Topic “Bleeding and hemorrhage control”Questions1. General information. Causes and signs of external bleeding. Critical

external bleeding2. Techniques of bleeding control: pressure bandage, extremity elevation,

buccellation (wound packing), Israeli bandage, digital pressure, maximum limb flexion in the joint.

3. Tourniquets: indications, types, application technique.4. Hemostatics: gauze based, chemical agents. Indications for its’ application5. Internal bleeding: causes and sings. First aid for internal bleeding.6. Collapse, syncope and shock: causes, recognition, first aid.

1. GENERAL INFORMATION. CAUSES AND SIGNS OF EXTERNAL BLEEDING

Bleeding is the loss of blood. Bleeding is the loss of blood from the circulatory system. Causes can range from

small cuts and abrasions to deep cuts and amputations. Injuries to the body can also result in internal bleeding, which can range from minor (seen as superficial bruising) to massive bleeds. 

Bleeding may be: Inside the body when blood leaks from blood vessels or organs Outside the body when blood flows through a natural opening (such as the

vagina, mouth, or rectum) Outside the body when blood moves through a break in the skinThere are six sites of bleeding in the injured patient:1. Head2. Intra-Thoracic3. Intra-abdominal4. Pelvic5. Long bones6. Externally СausesBleeding can be caused by injuries or may be spontaneous. Spontaneous bleeding

is most commonly caused by problems with the joints, or gastrointestinal or urogenital tracts.

There are many causes of external bleeding, which fall in to seven main categories, which are:

Abrasion - Also called a graze, this is caused by transverse action of a foreign object against the skin, and usually does not penetrate below the epidermis

Excoriation - In common with Abrasion, this is caused by mechanical destruction of the skin, although it usually has an underlying medical cause

Laceration - Irregular wound caused by blunt impact to soft tissue overlying hard tissue or tearing such as in childbirth

Incision - A clean 'surgical' wound, caused by a sharp object, such as a knife

Puncture Wound - Caused by an object penetrated the skin and underlying layers, such as a nail, needle or knife

Contusion - Also known as a bruise, this is a blunt trauma damaging tissue under the surface of the skin

Gunshot wounds - Caused by a projectile weapon, this may include two external wounds (entry and exit) and a contiguous wound between the two

Road rash can vary in severity; here it caused some minor bleeding and fluid discharge.

Minor bleeding from an abrasion.According to source external bleeding falls into three categories:1. Arterial bleeding Arterial bleeding is rapid and profuse. As the blood is under

pressure from the heart it will spurt from the wound with each contraction of the heart which makes clotting difficult.

2. Venous bleeding Blood flows from the wound at a steady rate as the blood is not under as much pressure. This is dark red blood and clots more easily.

3. Capillary bleeding Blood oozes from the wound. It is very simple to control as the blood pressure in capillaries is very low. Clotting occurs easily with this type of bleeding, as the blood flow is extremely slow. 

Most bleeding is not serious; it involves minor blood loss and is easily stopped. Often bleeding can be managed by the body’s own clotting processes and/or simple first aid intervention. Severe bleeding that cannot be controlled is life-threatening.

Signs and symptoms of life-threatening external bleeding Blood that gushes or spurts from a wound Blood that does not clot after efforts to control it Faintness Pale skin colour Nausea Vomiting

DizzynessRecognitionRecognizing external bleeding is usually easy, as the presence of blood should

alert you to it. It should however be remembered that blood may be underneath or behind a victim. It may be difficult to find the source of bleeding, especially with large wounds or (even quite small) wounds with large amounts of bleeding. If there is more than 5 cups of blood from a wound, then the wound is life-threatening.

Symptoms Blood coming from an open wound Bruising2. TECHNIQUES OF BLEEDING CONTROL: PRESSURE BANDAGE,

EXTREMITY ELEVATION, BUCCELLATION (WOUND PACKING), ISRAELI BANDAGE, DIGITAL PRESSURE, MAXIMUM LIMB FLEXION IN THE JOINT.

1. Apply direct pressure to the bleeding wound Apply firm pressure over the wound. Use a sterile or clean bulky pad and

apply it firmly with hand pressure. Apply a bandage to keep the dressing in place.  If bleeding is severe, DO NOT waste time looking for suitable padding, but

be prepared to use the patient’s hand or your hand to hold the wound together if the patient is unable to do this unaided.

Apply direct pressure to the bleeding wound2.      Raise the injured area If the wound is on a limb, raise it in a supported position to reduce blood

flow to the injured area.  If an arm is injured, you could apply an arm sling or elevation sling. Try to avoid any direct contact with the patient’s blood or other body fluids. Use

disposable gloves if possible. If gloves are not available, place your hands inside a plastic bag.

If there has been any contact with blood or any other body fluids, wash your hands or any blood splashed on the skin thoroughly with soap and water as soon as possible after the incident.

If you are concerned about a possible risk of infection, obtain advice from your doctor as soon as possible.

If blood leaks through the pressure pad and bandage Apply a second pad over the first. Use a tea towel or similar bulky fabric and

apply maximum pressure to the area.  For major uncontrolled bleeding quickly remove the blood-soaked pad and

bandage and replace with a fresh bulky pad and bandage. The continuing bleeding may be due to the pad slipping out of position when the first bandage was applied.

If blood leaks through the Raise the injured areapressure pad and bandage

3. If a foreign body is embedded in the woundIf there is something embedded in the wound, do not remove it. Instead, apply pressure around the object using sterile gauze. Rolled bandages are

perfect for this. Be careful not to disturb the object, as moving it may exacerbate the bleeding. This doesn't apply to superficial splinters and such. A useful rule of thumb: if it's causing bleeding, don't remove it. If it isn't, feel free. Apply pressure and secure with bandages then get medical aid.

