Controlling external bleeding
• External bleeding from the extremity, and
particularly bleeding from the junctional
segment of the extremity vasculature (ie,
axillary artery, common femoral artery), is
life-threatening and should be controlled as
soon as possible.
• Bleeding from extremity vascular injury can
usually be controlled using direct pressure.
However, because prolonged application of
direct pressure, particularly bleeding from
junctional vessels, is not practical during
transport in the prehospital or tactical
environment, other approaches have been used
including topical agents, external compression
clamps, and endovascular occlusion devices.
• Bleeding can also be controlled using a tourniquet,
or direct clamping of visible vessels. Clamping
vessels that cannot be clearly identified should not
be performed. Pneumatic tourniquets are
commonly used to lessen bleeding during the
course of upper and lower extremity surgery.
Although there is renewed interest in the civilian
community in the use of tourniquets for control of
extremity hemorrhage, civilian institutions have
not uniformly endorsed their use.
Hemorrhage control
• — Basic measures for controlling hemorrhage consist of direct
pressure to the wound followed by pressure dressings, with
elevation and pressure points used as adjuncts. When penetrating
trauma occurs to certain anatomic areas, hemorrhage control may
be difficult with pressure dressings alone. As an example, gross
hemorrhage may not be apparent with gunshot wounds to the
thigh. In such circumstances, direct manual pressure must be
applied throughout the prehospital phase of care to ensure that
occult, internal bleeding is controlled as well as possible. In
uncommon instances (eg, injury from an explosion), application
of a tourniquet may be necessary to control life-threatening
bleeding from a severe extremity wound.
Definition: Defusing or oozing of blood from
blood vessels (Hemorrhage)
Types of bleeding
Arterial bleeding- bright red in color, flow from
the wound inside Blood loss
Venous bleeding – dark red in color, flow is steady
Capillary bleeding –oozing from bed of
capillaries, red in color, usually less bright than
arterial blood with slow flow.
Methods of controlling bleeding externally
• Direct pressure-
• using compresses - Pressure bandage
can be placed to hold pads of cloth.
• - Put a thick pad of cloth held between the
hand and wound.
EXTERNAL BLEEDING CONTROL
Direct pressure for external
bleeding
o A wound that is deep and bleeding
heavily may not stop bleeding on its
own. Applying direct pressure with a
clean dressing such as gauze can help
to slow or stop the bleeding.
Direct pressure for external bleeding…
o Put on gloves.
o Use gauze or another clean non-adherent dressing.
o Do not use bulky dressings as they can make it difficult to put
enough pressure in the right place.
o Apply firm pressure as directly as possible to the source of
bleeding, usually with two or three fingers.
o If the wound is on a limb, elevate the limb above the heart.
o If the first dressing becomes soaked with blood, do not remove
as this will dislodge any clots that have formed. Instead add
another pad and apply firm pressure.
o When bleeding stops, apply a bandage to keep the gauze/pad
in place.
o If bleeding does not stop, consider deep wound packing or
tourniquet.
Direct pressure for external bleeding…
Deep wound packing for external
bleeding
If the wound is deep or gaping and
simple pressure does not stop the
bleeding, deep wound packing may
help. However, deep wound packing
is a temporary procedure to stop the
bleeding since it can lead to infection
if left for more than 24 hours.
Deep wound packing for external
bleeding
o Put on gloves.
o Always assess pulses, capillary refill and sensation before
and after dressing or splinting any wound.
o Thoroughly wash out the wound by flushing with at least a
litre of clean water (under pressure when possible; see next
section).
o Use gauze or another clean, compact material to
completely fill the space within the wound.
o Use additional gauze on top of the wound surface and apply
direct pressure with your gloved hand or a bandage
wrapped firmly around the wound/limb.
o For limb wounds requiring packing, apply a splint to reduce
the risk of re-bleeding.
o A deep wound pack should not be left in place for more
than 24 hours because of the risk of infection.
o If bleeding does not stop, consider tourniquet (see next
section).
