating blood volume. At the site of injury, blood tends to clot and plug the opened vessel. If vasoconstriction and blood clotting are unsuccessful, the resulting blood volume reduction causes a fall in blood pressure which, among its other effects, facilitates clot formation. If hemorrhage persists, the person dies of lack of oxygen and other nutrients.

Thrombophlebitis and Embolism

Of the many complication dangers involved in handling an injury victim, throbophlebitis and the potentiality of embolism are common concerns. Venous stasis and pressure or other injury to vein walls predispose the development of thrombophlebitis. The overt signs and symptoms are cramping pain in the calf; possible redness, warmth, and swelling along the course of the involved vein; and pain which may appear only on dorsiflexion of the foot. The most common sites are in the veins of the pelvis and legs.

The affected limb should never be rubbed or massaged. It should be placed horizontal and at rest, supported by pillows. Cotton elastic bandages may be used if available on each extremity from foot to groin to assist venous circulation.

Be alert to any complaint or other evidence of respiratory difficulty or chest pain due to a possible embolism. Sudden dyspnea, violent coughing, hemoptysis, or severe stabbing chest pain may be the first sign of a dislodged thrombus. Sudden signs of shock and collapse should be anticipated.

Controlling Hemorrhage

The management of external hemorrhage is best accomplished if the wound is first exposed to view. Clothing or other material over the injury should be cut, torn, or lifted away carefully so that additional harm is not inflicted. Unnecessary movement or exposure of the patient to general cold should be avoided if to the extent that it may induce or hasten the lowering of body temperature.
External Venous Hemorrhage. Venous bleeding can be profuse during physical competition or vigorous work because of the increased blood flow to active limbs. However, the bleeding is often quickly stopped by a pad, firm bandage, and cold pack applied to the elevated part. Nothing more is usually necessary for the next 24 hours unless referral for surgical cleansing or suturing is required.

External Arterial Hemorrhage. Arterial injuries may be classed as either (1) complete, where the entire vessel wall is disrupted, or (2) incomplete, where only the outer coats or, at most, a portion of the circumference is damaged. These injuries originate from contusions, incised and lacerated wounds, and puncture wounds. The early manifestations are hemorrhage and possibly the appearance of a hematoma. In the later stages, thrombosis, traumatic aneurysms, and secondary hemorrhage are to be feared.

Internal Hemorrhage. Internal bleeding is a medical emergency. Treatment should only be first-aid measures to benefit the patient until transportation can be made to an appropriate trauma center or emergency ward. In some cases, such facilities may be many miles away. Initial actions can be life saving. If on-the-scene attention is made, the examiner should seek evidence of "pattern bleeding" in which the pattern of clothing texture is imprinted on the skin. This indicates severe compression and suggests possible visceral rupture.

Note the presence of blood in vomitus, sputum, or excretions. Hemorrhage within the cranium or lungs may be indicated by bleeding from the nose, mouth, or ears. Evidence of internal bleeding may also be represented in such signs as restlessness, apprehension, thirst, falling blood pressure, and increasing pulse rate. Swelling and discoloration may be seen. Treat for shock, and prepare the patient for referral for hospitalization and blood transfusion.

Pressure Points

A pressure point is any site where a main artery supplying the wounded area lies near the skin surface and over a bone or firm tissue. Pressure at these points is applied with the fingers, thumb, or hand. The object of the pressure is to compress the artery against a firm substance to occlude the flow of blood from the heart to the wound. Since it is often difficult to maintain occluding pressure manually on a pressure point, the pressure point method is used only until a pressure dressing can be applied.

Pressure Dressing

A sterile dressing applied with pressure to a hemorrhaging wound enhances clot formation, compresses open blood vessels, and protects the injury from further invasion by infectious organisms. Sometimes more harm is done to the patient by secondary infection than the trauma itself.

