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Home , Internal bleeding

Ministry of Health of Ukraine Ukrainian Medical stomatological Academy

It is ratified On meeting department Of accident aid and military medicine «___»______20__ _y. Protocol It is №_____ Manager of department DMSc ., assistant professor ______К.Shepitko

METHODICAL INSTRUCTION FOR INDEPENDENT WORK OF STUDENTS DURING PREPARATIONS FOR THE PRACTICAL LESSON Educational discipline «Emergency First Aid» Module № 1 Emergency and Combat First Aid Topic 2 Hemorrhages and Modes of Its Arrest

Bleeding and methods of stopping it. Lesson 3 Causesand symptoms of externalbleeding

Сourse ІІ Foreing students training dentistry Faculty

Training of specialists of the second (master) level of higher of education (название уровня высшего образования) Areas of knowledge ______22 «Health protection»______(шифр и название области знаний) Specialty ______222 «Medicine», 221 «Stomatology»______(код и наименование специальности)

Poltava 2019

Relevance of the topic: is one of the most difficult complications after , injuries with damage to the main or peripheral vessels. No less dangerous are internal bleeding with damage to the organs of the abdominal and chest cavities. Timely stopping of bleeding determines and gives a chance for recovery. Mastering all methods of stopping bleeding increases the chances of life of both military and civilians. Specific objectives: To master the technique of applying the Esmarch harness, twist, pressure bandage, belt; to stop bleeding with finger pressure in all parts of the human body to use chemical hemostatic agents, to perform plugging; use an individual dressing bag (IDD). Basic knowledge, skills needed to study the topic (interdisciplinary integration): Name of previous disciplines Acquired skills 1. human anatomy Anatomy of the head and neck, anatomy of the chest, , and limbs. Anatomy of the vascular system. 2. Normal physiology Physiological basis of the functioning of the respiratory system.

Tasks for independent work in preparation for the lesson and in the lesson: 1. Causes and signs of external bleeding. 2. The concept of massive external bleeding. 3. Technique for stopping external bleeding: pressure on the wound, wound plugging, pressure dressing, limb raising, rest. 4. Hemostatic agents on a gauze basis, application technique. 5. The technique of stopping bleeding by pinching an artery at a distance. 6. Indications and technique of applying different types of tourniquets, makeshift spins.

The list of basic terms, parameters, characteristics that a student must learn in preparation for the lesson: Term Definition 1. Bleeding leakage of from damaged blood vessels. 2. Internal bleeding characterized by leakage of blood from damaged vessels into cavities, organs and surrounding tissues.

3. Internal bleeding is characterized by: - pallor of the skin; - frequent weak ; - frequent breathing; - nausea, vomiting, thirst; - , lowering ; - a decrease in the level of hemoglobin, red blood cells in a blood test - secretion of blood from feces, urine, food.

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4.Wound this is a violation of the integrity of the skin or mucous membrane with possible damage to surrounding tissues.

5. Chemical methods of stopping bleeding chemicals that cause vasospasm (adrenaline) Sol. adrenalini hyfrochloridi 0.1% - 1 ml, (norepinephrine) Sol. nor adrenalini 0.2% - 1 ml. Vasoconstriction causes a drug such as ephedrine (Sol. Ephedrine hyfrochloridi 5% - 1ml), but drugs like naphthyzine 10 ml, sanorin, galazolin, isadrine, novodrin, euspiran narrow the blood vessels in inflammatory processes and do not cause bleeding to stop. Calcium chloride (Sol. Calcii chloride 10% 10 ml), hemophobin (Sol. Haemophobini - 150 ml), fibrinogen (Sol. Fibrinogeni 250, 500 ml) take part in the creation of a convolution and stop bleeding. Hemophobin and fibrinogen are released in bottles, obtained from the of the donor.

It has a length of 125 cm, a width of 6. Esmarch Harness 2.5 cm, a thickness of 3-4 mm. A metal hook is fixed at one end, and a metal chain at the other.

7. Temporary stop external bleeding - the imposition of a pressure bandage; - the elevated position of the limb; - digital pressure of the artery throughout; - maximum limb flexion in the joint; - stop bleeding with a tourniquet; - stop bleeding with a tourniquet; - stop bleeding from the carotid artery according to the method of Mikulich.