Tourniquet technique for uncontrolled
external bleeding
o You will not be expected to perform the tourniquet
technique BUT you will be expected to know what
life-threatening conditions it can be used for, the
special considerations around use of a tourniquet
and the ongoing care of the patient.
o Use this technique ONLY if all other bleeding control
measures have failed AND haemorrhage is life-
threatening. If you place a tourniquet, there is a
possibility that tissues below the tourniquet will be
permanently damaged and even require
amputation. If you are considering using a
tourniquet, CALL FOR HELP IMMEDIATELY and plan
for handover/transfer to a unit where surgery is
possible.
Tourniquet technique for uncontrolled
external bleeding
o If available, use a pneumatic tourniquet (like a blood pressure
cuff) over padded skin and inflate until bleeding stops. If not,
use a thick band or piece of cloth or belt (the wider, the better),
over padded skin.
o Apply as close to wound as possible, but do not place over a
wound or a fracture.
o Apply enough pressure to make distal pulses disappear and re-
assess bleeding.
o If bleeding stops, leave dressing in place if already present or
dress the wound and prepare for handover/transfer to a surgical
care unit.
o If the bleeding does not stop, increase tourniquet pressure until
major bleeding ceases.
o Record the exact time the tourniquet was applied in the notes
AND write it on the patient’s skin or the tourniquet itself.
Tourniquet technique for uncontrolled
external bleeding…
o Consult advanced provider as soon as possible (and never more
than 2 hours) after placing a tourniquet.
o The tourniquet should be released every 2 hours for at least 10
minutes. Hold direct pressure to the bleeding area during this
time. Do not re-apply the tourniquet unless evidence of continued
active bleeding.
o Location of the tourniquet: tourniquets should only be placed on
extremities and should be placed above the level of the bleeding.
Because of the relationship between the bones and blood vessels,
tourniquets on the upper arm or leg are often more effective than
tourniquets placed below the elbow or knee.
o Make sure the tourniquet is clearly visible.
o Remember tourniquet should be placed as a last resort. If you
place a tourniquet, you are cutting off blood supply to the limb, so
only do this for life-threatening bleeding. When tourniquet use is
absolutely necessary, use a wide, yet constrictive, band.
Bleeding control (SOP)
1. Assess for :
The surrounding for farther risk of injury
General appearance of the victim
"ABC".
A - airway
B - Breathing
C - circulation
Level of Orientation
2. Wash your hands and prepare all the necessary
materials.
3. Direct pressure
Is the application of pressure on the wound and
around the wound.
Wear your surgical gloves
First assess the site for any foreign body embedded.
Prepare a pad of gauzes and put over the bleeding
sit.
Apply a steady and firm pressure over the bleeding sit
with your palm of hand
After certain (usually 5min) slightly release
and observer for condition of bleeding.
If the gauze pad fully stocked and bleeding
continues, add another piece of gauze over the
previous one. Then apply sufficient pressure over
the new pad applied on the bleeding site.
if the bleeding is getting minimized, then apply a
rolled pressure bandage over the gauze pad
If the is not sufficient enough to stop the
bleeding, then it can be supported with
elevation.
4.Elevation
Unless there is evidence of a fracture a
severely bleeding open wound of the hand and
legs should be elevated. i.e the injured part of
the body should be raised above the level of
the victim's heart.
Elevation uses the force of gravity to help
reduce bleed pressure in the injured area and
thus aids in slowing down the loss of blood
through the wound.
5. Indirect Pressure (Use of Tourniquet)
If the bleeding can't be controlled by applying
a direct pressure and elevation.
Usually used to arrest arterial bleeding. So
should be used only for sever, life threatening
bleeding that can't be controlled by other
means.
Steps
1. Place the Tourniquet just above the
wound. Do not allow it to touch the wound
edges.
2. Wrap the Tourniquet band tightly around
the limb twice and tie a half knot
3. Place a short, strong stick or similar
object that will not break on the over head
of the knot and then tie two additional knots
on the top of the stick
4. Twist the stick in place with the loose
ends of the Tourniquet
5. secure the stick in place with the loose
ends of the Tourniquet with a strip of cloths
• Note:
A Tourniquet should applied above and close to the
wound
Don't use rope, wire, string which may cut in the
flash body.
Never cover a Tourniquet
Make a written note of the location of the
Tourniquet, the time it was applied and attach the
note to the victim's cloth
check vital sign of the Victim
Should be referred to nearest health center or
hospital immediately.