DO NOT remove it but apply padding on either side of the object and build it up to avoid pressure on the foreign body. 

Hold the padding firmly in place with a roller bandage or folded triangular bandage applied in a criss-cross method to avoid pressure on the object.DO NOT remove the foreign object, but apply padding on either side.4.      Keep the patient at total rest Even if the injury involves the arm or upper part of the body, the patient should rest in a position of greatest comfort for at least 10 minutes to help control the bleeding. 5.      Seek medical assistance If the wound appears to be minor and the patient is able to travel by car, arrange an urgent appointment with a local doctor to assess and treat the injury. While waiting for an ambulance to arrive, observe the patient closely for any change in condition.

Severe bleeding Put on sterile disposable gloves and a face shield if available. Calm and reassure the person. Lay the person down. Apply firm, direct pressure using a clean pad (or sterile dressing if available)

over the wound. The person's own hand can be used to apply pressure whilst getting a suitable dressing/putting on your gloves.

Whilst applying the direct pressure, elevate and support the injured area above the level of the heart.

Firmly wrap a bandage around the pad or dressing to hold it in place, but not so firmly that it cuts off the circulation extremities.

If blood soaks through the pad and bandage, do not remove but cover with another pad and bandage, continuing to apply pressure to the wound until bleeding is controlled.

Monitor for symptoms of shock: pale, cold or clammy skin; rapid breathing; rapid or weak pulse; reduced level of consciousness.

If symptoms of shock are present: With the person lying down, raise and support their legs above the level of

their heart (continue to keep the injured part elevated as well). Loosen any tight clothing around their neck or their waist. Keep the person warm.Wound packing.

- Open clothing around the wound. If possible, remove excess pooled blood from the wound while preserving any clots already formed in the wound.

- Locate the source of the most active bleeding.- Pack hemostatic dressing or gauze roll into wound and directly onto the source of

bleeding.

- Quickly apply and hold direct pressure for 3 minutes if using a hemostatic dressing and 10 minutes if using plain gauze.

- Reassess to ensure bleeding is controlled.

- If initial packing fails to stop bleeding, pack a second gauze on top of the first and reapply pressure.

- Leave packing in place.- Wrap to secure the packing in

the wound. The wound may be secured with any type of compression bandage or roll of gauze.

Israeli Bandage

Israeli Bandage Demonstration video https://www.youtube.com/watch?v=wNR8rRFgwNk

Apply DIGITAL PRESSURE, if needed. If an artery is damaged, you can use your finger, thumb, hand, or knee to apply

pressure to the artery at a pressure point above the wound. The pressure compresses the artery against the bone, thus reducing blood flow or stopping the blood flow entirely. Since it is difficult to maintain sufficient pressure on the artery and more than one blood vessel is usually involved in the injury, the pressure point method is used only until a pressure dressing can be applied.

Figure 2-10 shows the location of common pressure points. A pulse can always be felt at a pressure point.

a. To control arterial bleeding of the upper part of the upper arm, apply pressure to the subclavian artery (figure 2-10 D).

b. To control arterial bleeding of the lower part of the upper arm or at the elbow, apply pressure to the brachial artery (figure 2-10 E).

c. To control arterial bleeding of the forearm, apply pressure to the lower part of the brachial artery (figure 2-10 F) or to the ulnar or radial artery.

d. To control arterial bleeding of the wrist or hand, apply pressure to the ulnar or radial artery (figure 2-10 G).

e. To control arterial bleeding of the thigh, apply pressure to the femoral artery (figures 2-10 H and I).

f. To control arterial bleeding of the lower leg, apply pressure to the popliteal artery (figure 2-10 J).

g. To control arterial bleeding of the foot, apply pressure to the anterior or posterior tibial artery

Figure 2-10. Locations of pressure points.

Maximum limb flexion in the joint.  To stop bleeding from large vessels where other methods can not be applied,

using the maximum bending limbs in the joint.Performance skills: maximum removal of the upper extremitiesIndications: bleeding from the subclavian artery.  Prepare everything you need: belt webbing other material.The victim lay on its side, take the maximum back hand above the elbow to put

the belt and pull his hands. This subclavian artery is pressed against the first rib Performance skills: the maximum bending arms at the elbow Indications: bleeding from the brachial artery in the elbow, forearm. Prepare everything you need: belt webbing, cotton wool, gauze, other material.In the sitting position the injured elbow in the hole to put previously prepared

with cotton and gauze tight roller. Maximum hand bend in the joint, apply a strap above the elbow joint and tighten. The result - bleeding will stop.

Performance skills: maximum hip flexion in the hip jointIndications: Bleeding from the femoral artery. Prepare everything you need:

cotton, gauze belt webbing other material.Quickly produce cotton-gauze roller. In the supine position the victim on his back

to put a roller in tight groin. Bending the lower limb at the knee and hip joints, hip pressed to the abdomen. Belts wraps torso and thigh in a folded belt loop and pull. Strap lock.

Performance skills: the maximum bending limbs in the knee joint Indications: bleeding from the popliteal artery.Prepare everything you need: cotton, gauze belt webbing other material.The victim is in the supine position. Pre-prepared thick cotton-gauze roller

popliteal fossa put in maximum bend and ending in the joint. Loop belt put on a bent l

Figure 2-10. Maximum limb flexion in the joint.

