UNCLASSIFIED

MASSIVE BLEEDING
MANAGEMENT
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TERMINAL LEARNING OBJECTIVE

ASSIVE BLEEDING STOPPED

Hemorrhage is a life threatening condition that requires

IMMEDIATE ATTENTION
Hemorrhage control is THE FIRST STEP
THE SURVEY CANNOT PROCEED unless hemorrhage is
controlled
PERFUSION will not improve in the face of ongoing
hemorrhage (no matter how much oxygen or fluid the
casualty receives)
TAKE WHATEVER ACTION IS NEEDED TO STOP MASSIVE BLEEDING!
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ENABLING LEARNING OBJECTIVES

The importance of hemorrhage control in preventable
combat deaths
Anatomy and physiology: blood, vessels and blood
circulation

Blood loss estimation classes of hemorrhage

HEMORRHAGE CONTROL METHODS

DIRECT PRESSURE
ELEVATION
PRESSURE POINTS
TOURNIQUETS
COMBAT READY CLAMP (CRoC)
PRESSURE DRESSING
PACKING DRESSING
HAEMOSTATS
TRANEXAMIC ACID

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REFERENCES
Pre Hospital Trauma Life Support (PHTLS)
Military 7th ed. 2011 ISBN 978-0-323-06503-0
Chapter 6, pp. 114-115
Chapter 17, p. 426
Chapter 25, pp. 602-604
Chapter 26, pp. 618-619
Tactical Combat Casualty Care guidelines
Special Operations Forces Medical Handbook
US Special Operations Command 2nd ed. 2010 ISBN 978-0-16-084744-8

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COMBAT DEATHS

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KIA: 31% penetrating head trauma

KIA: 25% surgically uncorrectable torso trauma
KIA:

7% mutilating blast trauma

KIA: 10% potentially surgically correctable trauma

KIA:

9% hemorrhage from extremity wounds

KIA:

5% tension pneumothorax

KIA:

1% airway problems

DOW: 12% mostly from infections & shock complications

SHOCK COMPLICATIONS WILL BE REDUCED IF THE BLEEDING HAS BEEN STOPPED AND/OR THE
CIRCULATION HAS BEEN SUSTAINED
BEFORE THE CASUALTY HAS GONE INTO SHOCK

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PREVENTABLE DEATHS STILL OCCUR

ON THE BATTLEFIELD BECAUSE OF
UNCONTROLLED HEMORRHAGE

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SEVERE BLEEDING IS THE SINGLE

GREATEST PREVENTABLE COMBAT DEATH
HEMORRHAGE
Compressible

79 %

91%

Extremities 24.5%

13.5%

Junctional

16.6%

19.2%

37.9%

67.3%

AIRWAY

7%

7.9%

TENSION PNEUMOTHORAX

7%

1.1%

_____

_____

100 %

100 %

NON-compressible (Truncal)

HEAD INJURY

7%

PREVENTABLE COMBAT DEATHS

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HEMORRHAGE DEFINITION
Bleeding is the loss of blood, hemorrhage or
haemorrhage is THE MEDICAL TERM FOR BLEEDING

Although technically hemorrhage means escape of

blood to extra-vascular space, in common usage it
means particularly SEVERE BLEEDING

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BLOOD LOSS ESTIMATION

SEVERE = when you can actually see blood
flowing out of the wound
INDICATORS = vital signs
heart rate
respiratory rate
blood pressure
capillary refill time (CRT) indicator of perfusion
WRONG ESTIMATION on clothing / ground
non-porous / appears like a lot
porous
/ soaked & seeping
internal
/ hidden
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CLASSES OF HEMORRHAGE (ATLS)

CLASS I: < 15% of blood volume
no change in vital signs
can be endured in healthy people without any
clinical consequences = fluid resuscitation is not
usually necessary

CLASS II: 15-30% of blood volume

tachycardia, pale and cool skin
IF NO RADIAL PULSE PRESENT then fluid
resuscitation is required: 500(+500)ml colloids

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CLASSES OF HEMORRHAGE (ATLS)

CLASS III: 30-40% of blood volume
heart rate, blood pressure, peripheral
perfusion and mental status worsen
fluid resuscitation with BLOOD TRANSFUSION
is usually necessary

CLASS IV: >40% of blood volume

all vital signs worsen
AGGRESSIVE RESUSCITATION IS REQUIRED

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HEMORRHAGE COMPENSATION
EARLY MECHANISMS
TO COMPENSATE BLOOD LOSS, THE BODY REACTS:
HEART FREQUENCY
VASOCONSTRICTION of peripheral blood vessels
FLUID SHIFT: fluid is flowing from the extra-vascular
space into the intra-vascular space
FLUID RETENTION (e.g. kidneys, digestive system)

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COAGULATION (CLOTTING)
ESSENTIALS
MAJOR MECHANISM TO STOP & PREVENT BLOOD LOSS
ACTIVATED PLATELETS
collect on the bleeding site
a first soft and jelly-like
UNSTABLE RED CLOT
FIBRIN binds the platelets together trapping the red
cells inside (some serum can still go trough the clot)
a firm and SOLID WHITE CLOT acts as a plug

Hypothermia affects the clotting process!

