Hemorrhage management:
Gross hemorrhage can rapidly progress to shock, decompensation, and death. Rapid intervention on the part of first responders, including members of the public, police, fire, and EMS, is integral to ensuring survival. Notice that I mention members of the public here. It can take anywhere from 4 to 30 minutes for EMS to reach a scene depending upon where an injury occurs. In the case of life threatening arterial bleeds, it only takes 3-6 minutes to bleed to death. For this reason there is a push to get the public on board with campaigns such as the Stop The Bleed program, and others like it. Going beyond basic first aid, these programs aim to provide members of the public with the skills to stop significant bleeding and buy EMS personnel time to reach the patient. As always, this blog is not medical advice and is not a substitute for professional training or protocols at local agencies.
When we are talking about gross hemorrhage, we aren’t speaking of superficial wounds. I am describing wounds that are uncontrolled, and large volumes of blood are being lost. There are 3 types of bleeds:
1. Capillary bleeding: Slow, oozing wounds that usually stop on their own. An example would be the bleeding encountered when you cut yourself shaving.
2. Venous bleeding: These come when there is damage to the wall of a vein. They tend to produce dark red, flowing hemorrhage.
3. Arterial bleeding: Bright red, spurting bleeds, that occur when an artery is severed. By far the most significant type of hemorrhage.
How we manage bleeding depends largely on where the injury is located. Extremity wounds to the arms, or legs are managed differently than injuries to the head, trunk, or junctional areas such as the armpit or groin.
Extremity wounds:
We want to begin by assessing the wound to see if the source of bleeding is visible. If the vessel can be visualized, apply digital pressure to the site. Next we want to place a tourniquet 5 cm above the wound and tighten it as much as possible. If bleeding stops, perfect; if not, apply a second tourniquet above the first one. Next apply a pressure dressing at the site.
Junctional wounds:
These wounds do not provide enough room for a tourniquet. Attempt digital pressure, and then pack the wound, either with hemostatic gauze, or regular sterile gauze. Next apply a pressure dressing to maintain pressure on the wound.
Wounds into hollow cavities in the head, neck, chest, or abdomen:
DO NOT pack these wounds, and no tourniquets are not an option. Head wounds should be managed with adequate, but minimal pressure, and wrapped loosely. Neck wounds require an occlusive dressing and should not be circumferentially wrapped. Chest wounds cannot be packed, and should be covered with a chest seal. Abdominal wounds require an abdo pad or blast style dressing and direct pressure at the site. Eviscerations are a different animal and not part of this discussion.
Some services utilize additional measures such as TXA. Mine does not and I am not familiar enough with its use to discuss it here. Key points to remember are:
1. Direct digital pressure
2. Get a tourniquet on early, and remember to write the time on it.
3. If a tourniquet is placed, ensure this is indicated somewhere on the patient (I prefer the forehead)
4. Pack wounds aggressively. Yes it will hurt.
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