Theoretical questions for the lesson: 1. Causes and signs of external bleeding. 2. The concept of critical external bleeding. 3. Methods and techniques for temporarily stopping external bleeding: raising a limb, pressing on a wound, plugging a wound, pressure bandage (Israeli bandage). 4. Display and technique of applying different types of harnesses and makeshift twists. 5. Display and rules for the use of chemicals to stop bleeding. 3

Practical work (tasks) that are performed in class: 1. The imposition of the Esmarch harness, twist, pressure bandages, belt. 2. Stop bleeding with finger pressure in all parts of the human body. 3. Apply chemical hemostatic agents. 4. Perform plugging of .

The content of the topic: The concept of bleeding, methods of stopping external bleeding. Bleeding is the bleeding of blood from damaged blood vessels. Depending on the anatomical structure and physiological characteristics of the damaged blood vessels, bleeding can be: arterial, venous, parenchymal, capillary, mixed. Arterial blood has a red color, follows a pulsating stream. Venous blood of a dark color flows continuously. Capillary blood flows from the entire surface of the wound. Parenchymal bleeding occurs with damage to internal organs, followed quickly by a large number. Depending on the direction of blood flow, internal and external bleeding is distinguished. Internal bleeding is characterized by the flow of blood from damaged vessels into cavities, organs and surrounding tissues. Blood flowing into the abdominal, chest cavity loses its tendency to clot. Internal bleeding is characterized by: - pallor of the skin; - frequent weak pulse; - frequent breathing; - nausea, vomiting, thirst; - tachycardia, lowering blood pressure; - a decrease in the level of hemoglobin, red blood cells in a blood test - secretion of blood from feces, urine, food. If blood seeps into the tissue, a forms, if blood exfoliates the tissue to form a cavity filled with blood, a forms. Depending on the time of bleeding after the , it is determined: primary bleeding (during the injury) and secondary (occurs some time after the formation of a blood clot), as well as early secondary bleeding 3-5 days after the injury and late secondary bleeding after 10 -15 days. Distinguish: I. Temporary stop external bleeding: - the imposition of a pressure bandage; - the elevated position of the limb; - digital pressure of the artery throughout; - maximum limb flexion in the joint - stop bleeding with a tourniquet; - stop bleeding with a tourniquet; - stop bleeding from the carotid artery according to the method of Mikulich.

II. The final stop external bleeding. It is the mechanical, physical, chemical, biological methods. Mechanical methods include: - ligation of both ends of the vessel in the wound; - the ligation of the vessel throughout its locations. - lateral or circular suture of the vessel;

