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Radial Artery Bleed

Discussion in 'BLS Discussion' started by Shabo, Mar 18, 2007.

  1. Shabo

    Shabo New Member

    Guys, I recently completed an ER clinical where we had a pt arrive by BLS truck with a 1-2 cm lac to the middle of the rt forearm. The elderly pt had apparently been bleeding for a while before help arrived. Pt was Alert upon BLS arrival and the bleeding was uncontrolled. They attempted to stop the bleed but couldn't and wrapped it in gauze and a cravat for transport. The pt completely decompensated before arrival to the ER and resuscitation was unsuccessful. I was hoping that you could help me with a few questions.

    1. How long do you think it would take to bleed out from this wound? (meds unknown)
    2. Is there a reason a tourniquet wouldn't be applied?
    3. What would your response have been?

    Thanks,
    Shabo
  2. Jon

    Jon Administrator Community Leader

    Location:
    Southeastern PA
    EMS Training:
    EMT-Paramedic
    Time to bleed out?

    I've been told, anecdotaly, that if you slit your wrist the "right way" to kill yourself, you will only be able to slit one wrist (because you won't be able to make the slit wrist arm work to cut the other one) and that you will die very quickly.

    In First Aid, for the last few years, torniquets have been "frowned on" because there is concern for ischemia of the appendage. My BLS protocols call for a torniquet only if the exsanguination is uncontrollable, where the descion is between a possible amputation of the arm or the patient dying. This is only after all other methods have failed.

    As for why BLS didn't use a TQ... well, their protocols may not allow it, the EMT's may be under the impression that a TQ is evil (like leeches), and the EMT's may not have felt that the bleeding was really uncontrolled.

    Might I have used a tourniquet? Perhaps... I wasn't there... I can't say what I would have done.
  3. Ridryder911

    Ridryder911 EMS Guru

    In my thirty years, I have yet seen anyone die from "slit wrist".. and I have seen some real nasty ones that even caused amputations. Usually the vessels will constrict initially and there may be even little bleeding.

    Second, I do not understand allowing anyone to exsanguinate out. Direct pressure, pressure points should be able to control any extremity bleeding. I have even used a blood pressure cuff pumped just tight enough to cease the arterial flow on a patient that was on Coumadin. (This was per physician orders)..

    Many people "spazz" over bleeding, chances are they did not hold enough pressure or long enough. Many attempt to pull off bandages and place new ones, this is just like pulling off scabs.. allowing bleeding to occur.

    R/r 911
  4. Guardian

    Guardian New Member

    EMS Training:
    Critical Care Paramedic

    I tourniquet is a great thing if used by educated medical professionals (paramedics) and not boy scouts--lol. Talk to trauma surgeons and they will tell you they use them routinely for hours in the operating room. In 99.9% cases like the one you mentioned, a tourniquet would not be needed. I would do what I've been trained to do. Remember your 4 Ps. Pinpoint, prompt, precise, pressure. Don't just hap-hazardly wrap the wound with gobs of dressing. Then elevate the extremity. I would be willing to bet money this would have worked. If not however, use the BP cuff and partially constrict it. Then as a last resort, cut off all blood flow with the big T of some sort. This all should be done very quickly and calmly. There are some cases where you may have to "clamp" an artery shut with a tool, but I'm not going there.

    And let me end this with a public service announcement. If you completely cut thought an artery, the body will restrict (suck up) that artery and stop the bleeding itself. The key to killing yourself is to only partially cut an artery. That way, you will bleed and bleed and the artery won't be able to constrict itself. good luck!
  5. Nycxice13

    Nycxice13 New Member

    Location:
    Brooklyn
    EMS Training:
    EMT-Basic
    in NYC it is against protocol to use a tourniquet (as well as a BP cuff to constrict blood flow, which is acting as a tourniquet)
  6. Guardian

    Guardian New Member

    EMS Training:
    Critical Care Paramedic
    yea, nyc routinely goes against recognized national standards of care and common sense. I feel for you. There is good news though, protocols are just guidelines so screw em'.
  7. Nycxice13

    Nycxice13 New Member

    Location:
    Brooklyn
    EMS Training:
    EMT-Basic
    Has nothing to do with going against common sense, has to do with the fact that in NYC you are never more than 5 minutes from a hospital. If you apply the right skills to control bleeding, you should make it to the hospital before it gets any worse.
  8. Guardian

    Guardian New Member

    EMS Training:
    Critical Care Paramedic
    what if someone is pinned in a car and has already lost enough blood to put them in compensated shock. What if the extrication takes 40 mins for some reason. what are you going to do then? NYC is a great place, but their ems is stone age.
  9. Nycxice13

    Nycxice13 New Member

    Location:
    Brooklyn
    EMS Training:
    EMT-Basic
    If they have that many problems, they ain't making it. Be realistic, not outlandish.
  10. Guardian