Direct pressure on a wound is usually ineffective in controlling hemorrhage. Pressure is applied for the purpose of minimizing the size of the vessel opening by compression, temporarily or for an extended period, thereby lessening the amount and the velocity of the escaping blood and aiding clot formation. Firm pressure may be applied to a wound if there is no broken bone in or near the wound. Hemorrhage does not always stop immediately. At times, firm pressure on the dressing over the wound may be required for many minutes until a clot has formed with sufficient strength to hold with only the help of dressing ties. If a clot does not form quickly, a tourniquet must be considered (if feasible).
The dressing should be of absorbent material that spreads and slows the blood it absorbs. This spreading and slowing action exposes a relatively large and thin surface of the outflowing blood to the air and thereby aids clot formation. Accordingly, one dressing partially filled with the victim's blood is more effective in controlling hemorrhage than is a series of others because clot formation is in progress within the bloody dressing. Clot formation tends to spread back toward and into the wound until diminished air exposure, coupled with an adequate circulating speed, brings the bleeding to a halt.
It is the clot that stops the hemorrhage. If the blood had no ability to clot, the absorbent dressing applied would merely draw blood out through the wound and do more harm than good. When blood is about to clot, it begins to turn darker and becomes progressively darker as the clot takes form. A hard clot is almost black as its iron content oxidizes. Unnecessary prolonged pressure must be avoided. The dressing should be anchored snugly to prevent slipping, but not tightly. The wounded part, especially if it is an arm or leg, will swell after a time, tightening the bandage still more and impairing or stopping circulation within the part to the detriment of the patient.

Hygiene

An external wound easily becomes contaminated with microorganisms at the moment of occurrence, thus the prompt application of a sterile dressing serves to limit the entrance of infectious organisms. Once a dressing is applied, it should remain in place if at all possible. Removal permits entrance of additional microorganisms and may disturb the clot so that hemorrhage recurs. Also, leaving the original dressing in place helps the surgeon viewing it later to estimate the amount of blood the patient has lost.

When a wound is dressed, care must be taken to avoid touching the wound or the surface of the dressing that is to be placed directly on the wound, breathing onto the dressing or wound, stirring up dust about the patient area, or allowing other actions which would permit infectious organisms to enter the wound.

Elevation of a Wounded Limb

Hemorrhage, especially of the venous type, can frequently be lessened appreciably by raising the injured limb to a height slightly above that of the heart. Because elevation tends to drain the elevated limb by gravity, an initial gush of blood downward from open veins should be expected when the limb is first elevated. Elevation helps to lower the blood pressure at the wound site. It may be used before, during, or after application of a pressure dressing, depending mainly on the type and severity of the wound.

The patient may be instructed to elevate an less serious wound while waiting for a dressing and to maintain the height after the dressing is applied. Serious hemorrhage, especially of the arterial type, may require simultaneous and continuous application of elevation, dressing, pressure, and cold. If there is a broken bone in the wounded limb, elevation must be postponed until after the limb is splinted.

Use of a Tourniquet

A tourniquet is any constricting band placed around the circumference of one of the extremities to stop hemorrhage. In an emergency, careful judgment is required in making the decision to apply or withhold a true tourniquet. Both arterial and venous blood flow stops at the tourniquet. Without circulating blood, the part distal to the tourniquet begins to die. Rarely will a tourniquet be required unless a limb is severely mangled. When a tourniquet is used unskillfully, more harm can be done than from not using one.
Professional Judgment. While later surgical amputation of the limb distal to the point of application of the tourniquet does not necessarily always follow, the person who decides to apply a tourniquet must do so with the realization that this distal portion will probably be sacrificed. Thus, a tourniquet applied to a patient must represent a choice between saving a life or saving a limb. It must not represent a choice between the quick results a tourniquet produces and the sometimes tiring application of a pressure dressing.

Commitment. The decision to apply a tourniquet is irreversible. Once a tourniquet is applied, it must be left in place until removed by a surgeon as soon as possible. It must not be loosened and retightened in the mistaken belief that the portion of the limb distal to the tourniquet is being kept alive. The patient whose system is stabilized after the tourniquet has reduced the capacity of his circulatory system may not be able to withstand the shock of its sudden enlargement if the tourniquet is loosened.

General Guidelines. The need of a tourniquet is minimized when good techniques are used in pressure points, pressure dressings, elevation, local cold, and rest. Nonetheless, bleeding from a major artery of the thigh, lower leg, or upper arm, or hemorrhage from multiple arteries that is seen in traumatic amputation may prove beyond control by these methods. There is no set rule as to how long one should continue to try to control hemorrhage by pressure dressing, elevation, etc. However, in the emergency treatment situation, the absorbent capacity of the injured person's first-aid dressing may be used as a guideline.

