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Public First Aid Certificate Course (English) Lecture 2 Wounds & Bleeding Mr. N. Tang

Learning Objectives Upon completion of this lecture, participants will be able to : 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 Tooth 5. 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 System 1. The Heart 2. The Blood Vessels 3. Blood *

The Position of the Heart in Adult Mid-clavicular line 2nd 4th 5th 2nd 5th Clavicle fifth inter-costal space Sternum Ribs Heart 7th 8th 9th 6th 6th

The Internal Structure of the Heart Pulmonary arteries Pulmonary veins Left atrium Left ventricle Valve Descending aorta Rt. ventricle Inferior vena cava Rt. atrium Superior vena cava Ascending aorta

The Heart Structure 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 bea t Brachial artery Radial artery Femoral artery Popliteal artery Posterior tibial artery Dorsalis pedis artery

Checking Carotid Pulse Place two fingers on laryngeal prominence �ݺ�ߣ 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 & Bleeding Types Blood Flow Characteristics Bleeding 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 Blood Total volume : about 5 - 6 litres Composition 1. 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 �C haemoglobin to carry O2, CO 2.2 White blood cells �C defend against infection 2.3 Platelets �C 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 Artery Veins

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

Wounds Meaning A break in the skin or internal organ surfaces Types Closed wound 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 Wounds Type 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 Wounds Type 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 �C 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 bleeding 4. 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 heart 7. Check circulation 8. Rest / lie down Check vital signs Apply dressing and pressure Lie down on a blanket , elevate & support the bleeding part

Direct & Indirect Pressure 1. 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 3 4 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 container Crushed ice cubes

Infected Wound Sources of microorganisms Source of injury, air, fingers, breaths, dressing, lotion Signs and symptoms 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 Wound Signs and symptoms b. General: fever, sweating, thirst, shivering, tired First aid Wound care Supported by sling Advise to see a doctor

Scalp of the Head Scalp Connective tissue Aponeurosis Loose areolar tissue Skull Periosteum Dura mater

Scalp & Head Injury Results 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

Conchae Superior concha posterior ethmoidal sinus Middle concha Ethmoidal (anterior and middle) sinus frontal sinuses c. maxillary sinuses Inferior concha 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 fossa Fracture of temporal bone

Human Eye Source : Ellis, H. (2006). Clinical anatomy. (11 th 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 Injury Causes 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

Human Ear External auditory meatus Ear drum Temporal Bone Bone Eustachian tube Cochlea Vestibular apparatus Bones Source : Wilson, K.J.W. & Waugh. (1996). Anatomy & Physiology in health and illness. (8 th ed., P.192). New York : Churchill Livingstone.

Ear Bleeding Causes - 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 Bleeding Causes ? Direct blow ? Sneezing, picking or blowing the nose forcefully Disease �C hypertension Head injury �C fractured skull Drug - anticoagulant B.P.

Nose Bleeding Sit down & rest Reassure Loosen clothing at the flexed neck Mouth breathing Pinch the soft part of the nose Not to speak, swallow, cough, spit, sniff Mop up any dribbling blood Check after 10 min. Reapply force if necessary No physical exertion To hospital: . Uncontrolled bleeding . Bleeding >30 min. . Head injury

Teeth Soft Palate Uvula Tonsil Lower Lip Tongue Pharyngeal wall Arch The Mouth

Bleeding from the Mouth Bleeding 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. (8 th ed., P.289). New York : Churchill Livingstone. Crown Root Enamel Dentine Pulp cavity Gum Neck Dentine Cement Blood vessels and nerves

Knocked-out Tooth Care 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.

Bleeding Wound on the Palm Associated 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

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 999 2. Loosen tight clothing or belt 5. Support the wound when coughing or vomiting, check vital signs 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

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 Lung Pneumothorax 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 Wound Signs 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 Wall Cover 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

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

Varicose Vein Veins 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 Causes 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 Injury First 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

Summary Structure & Functions of circulatory system Different types of wound and bleeding Signs and symptoms of external bleeding 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 / Dressings Types 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

Bandages Types Triangular bandage Roller bandage �C 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 �C upper arm, elbow, forearm, wrist, hand . 3 inches �C 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., �C temperature, pulse, colour, blanching test, movement, sensation Remove and reapply bandage if there are signs of circulatory impairment

Patterns of Roller Bandage Types 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 Expose all fingers 2. The base is slightly elevated Knot : on the injured side. End Point End End Point

Roller Bandage �C Control Bleeding 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 Bandage 3.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 �C supported by an arm sling after bandaging Knees �C elevate the foot after bandaging Heels �C elevate the foot after bandaging 1 2 3

2. Divergent Spica 2.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 arm 1 2 3 5. Supported by an arm sling 1.Place gauzes on top of the wound

References St. John Ambulance, St. Andrew��s Ambulance Association, British Red Cross. (2009). First Aid Manual . (9 th ed., P. 102-109, 114 -115, 118-129, 225 �C 226, 235 -248, 266-267). London : Dorling Kindersley. ��}�s��o�C�� (2007) �� C��n��փ� �� ( �� 棬�� 13-34 �� 40-41,195-198, 201-203 � ) �� : ��}�s��o�C��

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

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