Public First Aid Certificate Course (English)

Lecture 2

Wounds & Bleeding

Mr. N. Tang

Learning ObjectivesUpon completion of this lecture, participants will be able to :3. Conceptualize the structure & functions of circulatory system.2. Differentiate between open wound and closed wound regarding the cause, nature of the wound and bleeding.3. List 4 common signs and symptoms of severe external bleeding.4. State first aid of bleeding from the following parts of

the human body: 4.1 Scalp and Head 4.2 Ear 4.3 Nose 4.4 Mouth 4.5 Palm 4.6 Chest

Learning Objectives

4.7 Abdomen

4.8 Vagina 4.9 Crush injury 4.10 Amputated finger 4.11 Tooth5. Secure a dressing covering the bleeding wound on the various body parts using a roller bandage : 5.1 Upper arm and forearm 5.2 Thigh and leg 5.3 Elbow, knee and heel 5.4 Hand and foot

Circulatory System1. The Heart

2. The Blood Vessels3. Blood *

The Position of the Heart in Adult

Mid-clavicular line

2nd

4th

5th

2nd

5th

Clavicle

fifth inter-costal spaceSternum

Ribs

Heart

7th

8th

9th

6th6th

The Internal Structure of the Heart

Pulmonary arteries

Pulmonary veins

Left atrium

Left ventricle ValveDescending aorta

Rt. ventricle

Inferior vena cava

Rt. atrium

Superior vena cava

Ascending aorta

The HeartStructure- Cardiac muscle- Left and right sides- Each side : atrium (upper) ventricle (lower); heart valves- Enter : superior and inferior vena cava, pulmonary veins- Leaving : pulmonary arteries (to lungs) and aorta Function : pumping blood

Blood pressure - Normal systolic / diastole pressure : 120/80 mmHg - Factors : contractility, elasticity of arterial wall, volume

Arteries & Pulse

Temporal artery

Carotid artery

Apical beat

Brachial arteryRadial artery

Femoral artery Popliteal artery

Posterior tibial artery

Dorsalis pedis artery

Checking Carotid Pulse

Place two fingers on laryngeal prominence

Slide 2 fingers to one side for one inch to

detect pulse

Brachial Artery & Pulse

Baby

Radial artery & pulse

Adult

Artery Vein

Blood Vessels

Capillary

Venules

From heart

　Lungs

Valve

Lumen

Arterioles

Blood Vessels & BleedingTypes Blood Flow Characteristics Bleeding

1. Artery

(muscular and elastic tissues)

From : heart

To : organs/tissues

Except :

- pulmonary arteries

(carry deoxygenated blood to the lungs)

Oxygenated blood,

bright red,

high pressure

Profused bleeding, blood spurts out in time with the heart beat)

2. Capillary

(thin wall with pores)

Connect artery to vein Oxygenated blood

Brisk bleeding or oozing; slight blood loss

3. Vein

(Valves in legs)

From : organs/tissues

To : the heart

Except :

- pulmonary veins

(carry oxygenated blood to the heart)

Deoxygenated blood, dark red

The blood may gush from the broken vein profusely

Brachial Artery & Femoral Artery

*

Inguinal ligament

Femoral artery

Brachial artery in

upper arm

*

Source : ref. no. 4

Heart Groin

The BloodTotal volume : about 5 - 6 litres Composition1. Plasma 55% - water, electrolytes, glucose, fatty acid, amino acid, gases (oxygen, carbon dioxide, nitrogen etc.),

enzymes, antibodies/antitoxin, clotting factors, heat, hormones 2. Blood cells 45% 2.1 Red blood cells – haemoglobin to carry O2, CO 2.2 White blood cells – defend against infection 2.3 Platelets – help blood to clot

Serum : when blood clot, fluid (blood plasma) with no fibrinogen

Normal Circulation of Blood Head, Neck & Upper Limbs

Lungs

Heart

Trunk and Lower Limbs

Oxygenated Blood

Deoxygenated Blood

Aorta

ArteryVeins

Signs & Symptoms in Bleeding• Blood loss less than 10% (500ml), the body

can adjust, no obvious signs and symptoms

2. Blood loss more than 15% (about 750ml) - signs : pale, cool and moist skin : weak and rapid pulse - symptoms : thirst

3. Blood loss more than 40% (about 2 litres) - signs : BP drops, confused, irritable, shallow

and rapid breathing, weak pulse, LOC, heart stops beating

12

3

4

Wound

WoundsMeaning - A break in the skin or internal organ surfaces

Types 5. Closed wound 6. Open wound

Risks Haemorrhage (bleeding) -> shock, cardiac arrest and death Wound infection

1. Closed Wound

Type Description

Contusion

(Bruise)

- Caused by a blunt blow or punch - No break of skin surface- Rupture of capillaries under the skin -> internal bleeding (bruise) or

fracture

2. Open WoundsType Description

a. Incised - Caused by knife, razor etc.- Clean wound with active bleeding- Cut blood vessels, tendon, nerves

etc.