Reactionary Hemorrhage

The possibility of delayed hemorrhage occurring either externally or internally as a postinjury complication is not remote. Reactionary bleeding may occur within a few hours after injury when blood pressure and circulation return to normal after shock. This increased pressure may also cause bleeding by displaced blood clots previously formed. If signs of renewed hemorrhage from a wound appear after a dressing is snugly in place, reapplication of manual pressure may be all that is necessary to assist clot formation. Sufficient pressure must be used to occlude the opened vessel(s).

Signs of renewed or continued hemorrhage are (1) the appearance or enlargement of a bloodstain on the outer surface of the dressing and (2) the appearance or continuance of blood trickling between the dressing and the skin.

Lacerations

A clot protruding beyond the surface of the skin is presumptive evidence of arterial damage. The circulation of the part distal to the injury may be jeopardized because of marked damage to vital vessels or be merely a result of pressure resulting from a hematoma. If subcutaneous fat is exposed, the rule of thumb is that the wound should be sutured. An emergency attendant is rarely involved in the handling of wound closure materials such as suture needles or thread. However, it may be necessary to apply specially prepared adhesive strips for a sutureless wound closure before transporting the victim.

Hematoma Formation

A hematoma arises from a rapid extravasation of blood and tissue fluid that pools into a singular large fluctuant mass. After injury, it may localize within a tissue space, a compartment, or an organ at any depth at most any site in the body. More specifically, O'Donoghue defines hematoma as a collection of pooled blood, within a relatively restricted area, that has collected in a localized area (self-made space) and has maintained its identity as blood. Bleeding within an anatomically closed space such as a joint, bursa, or viscus is not commonly called a hematoma.
Etiology. Interstitial hematomas are usually the result of contusion, while intramuscular hematomas are the product of intrinsic tears. Both contractile and noncontractile elements are damaged during muscle strain, but the greatest injury is suffered by the capillary network between skeletal muscle fibers. The effect is seepage of blood and tissue fluid into interstitial and extracellular muscle spaces that are already congested by activity hyperemia. A degree of hematoma is the result, and it may protrude within the potential space between muscles.

When extrinsic stress is severe, bleeding may also result in deep and subcutaneous connective tissues to compound the problem. When intramuscular tension returns after injury, bleeding points tend to become compressed. Firm clotting occurs within a few hours, but slight trauma (eg, massage, bump) may cause further hemorrhage even after 2-3 days. Resolution follows with a degree of absorption and fibrosis.

Inspection and Palpation. After a hematoma develops, the body's reaction is to make an inflammatory response enabling it to cope with the blood pool. This reaction increases local tenderness and heat (similar to that seen in cellulitis) for 2-3 days until the stage of reactionary inflammation subsides. A large hematoma is never absorbed, it undergoes organization, fibrosis, and scar. The extent of a palpable hematoma should be noted, along with tissue tension and the presence of a bruit. If the hematoma pulsates, it may be due to transmitted arterial impulses or the development of an aneurysm. With aneurysm, a bruit can usually be auscultated. A hematoma itself is not tender, but adjacent soft tissues are frequently so. As the hematoma begins to age, the initial pool firms. If palpable, it will feel from doughy to fluctuant depending on its stage.

Management. First air for typical hemorrhage is compression, cold pack, elevation, and rest. Although a distinctly large extremity hematoma may become obliterated in 1-2 days with this treatment, local compression and padding should be continued for 1 or 2 weeks to assure complete resolution. Certain enzymes tend to help disbursement of a hematoma, but they are less effective than evacuation.

Referral. In severe cases or when fluctuation is obviously evident, referral for aspiration may be necessary. If so, it must be done early as a firm clot cannot be aspirated; open drainage must be used for evacuation. Aspiration should be followed by continued compression. If a semifirm clot resists aspiration, continued compression and padding are applied to encourage clot liquefaction. This should occur in 2-5 days. Open surgery is rarely necessary; when it is, the probability of secondary infection is always a problem. A dozen or more sterile needle aspirations are safer than one incision.