Physical methods include: 4

- the use of (local) high temperature which causes coagulation of the protein, the local tromboobrazovaniya using electrocautery, diathermocoagulator; - the use of low temperature (about 0 ° C), which reinforces the spasm vessels and accelerate blood clots arising from the application of bubble ice, liquid nitrogen through the cryoprobe; - use of high energies, which lead to the fumes of the fabric to form a thin zone of necrosis (laser knife, plasma scalpel). Biological methods include: - the transfusion of blood into hemostatic doses (50-100 ml), the introduction in the wound a hemostatic sponge, fibrinoly film. The concept of critical external bleeding. The main reason for the bleeding, which is 55% -85% is gastric ulcer and duodenal ulcer, bleeding from (portal hypertension) is 5% -18%. All of them are vomiting (coffee grounds) and ground (blood in feces), decrease in body temperature, sweating, pale skin. On examination, the abdomen is symmetrical swollen, painful. Trying to make a diagnosis and determine the source of bleeding - USD endoscopy, rentgenissledovany. The best method of study is fibroezofagogastroduodenoscopy (colonoscopy). Through the endoscope it is possible to conduct using a special action of coagulation - cauterizing, or cooling with nitrogen. Also appoint hemostatic agents: 12.5% solution of dicynone (etamzilata) intravenously, 2-4 mm every 4-6 h (effect in 1-2 hours); a 5% solution of Epsilon-aminocaproic acid 100 ml / every 4 4 hours; 5% / 10% ascorbic acid solution in / in 1-2 ml 10% solution of chloride of Calcium 50-60 ml / V; 1% solution vikasola / m, can be per os; 0.2% solution of thrombin in the hemostatic sponge 1 tablespoon every 1-2 hours. Through endoskop hold diathermocoagulation of the bleeding vessel, an injection in gemostatiki on slime layer at the source of bleeding, hemostatic blending terminals on the receptacle. Blood loss of up to 10-15% of volume of circulating blood (BCC) symptoms will be a little severe, but when blood loss more than 15% results in a typical picture of hypovolemic (emerging) . For external bleeding (critical) when the main vessels are damaged - comes (loss of a large amount of blood 40% or more [2000 ml]), blood pressure not determined, the Central venous pressure is also not defined. Venous pressure is determined on or subclavian Vena cava, the apparatus Waldman. Normal venous pressure is 50-120 mm of water If systolic blood pressure less than 70 mm of mercury.St, on a.radialis tonometer pressure is not determined. It is a sign of (the critical state). Help adequate when after 10 minutes the systolic blood pressure reaches 90 mm.RT.St and CVP -75 mm of water.St. Arterial bleeding is stopped with the harness, and then tamponade the wound (ATO). You need to quickly restore the blood stream by the introduction of crystalloid (solution of ringer-Locke, Trisol, Glycol, Lacteol at a speed of 400-500 ml / min in two or three veins simultaneously (preferably via a catheter in the subclavian, inferior Vena cava, veins), connect the colloids (10-20 % albumin, reopoligljukin, Ecodes, Gemodez, HES [hydroxyethyl starch]. in the ATO zone use a GEK-500 mm (1000 ml). in civil terms absolute indication to (erythrocyte mass) is the reduction of BCC by more than 40 % (loss of more than 2 l of blood), hemoglobin less than 80 g / l, hematocrit less than 25%. When a mass arrival of wounded allow blood transfusion universal donor I (o), with a negative RH factor is not more than 500 ml in carrying out all necessary tests. Blood transfusions with a shelf life of not more than 3 days (for large stages of blood the concentration of oxygen in red blood cells decreases, the formation of micro clots in arteriolo-venous shunts). In critical

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situations use not blood and erythrocytic mass. At a critical external bleeding, blood transfusion is carried out in specialized institutions. The concept of injury. A wound is a violation of the integrity of the skin or mucous membrane with possible damage to surrounding tissues. Local elements of a wound are: pain in the wound, gaping of the wound, bleeding, impaired organ function. The intensity of pain in the wound depends on the depth of damage to the receptors and nerve endings in the wound, the wounding subject, and the rate of damage. The gaping of the wound due to the depth of damage to the muscles, subcutaneous fat. Bleeding depends on damage to blood vessels, anatomical organ. Severe bleeding occurs when organs with large arteries and veins are damaged, which can lead to the loss of large amounts of blood, anemia and death. With small wounds, a clot forms quickly and bleeding stops. When injured limbs, as a rule, their function is impaired, associated with gait or work, resulting from limitation of movements. The wound has edges (depending on the injuring object), bottom, corners, and sometimes contents (particles of clothing, dirt, blood clots). Wound Classification: 1. By the nature of the action of the wounding agent, the following types of wounds are distinguished: - chipped (action of an awl, bayonet, pitchfork) - cut (action of a knife, scalpel) - chopped (action axes, sabers) - beaten (when falling, hitting) - crushed (when the extremity gets under the moving mechanisms) - torn (when struck with blunt uneven objects) -scalped (when struck with a sharp object, moves tangentially to the surface of the skin) - bitten (with the bite of animals, people) - firearm (action of a bullet of a firearm) - poisoned (action of toxic substances: organophosphorus, acids, alkalis).

2. According to the degree of pollution: aseptic (surgical wound) - contaminated with microbes (a wound formed in non-sterile conditions or applied in everyday life, production, etc.).

3. The depth of damage: -surface (damaged skin, subcutaneous adipose tissue) - penetrating (into the cranium, chest or cranial cavities of the joint cavity, cardiac chemise, heart cavity, etc.) - through (when the wound has an inlet and outlet).

4. By the nature of , there are: - primary intention healing (surgical wound, some cut wounds) - healing under the scab (for fatal wounds of skin damage) - healing by secondary intention (after suppuration, the wound is cleaned, granulation tissue is formed).