2. Open Wounds

Type Description

b. Lacerated

- By crushing or ripping forces

e.g. animal bite- More tissues damage

- Dirty wound -> high risk of infection- Less bleeding

2. Open Wounds

Type Description

c. Abrasion

(graze)

- By a sliding fall or a friction burn- Superficial skin scrapped off- Raw and tender area

- Dirty wound with foreign body

-> infection

is likely

2. Open Wounds

Type Description

d. Puncture

- By needle or nail- Small deep wound- May cause severe internal bleeding

- High risk of tetanus

2. Open WoundsType Description

e. Stab wound

- By knife- Severe internal bleeding

and organs damage

2. Open Wounds

Type Description

f.

Gun shot wound

- By a bullet or missile- Small and neat entry wound- Large and ragged exit wound

- Severe internal injury - Dirty wound

3 Aims of First Aid Save Life Prevent the Condition

From Getting Worse Promote Recovery

- Dial 999 - DRABC, HSF: . Safe environment Save on the spot . Response . ABC +/- CPR . Control bleeding * . Treat shock : a. lie down b. loosen tight clothing c. keep warmth d. elevate the lower limbs 20 – 30cm high

- Reassure the

casualty

- Monitor :

. bleeding condition

. vital signs every 10

min.

- Treat other injury

- retrieve and keep the amputated part and send it with the casualty to hospital ASAP (microsurgery under general anaesthesia);

- keep nil by mouth

-Vaccination : anti- tetanus toxoid (ATT) against tetanus (Clostridium tetani)

Principles of Controlling Bleeding

• Wash hands, wear gloves• Inspect the wound for any foreign body • Assess bleeding4. Apply sterile / clean dressings to cover the wound• Apply direct pressure on the bleeding wound for 10 min.• Bandage and elevate the affected site above the heart7. Check circulation8. Rest / lie down9. Check vital signs

Apply dressingand pressure

Lie down on a blanket , elevate &

support the bleeding part

Direct & Indirect Pressure1. Direct pressure- for 10 min.- if blood is still oozing out, not remove old dressings but reinforce it ***

2. Indirect pressure - 4 pressure points : a. brachial artery for each upper limbs b. femoral artery for each lower limbs- never use tourniquet

Brachial artery

Femoral artery

Small Dirty Wound, Cuts or Grazes

- Flush the wound with water, pat it dry - Cover with sterile gauze- Clean the surrounding skin with soap and water; pat dry- Remove the wound cover and apply an adhesive dressing - Elevate and support the affected part- Advise to see a doctor and vaccination

Peel back the stripes

Open Wound with Foreign Object

2

34

1

Push the edges of the wound together

Care of Amputated Part

Name

Date & Time of injury

Amputated part

(b)*Use gauze or soft fabric to hold the amputated part

Use a plastic bag or kitchen film to wrap the part

or (b)

Never wash or Clean it

with water

Plastic bag or containerCrushed ice cubes

Care of amputated part

Infected WoundSources of microorganisms- Source of injury, air, fingers, breaths, dressing,

lotion

Signs and symptomse.Local : - redness, swelling, pain, hot, pus, loss of function, tenderness of lymph nodes, faint red trails on the skin surface

- wound does not heal within 48 hrs after injury

Infected WoundSigns and symptomsb. General: fever, sweating, thirst,

shivering, tired

First aid- Wound care- Supported by sling - Advise to see a doctor

Bleeding From Different Sites

Scalp of the Head

Scalp

Connective tissue

AponeurosisLoose areolar tissue

Skull

Periosteum

Dura mater

Scalp & Head InjuryResults- Profused bleeding- Skull fracture, neck injury

First aid• Unconscious : DRABC

B. Conscious : . Wear gloves . Replace skin flap over the wound . Apply sterile / clean dressing . Apply direct pressure and bandage, . Lie down with the head & shoulders slightly elevated . Keep the bleeding wound in the uppermost position . Observe vital signs . Send to hospital

After Head Injury

Seek medical advice if• Severe headache• Repeated vomiting• Convulsion• Increasing drowsiness• Unconsciousness• Double vision• Weakness of limbs or face• Difficulty in walking