Handle with care to preserve the first red clot!
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COAGULATION
BY FAR MORE COMPLEX
BUT
YOU DONT NEED TO LEARN THIS

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TWO SYSTEMS IN COMPETITION

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COAGULATION SIMPLIFIED
TISSUE FACTOR
(released by damaged tissues/vessels) leads to
THE TRANSFORMATION FROM FIBRINOGEN TO FIBRIN
THIS SYSTEM STARTS FIRST AND AIMS TO THE
DEVELOPMENT OF THE WHITE CLOT
IT WINS AGAINST HIS COMPETITOR
(THE PLASMINOGEN - PLASMIN SYSTEM)
UNLESS THE RED CLOT IS NOT PRESERVED
(e.g. DIRECT PRESSURE RELEASED TOO SOON,
AGGRESSIVE FLUID RESUSCITATION,
IMPROPER HANDLING, etc.)
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TRANEXAMIC ACID
IMPROVES THE CLOT
BY SLOWING DOWN THE CLOT BREAKDOWN
Deaths due to all causes decreased by 9%
Deaths due to bleeding decreased by 15%
The TXA administration I.V. has been included in the
TCCC Guidelines since Apr 2011
Recommended for any trauma patient requiring blood

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TRAUMATIC BLEEDING
EXTERNAL
e.g. penetrating: knife, GSW, shrapnel, etc.
vessels may be cauterised by hot fragments or projectiles

INTERNAL
e.g. blunt trauma: blast, assault with a club, fall, MVA, etc.

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Intervention-Based Classification
THE BEST YOU CAN DO
External hemorrhage
Limbs
Tourniquets (TQ)
Junctional
CRoC, JETT
Non compressible
Packing (Haemostatic gauzes)
Skull, abdomen, chest, etc.

Internal hemorrhage
Clot preservation
If radial pulse palpable
reduce IV fluids
If available & hemorrhage class > II Blood &TXA
Additional care
Handle with care
Ongoing research (intraperitoneal foam)
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External hemorrhage is a mix of

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types of HEMORRHAGES
ARTERIAL, VENOUS OR CAPILLARY BLEEDING
are different because of:

PRESSURE

VESSELS ANATOMICAL STRUCTURE

BLOOD COLOUR (% OF OXYGENATION)

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ARTERIAL bleeding
ARTERIAL BLEEDING IS LIFE-THREATENING
AND DIFFICULT TO CONTROL
Arteries are blood vessels that carry a HIGH PRESSURE
blood away from the heart
Arteries have a THICKER & MUSCULAR WALL to stand
the pressure. Because of their tension and elasticity
they contract and retract when cut suddenly
Arterial bleeding is BRIGHT RED
The BLOOD "SPURTS" from the wound

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ARTERIAL bleeding

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VENOUS bleeding
VENOUS BLEEDING IS NOT LIFE-THREATENING
UNLESS SEVERE OR NOT CONTROLLED
Veins are blood vessels that carry a LOW PRESSURE
blood to the heart
Veins have THIN WALLS and also because of the low
internal pressure they tend to collapse when cut
Venous bleeding is DARK RED OR MAROON
The BLOOD FLOWS IN A STEADY STREAM

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CAPILLARY bleeding
Capillaries are very small blood vessels that carry a
LOW PRESSURE blood to/away from all tissues of
the body
Capillaries have THINNER WALLS (one layer)
Capillary bleeding is a MIX OF DARK AND BRIGHT
RED BLOOD
BLOOD OOZES because of the slow flow (e.g.
abrasions & scraps)

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External Hemorrhage
SIGNS & SYMPTOMS
BLOOD EXITING AN OPEN WOUND = HEMORRHAGE
SHOCK = HYPOVOLEMIC SHOCK
pale & clammy skin
dizziness / weakness
level of consciousness
heart rate = tachycardia
blood pressure (weak/absent radial) = hypotension
respiratory frequency = tachypnea
capillary refill time (CRT)
urine output
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External Hemorrhage CONTROL

SAFE APPROACH
ELEVATE THE EXTREMITY (LIMBS)
DIRECT MANUAL PRESSURE
PRESSURE POINTS
TOURNIQUET
COMBAT READY CLAMP (CRoC)
PRESSURE DRESSING
PACKING DRESSING
HEMOSTATS
TXA
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SAFE APPROACH
Be determined in achieving your
goals
but understand the situation first !!!