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The nature of the wounds depends on the wounding object. Incised wound is equal to the gaping edges, bleeding heavily, which contributes to the outflow of secretions with dirt and microorganisms. Such wounds heal quickly. Chopped wounds have a greater depth with frequent damage to the bones. They are stronger bleed damage vital organs. A is characterized by minor skin damage, deep wound channel, while reducing muscle shifts and merges, resulting in the wound may not be bleeding, or discharge at the damage of hollow organs (stomach, intestines, etc.). This leads to errors in the diagnosis of wounds or for first aid. In such wounds can be broken part of the wounding object, the source of infection. When first aid has passed object in the wound is removed. Torn, bruised and crushed wounds are characterized by a large wound surface with the presence of crushed tissues, blood clots, sometimes dirt, foreign bodies Scalped wound occurs when applying a sharp or blunt object, which separates the skin and subcutaneous tissue from the underlying tissues. Feature of scalped wounds is the formation of significant defects of the skin, which form of difficulty in the healing of wounds. Bite wound often occurs in children in the head and extremities. Has a bite mark of an animal (person). The wound is deep, jagged, with saliva contamination and massive infection. A as the result of the action of bullets and fragments is: the wound channel filled wound detritus, foreign bodies; a zone of traumatic necrosis and a zone of molecular concussion tissue. Such wounds are very infected. Organization of wound care. The provision of first aid. Superficial wounds do not bleed much, so their edges are smeared with 5% iodine (without iodine entering the wound). A sterile napkin is taken from an individual bag, a wound is covered, and the wound area is bandaged. If the edges of the wound are widely dispersed and time allows (there are not many victims), the edges of the wound are brought together by 2-3 strips of adhesive tape, a sterile dressing is applied. Accomplishment of skills: rules for using an individual dressing pack - PPI-1. Indications: wounds of various origins. In order to apply a bandage to the wound, an individual dressing package is used - PPI-1, which is in the sanitary bags of the medical squads, ambulance teams. The bag is fixed in the left hand. Two cuts are found in the upper part of the bag. With his right hand, the notched part of the rubberized cover is torn off. Dressing bag - PPI: - 1 pin and bag wrapped in yellow paper. Having placed the bag in the left hand, carefully unfold the paper to release its contents. They take everything in the left hand, and turn it around with the right until two pads and a bandage appear. It is allowed to manipulate the pads from the outside, where black threads are applied on one movable pad (on this side, the pad is fixed with one hand, and the second pad is on the side of the sewn bandage). Thus, in the left hand, the opposite surface of the sewn bandage remains sterile, in the right hand, the opposite surface in the black threads of the movable cushion. These sides of the pads are applied to the through wound (inlet and outlet) or cover the entire wound with two adjacent pads. They are fixed with bandage tours. The end of the bandage is fixed with a pin. If there was not enough bandage from the bag to fix the pads, use any bandage. It is forbidden to wash the wound with water, alcohol, iodine, which cause pain, death of damaged cells. With puncture wounds, if they have a wounding object, they remove it, apply a sterile dressing, warn the injured person about it and send him to the surgical department. If there is a wound with the amputated part of the body, the torn off part is wrapped in sterile gauze (tissue) and put in a plastic bag. This bag is placed in a second bag filled with ice. A sterile dressing is applied to the wound, the victim is urgently sent to a specialized 7