Uniqueness of Athletic Injury. The well-conditioned athlete (or hard laborer) not only has increased work capacity but also has altered typical metabolism at the microscopic level. Injury interrupts training and work causing a diminished level of physical fitness. It also produces a different type of lesion than that seen in general practice. This is due to the effects of training that increase muscle-fiber bulk and interstitial tissue vascularity.

Because of the increased muscle bulk, vascularity, and conditioning to demands in the physically active individual, bleeding is more marked than in the unconditioned individual. Well-trained muscle offers more efficient physiologic mechanisms to remove extravasated blood from muscle, and absorption is much more rapid. Thus, in the management of hematoma or any similar injury, treatment must be modified when dealing with the rigorously trained or with the sedentary person.

      SHOCK

Shock is a reaction to injury or disease, a manifestation of the rebellion of the body against a major insult or injury -an alarm reaction. It may appear suddenly after trauma or develop insidiously. There is inadequate circulating blood to fill the vascular system. There is interference with the basic physiologic process of the blood stream delivering oxygen and other essential elements to body tissues and removing waste products.

Besides the predominant characteristic of a reduction in volume of circulating blood and initial vasoconstriction, vasodilatation, hypotension, tachycardia, and prostration follow. The initial circulatory deficiency is rapidly complicated by widespread oxygen deprivation and by a lessening of function of all tissues, especially the brain, liver, heart, and kidneys.

Typical Causes in Sports and Manual Labor

Reduction of blood volume in circulation can result from (1) loss of blood through internal or external hemorrhage; (2) loss of plasma by seepage into tissues at the site of injury (eg, burns, contusions, crash injuries); (3) excessive loss of fluids and electrolytes from the intestinal tract through severe vomiting or diarrhea; or (4) an abnormally sudden increase in the volume capacity of the vascular system because of extensive vasodilatation. In the latter instance, many blood vessels dilate at the same time and, although there is no actual loss in the amount of blood, blood fails to move forward in the dilated vessels, thus mimicking cardiac output failure.
Clinical Features. The signs and symptoms of shock are related to ineffective circulation and depression of vital body processes. The classical signs of shock exhibit the body's attempt to compensate. They are:
Progressive loss of blood from active circulation, which may lead to failing heart output and insufficient oxygen to cells vital for survival. Cold perspiration, pallor, and possibly slight cyanosis, reflect the body's attempt to produce peripheral vasoconstriction.

Sustained, progressively failing hypotension, which may lead to kidney and liver failure reflected by oliguria, indicative of physiologic-compensation failure.

Rapid-shallow breathing (air hunger), tachycardia, and a rapid weak thready pulse in compensation for cerebral anoxia. Anxiety, excitement leading to confusion, listlessness, irrelevant phrase repetition, apathy, and coma are also effects of cerebral anoxia.

Early syncope, which is mainly neurogenic and may be fatal. During this process, the patient will usually present a staring or vacant expression in the eyes. The pupils are dilated unless morphine has been given or taken.

Preventive Measures

Shock should be anticipated in any person subjected to known causes of shock such as unusual physical and emotional stress, any severe injury, loss of blood, or loss of other body fluids. It may develop slowly. In fact, characteristic signs might not appear for several hours. In incipient or impending shock that has not yet developed, no sign may manifest but preventive measures should be taken if shock is considered possible.

Prevention goals are met through the control or relief of factors tending to reduce aeration and circulation of an adequate blood volume. Aside from hemorrhage or even in its absence, circulatory collapse can be hastened or aggravated by such factors as fear, fatigue, or pain; dehydration resulting from excessive sweating, vomiting, or diarrhea; movement of injured parts; or use of morphine.

The patient should be kept horizontal so available circulating blood does not have to move against gravity. If the patient must be moved, move the victim gently. Cover the person lightly to preserve heat in a cold environment, but not so many blankets that would increase core temperature. Do whatever is possible to relieve pain. Establish a quiet atmosphere and a calm attitude to reassure and secure the patient. Check vital signs frequently to seek signs of irregularities and sudden changes.

Emergency Care

Williams/Sperryn warn that the worst treatment given is overheating as this increases peripheral vascularity depriving deeper essential circulation. Elevated body temperature places stress on the cardiovascular system. As the superficial vessels dilate in an attempt to cool the blood within them, the system may become too large for the amount of blood it contains. In addition, there is an increased loss of electrolytes, particularly sodium and chloride. In a warm or hot atmosphere, padding used beneath the patient should not be made of wool. The patient should be shaded from the sun.