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ELEVATION
Its effect is often UNDERESTIMATED

Raise the wound (limb) ABOVE HEART LEVEL

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DIRECT PRESSURE

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DIRECT PRESSURE
THE FIRST AND MOST IMPORTANT RESPONSE
IN ANY SETTING, FOR ALL HEMORRHAGES
Pressure applied ON THE WOUND & AROUND IT can
control most of external bleedings by compressing the
artery against the underlying structures (muscle & bone)

Maintain pressure for AT LEAST 5 MINUTES before

checking the effectiveness of clotting

USE ANYTHING that will assist you in applying direct

pressure (gauze, cloth, damp cloth, whatever the wound is not
sterile, a sterile bandage does not make it sterile )
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DIRECT PRESSURE
IF YOU SEE IT BLEED,
YOU CAN STOP IT WITH DIRECT PRESSURE
DO NOT LET THEM BLEED TO DEATH
while assessing the situation,
deciding on a course of action,
looking for any tourniquet
or haemostatic agent

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PRESSURE POINTS
APPLY PRESSURE
your team-mates or your FIST OR KNEE
over the casualtys ARMPIT / GROIN
IOT OCCLUDE THE ARTERY (brachial or femoral)
BUY TIME by slowing down the hemorrhage from
the extremity
Groin pressure should be regarded as the first procedure to control
bleeding from a high leg amputation, whilst a tourniquet is attempted and/or
other treatments (Hemostatic gauze to pack the wound; field dressings) are
used to stop bleeding.
UK Good practice guide Sep 2010

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PRESSURE POINTS

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PALM vs FINGER TIP pressure

DIFFUSE PRESSURE is the key (e.g. EMT/hospital TQ)
more effective due to the surface area covered
allows for greater pressure to be applied
able to be maintained over long periods
less damage to tissues
FINGER TIP PRESSURE does not ensure full contact
with wound (no artery hunting with finger tips)
GAUZES / haemostatic gauzes must be in full contact
with the wound / bleeding site to be effective
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Oh, nooo more tourniquets!

BECAUSE TOURNIQUETS SAVE LIVES
Ibn Sina Hospita, Bagdad, 2006
31 lives saved in 6 months period by the use
of pre-hospital tourniquets, author estimates
2000 LIVES SAVED IN OIF

Kragh, et al, Annals of Surgery, 2009

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Oh, nooo more tourniquets!

PREVENTABLE COMBAT DEATHS FROM
NOT USING TOURNIQUETS STILL OCCUR
Moughon Military Medicine, 1970: Vietnam
193 of 2,600
7.4% of total
Kelly Journal of Trauma, 2008: OIF + OEF
72 of 982
7.8% of total
Eastridge Journal of Trauma, 2012: OIF + OEF
119 of 4,956
2.6% of total
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Tourniquets PRINCIPLES
A CONSTRICTING BAND
single use
non-elastic
at least 5cm wide
ABLE TO STOP THE ARTERIAL FLOW
ONLY USED ON AN ARM, FOREARM, THIGH OR LEG
NEVER OVER A JOINT, A FRACTURE OR POCKETS
CONTAINING BULKY OBJECTS

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Tourniquets CONSIDERATIONS
Not all types available have the same EFFECTIVENESS
PATIENT MUST GET PAIN MEDICATION Tourniquets
are painful when applied but the worse pain comes
when ischemia sets in approx 20 min after application
They have LIMITATIONS TO LOCATION

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Criteria for tourniquet

EFFECTIVENESS
Must STOP ARTERIAL BLOOD FLOW in the extremity
More effective in saving lives when applied BEFORE
THE CASUALTY HAS GONE INTO SHOCK from blood
loss
IN THE CARE UNDER FIRE PHASE must be applied
first, OVER THE CASUALTYS UNIFORM, since there is
no time for exposing the wound and for other methods
(they could not be adequate to control the bleeding)