medical institution together with the torn off (cut off) part of the body. If intestinal loops have fallen out of the wound or brain tissue is visible, they are not repaired, but covered with sterile gauze and quickly sent to a medical institution. Temporary methods for stopping external bleeding. In emergency situations, temporary methods of stopping external bleeding are most often used. Of them: Pressure bandage. Indications: capillary bleeding, damage to the small arteries of the upper and lower extremities, damage to the skin, muscles. Prepare everything you need: antiseptic, sterile wipes, gauze, bandage, cotton wool. Before applying the dressing, follow the following rule: treat the skin of the wound with a solution of alcohol (iodonate), apply a sterile cloth to the wound, which is fixed with 2-3 layers of bandage. Take cotton wool, use gauze to roll it tightly into a roller and put on the projection of the wound to locally compress bleeding tissues, and with subsequent tight layers continue bandaging to stop bleeding. It is better to use an individual dressing bag in which one pillow will press on the vessels or tissues that bleed. The bandage is fixed above the wound. Of the temporary methods for stopping bleeding use: elevated position of the limb. Finger compression of arteries. In emergency situations, use finger pressure of the arteries. To do this, you must have knowledge of the topography of the vessels of the body. It is impossible to conduct it for a long time, since it requires a lot of physical effort, the one who provides assistance quickly gets tired and practically excludes the transportation of the victim. Accomplishment of skills: finger pressing of a temporal artery. Indications: bleeding from the upper and lower eyelids, lateral surface of the forehead, cheek. Prepare everything you need: a bandage, sterile wipes, antiseptics. Press the temporal artery to the zygomatic bone 1-2 cm in front of the tragus of the auricle. Performing skills: finger pressing of the jaw artery. Indications: bleeding from the upper, lower lip, gums, tongue, chin. Prepare everything you need: a bandage, a sterile napkin, an antiseptic. Press the jaw artery to the edge of the lower jaw in the middle between the corner of the jaw and the chin. Accomplishment of skills: finger pressing of axillary artery. Indications: bleeding from the shoulder. Prepare everything you need: a tourniquet, bandage, cotton wool, gauze, napkins, antiseptics. Raise a damaged arm up and back as far as possible. With four fingers of the hand, press the axillary artery to the head of the humerus in the axillary fossa. You can stop bleeding with a cotton-gauze roller, which is made of material and placed in the armpit, on a previously applied sterile napkin, fixed with a bandage. The roller is firmly fixed to the body. Accomplishment of skills: finger pressing of a carotid artery. Indications: bleeding from the neck. Prepare everything you need: a wide bandage, cotton wool, gauze, napkins, antiseptics. Put the victim on his back, turn his head in the opposite direction from the wound. Press the carotid artery to the cervical spine in the center of the inner edge of the sternocleidomastoid muscle (place IV of the cervical vertebra). Accomplishment of skills: finger pressing of a subclavian artery. Indications: bleeding from the upper limb. Prepare everything you need: bandage, cotton wool, gauze, napkins, antiseptics. Put the injured on his back. The one who provides assistance puts one hand under the shoulder of the victim, with the thumb of the 8

other hand located in the supraclavicular fossa presses the subclavian artery to the first rib. Performance skills: finger pressure of the brachial artery. Indications: bleeding from the forearm, hand. Prepare everything you need: gauze, cotton, bandage, napkins, antiseptics. Maximize biceps up and back. With four fingers, the brachial artery is pressed against the inner surface of the humerus. Maximum limb flexion in the joint. To stop bleeding from large vessels, when other methods cannot be applied, use the maximum flexion of the limb in the joint. Performance skills: maximum withdrawal of the upper limbs. Indications: bleeding from the subclavian artery. Prepare everything you need: belt, webbing, other material. Put the victim on his side, take his arms back as far as possible, put a belt above the elbow joints and tie his hands. In this case, the subclavian artery is pressed against the first rib. Performance skills: maximum bending of the arm at the elbow joint. Indications: bleeding from the brachial artery in the elbow joint, forearm. Prepare everything you need: belt, straps, cotton, gauze, other material. In a sitting position, put a dense roller pre-prepared from cotton wool and gauze into the elbow fossa. Bend the arm in the joint as much as possible, apply a belt above the elbow joint and tighten. The result of the action will be the stopping of bleeding. Performance skills: maximum limb flexion in the knee joint. Indications: bleeding from the popliteal artery. Prepare everything you need: cotton, gauze, belt, straps, other material. The victim is in a supine position. Put the previously prepared dense cotton-gauze roller in the popliteal fossa and bend the limb in the joint as much as possible. Loop the belt onto the bent limb and tighten. Stopping bleeding with a tourniquet Esmarch's tourniquet (rubber band) has a length of 125 cm, a width of 2.5 cm, a thickness of 3-4 mm. A metal hook is fixed at one end, and a metal chain at the other. There are harnesses in which the ends are replaced with plastic buttons on the one hand, on the other - several round holes. Since 1987, the production of mechanical harnesses has been established. Such a tourniquet has the form of a coil on which a white synthetic tape is wound. Externally, the reel is closed by a plastic case, on the side of the axis there is an asterisk, which is used to tension the tape, or looseness. There is a dial on the case with which you can fix the time of applying the tourniquet. This jute is better to use in a medical institution (operating room). Performing skills: stopping bleeding with a tourniquet. Indications: arterial bleeding from the main vessels: brachial and femoral arteries. Prepare everything you need: a tourniquet, a bandage, a scarf, a scarf, a pencil, paper. Before applying a hemostatic tourniquet above the wound, the skin is wrapped with a bandage, scarf or scarf so as not to pinch it. It is advisable to raise the limb to increase the outflow of blood from the periphery to the center and restore the blood circulation. Bleeding temporarily stop (with the help of an assistant) by finger pressure. The tourniquet should be taken with the right hand at the end where the chain (button) is located, with the left hand - 30-40 cm closer to the middle, stretched, put the first circular tour so that the next round overlaps the previous one by a third. Fix the end of the harness with a hook (hole) to the chain. Attach a note to the tourniquet stating the date and hours with minutes of applying the tourniquet and the signature of the person who provided assistance. The tourniquet is bandaged and not covered. The limb is immobilized using vehicle tires or improvised means.