Base of the Skull

Anterior cranial fossa

Ethmoid bone

Sphenoid bone

Middle cranial fossa

Right parietal bone

Right temporal bone

Foramen magnum

Posterior cranial fossa

Occipital bone

Bones & Sinuses

Frontal

Conchae

Superior concha

posterior ethmoidal sinus

Middleconcha

a. Ethmoidal (anterior and middle) sinus

b. frontal sinuses c. maxillary sinuses

Inferiorconcha

Nasolacrimal duct

C.S.F. Rhinorrhoea and Otorrhoea

C.S.F.Rhinorrhoea

C.S.F.Otorrhoea

Meaning Leakage of cerebro-spinal fluid (C.S.F.) from the nose

Escape of C.S.F. from the external auditory meatus

Cause Fractures of anterior cranial fossa and frontal sinus -> tearing of meninges -> C.S.F. flows out -> nasal cavity

Fracture of middle fossaFracture of temporal bone

EYES

Human Eye

Source : Ellis, H. (2006). Clinical anatomy. (11th ed., P.388). U.S.A.:Blackwell.

Iris

Conjunctiva

Retina

Vitreous Body

Fovea centralis

Artery

Cornea

Aqueous humour

Choroid

Sclera

Optic nerve

Dural sheath

Eye InjuryCauses - Direct blow -> bruised- Work-related injury : foreign body e.g. sharp, chipped fragments of metal, grit and glass

Risk : eye infection -> scarring -> affect vision

S/S : intense pain, impaired vision, leakage of fluid/blood, bloodshot eye

First aid- Lie down, keep the head still, not move both eyes- Cover the eye and secure dressing; not remove FB- Send to hospital

EAR

Human Ear

Externalauditory meatus

Ear drum

Temporal Bone

Bone

Eustachian tube

Cochlea

Vestibular apparatusBones

Source : Wilson, K.J.W. & Waugh. (1996). Anatomy & Physiology in health and illness. (8th ed., P.192). New York : Churchill Livingstone.

Ear BleedingCauses- Perforation of ear drum by . Foreign object . Explosion- Direct blow to the ear- Ear infection

Signs and symptoms- Ear ache, deafness, dizziness, bleeding- Leakage of cerebral spinal fluid (CSF) if fractured base of skull

Ear Bleeding

First aid Tilt the head to the side of bleeding Cover the ear with sterile dressing Do not plug the affected ear Send to hospital

NOSE

Nose BleedingCauses Direct blow Sneezing, picking or blowing the nose

forcefully Disease – hypertension Head injury – fractured skull Drug - anticoagulant

B.P.

Nose Bleeding

Sit down & restReassureLoosen clothing at the flexed neck

Mouth breathingPinch the soft part of the noseNot to speak, swallow, cough, spit, sniffMop up any dribbling blood Check after 10 min. Reapply force if necessaryNo physical exertion

To hospital: . Uncontrolled bleeding . Bleeding >30 min. . Head injury

MOUTH

Teeth

Soft Palate

Uvula

Tonsil

Lower Lip

Tongue

Pharyngeal wall

Arch

The Mouth

Bleeding from the MouthBleeding Sites- Lips, lining of the mouth, tongue, tooth cavity after dental extraction

First aid- Sit down- Tilt the head to the injured side- With gloved fingers, place a pad over the bleeding

wound, bite and squeeze it for 10 min.- Bleeding socket : bite a gauge pad placed across the empty socket - No mouth wash or hot drinks- Send to hospital if bleeding >30 min .- Avoid drinking anything hot for 12 hrs.

Tooth• Source : Wilson, K.J.W. & Waugh. (1996). Anatomy & Physiology in health and

illness. (8th ed., P.289). New York : Churchill Livingstone.

Crown

Root

Enamel

Dentine

Pulp cavity

GumNeck

Dentine

Cement

Blood vessels and nerves

Knocked-out ToothCare of the tooth- Keep it moist- Immerse it under salted or plain water,

milk (without sugar) or saliva- Wear gloves, replace the detached tooth

in the socket, keep it in place by covering it with a gauze pad and then bite on it

- Don’t clean or brush the detached tooth - Don’t touch the root of a tooth - Consult dentist within 30 min.

