External hemorrhage

Exyernal Hemorrage

1. External Hemorrhage Dr Bedeer elsherbiny Pharm d, MS clinical pharmacy,bcps

2. MECHANISM OF INJURY Penetrating trauma in combination with an increase in high-energy road traffic accidents may account for the increased incidence of major thoracic vascular injury . In one large review, 5760 cardiovascular injuries were sustained in 4459 patients, mainly in young males, who represented 90 percent of all of penetrating injuries. Truncal (including neck) vascular injuries predominated at 66 %, with the lower extremity region representing only 19 % of all vascular injuries. The mechanism of injury varied and included high-velocity weapons (70 to 80 percent), stab wounds (10 to 15 percent) and blunt trauma (5 to 10 percent).

3. CLASSIFICATION OF HEMORRHAGE Class 1 Mild Class 2 Moderate Class 3 Severe Class 4 Severe Blood loss up to 15% 15 to 30% 30 to 40% more than 40% Heart rate minimally elevated or normal, tachycardia (HR 100 to 120 bpm) Heart rate (≥120 bpm) Marked tachycardia (HR >120 bpm). Blood pressure No change Minimum change in systolic blood pressure significant drop in blood pressure significant depression in blood pressure Pulse No change decreased markedly elevated Pulse pressure is narrowed (≤25 mmHg) Respiratory rate No change tachypnea markedly elevated markedly elevated

4. INITIAL ASSESSMENT AND INTERVENTIONS Initial assessment focus on

5. Initial Assessment

6. Initial Assessment of external hemorrhage Direct pressure is the primary and preferred means for controlling external hemorrhage. A tourniquet may be required to control bleeding from a severe extremity injury.  Vascular access is obtained as rapidly as possible. Two short, large-bore (16-gauge or larger) intravenous (IV) lines placed in the antecubital region are ideal but not always possible. Intraosseous devices can be placed rapidly and offer an effective alternative when there is difficulty placing an IV catheter Placement of a central venous catheter (size 8 French) can be performed when adequate peripheral access cannot be obtained and allows measurement of central venous pressure. Some experts advocate use of distal saphenous vein cut downs due to ease of access and consistency of anatomy Traumatic shock occurs most often from hemorrhage, commonly from an intra-abdominal injury due to blunt trauma. Ultrasound is an integral part of the initial evaluation of the trauma patient. During the initial resuscitation, the extended Focused Assessment with Sonography for Trauma ( eFAST ) exam is performed to assess first for pericardial blood and then for intraperitoneal bleeding and pneumothorax Ultrasound has largely replaced diagnostic peritoneal lavage (DPL) in the initial assessment of the trauma patient, although DPL may retain a role in specific circumstances.

7. INITIAL MANAGEMENT OF HEMORRHAGE Control of compressible or extremity bleeding Direct pressure is the preferred means for controlling external hemorrhage clamping bleeding vessels under direct visualization is acceptable. blind clamping should  not  be performed Scalp lacerations can bleed profusely can be managed by inject lidocaine with epinephrine directly into the wound, by placing clips ( eg , Raney clips) or by closing the wound with stitches using heavy suture Use of a tourniquet to stop hemorrhage in cases of amputation or severe extremity injury when other measures have not successfully controlled bleeding. Tourniquets should be released periodically ( eg , every 45 minutes) when possible to avoid prolonged ischemia and possible tissue loss

8. INITIAL MANAGEMENT OF HEMORRHAGE Hemorrhage from pelvic fracture Unstable pelvic fractures and associated vascular injuries can cause hemorrhagic shock. Stabilization of the pelvis by applying a circumferential pelvic binder or tying a sheet firmly around the pelvis can reduce bleeding. Such interventions are most important with "open-book" pelvic fractures (in which the symphysis pubis is disrupted [≥2.5 cm], the pelvis opened, and the retroperitoneal space enlarged) In addition to immediate orthopedic consultation, interventional radiology and vascular surgery may be needed to help control hemorrhage. This anterior-posterior (AP) radiograph of the pelvis reveals significant diastasis at the symphysis pubis of this trauma patient. Such fractures can cause significant hemorrhage. Emergent treatment consists of closing the fracture and stabilizing the pelvis by applying a pelvic binder or tying a sheet tightly around the lower pelvis.

9. INITIAL MANAGEMENT OF HEMORRHAGE Control of non-compressible bleeding Methods for identifying no compressible bleeding include focused abdominal sonography for trauma (FAST) for the abdomen. chest radiograph for the chest. computed tomography (CT) for the retroperitoneal space. Hemodynamically stable patients can undergo CT for further assessment. Unstable patients should be stabilized either by resuscitation in the operating room or, in some situations, with resuscitative endovascular balloon occlusion of the aorta (REBOA) prior to going to the CT

10. 1 2 Control compressible and extremity bleeding Minimize the use of intravenous (IV) fluids in the resuscitation of trauma patients Give IV fluids only for the resuscitation of hypotensive patients ( eg , MAP <65), and then only until blood is available 4 5 6 Transfuse blood products as soon as the need is recognized. Blood products ( ie , red blood cells, plasma [clotting factors], and platelets) should be given in equivalent amounts Use thromboelastography, or comparable rapid point-of-care assessment of coagulation, to guide trauma resuscitation whenever possible. 2 Rapidly mobilize all needed resources ( eg , surgery, anesthesia, blood bank, transfer to trauma center). 3 RESUSCITATION AND TRANSFUSION Key principles guide the management of hemorrhage due to trauma in a 1:1:1 ratio. Whole blood can be used if available

11. Commonly used IV solutions

12. DRUG TREATMENTS FOR HEMORRHAGE

13. Haemostatic agents In some circumstances, external hemorrhage cannot be controlled using direct pressure and standard dressings. Hemostatic products that control bleeding, including Chitosan dressing, Kaolin-impregnated sponge fibrin sealant dressing Ant fibrinolytic agents   safe and effective at reducing bleeding Aminocaproic acid Tranexamic acid reduce mortality from bleeding Aprotinin Recombinant factor VIIa   off-label use Red blood cell substitutes   Research continues into oxygen-carrying resuscitation fluids that can serve as alternatives to packed red blood cells. The ideal replacement fluid would Transport oxygen effectively, Expand intravascular volume, Exhibit few or no side effects, Demonstrate great durability. Potential substitutes ( eg , hemoglobin-based oxygen carriers, perfluorocarbons ).

14. References Initial management of moderate to severe hemorrhage in the adult trauma patient https://www-uptodate-com.eu1.proxy.openathens.net/contents/initial-management-of-moderate-to-severe-hemorrhage-in-the-adult-trauma-patient?source=history_widget#H3772339605 Author:Christopher Colwell, MDSection Editor:Maria E Moreira, MDDeputy Editor:Jonathan Grayzel , MD, FAAEM Contributor Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Nov 2020. | This topic last updated: Apr 21, 2020.