3. TOURNIQUETS: INDICATIONS, TYPES, APPLICATION TECHNIQUE.

How to Use a Tourniquet to Control Major Bleeding A tourniquet is a constricting or compressing device, specifically a bandage,

used to control venous and arterial circulation to an extremity for a period of time. Pressure is applied circumferentially upon the skin and underlying tissues of a limb; this pressure is transferred to the walls of vessels, causing them to become temporarily occluded. It is generally used as a tool for a medical professional in applications such as cannulation or to stem the flow of traumatic bleeding, especially by military medics. The tourniquet is usually applied when the patient is in a life-threatening state as a result of continuous bleeding.

Indications: Catastrophic Bleeding:  In all military situations a tourniquet is proposed as

the initial treatment.  In a civilian setting this is not openly or universally directed but where appropriate this could be applied in the first instance. After Airway and Breathing have been managed and upon reassessment of bleeding wounds under Circulation, the tourniquet may be able to be replaced by simpler means.

Non-Catastrophic Bleeding:  tourniquets form part of a hierarchical approach to treating all bleeding wounds which may not controlled by simpler means.

One of those skills is knowing how to control major blood loss without dedicated gear. And it’s something every man—whether soldier or civilian–should be well-versed in.

Your Blood Loss Control Battle PlanIf there’s someone else with you besides the victim, have them call an ambulance

(103, 112). If it’s just you and the victim, stop the victim’s blood loss first, and then call. To stop the blood loss, follow these steps:

Discover where the blood is coming from. If you find yourself in an emergency situation where someone (or animal) is severely injured and bleeding, approach with confidence and reassurance. Helping someone in a life threatening situation is brave, but you must try to discover and assess the injury as quick as you can. Have the person lay down and find out where the blood is coming from because tourniquets only work on limb injuries, not trauma to the head or torso. Injuries to the head and torso require applied pressure with some absorptive material in order to slow or stop bleeding, not a tourniquet.

A severely injured person may also require basic life-saving measures, such as CPR (clearing airways, mouth-to-

mouth resuscitation) and shock prevention. The term "tourniquet" originated in the late 1600s from the French word

"tourner," which means to turn or tighten.

Apply pressure to the wound. The majority of external bleeding injuries can be controlled by direct pressure. Therefore, grab something absorptive and preferably clean such as a sterile gauze pad (although it may have to be your own shirt) and place it over the wound while applying significant pressure. The aim is to plug the wound and promote blood clotting, because blood will not coagulate while freely flowing. Gauze pads (or something absorptive such as terrycloth or cotton fabric) work well to prevent the blood from escaping the wound. If the gauze, towel or article of clothing soaks through with blood, add another layer — don't take off the original make-shift bandage. Peeling off a blood soaked bandage from the wound removes the quickly forming clotting factors and encourages bleeding to resume. However, if the wound is too severe and the bleeding cannot be stopped with applied pressure, then (and only then) should you consider a tourniquet.

If left uncontrolled, bleeding will eventually lead to shock, then death. If at all possible, use latex or similar types of gloves while handling the

blood of another person as it will help stop the transmission of certain diseases. Even if you have to use a tourniquet, leave the make-shift bandage on the

wound because it will help promote clotting when the blood flow slows down.Calm the injured person down. In any emergency situation, panic is a

detriment, so try to calm the person down in a reassuring tone. Make the injured person as comfortable as possible while you're giving them help. Put something padded underneath their head and try to keep their injured limb elevated in order to help reduce blood flow.

Select the appropriate material. If you have a well-designed medical tourniquet at your disposal then that's great, but in most emergency situations you'll have to improvise. In the absence of a specially designed tourniquet, choose something that is strong and pliable (although not too stretchy), but long enough to tie around the injured limb.[7] Good choices would be a necktie, bandana, leather belt, straps from knapsack or handbag, cotton shirt or long socking.

To minimize cutting into the skin, ensure that the improvised tourniquet is at least an inch wide and preferable 2-3 inches in width. However, it the tourniquet is for a finger, a somewhat smaller width is fine, but avoid string, twine, dental floss, wire etc.

In an emergency situation with lots of blood, you need to resign yourself to the fact that you'll be getting blood on your clothes, so don't be hesitant to use an article of clothing for a tourniquet.

Apply the tourniquet between the heart and injury. Place your tourniquet around the injured limb, between the open wound and the heart (or proximal to the wound) — the purpose is to cut off the strong blood flow within arteries leaving the heart, not the more superficial veins returning blood back to the heart. More specifically, place your tourniquet about 2-4 inches away from the edge of the wound. Don't place it directly over the wound because the arteries upstream from the injury will still drain into and out from the open wound.

For wounds that are just below a joint (such as the elbow or knee), place your tourniquet just above and as close to the joint as you can.

Your tourniquet should have some padding underneath it to prevent skin damage, so use the victim's clothing (pant leg or shirt sleeve) to place under it if you can.

If your tourniquet is long enough, wrap it around the injured limb numerous times, keeping it as flat as possible. You want the tourniquet to stop blood flow in the arteries, but not cut into and damage any soft tissues while doing so.

Use a stick or rod for tightening. Tying a regular knot after you have tightly wrapped your tourniquet may not be sufficient to control the flow of blood, especially if the material expands a little when wet. As such, use some sort of elongated wooden or plastic stick or rod (at least 4 inches long) as a torsion device. First, tie a half-knot with the tourniquet, then place the rigid object on top before tying a full knot over it. You can then twist the elongated object until the tourniquet is tight around the injured limb and the bleeding stops.

Blood from arteries is typically bright red in color (due to the oxygen content), whereas venous blood is darker with an almost bluish hue.

Small tree branches, a screwdriver or wrench, thin flashlights, or thick marker pens all work well as torsion devices for tourniquets.