PALM OF HAND

Bleeding Wound on the PalmAssociated injury - tendons, nerves, blood vessels

First aid- Place a thick dressing covering the wound- Clench the fist- Bandage fingers- Apply an elevation sling- Send to hospital

Elevation sling

ABDOMEN

Abdominal Wound

Causes- Trauma . stab wound . gunshot . crush injury

Result: - punctured, lacerated or rupture internal organs - internal and external bleeding- protrusion of abdominal contents- infection and shock

Abdominal Injury

4. For protruding intestine, do not touch it, cover it

using kitchen wrap or moist dressing and then secure it

using bandage

* Nil by mouth

3. Wear gloves, cover and secure the wound with bandage or strapping

1. Dial 999, lie flat, bend knees with support

999

2. Loosen tight clothing or belt

5. Support the wound when coughing or vomiting, check vital signs

CHEST

Penetrating Chest Wound

Causes- Trauma : gun shot wound, stab wound

Result- Internal bleeding, shock- Pneumothorax , haemothorax- Tension pneumothorax : fatal

Penetrating Chest Wound

Healthy Lung

Collapsed LungPneumothorax

Haemothorax

Tension Pneumothorax

On inspiration, the mediastinum shifts towards the unaffected lungs, impairing ventilation.

On expiration, the depressed diaphragm augments medinastinum shift, distorting the vena cava and reducing venous return.

Penetrating Chest WoundSigns and symptoms- Fear- Breathing : difficult, painful, rapid, shallow, uneven- Cyanosis (grey-blue skin): hypoxia- Coughed-up frothy and red blood- A crackling feeling of the skin around the wound - Blood bubbling out of the wound- Sound of air being sucked into the chest during inspiration- Prominent neck vein

Perforated Chest WallCover the open wound with palm or sterile dressing and plastic foil / kitchen film immediately, then seal 3 sides of the dressing

999

Lean the chest towards the injured side (even in recovery position)

Check vital signs

Send to hospital urgently

VAGINA

Vaginal Bleeding

Causes- Menstruation- Pregnancy : . miscarriage . recent abortion . childbirth- Sexual assault

Vaginal Bleeding

First aid- Attend by a female first aider- Privacy- Give a sanitary pad or a clean towel- Sit-up with knees bent and supported- Dial 999 for an ambulance- Allow self-administer drugs if she has

cramp (because of menstruation)

Vaginal Bleeding

First aid- if sexual assault case : . attended by a female first aider . preserve all evidence if possible - advise to refrain from washing or using toilet until being examined by doctor (but do not insist) - if clothing has been removed, keep it in a clean plastic bag

LEG

Varicose VeinVeins in legs- with one-way valves : blood in leg -> heart

Dysfunctional valves : -> accumulate blood in the legs -> engorged veins -> injury to the distorted vein -> open wound with profused bleeding -> shock

Valves

Varicose Veins- Apply dressing and direct pressure- Remove garters, elastic-topped stockings- Check vital signs - Send to hospital

CRUSH INJURY

Crush InjuryCauses- Accident : . Traffic . Construction site . Explosion . Earthquakes

Result- Internal bleeding, fracture - Acute renal (kidneys) failure / crush syndrome- Impaired circulation -> numbness below the site

of crush injury

Pathophysiology• Crush syndrome : crushing of muscle -> damage ->

bleeding into the injured areas -> shock• When pressure on tissues is relieved, reperfusion of

blood occurs, free radicals are generated, which causes further tissue damage (i.e. reperfusion-induced injury).

• Increased Ca2+ in damaged cells can reach toxic levels.

• Large amount of K+ enters the circulation.• Myoglobin and other products from reperfused tissue

can accumulate in kidneys in which glomerular filtration is already reduced by hypotension, and the tubules can become clogged, causing anuria.

(Source : McPhee, S.J. (2003). Pathophysiology of Diseases, (5th ed., P. 324). New york : McGraw-Hill)

Crushed InjuryFirst aid- If crushed less than 15 min.: . Remove the object safely (adequate helpers) . Wear gloves . Care of external bleeding wound . Secure and support any suspected fracture . Treat shock . Nil by mouth . Check vital signs . Send to hospital

Crushed Injury

First aid- If crushed more than 15 minutes . Do not release the casualty who has been crushed . Reassure the casualty . Check vital signs . Wait for the ambulance

Summary1. Structure & Functions of circulatory system2. Different types of wound and bleeding3. Signs and symptoms of external bleeding4. First aid of bleeding from the following parts

of the human body: 4.1 Scalp and Head 4.2 Ear 4.3 Nose 4.4 Mouth 4.5 Palm 4.6 Chest 4.7 Abdomen 4.8 Vagina 4.9 Crush injury 4.10 Wound and amputated part 4.11 Tooth

Demonstration & Practice

- Roller bandage

a. Simple spiral

b. Divergent spica

Gauze Pads / DressingsTypes of dressing Adhesive dressings or plasters Dressing pad and bandage Sterile eye pads

