Circulation emergencies

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Facilitator: Grace + Becca
Medics: Greg + Charis
Patients: Peter
Time: 25 mins; 1125-1150
Actual time:
Learning Objectives:
Materials: Old t-shirt, fake blood, gloves for trainers, cardboard, blankets, jackets, 4x4s.

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Peter's fence laceration skills drill (C => LOR/D)

Story

Facilitator says

When the people hanging the banner fell, the crowd around the lockdown on the freeway panicked. A bunch of them bolted towards a chain-link fence into a Banner Health parking lot and all tried to climb it at once.

One guy got pushed while he was going over. He got the fence hooked on his inner upper arm, then fell into the parking lot with a nasty 4-inch laceration gouged on the inside of his bicep. His shirt was instantly soaked with blood.

A buddy pair already on the parking lot side of the fence saw him fall from the fence and saw the bleed start. The crowd was still sparse on their side of the fence. Let's watch them manage a bleeding emergency.

Model

Get "Peter" into a disposable shirt and pour some fake blood on him.

Buddies talk to each other, patient, and patient's friends, but not to classroom while they demonstrate:

• Ground, put on gloves.

• Scene survey.

Patient care buddy

• Introduces pair, is nice, "what can I call you?" ("Peter"), explains every touch, uses pt's name.

• Checks LOR (A+O, talky (A+B ok), adrenaline and light-headed), asks consent (Peter consents to care).

• Tells scene assessment/comms buddy: "Call 911 about the bleed."

• Does bloodsweep and explains why. "Were you hurt anywhere else, or just the arm?"

• Applies well-aimed direct pressure with a 4X4 and elevation to the bleed. Keep piling more 4X4s on top as the blood soaks through.

• When buddy holds phone to ear, tells 911 operator "He has an uncontrolled bleed of the upper arm from a laceration, with early shock signs" and nods for buddy to take the phone back.

• Keeps eye contact, conversation, calm, attentiveness (Peter decompensating: getting more woozy, thirsty, shallower fast breathing, scared).

• Asks buddy: "Can you get us some shock position stuff?"

• When buddy hands over cardboard, blankets, jackets, etc., patient care buddy maintains pressure and elevation and helps Peter lay on cardboard and get bundled up, including the top of his head. Do not elevate feet -- this is no longer recommended because it makes no difference.

• "I can't give you anything to drink, Peter, but the ambulance is on the way and those IV fluids are going to feel better than the biggest Slurpee you ever had -- except without the brain freeze."

Scene assessment buddy

• Continues scene survey, calls 911 gives location: "We are in a Banner Health parking lot on the Freeway side, about 10 yards east of 3rd Street," before holding phone to lead medic's ear to transmit patient's condition.

• (Still on phone) Mobilizes bystanders to get cardboard and blankets for shock position when asked by buddy, and (still on phone) helps get pt into position. Do not elevate feet -- this is no longer recommended because it makes no difference.

Both buddies

calm, comfort, reassure; maintain consent all the way.

Debrief

Facilitator asks

What did we find out? Good answers:

• Peter's wound is from the fence, no evidence of other wounds (MOI).

• He's A+O but starting to get shocky (LOR ok, but threatened).

• He's breathing because he's talking (A+B ok).

• He has an uncontrolled bleed (C).

Facilitator asks

What did the medics do? Good answers:

• Had a buddy and clear roles, grounded, BSI, scene survey, stayed out of the blood puddle (made the scene safer for themselves).

• Introduction to pt, calm, consent/explanation, ongoing scene assessment (controlled the scene and made it safer for pt).

• Witnessed MOI, assessed LOR, ABC, activated EMS for bleeding emergency (stop and fix).

• Helped into shock position and nothing by mouth.

Practice Well-Aimed Direct Pressure and Elevation

Students get back into groups of 3.

Trainer buddy pair demonstrates well-aimed direct pressure and elevation.

Use water or fake blood to simulate the slickness of blood and situational awareness of the pool of blood.

• Wet gloves: why 4x4's are nice (grip).

• Add more 4x4's; don't pull out clot.

• "Number three: don't get any on me!" -- For a big bleed this means situational awareness as well as gloves.

• Help the patient sit or lay down.

• Stay with patient until ambulance arrives.

Facilitator asks

How much pressure should you put on an uncontrolled bleed? Good answer: Enough pressure to bring bleeding under control.

Trainers

• Ask anyone who wants to feel the kind of pressure that may be needed to bring a big bleed under control to raise her hand.

• Apply pressure to these peoples' wrists with laced fingers and a clamshell of the heels of the palms.

Students practice

well-aimed direct pressure and elevation. They must use gloves. Provide them with 4X4s and make the patients' skin slick with water.

Shock

Facilitator asks

When the medics were caring for Peter, he started to go downhill and get distressed -- then to hyperventilate, get ashy, and get very thirsty. What did the medics do? Good answers:

• Helped him lay down.

• Padded under him.

• Covered him with warm things, and covered his head.

• Didn't give him anything to drink.

• Kept his bleed elevated.

What they did was recognize and respond to signs of hemmorhagic shock.

Shock physiology and response quick lecture

Facilitator says

¹ The body manages its response to hemorraghic shock via the "fight-or-flight" sympathetic nervous system. The more fluid is lost, the more the body goes into survival mode. The heart races, the skin becomes ashen, the person becomes anxious and breaks out in a cold sweat.