Reducing ComplicationsDon't leave the tourniquet on too long. Tourniquet use is temporary and short-

term only, although there is no research that indicates exactly the time limit before the lack of blood supply starts to cause tissue death (necrosis), as all people are physiologically a little different. If necrosis sets in, then leg amputation is very likely. As a general guideline, 2 hours is considered the length of time a tourniquet can be tied before neuromuscular injury begins (loss of normal function) and perhaps 3-4 hours before necrosis becomes a serious concern. However, in an emergency situation with no medical help close by, you may have to make the choice of sacrificing a limb to save a life.

If you think medical help will take longer than 2 hours to arrive, then cool the limb down with ice or cold water (while elevated) if you can — it may help delay tissue injury and loss of function.

Mark the victim's forehead with a "T" to indicate a tourniquet has been applied and also note the time when it was applied so medical personnel know.

Keep the wound as clean as you can. Ideally, your tourniquet will stop or considerably slow down the flow of arterial blood from the wound, although you should still take care to prevent any debris from landing on the injury. Any open wound is at risk or infection.[12] Before applying a pressure bandage, rinsing the wound with clean water is a good idea, but once the gauze or bandage is applied you shouldn't remove it. However, you can prevent debris from landing on the make-shift bandage by covering it with a blanket or article of clothing.

If you don't have any latex gloves to wear, look around or ask any bystanders for some hand sanitizer before you touch the wound.

Alcohol, vinegar, natural honey, hydrogen peroxide and bleach are all good antiseptics that may be available for you to use on your hands or the victim's injury before you dress it.

Assess for shock.

Tourniquets are ONLY applied on limbs! Never on a neck! (If you did this, you wouldn’t be the first.) Major bleeding control practices in areas not accessible by tourniquets (like the stomach and back) will be covered further at another time.  With that out of the way, here are the steps of applying a tourniquet:

Wrap the limb with a rope/belt/bra at least two inches closer to the body than the wound. Do not apply a tourniquet over a joint--blood passageways are protected in joints, and you’ll never put pressure on the arteries. Place it closer to the body than the joint. Then tie the tourniquet in place once using an overhand knot.

Place your desired torsion device on top of the overhand knot. Tie another overhand knot, then another (or tie a square knot if you’re knot savvy) to secure the torsion device onto the tourniquet.

Twist the torsion device in one direction until bleeding stops.

Secure the tourniquet in place. This can often be accomplished by using the loose ends from your last knot to tie one end of the torsion device to the tightened tourniquet, or to the limb.

A primitive tourniquetCongratulations! You now know how to save a

life! Go out unto the world knowing you can help make it a safer place.

APPLYING AN IMPROVISED TOURNIQUET IMPROVISED TOURNIQUETS Improvised tourniquets are extremely effective and should be readily available.

As stated previously, the immediate need for access to a tourniquet is essential to the combat medic. A limited number of manufactured tourniquets may be available. There are many techniques for pre-tying the windlass device to the cravat so that tourniquet application can be faster. The following steps do not address many of these techniques, but they give the good basic technique.

GATHER MATERIALS FOR MAKING AN IMPROVISED TOURNIQUET If you do not have a field tourniquet available, you can make an improvised tourniquet. You will need a tourniquet band, a rigid object, and padding materials. Additional securing material may also be needed.

a. Tourniquet Band. Obtain a band of strong, pliable, folded material which is at least two inches wide. A cravat made from a folded muslin bandage is preferred. A folded handkerchief, a folded strip of clothing, or a belt can also be used as the tourniquet band. Do not use wire, shoestrings, or other narrow materials for the tourniquet band. A wide tourniquet band protects the tissues beneath the tourniquet when it is tightened. Very narrow materials may result in serious damage to the nerves and blood vessels when the tourniquet is tightened.

b. Rigid Object. Obtain a rigid object, usually a stick, which is long enough and sturdy enough to tighten the tourniquet band and be secured.

c. Padding. Obtain padding material to be placed between the limb and the tourniquet band to protect the skin from being pinched and twisted when the band is tightened. Soft, smooth material should be used for the padding. The casualty's shirt sleeve or trouser leg can be used as padding.

d. Securing Materials. Obtain material to be used to secure the rigid object once the tourniquet band has been tightened. If the cravat used as a tourniquet band is long enough, the tails of the cravat can be used to secure the rigid object. Another cravat or strip of cloth similar to the tourniquet band can be used to secure the rigid object.

APPLY THE TOURNIQUET

a. Select the Tourniquet Site. Select a site that is two to four inches above the edge of the wound, but not over a joint or at the edge of the field dressing. If the wound is just below the elbow or knee, select a site above the joint and as close to the joint as possible.

b. Apply Padding. Place padding around the limb where the tourniquet will be applied. If the casualty's shirt sleeve or trouser leg is used as padding, smooth the shirt or trouser material and apply the tourniquet band over the clothing.

c. Apply the Tourniquet Band. Place the tourniquet band material around the tourniquet site. If possible, wrap the tourniquet band around the limb twice.

d. Apply the Rigid Object. (1) Tie the band with a half knot (figure 2-24 A). This is the same as the first part

of tying a shoe. (2) Place the rigid object on top of the half-knot (figure 2-24 B). (3) Tie a full knot over the rigid object (figure 2-24 C). e. Tighten the Tourniquet. Twist the rigid object either clockwise or

counterclockwise (figure 2-24 D) until the tourniquet is tight enough to stop arterial blood flow beneath the band.