    Guardian New Member

    EMS Training:
    Critical Care Paramedic
    Lets say the only problem they had was an uncontrollable arterial bleed in the right leg and they were "trapped" with no other injuries. Don't play this game with me. And this is a completely reasonable scenario.
  11. Nycxice13

    Nycxice13 New Member

    Location:
    Brooklyn
    EMS Training:
    EMT-Basic
    If it is going to take 40 minutes to extricate him, hes not making it.
  12. Guardian

    Guardian New Member

    EMS Training:
    Critical Care Paramedic
    Here's a little challenge to the great readers of this site. You show me a protocol and I guarantee I can come up with a reason it can and should be disobeyed.
  13. Guardian

    Guardian New Member

    EMS Training:
    Critical Care Paramedic
    Can someone live 40 mins with a Tk on their leg? Of course they can. I'm not going to argue anymore.
  14. Nycxice13

    Nycxice13 New Member

    Location:
    Brooklyn
    EMS Training:
    EMT-Basic
    besides, if it is a 40 minute extrication, how the heck do you suppose I apply a tourniquet?
  15. Guardian

    Guardian New Member

    EMS Training:
    Critical Care Paramedic
    reach in through the 1 ft of clearance you have though the windshield. Now really, we got to stop this. And by the way, I've had calls like this. You better get this straight in your mind before it happens. You're going to feel pretty bad when someone dies for no reason other than your inability to see protocols for what they are. I know this probably goes against you marginal emt training, but now that you here, you should try and open you mind up to new ideas. They can't say enough good things about tks since the war started in iraq. It can take hours to do any major harm with tks. Read and know that this world isn't black and white and protocols.
    Last edited by a moderator: Mar 19, 2007
  16. Recycled Words

    Recycled Words New Member

    Location:
    New York/New Jersey
    EMS Training:
    EMT-Basic
    Exactly. New Jersey (or at least the part where I work) has the same protocol because within a 10 mile radius, we have 5 hospitals including a trauma center. The rule makes sense. For the same reason, we don't carry activated charcoal on our rigs and we don't get medics half the time we need them because the ride is too short for us to bother waiting for them once we're on scene.
  17. Jon

    Jon Administrator Community Leader

    Location:
    Southeastern PA
    EMS Training:
    EMT-Paramedic
    Guardian - I belive you... and I can probably think of some of the same reasons... I'll have to look through my protocols and find a "good" one for you ;)
  18. Jon

    Jon Administrator Community Leader

    Location:
    Southeastern PA
    EMS Training:
    EMT-Paramedic
    What, exactly, lets you say that? I've had vehicle extrcations where the second patient cannot be accessed until the first is packaged and removed, dramatically increasing the exrication time. Also, out here, the VFD often arrives after us, and if it is an exended extrication, it can take a few minutes for them to stage their tools and crib the vehicle... increasing your extrication time. I know that the NYPD ESU guys are great :)(FDNY's Rescue and Ladder guys are also great ;))... but even the best take time to do it RIGHT. A 40-minute extrication time is unusual, but not automatically fatal.

    Right.... however, some folks will use the arguement that the MAST-Pants were "the next great thing" duing the Vietnam era.... and look what happened to them.

    I agree that tourniquets have a place for use by trained professionals, and even boy scouts, when ALL OTHER METHODS fail... BSA still teaches Tourniquets, as a last-ditch measure after direct pressure, elevation, and pressure points fail to stop the bleeding.


    The idea that "you're 5 minutes from the hospital" works just fine... until the fecal matter hits the ventilation device... then you are up a creek without a paddle, and open to lawsuits.... Can you see youself on the stand: "Why did my client die? Becuause Joe EMT decided that they didn't NEED to carry actvated charcoal because they were close to a hospital.... but during the blizzard, after my patient ingested 400 tylenol and the ambulance broke down in the middle of the Blizzard... They failed to have the appropriate medication on hand, and my client died... The family needs 50 Million dollars for pain and suffering."

    I realize it isn't your choice, really, as to how your service stocks their rigs... but as Guardian already pointed out... a prolonged vehicle extrication can make your time in contact with the patient invcrease dramatically.
  19. Recycled Words

    Recycled Words New Member

    Location:
    New York/New Jersey
    EMS Training:
    EMT-Basic
    True, however it's not the service, it's the state that prohibits us from doing so because it makes more sense to administer the medication 5 minutes later in a controlled environment.
  20. DT4EMS

    DT4EMS Kip Teitsort, Founder

    Location:
    Cartersville, GA
    EMS Training:
    EMT-Paramedic
    I would like to point out something.

    Darn near every advance we made (trauma related) has been due to combat.

    I was able to see a study that was conducted in the field in Iraq. It is called Damage Control Rescue.

    Very, very interesting. One of the results of the study were tourniquets we placed EARLY. I thought it was pretty wild at first but the results were outstanding.

    Another thing.......... look at the recent EMT books. Look how the new EMT-B is taught to contrl bleeding. It may surprise you.............. It did me and the past two EMT-B refresher courses I have taught. Let me know what you think of it.

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