KURSK STATE MEDICAL UNIVERSITY

Department of Traumatology and Orthopedia

Teacher : Коклина Наталья Юрьевна

Student : Habarakada Henadeerage Manushee Kaushala

Topic 10 - Bleeding, Bleeding from major vessels, Compensation of bleeding.

Date - 16/04/2020

TASK 1

1. The preliminary diagnosis and the first medical aid.

Open, penetrating wound of the left arm with Hypovolemic shock.

First Aid -

Assess airway (A) to ensure it is clear. Following evaluation of the airway, determine
adequacy of breathing (B) and provide rescue breathing if necessary. Assessment of
circulation (C)

An immediate step is to put in at least two large bore intravenous cannulas (No. 16
or No. 14).
2000 ml of crystalloids (preferably Ringer lactate), should be infused rapidly, followed by
colloids (Haemaccel) and blood.

Wash your hands to avoid infection and put on gloves

Lay on the injured person down and cover the person to prevent loss of body heat.–If
possible, position the person's head slightly lower than the trunk or elevate the legs and
elevate the site of bleeding.

Remove dirt or debris from the wound.

Apply pressure directly on the wound until the bleeding stops–Use a sterile bandage or
clean cloth and hold continuous pressure for at least 20 minutes without looking to see if
the bleeding has stopped. –Maintain pressure by binding the wound tight adhesive tape.

If the bleeding continues and seeps through the gauze or other material you are holding on
the wound, don't remove it. Instead, add more absorbent material on top of it.

Apply pressure to the artery. Squeeze the main artery in these areas against the bone.

Immobilize - use tourniquet. Check it every 10 minutes.

Immobilize the arm against the hard surface.

2. Plan of investigation.

Clinical Examination -

Clinical signs of vascular injury are generally divided into “hard” or “soft” signs of injury.

The hard signs are as follows: active hemorrhage, rapidly expanding hematomas, absent
pulses, pallor, paresthesia, pain, paralyses, poikilothermia, or palpable thrill or audible
bruit.

The soft signs are as follows: history of arterial bleeding at the scene of injury, diminished
distal unilateral pulse, small hematoma, neurological deficit, abnormal flow velocity wave
on Doppler examination, or abnormal ankle-brachial pressure index (ABI, <0.9)

Monitor and reassess vital signs throughout the incident.

Cardiac monitoring and pulse oximetry.

Note potential circulatory compromise (absence of distal pulses either from direct injury
or hypotension from hemorrhagic shock).

Check neurological impairment (inability to sense distal stimuli).

Evaluate the extremities' skin for color, temperature, turgor and bruising.
Evaluation Radiographs - Obtain to identify bone involvement and/or fracture pattern.

CT scan

Multiple modalities exist for measuring fluid responsiveness such as ultrasound, central
venous pressure monitoring, and pulse pressure fluctuation

3. Formulate a clinical diagnosis.

Open, penetrating wound of the left arm, with laceration of the Brachial Artery, and
Hypovolemic shock.

4. The plan of treatment

Start with 2 liters of isotonic crystalloid solution infused rapidly as an attempt to quickly
restore tissue perfusion.
Fluid repletion can be monitored by measuring blood pressure, urine output, mental
status, and peripheral edema.

Blood plasma transfusion

Platelet transfusion

Red blood cell transfusion

Endovascular surgery

Surgery conducted with general anesthesia. Foley’s catheter is used for bleeding inhibition.
Compression with Foley catheter balloon is a safe and efficient method to stop bleeding.

During the operation, by clamping the proximal and distal ends of the vascular structures,
hemorrhage is controlled following hemodynamic stabilization of the patient.

Patient given heparin (80 IU/kg) injections before clamping vessels.

Prophylactic antibiotherapy and tetanus prophylaxis.

5. Plan of rehabilitation.

Rehabilitation -

Arm in sling before resuming mobility exercises.

Range of motion exercises to regain mobility and function of the arm.

Pain control.