Uses of dressing Cover the wound to prevent infection Absorb blood or exudates Aid blood-clotting process

Preferably, use pre-packed sterile dressing; if not, use any clean, non-fluffy material instead

BandagesTypes Triangular bandage Roller bandage – cotton, crepe, elastic bandages Tubular bandage / Tubegauze - use applicator; for

heads, limbs and fingers only, not the trunk

Uses Secure gauze pads / dressings covering the

(bleeding) wound Control bleeding Support & immobilize limb Reduce swelling e.g. sprained ankle

Gauze Tubular Bandage

Applicator Dressing covers the wound

Tubegauze

Principles of Applying Roller Bandage

- Stand in front of the casualty (sit or lie down)

- Reassure and explain the action to be taken

- Wear latex /disposable gloves

- Support and examine the injured part; ensure no foreign body in the bleeding wound

- Select 2 pieces of clean / sterile gauze pads of appropriate size; hold it by the edges; place it directly on to the wound; do not use any contaminated dressing (e.g. by droplets, floor or skin /finger dirt)

Principles of Applying Roller Bandage

- Apply direct pressure on the bleeding wound

- Choose the correct size of bandage : . 2 inches – upper arm, elbow, forearm, wrist, hand . 3 inches – thigh, knee, leg, ankle, foot

- Parts of bandage : head (keep it uppermost) and tail

- Start with a fixation turn (2 straight turns) and finish with a straight turn

Principles of Applying Roller Bandage

- Unroll the bandage along the skin surface, no pulling of bandage, from inside to outside of the limb and from below upward

- Each turn covers the previous turn width by 2/3 and exposes 1/3; anchor the flap laterally using 2 bandage clips, safety pin or adhesive tape; apply sling to support the injured upper limb

Principles of Applying Roller Bandage

- Check circulation of toes or fingers every 10 min., – temperature, pulse, colour, blanching test, movement, sensation

- Remove and reapply bandage if there are signs of circulatory impairment

Patterns of Roller Bandage

Types2. Simple spiral - upper arm, forearm : with arm sling - thigh, leg : elevate the foot after bandaging

2. Divergent spica - elbow: with arm sling - knee, heel : elevate the foot after bandaging

3. Figure-of-eight - hand : with elevation sling - foot, ankle : elevate the leg

Elevation Sling

Scapula

Arm Sling

1. Expose all

fingers

2. The base is

slightly elevated

Knot : on the injured side.

End

Point

End

End

Point

Roller Bandage – Control Bleeding1. Simple spiral bandage - sites

1. Upper arm

2. Forearm

3. Thigh

4. Leg

Anchor the end of bandage on the outer aspect of limb

1. Simple Spiral Bandage3.Direction of moving bandage:

. From inside to outside. From below upward

2 Straight turns : beginning 1 Straight turns : ending

2.Use :- 2” bandage for the upper limbs,- 3” for the lower limbs

4.Cover 2/3 and expose 1/3 width of the previous turn of

bandage

5.After bandaging,

(a) apply an arm sling to support the

injured upper arm

(b) elevate the affected lower

leg

1.Support, place gauzes and apply direct

pressure

2. Divergent Spica

Sites :•Elbows – supported by an arm sling after bandaging•Knees – elevate the foot after bandaging•Heels – elevate the foot after bandaging

1

23

2. Divergent Spica2.Fixation turn :

just on top of gauzes, move from inside to

outside

3.Cover the upper 1/3 and the lower 1/3 width of the bandage -> ‘Eye’ is the

middle 1/3

4.Anchor the end of bandage

laterally on the upper

arm1

2

35. Supported by an arm sling

1.Place gauzes on top of the wound

ReferencesSt. John Ambulance, St. Andrew’s Ambulance Association, British Red Cross. (2009). First Aid Manual. (9th ed., P. 102-109, 114 -115, 118-129, 225 – 226, 235 -248, 266-267). London : Dorling Kindersley.

香港聖約翰救護機構 (2007)。急救證書課程手冊。 (第二版，第 13-34、 40-41,195-198, 201-203頁 )。香港 :香港聖約翰救護機構。

ReferencesEllis, H. (2006). Clinical anatomy. (11th ed., P.317-321). U.S.A. : Blackwell. Philips, S. et al . (2005). Total revision : ENT. (1st ed., P.59).North Yorkshire : Alden Press.Wilson, K.J.W. & Waugh. (1996). Anatomy & Physiology in Health and Illness. (8th ed., P.89, 100, 110, 192, 286, 289). New York : Churchill Livingstone.