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Signs of a correctly applied tourniquet are: 1) stopping bleeding; 2) lack of pulse on the limbs; 3) pallor of limb skin. If the skin of the limb turns blue, bleeding continues, the tourniquet needs to be reconstituted. Relocation of the tourniquet is a fairly responsible manipulation, especially in patients with acute blood loss, when even slight bleeding can lead to severe hemorrhagic shock. Therefore, if time permits, the victim should be brought to the institution, do not carry out the repackaging of the tow. But in some cases (limb ischemia) it is necessary to carry out this manipulation. Relocation of the tourniquet is carried out as follows: finger pressing of the main artery is performed. Completely removing the tourniquet is extremely dangerous, it is only weakened. In case of ineffective finger pressure, the tourniquet is immediately tightened. When the tourniquet is loosened, wait 3-5 minutes for the blood through the collateral to resume blood circulation in the small vessels of the lower extremities. It is possible to determine this by warming the skin, its redness, and also by filling the nail plate with blood: its pallor when pressed and redness after the cessation of pressure. If these signs appear, apply the tourniquet again, subject to all the technical rules, but 4-5 cm higher than the previous level. This manipulation can be performed 2-3 times. In this case, one need to adhere to one requirement: the maximum time of a re-laid harness on a limb should not exceed ½ of the previous time. For example, if in the summer period the maximum term of the applied tourniquet is 2 hours, then after the first repacking it will be 1 hour, and after the second - 30 minutes. Too tightening the tourniquet causes unbearable pain. A complication of an improperly applied tourniquet is a turnstile shock, which occurs after a large amount of toxins from the tissues below the applied tourniquet enters the bloodstream. They appear after crushing muscles. In addition, paresis, paralysis, muscle atrophy, necrosis (tourniquet for more than 2 hours) can be complications. The wounds in such patients heal slowly, often suppurate. In case of massive lesions, when there are numerous injuries to the extremities and there are no standard harnesses, temporary bleeding is performed using improvised means: a scarf, scarf, tie, rubber tube, rubber bandage, belt, etc. Do not use a thin rope, threads, telephone cable, electrical wire that cut deep into the tissue and can lead to necrosis. Stopping bleeding with a tourniquet. Indications: arterial bleeding from the forearm, the absence of tourniquets and other standard means. To prepare everything you need: a scarf, a twist. The tourniquet is improvised from a scarf (scarf), with which to wrap a limb several times above the wound. Tie the ends with a double knot so that there is space between them. Spin the top of the knot and tie it again. Twist the spin until the effect appears. So that the twist does NOT unfold, fix one free end above the twist with a bandage, a scarf. Apply a bandage to the wound, send the victim accompanied to a medical institution. Steps for applying a twist-tow: a) imposing a scarf with a knot; b) stopping bleeding with a twist; c) fixation of the twist. Indications and techniques for applying an Israeli compression bandage.

