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INTRODUCTION

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This chapter will discuss the role of the EMS physician in the treatment of acute wounds and hemorrhage. As a first responder, a physician should be able to accurately characterize wounds, differentiate between stable and life-threatening hemorrhage, and effectively treat these wounds in a timely manner. We will start with a discussion of wound evaluation and treatment fundamentals. Then, we will cover the role of advanced hemorrhage control procedures, the use of hemostatic agents, and administration of blood products. An understanding of these fundamentals is essential to the EMS physician operating in the prehospital settings. These are especially important to providers operating in austere environments such as tactical medicine, urban search and rescue, and those tending to the entrapped victim.

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OBJECTIVES

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  • Describe the initial prehospital evaluation and management of acute traumatic wounds.

  • Describe the initial prehospital evaluation and management of open nonacute wounds.

  • Describe the initial prehospital evaluation and management of active hemorrhage.

  • Discuss prehospital use of tourniquets.

  • Discuss prehospital use of hemostatic agents.

  • Discuss prehospital use of blood, blood products, and factors for acute traumatic blood loss anemia.

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ACUTE TRAUMATIC WOUNDS

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Most wounds evaluated during EMS operations are acute traumatic wounds. These include a large spectrum of injuries ranging from abrasions to amputations. Evaluation of each of these wounds should include the same components. When first evaluating a wound, identify if there is a source of acute life-threatening hemorrhage. If present, address the source of hemorrhage first. The techniques for managing hemorrhage will be discussed later in this chapter. Wounds without life-threatening hemorrhage can be evaluated for the extent of tissue damage present and structures involved.

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When evaluating extremity wounds, placing a temporary tourniquet similar to those used when placing a peripheral IV may be useful when evaluating a wound with non-life-threatening hemorrhage. Similarly, a blood pressure cuff may be used to temporarily control bleeding during wound evaluation. The temporary tourniquet is used only long enough to evaluate the extent of the wound and should not exceed a total of 15 to 20 minutes in duration.1

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When evaluating the wound, note the depth, involved structures, and signs of contamination. If the wound involves major vascular structures, your priority should focus on hemorrhage control. If no major vascular structures are identified, continue to evaluate the wound for gross contamination.

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The same components are required when evaluating wounds of the abdomen and thorax. Wounds involving the groin, axilla, and clavicles are at high risk for life-threatening hemorrhage. The close proximity of major vascular structures found within these areas make then more susceptible to injury. Wound packing and pressure dressings should be applied immediately to wounds with life-threatening hemorrhage in these locations. Additional techniques for hemorrhage control will be discussed later in this chapter. If the wound involves deep structures of the abdomen or thorax, immediately treat the underlying injury ...

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