Figure 2-24. Applying an improvised tourniquet to a limb.SECURE THE RIGID OBJECT Once the tourniquet is tightened, you must secure the rigid object so the

tourniquet will not untwist.

a. Tourniquet Band Tails. If the remaining tails of the tourniquet band are long enough, use them to secure the rigid object.

(1) Align the rigid object lengthwise (parallel) with the limb. (2) Wrap one tail of the tourniquet band over and around one end of the rigid

object (figure 2-24 E). (3) Bring that tail down the side of the injured limb. (4) Wrap the other tail of the tourniquet band over and around the other end of the

rigid object. (5) Bring that tail down the other side of the injured limb. (6) Bring the tails together and tie them in a nonslip knot under the injured limb

(figure 2-24 F). Applying an improvised tourniquet to a limb. b. Other Securing Materials. If the tails are not long enough to secure the rigid

object, use a cravat or strip of cloth to secure the object. (1) Wrap the cravat or other piece of material around the limb below the level of

the tourniquet band, but near enough to the tourniquet so the rigid object passes over the securing material. Wrap the material around the limb twice, if possible. NOTE: The rigid object is secured below the tourniquet so the additional securing material will not interfere with blood circulation above the tourniquet.

(2) Align the rigid object lengthwise (parallel) with the limb. (3) Wrap the material around the end of the rigid object so the rigid object is

secured. This will prevent the tourniquet from unwinding. (4) Tie the tails of the material in a non-slip knot. CHECK EFFECTIVENESS OF TOURNIQUET Check for a pulse below the tourniquet. If the tourniquet has stopped arterial

blood flow, there should be no pulse. Also, the bright red arterial bleeding will have stopped. If there is still a pulse below the tourniquet or if arterial bleeding continues, tighten the tourniquet.

CAUTION: Leave the tourniquet exposed so it can be located quickly by medical.

MARK THE CASUALTY AND CONTINUE SURVEY a. Mark the casualty to indicate that a tourniquet has been applied. b. Continue to your survey of the casualty. Check the Effectiveness of the Tourniquet. Check for a pulse below the tourniquet. If the tourniquet has stopped arterial

blood flow, there should be no pulse. Also, the bright red arterial bleeding will have stopped. The darker venous blood may continue to ooze even after the tourniquet has been properly applied. If there is still a pulse below the tourniquet or if arterial bleeding continues, tighten the tourniquet.

Typical places for tourniquet applying

4. HEMOSTATICS: GAUZE BASED, CHEMICAL AGENTS. INDICATIONS FOR ITS’ APPLICATION

Haemostatics are applications designed to stem blood-flow through the accelerated promotion of clotting.  As with all treatments it is important to understand their roles, applications and the differences between them.

Considerations Haemostatics are not the first line treatment for serious bleeds.  Always start

with direct pressure before considering haemostatics. They are used with direct pressure – not instead of. Every haemostatic agent (brand and type) is different and familiarisation

training should be sought. They are applied to the source of the bleed – the damaged blood vessel – not

somewhere near it. The packaging should be retained and handed-over to the EMS with the

instruction that it goes with them to hospital to enable their wound to be managed effectively.  Do not assume the hospital will know how to deal with the haemostatic you have applied.

ApplicationIn simple terms Haemostatic agents work in a variety of ways to stem the flow of

blood but their use, as with all advanced interventions, requires training and understanding.

The primary treatment for all serious bleeds is direct pressure; all haemostatics are designed to be used with direct pressure at the site of the bleed – directly onto the bleeding artery, deep within the wound if necessary.  They are not a ‘magic powder’ that can be casually applied somewhere near the wound and left to work.

Most brands are available as either a loose, granular powder, impregnated onto a bandage or retained inside a porous bag.   Loose powders present issue when trying to apply them accurately into the wound site and can be blown around by the wind. 

Powders cannot be applied against gravity – for example packing a wound underneath a casualty – nor can they be applied against very fast flowing blood.  Haemostatic bandages, gauzes and ‘sponges’ are often easier and more practical to apply.  These dressings are also easier to remove and clean in theatre, once the casualty gets to hospital.

Finally, Haemostatic agents should never be allowed to enter: The eyes The airway The chest Head injuries with exposed brain tissue or meninges

TYPES OF HAEMOSTATIC AGENTSFactor concentratorsThese agents work through rapid absorption of the water content of blood

concentrating the cellular and protein components of the blood encouraging clot formation.

One of the most common ‘myths’ you will hear of Haemostatics is that they cause burns.  One particular brand Quikclot used Zeolite, an inert volcanic mineral which rapidly absorbs water but creates an exothermic reaction.   Quikclot’s  2nd generation products had been seen to generate heat up to 42oC. 

Mucoadhesive agentsThese agents create a strong adherence to tissues and physically seal bleeding

wounds. Three common products –Celox, SAM Chito Hemcon - all use chitosan, a naturally occurring, bio-compatible polysaccharide derived from shellfish, and work in this fashion.

Celox Gauze and Chito-SAMBoth Celox Guaze and Chito-SAM are fibrous bandages coated in chitosan

powder.  This is easier to handle and apply than granules and is also easier to clean in theatre, usually with normal saline.  Chitosan is naturally broken down by the body’s natural enzymes unlike Kaolin or other minerals used in haemostatics which will remain in the body indefinitely unless removed.

As haemostatic bandages need to be packed into the wound, the user is limited by the length of their finger; the Celox Applicator is a unique design which allows the chitosan to be applied into deep wounds making it ideal for gunshot and penetrating wounds.