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They release it in double vacuum packaging, which allows you to take up little space. The tightness of the bandage eliminates the influence of external environmental factors (rain, snow). For this, the package has 2 layers of protection: the outer shell is gray, the inner transparent film ensures the sterility of the bandage even if the outer layer is damaged. distant air from the packaging reduces the bandage so much that it fits in the breast pocket, and also increases the shelf life. It consists of 4 elements: a sorption pad that is applied to the wound, an elastic dressing cloth, a plastic latch to secure the elastic web and a pressure applicator. The main part of the bandage is a sorption (absorbent) pad, which consists of several layers resembling a “layer cake”, one part of which absorbs liquid and the other retains it. The sorption capacity of the pads allows you to evenly absorb liquid and minimize leakage in any place. Externally, the pillow is covered with a thin atraumatic ball-gasket, which does not allow sticking to the wound, and not drying out on its surface, as well as painlessly removed during dressings. The second part of the Israeli bandage is dressing or a sterile elastic bandage (winding) that is attached to the pads. It has a special cut with a stitching that fixes the entire length of the material in one dense bundle as if "strung" on a long thread. It does not give the opportunity to unwind and become dirty when falling, like an ordinary bandage, but on the contrary, jump up and hang like a roll at the hand of the one who provides assistance. The dressing is elastic only in length and not in width, which allows the dressing to "sit" tightly on the limbs and not move out of the wound, as well as stretch and squeeze the wound harder or wrap more tightly in one place, if it became necessary to compress the vessels in the wound. The dressing is covered with a plastic latch, which has hooks at both ends for fixing the dressing. An important role in the Israeli compression dressing is played by the pressure applicator, which is located after the pressure pad. It is made of plastic material in the form of a staple, which helps to create pressure by tightly pressing the dressing on the wound, acting as a dressing and hemostatic tourniquet. Accomplishment of skills: rules of imposing an Israeli compression bandage. The cover is taken in two hands, tearing it along the length of the bandage. The compression bandage released from the cover is placed on the wound with a white sterile surface. A pressure applicator is attached on top of the pillow on the opposite side, which is convenient to hold the pillow on the wound and put it in place of bleeding. The first round of bandage reaches the pressure applicator. The limb and the applicator are fixed with one hand, the bandage edge is inserted into the slot of the pressure applicator with the other hand, and the bandage tours are applied back. The pressure of the bandage tours depends on the purpose of the bandage: to stop arterial or venous bleeding; apply a simple aseptic dressing, fix the limb in a certain position for evacuation. The pressure on the wound is proportional to the length of the bandage, the longer the bandage stretches, the greater the pressure on the wound, especially when the bandage rests on top of each other. Bandaging is completed by fixing the material with a plastic latch over the edges of the bandage tours. If the limb needs to be fixed for transport evacuation, then when bandaging it leaves part of the bandage (tail) and the tour is carried out from the limb to the front surface of the body behind the neck and lowered again to the previous rounds, fixing the end with a plastic latch. Bleeding control method Mikulich. Execution skills: bleeding control method Mikulich. Indications: arterial bleeding from the main vessel. Prepare everything you need: gauze, cotton wool (gauze W roller), tissue, Board, crutches from the bus Diterihs, 11

