Control Bleeding

 

INTRODUCTION

You will review methods of controlling bleeding.  Your ability to successfully to control bleeding under extreme circumstances will result in savings lives. Basic lifesaving steps for the soldier medic include clearing the airway/restoring breathing, stopping the bleeding, protecting the wound, and treating/preventing shock. These are the ABC measures that apply to all injuries. Certain types of wounds and burns will require special precautions and procedures when applying these measures. This block of instruction provides specific information on controlling bleeding.  When properly applied these techniques will save soldiers lives.

Review the structure and function of the circulatory system

Heart

Four chambers

Right atrium

(i)         Receives blood and upon contraction sends it to the right ventricle

(ii)        Superior vena cava and inferior vena cava are two large veins that return blood to the heart

(b)        Right ventricle

(i)         Receives blood from right atrium

(ii)        Pumps blood out to the lungs via the pulmonary arteries

(c)        Left atrium

(i)         Receives oxygen-rich blood from the lungs

(ii)        Contracts, sending blood to the left ventricle

(d)        Left ventricle

(i)         Pumps blood into aorta for distribution to entire body

(ii)        Most muscular and strongest part of the heart

 

Arteries

(1)        Carries blood away from the heart

(2)        Important arteries

(a)        Coronary - supply heart muscle

(b)        Aorta - Largest artery in the body, traveling along the spine

(c)        Pulmonary artery - carries oxygen-poor blood to the lungs

(d)        Carotid - major artery in the neck

(e)        Femoral artery - major artery in the thigh

(f)         Brachial artery - in upper arm

(g)        Radial artery - supplies lower arm

(h)        Posterior tibial artery - posterior aspect of the medical malleolus

(i)         Dorsalis pedis artery - top ot the foot

 

Arterioles, capillaries and venules

(1)        Arteriole is the smallest branch of an artery

(2)        Capillaries

(a)        Tiny blood vessels found throughout the body

(b)        Where gases, nutrients, and waste products are exchanged

(3)        Venule is the smallest branch of a vein

 

Veins

(1)        Carries blood from capillaries back to the heart

(2)        Important veins:

(a)        Venae Cavae - return blood to right atrium

(b)        Pulmonary vein - carries oxygenated blood from lungs to left atrium of the heart

 

Composition of blood

(1)        Plasma

(a)        Watery, salty fluid that makes up over half the volume of blood

(b)        Carries red and white blood cells and platelets

(2)        Red blood cells

(a)        Primary function is to carry oxygen to tissues and carbon dioxide away from tissues

(b)        Provide red color to blood

(3)        White blood cells

(a)        Involved in destroying microorganisms

(b)        Produce antibodies that help the body resist infection

(4)        Platelets

(a)        Membrane-enclosed fragments of specialized cells

(b)        Release chemical factors needed to form blood clots

 

Pulse

(1)        Formed when left ventricle contracts, sending a wave of blood through the arteries

(2)        Peripheral pulse

(a)        Radial

(b)        Brachial

(c)        Posterior tibial

(d)        Dorsalis pedis

(3)        Central pulses

(a)        Carotid

(b)        Femoral


 

Blood pressure

(1)        Force blood exerts against the walls of blood vessels

(2)        Systolic

(a)        Pressure created in the arteries by blood

(b)        Reported first

(c)        Average: 120

(3)        Diastolic

(a)        pressure remaining the arteries when left ventricle of heart is relaxed and refilling

(b)        Reported second

(c)        Average: 80

 

Review terminology for blood and bleeding

Bleeding -

(hemorrhage) is the escape of blood from capillaries, veins, and arteries. 

 

The adult body:

(1)        Contains approximately 5 to 6 (1000 ml) of blood (10 to 12 pints)

(2)        Can normally lose 1 pint of blood (usual amount given by donors) without harmful effects

(3)        Loss of 2 pints may cause shock

(4)        Loss of 5 to 6 pints usually results in death

 

Types of bleeding

(1)        Internal

(a)        Not always obvious

(b)        Suspicion should be based on mechanism of injury

(i)         Falls

(ii)        Blast injuries

(iii)       Penetrating trauma

(2)        External

 

Pressure points

(1)        Brachial arteries - for bleeding from upper extremities

(2)        Femoral arteries - for bleeding from lower extremities

(3)        Should only be used after direct pressure and elevation have failed.

(4)        To properly use, you need to know exactly where the points are located and how much pressure to apply


 

Identify external bleeding

Body substance isolation must be routinely taken to avoid skin and mucous membrane exposure to body fluids

 

(1)        In a tactical situation, your only line of defense may be gloves.