KURSK STATE MEDICAL UNIVERSITY

Department of Traumatology and Orthopedia

Teacher : Коклина Наталья Юрьевна

Student : Habarakada Henadeerage Manushee Kaushala

Topic 10 - Bleeding, Bleeding from major vessels, Compensation of bleeding.

Date - 16/04/2020

TASK 2

1. Make a preliminary diagnosis

Skin tear, partial flap loss with open fracture of the right arm, and laceration of the Axillary
artery.
2. Why is there slight bleeding from the wound?

Due to the application of a tight bandage immediately at the scene to reduce the bleeding.

Protruding bone causes compression.

3. What is the volume of first aid at the scene?

At the scene of injury, only a single basic protocol of first aid was followed, that is the
injury was treated with a tight bandage to control the bleeding.

Other measures of first aid that can be observed are -

First Aid -

Assess airway (A) to ensure it is clear. Following evaluation of the airway, determine
adequacy of breathing (B) and provide rescue breathing if necessary. Assessment of
circulation (C)

Lay on the injured person down and cover the person to prevent loss of body heat.–If
possible, position the person's head slightly lower than the trunk or elevate the legs and
elevate the site of bleeding.

Remove dirt or debris from the wound.

Apply pressure directly on the wound until the bleeding stops–Use a sterile bandage or
clean cloth and hold continuous pressure for at least 20 minutes without looking to see if
the bleeding has stopped. –Maintain pressure by binding the wound tight adhesive tape.

If the bleeding continues and seeps through the gauze or other material you are holding on
the wound, don't remove it. Instead, add more absorbent material on top of it.

Apply pressure to the artery. Squeeze the main artery in these areas against the bone.
Immobilize - use tourniquet. Check it every 10 minutes.

Immobilize the arm against the hard surface.

Because there is a risk of infection, it's important that people with open fractures are given
antibiotics as soon as possible. This is usually within an hour of injury and is by injection or
drip.

4. What kind of research will you do to the patient?

Make a clinical observation.

Observe the depth of the wound, and angle of protrusion of the bone.

X-Ray to identify the fragmentation.

CT to make a confirmation of the fracture.

Blood test to identify contamination and infection of the wound.

5. The treatment plan.

If there is vascular compromise thought to be secondary to fracture fragments

compressing a vessel, reduction of the fracture should be attempted immediately.

The wound should be thoroughly irrigated with at least one liter of saline or a combination
of saline and betadine, and then a sterile or betadine soaked dressing should be placed
over the wound, and the limb should be immobilized in a well-padded splint.

Thoroughly cleaned in the operating room to remove debris before being set

Syringe with a splatter shield used to irrigate the wound.

Start with 2 liters of isotonic crystalloid solution infused rapidly as an attempt to quickly
restore tissue perfusion.
Fluid repletion can be monitored by measuring blood pressure, urine output, mental
status, and peripheral edema.

Blood plasma transfusion

Red blood cell transfusion

Skin flap repositioning - Pedicle flap.

Skin graft

Antibiotic administration - Cephalosporins such as cefazolin or cefuroxime can be used.

The tetanus status of the patient should be assessed. If not, tetanus toxoid must be
administered.

Non-adherent dressing and tubular gauze of the area with skin flap.

Endovascular Surgery - During the operation, by clamping the proximal and distal ends of
the vascular structures, hemorrhage is controlled following hemodynamic stabilization of
the patient.

6. Tactics in the postoperative period and prevention of possible complications

The key is to minimize bacterial contamination of the wound.

Traction to prevent non-union and promote faster healing.

Mobility of exercises to regain function.

Do not let your wounds get wet. Always keep your wounds clean and dry.

Until it has set properly, avoid direct heat such as hot water bottles.
Rest the limb as much as possible.

Use the techniques shown to you by nurses to walk or manage day-to-day activities. For
example, you risk further injury if you use crutches incorrectly.

Avoid any lifting or driving until the fracture has healed.

Checking circulation of the flap.

Assess split thickness skin graft site - is it dry and intact.