Celox Gauze

Chito-SAM

Celox ApplicatorHemConHemCon products are also chitosan-based haemostatic and works on the same

adhesive principle as Celox.  Hemcon is a mucoadhesive pad which is intended to seal the wound (like a puncture repair) but, being a fairly stiff and brittle pad, it is not efficient as efficient at dealing with deeper wounds.  Hemcon pads have been known to break apart during use (12).  Recently Hemcon have introduced Hemocon Chitoflex which is a coated bandage similar toCelox and Chito-SAM which can be packed into the wound.

HemCon Bandage

HemCon Chitoflex

Procoagulant supplimentorsA third class of agents function by delivering procoagulant factors to the bleeding

wound. Current 3rd and 4th Generation Quikclot utilise Kaolin, a white aluminosilicate

nano-particulate which has been shown to accelerate the body’s natural coagulation cascade.

3rd Generation products are dispensed in a ‘tea bag’ like sachet which is applied directly to the wound.  This removes the problems associated with handling loose granules and enables a large area to be covered, deep wounds to be filled and direct pressure to be effectively applied.  This method of application also facilitates the quick and easy removal of the product in theatre.  Conversely, this method is not ideal for treating small, deep puncture wounds or incisions. 

4th Generation Quikclot Combat Gauze is fibrous gauze impregnated with Kaolin.  The bandage is packed deep inside the wounds as with other haemostatic bandages. 

Quikclot Combat Gauze

Quikclot ACE 'Sponge' But...what about just normal gauze?Comparisons of Quikclot Combat Gauze, Celox and Kerlix (a standard,

unmediated, gauze bandage)that standard gauze was faster to pack with no difference in haemostatic success or blood loss

Haemostatics should not be left in place for more than 24 hours.  If the casualty cannot be evacuated to definitive care within this time, their use is not appropriate.  This might limit their use in extremely remote environments.

A casualty with a catastrophic haemorrhage is very poorly.  Evidence suggest that this may account for 50% of trauma related fatalities, more to the point, these fatalities typically occur within one hour of the causing incident.   Whilst the haemostatic should not be left for more than 24 hours, can you evacuate your casualty to definitive care within one hour?

Let’s not be precious about brand but considers a gauze style haemostatic for ease of use. There may be merit in a chitosan based haemostatic over Combat Gauze for the critically ill casualty. If you do not have a haemostatic dressing any sterile gauze will do to pack the wound if a) direct pressure is not effective and b) a tourniquet is not appropriate. Communicate your treatment in your initial call for help – the use of a haemostatic has made your casualty time-critical.

Some people will die.   Not because of you, your actions or which brand of haemostatic you were or were not using.  That’s’ why it is call “Catastrophic” bleeding.

7. INTERNAL BLEEDING: CAUSES AND SINGS. FIRST AID FOR INTERNAL BLEEDING.

Internal bleeding occurs when there is a rupture of either an artery, vein or capillaries within the body.

Internal bleeding may be caused by the following conditions:1. Trauma - damage to a blood vessel that can't easily be repaired by the body's

internal mechanisms;2. Chronic disease – high blood pressure, aortic aneurism, liver cirrhosis, not

enough clotting factors (hemophilia A, B, etc.) in the blood to make the repair; 3. Medications - that are taken to prevent abnormal clotting (Aspirin, Warfarin,

Heparin, etc.);4. Other causes – ectopic pregnancy, pregnancy miscarriage, etc.If there is an injury, internal bleeding must be suspected. At the same time, the

most common reason of severe internal bleeding is an injury. Damaged internal organs commonly lead to the bleeding that is concealed. It can result in severe blood loss with resultant shock (hypoperfusion) and subsequent death.

Internal bleeding can be visible or concealed. Visible where the bleeding can be seen. Blood is exiting from: Ears - bright, sticky blood or blood mixed with clear fluid Lungs - frothy, bright red blood coughed up by the person Stomach - coffee color, bright or dark red vomit Bowel or intestines - bright red or dark/tarry blood (as the blood is partially

digested) Anus or vagina - usually red blood mixed with mucus Urinary tract - dark, red colored or pink tinged urine Under the skin (bruising) - dark/purple due to the blood under the skin and

not exposed to airConcealed - no direct evidence of obvious bleeding. Bleeding is contained within

the body: Head (intracranial hemorrhage)

Thorax (hemothorax, cardiac tamponade, bleeding due to large vessels’ rupture – aorta, superior and inferior vena cava, and their major branches)

Abdomen (hemoperitoneum due to liver, spleen damage) Pelvis (pelvic fractures) Around large bones (fractures)Suspicion and severity of internal bleeding should be based on the mechanism of

injury and clinical signs and symptoms.Relationship to mechanism of injury:1. Blunt trauma - This kind of trauma happens when a body part collides with

something else, usually at high speed. Blood vessels inside the body are torn or crushed either by shear forces or a blunt object.

a. Falls from over 3 metersb. Motorcycle crashesc. Pedestrian impactsd. Automobile collisionse. Blast injuriesf. Look for evidence of contusions, abrasions, deformity, impact marks, and

swelling.2. Penetrating trauma - This happens when a foreign object penetrates the body,

tearing a hole in one or more blood vessels1. gunshot wounds,2. stabbings, 3. falling onto a sharp object.Internal bleeding damages the body both from the loss of blood and from the

pressure the misplaced blood puts on other organs and tissues. At first the casualty may not present with any symptoms, although if an organ is bleeding usually this is often painful. This pain may be overlooked by the assessor or the casualty as they may be distracted with other injuries or issues. Also the injured person may not be able to express pain if they are drowsy, confused or (sounds obvious but) unconscious. So please be aware when helping an injured person that visible signs and symptoms, or even lack of them does not necessarily mean they are in the clear of a more serious injury or condition. Eventually, bleeding internally usually becomes apparent with possible signs and symptoms such as blood being vomited up or ears leaking fluid (see below for more possibilities). There are also more vague signs that develop such as generalized pain or tight, rigid abdominal muscles.