• The body compensates for loss of up to 30% of the blood by constricting blood vessels to shunt blood away from non-essential tasks -- like skin, digestion, and having good conversations. The visible results are anxiety and cool, ashen skin. As the person continues to lose blood, the heart beats faster and harder and the person breathes faster and shallower as the body tries to keep blood pressure from dropping and tries to blow off carbon dioxide before it causes damage. Anxiety and restlessness increase.

• After about 30% of blood has been lost, the body can no longer compensate by keeping blood pressure within normal limits. Light-headedness and intense thirst present. The skin feels cold and sweaty. Confusion, anxiety, and agitation progress to disorientation and lowered level of responsiveness (LOR). The heart races faster and faster and hyperventilation increases.

Facilitator says

What a person in shock needs is to stop losing fluid and to get IV fluids to replace what she's lost. Stop the bleeding and call 911. While you wait for back-up, interventions compensate for lost blood:

• Help patient sit or lay down so she doesn't fall.

• Don't give any fluids by mouth -- the stomach and small intestine are some of the many non-essential organs that get shut down to preserve bloodflow to the brain, heart, and lungs. Stimulating the shut-down stomach will probably cause vomiting -- further fluid loss and an airway risk.

• Pad under and insulate around a person to prevent hypothermia -- a person with poor circulation gets cold hands and feet, and a person with not enough blood gets hypothermia unless the ambient temperature is over 100 F and the air is still.

• Calm, comfort, and reassure -- shock is terrifying, and your gentle voice and handholding might be the thing that gets someone through.

Facilitator says

Elevating the bleed helps you control it, but there is no need to elevate the feet, as used to be recommended. Blood vessels spasm and squeeze as much blood as possible to the brain -- gravity doesn't offer any additional help getting blood to the brain.

Shock assessment

Facilitator asks

How can you tell someone is in shock? Any of these are good answers. "Fight or flight" plus MOI is the best:

• MOI: Any major injury or illness -- think shock.

• Altered mental status, especially general restlessness or combativeness, unresponsiveness.

• Shallow, rapid breathing.

• Increasingly rapid and bounding pulse.

• Skin that is pale or gray, cool and clammy.

• Blue lips, tongue, earlobes.

• Dizziness, fainting.

• Extreme thirst.

• Vomiting or other loss of bodily fluids.

• "Fight or flight" response.

Hidden bleeding

Facilitator says

In street medic settings, shock is likely to be associated with major trauma and a major bleed. Sometimes blood spills out of the body and is obvious, sometimes it spills out and is hidden by thick clothes, sand, or gravel. Sometimes spilled blood is hidden because it stays inside the body.

Most shock signs are late changes. Fear and restlessness usually kick in well before skin makes a distinctive change. If you see fight-or-flight signs, investigate the MOI.

• "Number two: What happened to you?"

• Visually inspect for hidden bleeding.

Hidden spilled bleeding

Facilitator says

Obvious injury can distract from worse, hidden injury. Blood can be disguised by thick clothing, sand, or gravel.

Consent and a confident, professional demeanor are key when doing a blood sweep, because it can feel both invasive and unnecessary to the patient. Practice this during scenarios this afternoon so that you're not awkward when you do it in real life.

Trainer buddy pair demonstrates blood sweep (facilitator narrates).

With consent, place both gloved hands under the person's body, anywhere that blood may collect. In between each time you put your hands under the person, check to see if there is any blood on your gloves.

• If pt is laying down, check under shoulders, upper back, mid-back, lower back, butt, thighs and knees.

• If pt is sitting, check under butt and thighs.

• Check inside bulky things. Expose respectfully if necessary and consensual.

You don't want black gloves because you can't see blood on them.

Hidden internal bleeding

Facilitator says

² If a person has mechanism of injury (MOI) for major trauma, or has "fight or flight" signs indicating shock, consider internal bleeding -- whether blood is coming out of their body somewhere or not.

Any major trauma to the abdomen, pelvis or thigh can cause significant blood loss, because of bleeding from liver, spleen, or major blood vessels into big (abdominal, pelvic) cavities that can accomodate pooling of most of the body's blood.

You can check the abdomen and thighs for tenderness, expanding size, weird bruising,³ or tense skin on surface, but most signs of internal bleeding take more than a day to show up -- go with fear and restlessness and MOI as the signs that you need to get hospital-level help.

Circulatory pathology overview

Facilitator says

Before lunch, we're going to shift the discussion from bleeding emergencies to other circulatory system emergencies.

Facilitator says

The circulatory system has three major components: the blood, the vessels, and the heart. Blood brings oxygen and removes CO2. It moves through the arteries and veins down to the capillary bed where it stops to exchange oxygen for CO2. Its rhythm is regulated by the heart. Circulatory emergencies can involve any of the three parts of the system.

• Damage to blood vessels that causes uncontrollable bleeding is an emergency.

• Severe brain or spinal cord injury causes blood vessels to relax so that blood pools in the vessels and stops circulating. Blood pressure drops, the heart slows, and level of responsiveness (LOR) drops.

• Heart attack or direct blow to the chest causes the heart to stop or to beat with an irregular rhythm.

Facilitator says

We're going to return to heart attacks on Sunday. For now, suspect a circulatory emergency if a person is:

• Unresponsive or with altered mental status.

• Pulse racing or really slow.

• Skin pale, blue, ashy.