Temperature, pulse, and blood pressure should be checked every 15 minutes. A critical point for effective kidney function is reached when systolic blood pressure drops below 80 mm Hg. This can be a fatal complication. The only effective treatment of severe shock is transfusion of whole blood. Until this can be arranged, assure that the patient's airway is open. Other measures are explained below.
Position the patient supine if conscious or in the three-quarter coma position if unconscious. The victim's limbs should be raised to a level about 6-inches above the head to let gravity assist venous drainage. Pillows can be placed beneath the patient's feet (with flexion at the knees) and buttocks. The good method is to raise the foot end of a spineboard, cot, or litter. This creates pooling of blood in the abdominal area without pressure on the diaphragm.

Placing the head of a sitting victim down is not good procedure because respiration is hindered from the weight of the viscera producing an elevated diaphragm. The semiprone coma position may be used when the patient is unconscious; when there is a wound of the head, face, neck (except fracture or dislocation), or chest; or when vomiting is likely. When the patient is in this position, drainage from the respiratory tract is assisted.

Loosen tight clothing around the neck, chest, waist, and at any other areas in which clothing tends to bind. Loosen but do not remove shoes.

Keep the patient comfortable. The patient should not be allowed to become either cold or overheated. A drop in skin temperature gives rise to constriction of the superficial blood vessels, thereby reducing the volume of the vascular system. In a cool or cold atmosphere, the patient's body and limbs should be covered with blankets. Wet clothing should be removed and blanket coverings tucked close to the patient's skin. Clothing may be left on and exposed to the atmosphere, provided a breeze does not evaporate perspiration in the clothing so rapidly as to chill the patient. The victim should also be protected against atmospheric temperature changes such as those brought on with nightfall.

Relieve thirst in the conscious patient who is not vomiting and has no wound in the abdominal cavity or alimentary canal. Warm sweet drinks may be offered. Never offer an alcoholic beverage because it will dilate the vessels, and never force fluids by mouth.

Oxygen must be started immediately at 6 liters/minute if cyanosis of lips, nailbeds, or earlobes is noticed. Reassure the patient if conscious that his or her best interests are being served.
Treatment should be discontinued gradually when vital signs return to normal and stabilize. One valuable test of returned circulatory control is the ability of the patient to maintain stable vital signs as the patient changes position gradually upright. No sudden or abrupt movements should be allowed.

      WEEPING CONTUSIONS

A contusion, states O'Donoghue, is the effect of any type of trauma causing bruised skin and subcutaneous tissue that results in capillary rupture and an infiltrative type of bleeding followed by edema and an inflammatory reaction. Soft-tissue damage is usually more painful and can be more serious than bone injury.

Bone heals with calcium. Soft tissue heals with fibrous scar tissue and is different from the original tissue by lacking its elasticity, pliability, plasticity, flexibility, and viability. Soft tissue also takes longer to heal than osseous tissue. Bone may actually be stronger after the healing process has taken effect, whereas soft tissue is usually weaker and less adaptable after repair.

BIBLIOGRAPHY OF MAJOR REFERENCES
Copass MK, Eisenberg MS: The Paramedic Manual. Philadelphia, W.B.
   Saunders, 1980.

Craig TT (ed): Athletic Injuries and First Aid: Comments in Sports
   Medicine. Chicago, American Medical Association, 1973.

Dolan JP, Holladay LJ: First-Aid Management, ed 4. Danville, Illinois,
   Interstate Printers & Publishers, 1974.

Hirata I Jr: The Doctor and the Athlete, ed 2. Philadelphia, J.B.
   Lippincott, 1974.

O'Donoghue DH: Treatment of Injuries to Athletes, ed 4.
   Philadelphia, W.B. Saunders, 1984, pp 94-103, 105-117, 682.

Schafer RC: Chiropractic Management of Sports and Recreational
   Injuries, ed 1. Baltimore, Williams & Wilkins, 1982.

Synder D: Chiropractic on the Field. Journal of Clinical Chiropractic,
   Special Edition: Athletic Injuries, 1(6).

Williams JGP, Sperryn PN (eds): Sports Medicine, ed 2. Baltimore,
   Williams & Wilkins, 1976.

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