It is important to remember that an injured person may be bleeding internally even if you can't see any blood.

Clinical signs and symptoms of internal bleeding: Bleeding usually causes pain and the area of the body affected is usually the

site of the person's complaint. Blood that leaks outside of a blood vessel is very irritating and causes an inflammatory response. There will be pain, tenderness, swelling or discoloration of soft tissues of suspected site of injury;

Bleeding from an orthopedic injury, usually of the forearm or shin, may cause gradual increase of the pressure within the muscle compartments causing blood

supply to the affected area to be compromised. This can lead to intense pain, tingling, numbness, and decreased motion. Fractures of long bones (humerus, femur) will cause deformation (extension of the extremity’s diameter), swelling of a damaged limb

Blood that irritates the diaphragm may cause pain in the chest or pain that radiates to the shoulder, and it’s going to be rigid, breathing problems can appear.

Blood in the peritoneum causes intense pain that is sometimes difficult to localize especially if blood is spilling everywhere. The abdomen is going to be tender, rigid, and/or distended.

Black tarry stools may indicate bleeding in the stomach or small intestine. (Please note that while a black bowel movement should be concerning, it may also be seen in patients taking iron supplements, Pepto Bismol, or other medications and dietary products).

Blood from a body orifice (mouth, nose, ears, anus, vagina, or urethra) may be a symptom of internal bleeding

Bleeding from the kidney or bladder may not be recognized until the patient needs to urinate and then the blood is apparent.

Orthostatic hypotension (becoming dizzy when attempting to stand) can occur in patients with internal bleeding.

Late signs and symptoms of hypovolemic shock (hypoperfusion) area. Anxiety, restlessness, combativeness or altered mental statusb. Weakness, faintness or dizzinessc. Thirstd. Shallow rapid breathinge. Rapid weak pulsef. Pale, cool, clammy skinpaig. Capillary refill greater than 2 seconds - infant and child patients onlyh. Dropping blood pressure (late sign)i. Dilated pupils that are sluggish to respondj. Nausea and vomiting

Steps to caring for patient with internal bleeding1. Follow standard precautions: look for danger, personal protection, look for

response. 2. Maintain the airway with cervical immobilization.3. Administer high-flow oxygen and provide artificial ventilation as necessary.4. Control all obvious external bleeding.5. Apply a splint to an extremity where internal bleeding is suspected.6. Monitor and record vital signs at least every 5 minutes.7. Give the patient nothing by mouth.8. Elevate the legs 15-30 cm (6” to 12”) in nontrauma patients.9. Keep the patient warm.10. Provide immediate transport for patients with signs and symptoms of shock.

Report changes in condition to hospital personnel.

8. COLLAPSE (FAINTING) AND SHOCK: CAUSES, RECOGNITION, FIRST AID.

Minor internal bleedings, especially visible with blood loss less than 50 ml, will stop by themselves and do not need anything but observation. Major bleedings can outcome into collapse, syncope and shock.

Collapse is a sudden and often unannounced loss of postural tone (going weak), often but not necessarily accompanied by loss of consciousness. Syncope refers to a sudden loss of consciousness often accompanied with collapse, more commonly known as a blackout or faint. It is caused by a lack of blood or oxygen to the brain. When this happens, the brain attempts to increase blood flow to itself by diverting blood away from the rest of the body. This causes pale skin and a white face, rapid heart rate (tachycardia), rapid breathing (hyperventilation) and weakness of the limbs, particularly the legs. Eventually collapse occurs.

There are a number of situations that can induce collapse and syncope. Too little food or water, low blood sugar (hypoglycaemia), intense physical exercise, and standing up too quickly can all cause an episode of fainting. Additionally, low blood pressure (hypotension) – due to blood loss in case of injury, and an abnormal heart rhythm (arrhythmia) can also cause a lack of blood to the brain.

Recurrent episodes of syncope may be a sign of a more serious underlying condition and require further investigation.

Simple syncope episodes can be diagnosed fairly easily by a doctor without complicated tests. However, recurrent episodes may be a symptom of another condition and a specialist doctor may order some tests to investigate what could be the cause of syncope.

It is treated at the time of fainting by lying down and raising the legs in order to improve blood flow to the brain. Treatment for an underlying cause may be necessarys.

Shock is a life-threatening condition characterized by multi-organ dysfunction and tissue hypoxemia caused by a decrease in oxygen delivery or impaired oxygen utilization.

Hypotension is a drop in systolic blood pressure of > 40-50 mm HG from baseline. Systolic < 90 mm Hg MAP < 65 mm Hg.

Several indicators can be used to assess volume status, including mean blood pressure, heart rate, respiratory rate, peripheral perfusion and urine output. While most patients in shock are hypotensive, a minority may have a normal blood pressure, likely due to a compensatory peripheral vascular constriction. Clinical hypotension is usually found, i.e., mean arterial pressure <60 mmHg or systolic blood pressure < 90 mmHg in previously normotensive persons.

Many conditions, including blood loss but also including nonhemorrhagic states such as dehydration, sepsis, impaired autoregulation, obstruction, decreased myocardial function, and loss of autonomic tone, may produce shock or shocklike states.

