KEY POINTS
- Prompt control of bleeding is a life-saving skill.
- You need to look systematically for sources of bleeding.
- The first clot is the best clot.
- Direct pressure, keeping the casualty warm and reassurance are the main treatments.
EXPLANATION
In an extreme sports accident, internal and external bleeding are the most immediate threats to the casualty.
When assessing the casualty, you need to look carefully and systematically for sources of bleeding.
When bleeding, the body uses components of the blood (‘clotting factors’) to form a plug to stem the loss of blood. The clotting factors are in finite supply, so the first blood clot made will be the strongest. To make sure the first clot stays in place, minimise movement of the casualty and avoid repeated removal-reapplication of pressure ie. don’t keep taking the bandages off to see if the bleeding has stopped!
Keep the casualty warm, as that assists blood clotting. Pain relief and reassurance also reduce blood loss.
The best way to stop external bleeding is with direct pressure onto the wound with a trauma bandage. Once the pressure is on, do not remove it until help arrives.
ASSESSING BLOOD LOSS AND SHOCK
The volume of blood lost is not always obvious, especially in poor light or when clothing absorbs the flow. As a guide, a healthy adult has roughly five litres of circulating blood. Losing around half a litre may produce only mild signs, but a loss of one litre or more becomes increasingly serious, and a two-litre loss in an adult is immediately life-threatening. In children, the total blood volume is much smaller, so a wound that looks minor to an adult can still cause dangerous shock.
Look for the early signs of shock while you control the bleeding: pale, cool and clammy skin, a rapid but weak pulse, fast shallow breathing, thirst, restlessness or anxiety, and later confusion or a falling level of consciousness. These signs mean the body is diverting blood away from the skin and non-essential organs. Treat every casualty with suspected blood loss as if shock is developing, even if their colour and pulse still seem acceptable.
The appearance of the blood itself can give you clues. Bright red, spurting blood suggests an injured artery and may need urgent pressure or a tourniquet. Dark red blood that flows steadily is more likely venous, while capillary bleeding is usually a slow ooze. Use these observations to decide how quickly you need to escalate your control measures, but do not waste time trying to classify the vessel when a casualty is heavily bleeding.
APPLYING AND MAINTAINING PRESSURE
Direct pressure works best when it is firm, focused and uninterrupted. Place a sterile dressing, trauma pad or any clean folded cloth directly over the wound, then press down with the flat of your hand or fingers. If you have a second dressing, do not remove the first one when it becomes soaked; instead place the next dressing on top and continue pressing. Removing a soaked dressing can pull away the developing clot and restart bleeding.
Your body weight is more effective than muscle strength alone. If possible, kneel or lean over the casualty and keep your arms straight while pressing, so that you can maintain steady force for several minutes without tiring. For limb wounds, you can use a pressure bandage to secure the pad in place, but check that the bandage is tight enough to control bleeding without cutting off the circulation below the injury.
When an object is embedded in the wound, do not pull it out. The object may be plugging the damaged vessel. Apply firm pressure on either side of the object and build up dressings around it, then bandage over the top without pressing directly onto the object itself. This lets you control bleeding while avoiding further injury.
USING A TOURNIQUET FOR LIMB BLEEDING
A tourniquet is used only when direct pressure cannot control severe bleeding from an arm or leg, or when the situation makes sustained direct pressure impossible. Place the tourniquet directly onto bare skin, around 5 to 7 cm above the wound, but never over a joint. Tighten it until the bleeding stops and you can no longer feel a pulse below the tourniquet. A correctly applied tourniquet is painful, but that is a sign it is tight enough.
Once the tourniquet is on, do not loosen or remove it to check the wound. Releasing a tourniquet can allow toxins and clots to enter the circulation and cause sudden deterioration. Write the time it was applied on the casualty’s forehead, on a piece of tape or on the tourniquet itself, so that the receiving medical team knows how long the limb has been without blood flow. Modern CAT-style tourniquets are designed for one-handed application and are preferable to improvised ones.
If you must improvise, use a wide band of strong cloth at least 5 cm wide and a rigid windlass such as a stick or carabiner. Never use wire, cord, string or anything narrow, as these cut into the skin and do not control deep bleeding. Tighten the windlass until the bleeding stops, then secure it firmly in place. Be aware that an improvised tourniquet is less reliable and needs frequent checking for slippage.
WOUND PACKING AND HAEMOSTATIC DRESSINGS
For deep wounds in areas where a tourniquet cannot be used — such as the groin, armpit or neck — simple pressure on the surface may not reach the bleeding vessel. In these cases, pack the wound cavity firmly with gauze, a trauma dressing or a haemostatic dressing. Push the material deep into the wound until it fills the space, then maintain firm direct pressure over the packed wound for at least three minutes before applying a pressure bandage.
Haemostatic dressings are impregnated with substances that accelerate the body’s own clotting process. They are particularly useful for severe bleeding that does not respond to ordinary gauze. Press the haemostatic dressing directly onto the source of bleeding and hold it there. Do not move it around once it is in place, as this can disrupt the forming clot.
Do not pack the chest or abdominal cavities after a penetrating injury, because you cannot see where the bleeding is coming from and packing may cause more harm. In these areas, apply gentle direct pressure with a flat dressing and leave the wound open if there is a sucking chest wound. Keep the casualty still, warm and monitored until advanced help arrives.
Casualties can also bleed internally, into their chest, abdomen, pelvis and thighs. Signs can include skin bruising or deformity, but sometimes it is only the mechanism of injury that will give you a clue. It is difficult to treat bleeding into the chest and abdomen in the field without special skills, however you can treat pelvic bleeding by binding the pelvis and bleeding into the thighs by splinting broken femurs. Keeping the casualty warm, reassured and minimising movement will help in almost all instances though.