(2)        Additional BSI equipment could include:

(a)        Eye protection

(b)        Masks

(c)        Hand washing following each run

 

Severity

(1)        Dependent upon amount of blood lost in relation to physical size of casualty

(2)        Sudden loss of 1 liter (1000 cc) of blood is considered serious

(3)        May also depend on casualty's condition - look for signs and symptoms of shock

 

 

Types of bleeding

(1)        Arterial

(a)        Often rapid, profuse and pulsating

(b)        Usually bright red in color because it is rich in oxygen

(2)        Venous

(a)        Steady flow

(b)        Usually dark red or maroon in color

(3)        Capillary

(a)        Slow and oozing

(b)        Often clots spontaneously

 

Provide emergency medical care

 

Direct Pressure: 

 

Quickest method to control bleeding. Bleeding is controlled by applying pressure directly to the wound

(a)        Place a sterile dressing on the wound

(b)        Tie a knot with the sterile dressing or adhere tape directly over the wound

(c)        Only tight enough to control bleeding

(i)         If bleeding is not controlled, apply another dressing over the first or apply direct pressure with your hand or fingers over the wound

(ii)        Direct pressure can be applied by the casualty or a bystander

 

Elevation to control bleeding

(a)        Raising (elevation) of an injured arm or leg extremity, above the level of the heart

(b)        Elevation should be used together with direct pressure

(c)        Do not elevate an extremity if you suspect a broken bone (fracture) until it has been properly splinted and you are certain that elevation will not cause further injury

(d)        Use a stable object to maintain elevation, such as a ruck sack. Placing an extremity on an unstable object may cause further injury

 

Pressure Points:

 

Used In cases of severe bleeding when direct pressure and elevation are not controlling the bleeding

 

(a)        Bleeding from an artery can be controlled by applying pressure to the appropriate pressure point

(b)        Pressure point

(i)         Areas of the body where the blood flow can be controlled by pressing the artery against an underlying bone

(ii)        Pressure is applied with the fingers, thumb, or heel of the hand.

(c)        Pressure points most often used

(i)         Arm (brachial)

*           Used to control severe bleeding of the lower part of the upper arm and elbow

*           Located above the elbow on the inside of the arm in the groove between the muscles

*           Using your fingers or thumb, apply pressure to the inside of the arm over the bone

(ii)        Groin (femoral)

*           Used to control severe bleeding of the thigh and lower leg

*           Located on the front, center part of the crease in the groin

(d)        Application of pressure points

(i)         Position the casualty on his or her back, kneel on the opposite side from the wounded leg, place the heel of your hand directly on the pressure point, and lean forward to apply pressure

(ii)        If the bleeding is not controlled, it may be necessary to press directly over the artery with the flat surface of the fingertips and to apply additional pressure on the fingertips with the heel of your other hand

 

Splints

(a)        Immobilization is one of the best ways to stop bleeding

(c)        Broken bone fragments may continue to grate on blood vessels and increase bleeding if they are not immobilized

(d)        Muscular activity can also increase the rate of blood flow

(e)        Air splints may be used to apply direct pressure over an extremity

(f)         Splinting using an air splint gives a double benefit splinting and direct pressure

 


 

Tourniquet

(a)        Used only as a last resort to control severe bleeding after all other methods have failed and is used only on the extremities

(b)        Before use, you must thoroughly understand its dangers and limitations. Tourniquets cause tissue damage and loss of extremities when used by untrained individuals. Tourniquets are rarely required and should only be used when an arm or leg has been partially or completely severed and when bleeding is uncontrollable.

(c)        The standard tourniquet

(i)         Normally a piece of cloth folded until it is 3 or more inches wide

(ii)        6 or 7 layers thick

(iii)       Can be a strap, belt, neckerchief, towel, or other similar item.

(iv)       Folded triangular bandage makes a great tourniquet

(v)        Never use wire, cord, or any material that will cut the skin.

(d)        Apply a tourniquet

(i)         While maintaining the proper pressure point, place the tourniquet between the heart and the wound, leaving at least 2 inches of uninjured skin between the tourniquet and wound

(ii)        Place a pad (roll) over the artery to be compressed

(iii)       Wrap the tourniquet around the extremity twice, and tie a half-knot on the upper surface

(iv)       Place a short stick or similar object on the half-knot, and tie a square knot

(v)        Twist the stick to tighten, UNTIL BLEEDING STOPS AND NO FURTHER

(vi)       Secure the stick in place

(vii)      Never cover a tourniquet

(viii)      Using a marker, make a 'T" on the casualty's forehead and the time and date tourniquet was applied

(ix)       Never loosen or remove a tourniquet once it has been applied. The loosening of a tourniquet may dislodge clots and result in enough blood loss to cause shock and death

 

Dress the stump (in case of amputation)

(a)        Apply dressing to cover the end of the stump

(b)        Often, blood vessels collapse or retract

(c)        Control bleeding by direct pressure, pressure dressing and/or tourniquet (as required or necessary)