Shock is classified into 4 major categories, of which most patients may present with more than one type:

1.Hypovolemic – due to intravascular volume loss (hemorrhagic and non-hemorrhagic intravascular volume depletion)

2.Distributive - vasodilation, which is a hyperdynamic process (septic, anaphylactic, adrenal crisis, and neurogenic)

3.Cardiogenic - pump failure (myocardial infarction, cardiomyopathy, valvular heart disease)

4.Obstructive - physical obstruction of blood circulation and inadequate blood oxygenation (pulmonary embolism, tension pneumothorax, cardiac tamponade)

Stages of shock - Initial : The cells become leaky and switch to anaerobic metabolism. - Non-progressive:(compensated stage) Attempt to correct the metabolic upset of shock.

- Progressive: (decompensated stage ) Eventually the compensation will begin to fail. - Refractory : Organs fail and the shock can no longer be reversedThe symptoms and signs of shock are those of tissue hypoperfusion and of

physiological compensatory mechanisms. Compensation is a condition where these latter mechanisms temporarily stabilize shock. It should always be recognized and never left untreated. These compensatory mechanisms may be quickly depleted and lead to sudden cardiovascular collapse.

Signs and symptoms of shock (hypoperfusion)1. Mental states

a. Restlessnessb. Anxietyc. Altered mental status

2. Peripheral perfusiona. Delayed capillary refill greater than 2 seconds

b. Weak, thready or absent peripheral pulsesc. Pale, cool, clammy skin

3. Vital signsa. Decreased blood pressure (late sign)b. Increased pulse rate (early sign) - weak and threadyc. Increased breathing rate

(1) Shallow(2) Labored(3) Irregular

4. Other signs and symptomsa. Dilated pupils

b. Marked thirstc. Nausea and vomitingd. Pallor with cyanosis to the lips

5. Infant and child patients can maintain their blood pressure until their blood volume is more than half gone, so by the time their blood pressure drops they are close to death. The infant or child in shock has less reserve.

Considering that we are studying the topic “Hemorrhage control”, we will pay our attention to the hypovolemic (hemorrhagic) shock.

Hypovolemic or hemorrhagic shock. The loss of volume in the circulation is the main feature in this type of shock. The

loss may be caused by bleeding or plasma loss into the interstitium, dehydration, burns. In all instances a decrease in the intravascular volume is the result. Hypovolaemia or haemorrhagic shock is most often seen in trauma patients.

Clinical features are common for most types of shock, listed up above.An estimate should be made of % Blood Volume Loss Normal blood volume of a human: Adults = 70 ml/kg Children = 80 ml/kg Neonates = 90 ml/kg Classification of hypovolemic shock according to it’s severity.

How is it possible to assess the amount of blood loss?The shock index = Allgower’s index (SI = pulse rate/systolic BP) gives an

indication of percentage blood loss: SI < 1 blood loss < 25% SI 1 - 1.5 blood loss 25 - 33% SI 1.5 - 2 blood loss 33 - 50% SI > 2 blood loss > 50% Search for possible sources of blood loss:(One on the floor and four more) - On the floor - history from paramedics

- In the chest - heart, great vessels, or lung laceration : > 2 litres - ribs : 100 - 200 ml each - In the abdomen - aorta, inferior vena cava, liver or spleen : > 2 litres - In the pelvis - pelvic fractures : 1 - 3 litres - In the thighs - femur fractures : 1 - 2 litres - other long bones : 0.5 - 1 litre First Aid Measures for ShockIn the field, on a scene, the first aid procedures administered for shock are

identical to procedures that would be performed to prevent shock. When treating a casualty, assume that shock is present or will occur shortly. By waiting until actual signs and symptoms of shock are noticeable, the rescuer may jeopardize the casualty’s life.

a. Position the Casualty. (DO NOT move the casualty or his limbs if suspected fractures have not been

splinted)(1) Move the casualty to the safe place, if the situation permits.(2) Lay the casualty on his back.NOTE: A casualty in shock from a chest wound or one who is experiencing

breathing difficulty, may breathe easier in a sitting position. If this is the case, allow him to sit upright, but monitor carefully in case his condition worsens.

(3) Elevate the casualty’s feet higher than the level of his heart. Use a stable object (field pack or rolled up clothing) so that his feet will not slip off.

WARNINGDO NOT elevate legs if the casualty has an unsplinted broken leg, head injury, or

abdominal injury.

Clothing loosened and feet elevated.WARNING: Check casualty for leg fracture(s) and splint, if necessary, before

elevating his feet. For a casualty with an abdominal wound, place his knees in an upright (flexed) position.

(4) Loosen clothing at the neck, waist, or wherever it may be binding.CAUTION: DO NOT loosen or remove protective clothing in a chemical

environment.(5) Prevent chilling or overheating. The key is to maintain body temperature. In

cold weather, place a blanket or other like item over him to keep him warm and under him to prevent chilling.

However, if a tourniquet has been applied, leave it exposed (if possible). In hot weather, place the casualty in the shade and protect him from becoming chilled; however, avoid the excessive use of blankets or other coverings.

Body temperature maintained.(6) Calm the casualty. Throughout the entire procedure of providing first aid for a

casualty, the rescuer should reassure the casualty and keep him calm. This can be done by being authoritative (taking charge) and by showing self-confidence. Assure the casualty that you are there to help him.

(7) Seek medical aid.b. Food and/or Drink.When providing first aid for shock, DO NOT give the casualty any food or drink.

If you must leave the casualty or if he is unconscious, turn his head to the side to prevent him from choking if he vomit).

Casualty’s head turned to side.

c. Evaluate Casualty.Continue to evaluate the casualty until

medical personnel arrives or the casualty is transported to the medical facility.

Treatment generally includes fluid resuscitation, correction of underlying etiology, and often vasopressors.

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