What kind of injury gives a true uncontrolled bleed?

[Asysin2leads]

This topic has been on my mind after seeing some pretty nasty injuries lately. I'd like to hear some discussion this, and maybe some ideas for care.

Controlling bleeding is one of the basis of BLS care, and if I remember correctly, a great deal of time was spent on soft tissue injuries and maintenence.

That being said, after working in the field for a little while, and seeing quite a few different types of injuries, I am really surprised how many times there is relatively little bleeding. The most extereme example of this I saw recently was a 45 year old woman who fell in front of the subway, and had an amputation of the leg at the mid femoral area.

I won't bore you with the gory details, but trust me on saying this was not a "clean" cut. To be perfectly blunt, what remained of her upper thigh looked like an under done pot roast that had exploded. Several structures were plainly visible, the patellar tendon, the marrow of the femur, and the remains of the muscle structure.

While I did not observe her removed from the actual scene, upon arrival at the ER, there was no blood coming from the injury whatsoever. She was A0x3, her BP was 100/50, so obviously she had LOST a lot of blood initially, but my point is she did not appear to be continuing to LOOSE blood. I do not have reason to believe that the train wheel was of sufficient temperature to provide an appreciable cauterizing effect.

So, I what I'm really asking is that if the body can pretty much compensate and itself control the bleeding after a severe insult to the longest bone in the body (which I believe contains also the most amount of marrow), the femoral artery, the femoral vein, and several large muscle structures, what type of injury could we reasonably expect to not be controlled without provider intervention?

If the body has this apparent ability to "seal itself", what does this mean for providing bleeding control in the field versus risking doing greater damage to an injury, causing pain, and inducing infection?

[ERDoc]

Arteries are covered in smooth muscle that spasm whenever there is an injury (just ask anyone who has ever missed an ABG, the second time is even harder). If the pressure coming down the pipe is higher than the spasm force then you will get bleeding. Veins don't have this compensation mechanism so they tend to bleed more. Luckily they are such low pressure vessels that it doesn't take much to stop them from bleeding. Organ injry such as splenic and liver tends to lead to massive blood loss because they don't have such mechanisms.

[Ace844]

"ASYS,"

I was on a call which was at a construction site. The 'site' foreman, wanted to talk to the 'Excavator operator'. So in classic non-thinking fashion, he approached the machine from behind and hopped up on the tread by the 'operators' door. The operator not knowing that his boss was on the tread put the machine into reverse just after the foreman had gotten up on it. The foreman slipped, and was 'rolled over' by the excavator tread. The tread began at just below the xyphoid process, and continued to abou the knee unequally placed on his body. Long story short, on initial presentation, COAX4, B/P 134/92, HR 100, RR26. Everything went great, got 4 IV lines running the helicopter crew was there, etc... Roll the 'excavator off the pt.....GOOD NIGHT IRENE!!!! 8)

There's an example for ya. We tried everything, including MAST, etc..

out here,

ACE844

[Scaramedic]

I had a pt with a mid-humerus amputation, clean cut and like you said very little bleeding. Pt was in a ton of pain though, but never dropped his BP.

The one thing I have found that you can't control bleeding on is penetrating trauma to the cranial vault. I'm talking GSW or crowbar to the head kind of stuff. Gushing blood, not much to do but slap a trauma dressing on and run like hell to the ER. Prognosis: Not Good.

The bodies mechanisms to control bleeding are amazing and something to keep in mind before slapping on a tourniquet. In fact in 14 yrs I have never used a TQ.

Peace,

Marty

:joker:

[AZCEP]

This type of discussion really disappoints the public when we tell them we really don't deal with that much blood and guts.

Recently transported a mid-30s female that was mauled by dog(s). Don't really know how many attacked her, never saw them, didn't care too much. When we pulled on scene, this lady was lying on a red sleeping bag, and blended into it nicely. This was the first time I had seen a patient that had blood coming out of every section of the body.

Head--yep

Neck--sure thing

Face--just a couple

Chest/abdomen--yes, and...yes

Lower extremities--who layed out the ground beef?

Upper extremities--were you preparing pulled pork sandwiches?

Back--I don't know how they did it, but right between the shoulder blades 5-6 punctures

More blood came out when we started the IV and ran in a little fluid(<100 mL). We emptied two rigs supply of trauma dressings covering this mess.

[hammerpcp]

"ASYS,"

I was on a call which was at a construction site. The 'site' foreman, wanted to talk to the 'Excavator operator'. So in classic non-thinking fashion, he approached the machine from behind and hopped up on the tread by the 'operators' door. The operator not knowing that his boss was on the tread put the machine into reverse just after the foreman had gotten up on it. The foreman slipped, and was 'rolled over' by the excavator tread. The tread began at just below the xyphoid process, and continued to abou the knee unequally placed on his body. Long story short, on initial presentation, COAX4, B/P 134/92, HR 100, RR26. Everything went great, got 4 IV lines running the helicopter crew was there, etc... Roll the 'excavator off the pt.....GOOD NIGHT IRENE!!!! 8)

There's an example for ya. We tried everything, including MAST, etc..

out here,

ACE844

But that is your classic crush injury. The Pt's death is not caused only by bleeding out but by electrolyte displacement (K+ in the blood stream) and other cellular waste products.

[hammerpcp]

oh! oh! The boozies bleed. Yep. Especially a chronic boozie with a head lac.

[ERDoc]

But that is your classic crush injury. The Pt's death is not caused only by bleeding out but by electrolyte displacement (K+ in the blood stream) and other cellular waste products.

Sorry Hammer, I'm going to have to disagree with you. The death is probably the result of severe internal blood loss. This guy probably has a liver and spleen the thickness of pancakes which just let loose once the pressure on them is removed. The aorta and illiacs have probably also seen better days. You are not going to get a build up of toxic products that quickly. Even electrolyte shifts should not happen that quickly.

[hammerpcp]

Sorry Hammer, I'm going to have to disagree with you. The death is probably the result of severe internal blood loss. This guy probably has a liver and spleen the thickness of pancakes which just let loose once the pressure on them is removed. The aorta and illiacs have probably also seen better days. You are not going to get a build up of toxic products that quickly. Even electrolyte shifts should not happen that quickly.

*Drafting letter to PCP school regarding "crush syndrome"*

[Ridryder 911]

In my 29 + years there are very few times I have "someone bleed out". I even worked a triple amputations (yes 3 on one motorcycle.. don't ask it's a redneck thing) ... and there was very little blood.

Even in ER, I have never seen a tourniquet placed or even the use of compression more that tight dressings (unless their on anticogulants) and once in great while a small bleeder, that has to be tied or a little Lido w/epi works.

I am curious though I have read that medics and surgeons are recommending more use of tourniquets in trauma. this should be interesting to see what comes out of the practice.

R/r 911