(d)        When possible, wrap the amputated part in a sterile dressing

(e)        Preservation of Amputated Parts

(i)         Rinse the amputated part free of debris with cool, sterile saline

(ii)        Wrap the part loosely in saline-moistened sterile gauze

(iii)       Seal the amputated part inside a plastic bag, and place it in a cool container.  Keep cool, but do not allow it to freeze

(iv)       Never warm an amputated part

(v)        Never place an amputated part in water

(vi)       Never place an amputated part directly on ice

(vii)      Never use dry ice to cool an amputated part

 

 

 

Continually reassess the casualty to include all vital signs

 

Identify internal bleeding

 

Severity

(1)        Internal bleeding can result in severe blood loss with resultant shock (hypoperfusion) and subsequent death

(2)        Injured or damaged internal organs commonly lead to extensive bleeding that is concealed

(3)        Traumatized painful, swollen, and deformed extremities, or long bone fractures may also lead to serious internal blood loss

(4)        Suspicion and severity of internal bleeding should be based on mechanism of injury

(5)        Although not usually visible, can result in serious blood loss. A casualty with internal bleeding can develop shock before you realize the extent of their injuries.

 

Mechanism of injury

(1)        Falls

(2)        Blast injures

(3)        Penetrating trauma

(a)        Gunshot wounds

(b)        Stab wounds

(c)        Impaled objects

 

Signs and symptoms - assessment findings of internal bleeding

(1)        Bruise indicates bleeding into the skin (soft tissues)

(2)        Severe internal bleeding occurs in injuries caused by a violent force (blunt injury), puncture wounds (knife), and broken bones

(3)        Signs of internal bleeding include:  (Steps 1 6 are the same as shock so there should be a strong suspicion of shock)

(i)         Anxiety and restlessness

(ii)        Excessive thirst (polydipsia)

(iii)       Nausea and vomiting

(iv)       Cool, moist, and pale skin (cold and clammy caused by lack of circulation to skin)

(v)        Rapid breathing (tachypnea)

(vi)       Rapid, weak pulse (tachycardia)

(vii)      Bruising or discoloration at site of injury (contusion)

(viii)      Tenderness or rigidity of abdomen

(4)        Severe internal bleeding

(i)         Notify MD/PA

(ii)        Rapid Transport

(iii)       Monitor airway, breathing, and circulation (ABCs)

(iv)       Treat for shock

(v)        Administer oxygen, if available

(vi)       Place casualty in most comfortable position

(vii)      Maintain normal body temperature

(5)        Nosebleed (epistaxis) can be caused by an injury, disease, the environment, high blood pressure, and changes in altitude

(i)         Nosebleeds frighten the casualty and may bleed enough to cause shock

(ii)        Cover the nose with a loose, dry, sterile dressing and notify the MD/PA

(iii)       Keep the casualty quiet, sitting with head tilted forward

(iv)       Put pressure on the upper lip just below the nose

(v)        Inform the casualty not to rub, blow, or pick their nose

(vi)       Seek MD/PA assistance if the nosebleed continues, bleeding starts again, or bleeding is because of high blood pressure

(vii)      If the casualty loses consciousness, place them on their side to allow blood to drain from the nose and call the MD/PA

 

Provide emergency medical care

(1)        Casualties with severe external bleeding and suspected internal bleeding must be seen by MD/PA as soon as possible and evacuated

(2)        All casualties with external and internal bleeding should be treated for shock. Includes IV fluids to maintain peripheral perfusion.

(3)        Maintain airway - provide artificial ventilation

(4)        Continue reassessments, pulse oximetry, if available

 

Review of dressings and bandages

 

Dressing

Any materials applied to a wound in an effort to control bleeding and prevent further contamination.

Dressings should be sterile.

 

Bandage

Any material used to hold a dressing/or splint in place.

Bandages should be clean but may not be sterile.

 

Three basic rules to dressing application:

(1)        Use sterile materials

(2)        Cover the entire wound

(3)        Control bleeding

 

Four basic rules to bandaging:

(1)        Do not bandage too tightly

(2)        Do not bandage too loosely

(3)        Do not leave loose ends

(4)        Do not cover tips of fingers, mouth, nose and toes


 

Types of dressings and bandages

(1)        Dressings:

(a)        Gauze pads (4x4's etc...)

(b)        Roller gauze (various sizes)

(2)        Bandages:

(a)        Roller gauze

(b)        Elastic Roller gauze (ice wraps)

(c)        Triangular (cravats)

(3)        Combo dressings/bandages:

(a)        Field dressing/Abdominal dressing

(b)        Adhesive bandages (band-aids = various sizes)

 

SUMMARY

As a medic the knowledge of how to control bleeding through the use of direct or indirect pressure, elevation, or the judicious use of a tourniquet can save soldiers lives.  The knowledge gained throughout this lesson will be used in conjunction with dressing and bandaging skills presented in the appropriate lesson.