harness. On the damaged artery or below it to impose a cotton-gauze roller at the level of IV cervical vertebra with an inner side of the Sterno-clavicular-shaped muscles. On the opposite side at head level and shoulder to place a makeshift splint. A harness around the neck tightly to press the cushion to the vessel using an improvised splint, so as not to damage the breathing, stop the bleeding. Harness pin from the opposite side of the wound. An impromptu tire fix on top of head, bottom and torso in the armpit and shoulder, where the bus. Execution skills: stop bleeding from the carotid artery according to the method of Mikulic. If there is no available material (Board, crutches), stop bleeding from the carotid artery performed using a thrown over the head hands method (Mikulich). On the projection of the carotid artery or below, damage is applied to the roller. Opposite from the wound hand throw over the head so that the fingers to reach the ear. The harness is pressed against the platen to the vessel due to bandaging of the tour, which goes through a raised shoulder, prodoljaetsa on the frontal part of the head, fix the head to the toes, falls back into the axillary region on the anterior surface of the neck, covering the previous tour in the area of the cushion. The ends of the harness is fixed outside the neck. Chemicals to stop bleeding. Chemical methods include: chemicals that cause spasm of the blood vessels (epinephrine) Sol. adrenalini hyfrochloridi 0,1% - 1 ml (noradrenaline) Sol. nor adrenalini 0,2% - 1 ml. Narrowing of the vessels causing this drug as ephedrine (Sol. Ephedrine hyfrochloridi 5% - 1ml), but the drugs as the 10 ml naphazoline, sanorin, galazolin, izadrin, novodran, aspirin constrict blood vessels and inflammation and do not cause bleeding. Calcium chloride (Sol. Calcii chloride 10% 10 ml), hemogobin (Sol. Haemophobini - 150 ml), fibrinogen (Sol. Fibrinogeni 250, 500 ml) taking part in creating the fold, and stop the bleeding. Hemogobin and fibrinogen release in bottles from the plasma of donated blood. Stop bleeding from the carotid artery according to the method of Mikulic. K ----- hemostatic means include: fibrinogenous film, thrombin, they are available in glass vials of 10 ml, used topically. Hemostatic sponge as a hemostatic agent is applied to the area of the ATO, produced under 1 g in cellophane, used to stop bleeding in the wounds; medical gelatin (10%, 10 ml), made from animal cartilage and is used to stop bleeding of local character, and in vials for injection under the skin; sponge gelatin is used, after processing, of food gelatin hemostat is valid locally. With herbal remedies used to stop bleeding, use: water pepper, bark viburnum, nettle leaves, grass, yarrow, Arnica. Aminocaproic acid (Sol. Acidi Aminocapronici 5% - 100 ml) is introduced in many types of bleeding. Suppresses or reduces dissolution of the clot. Grease the vessel with a view to their spasm and reduce bleeding used in the practice of ENT specialists, in particular, epinephrine, lidocaine, novocaine. Materials for self-control: Situational task number 1 The victim has a cut wound in the region of the left elbow bend. From the wound, pulsating bleeding is bright red. You, except for a bandage and a trouser belt, have nothing.

1. What measures do you propose to temporarily stop external bleeding? 12

2. Follow your proposed optimal method for temporarily stopping bleeding.

Situational task №2 The victim has a cut wound in the neck closer to the projection of the subclavian artery. 1. Indicate the amount of first aid. 2. Show the proposed measures on the phantom.

Situational task №3 Injured N., received a stab wound on the inner surface of the lower third of the right shoulder. From the wound pulsating bright red blood. Ripple on a.radialis absent. The victim is laid on his back, the right upper limb is given an elevated position. 1. Determine the best method for temporarily stopping bleeding. 2. Follow your optimal method for temporarily stopping bleeding.

Situational task №4 Private during the fighting received a shrapnel wound to the neck. On examination, a soft tissue wound was found in the neck area on the right. From the wound, pulsating bleeding is bright red. 1. What method of temporary stopping of bleeding should be applied? 2. Follow the optimal method to stop bleeding.

Situational task №5 The victim of 35 years was hit by a car. The condition is serious, unconscious. Diagnosed: combined skeletal and craniocerebral trauma. Objectively: in the area of the right shoulder, a wound 5x5x2cm with bleeding. Pulse 120 beats per minute, blood pressure 100/60 mm RT. Art. 1. Determine the Algover index. 2. In what position should the victim be transported? Demonstrate.

Литература Основная: 1. Материалы подготовки к практическим занятиям. 2. Домедична допомога (алгоритми, маніпуляції): Методичний посібник / В.О.Крилюк, В.Д.Юрченко, А.А.Гудима [та ін.] – К.: НВП “Інтерсервіс”, 2014. - 84 с. Дополнительная: 1. Стандарт підготовки І-СТ-3: Підготовка військовослужбовця з тактичної медицини (видання 2). К: “МП Леся”, 2015. – 148 с. 2. Електронная версия Стандарта подготовки І-СТ-3: Подготовка военнослужащего с тактической медицини (издание 2) – http://www.medsanbat. info/standart-pidgotovki-i-st-3-vidannya-2-pidgotovka-viyskovosluzhbovtsya-z- taktichnoyi-meditsini/ (название с экрана). 3. Видео сюжеты: www.youtube.com/playlist?list=PLGVZyDkrMM_QrjemyQ5j56G8sQolHsYoG

Guidelines prepared by PhD in medical sciences A. Levkov 13