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Tourniquets TRAINING
Pick a good one!
Carry it with you all the time and more than one,
if it is permitted
Learn how to apply it properly as quick and as
proximal as possible
Train, buddy aid, self aid, in the darkness
frequently!
Use the tourniquet from the casualty
Eventually convert to pressure bandage
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Tourniquets MYTH
DAMAGE TO THE LIMB is rare if the tourniquet is left
on less than two hours. Anyway in the face of massive
extremity hemorrhage it is better to accept a small risk
of damage to the limb than to have a casualty bleed to
death (approximately 3% transient nerve paralysis and
no amputation due to tourniquet use were reported)
place it 2-3 INCHES ABOVE THE BLEEDING
A BELT ALONE IS EFFECTIVE
NEVER LOOSEN IT

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Tourniquets MISTAKES
NOT USING ONE WHEN YOU SHOULD
NOT TIGHTENING IT ENOUGH TO STOP THE
ARTERIAL FLOW
NOT APPLYING A SECOND ONE SIDE-BY-SIDE IF
THE FIRST IS NOT COMPLETELY EFFECTIVE (BIG
THIGHS OFTEN REQUIRE TWO TQ)
PUTTING IT ON TOO LOW ON THE EXTREMITY
PUTTING IT TOO CLOSE TO A JOINT
USING ONE WHEN YOU SHOULD NOT
NOT TAKING IT OFF WHEN YOU COULD
NOT USING THE CASUALTYS TQ FIRST
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TWO TOURNIQUETS

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TIME OF APPLICATION
Some TQ have a TAG where to write down the time
Write a T (for Tourniquet) on the casualtys FOREHEAD
with an indelible ink marker and the time of application

10:45

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CONVERTING the tourniquet

IN THE TACTICAL FIELD CARE PHASE, once you have time to
properly evaluate and treat the casualty
EXPOSE and re-evaluated the wound
APPLY a trauma bandage or a pressure dressing
after applying a pressure bandage, LOOSEN THE TQ BUT
LEFT IN PLACE
CHECK THE BANDAGE FOR BLEEDING and if any make the
tourniquet tight again
In case of delayed evacuation, to convert the TQ will make it
more likely that the limb can be saved
Never loosen a TQ in case of amputations or if the casualty will
arrive at a hospital in 2 hours or less after application

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Combat Application Tourniquet

(CAT)

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Combat Application Tourniquet

(CAT)
THE MOST COMMONLY USED AND KNOWN
Red tip = where to start unpacking it
Windlass strap may be white (time of application can
be written on it)
Windlass rod made of hard plastic = could break
NOT COMPLETELY RELIABLE WHEN WET OR DIRTY
Velcro could make the application difficult
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Special Operations Forces

Tactical Tourniquet (SOFTT)

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49

Special Operations Forces

Tactical Tourniquet (SOFTT)

UNCLASSIFIED

IT IS EFFECTIVE ON LARGER THIGHS

IT HAS A SECONDARY SECURITY (screw)
Same basic components
It has a tag where to write time of application

LESS SURFACE PRESSURE = MORE TISSUE DAMAGE

Windlass strap is thinner than the CAT one
HARDER TO SECURE THE ROD THROUGH THE V RING
Metal rod and other metal parts could corrode
Screw can loosen
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Special Operations Forces

Tactical Tourniquet (SOFTTW )
Same basic components but THE BUCKLE

MORE SURFACE PRESSURE = LESS TISSUE DAMAGE

The windlass strap is wider
Metal rod and other parts made of aluminum

HARDER TO SECURE THE ROD THROUGH THE V RING

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Emergency and Military

Tourniquet (EMT)

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Emergency and Military

Tourniquet (EMT)
HAS BEEN FOUND HAVING THE BEST PERFORM ANCE
and it is strongly suggested in emergency departments
MORE SURFACE PRESSURE = LESS TISSUE DAMAGE
THE INFLATABLE RUBBER CUFF MAY DETERIORATE
prolonged time in the field
exposed to high / low temperatures
exposed to shrapnel strikes
MORE EXPENSIVE
LARGER PACKAGE SIZE
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NATO Tourniquet ZOOM

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NATO Tourniquet ZOOM

LESS COMPONENTS
EFFECTIVE UNDER ALL WEATHER CONDITIONS
MORE DURABLE
HARDER TO USE IN SELF-AID (ARM)
LESS SURFACE PRESSURE=MORE TISSUE DAMAGE strap is
thinner and could pinch the skin or became string-like while
twisting
NOT YET APPROVED
NO TAG WHERE TO WRITE TIME OF APPLICATION

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Combat Application Tourniquet

(CAT)

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56

Special Operations Forces

Tactical Tourniquet (SOFTT)

UNCLASSIFIED

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57

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WIDER IS BETTER (SOFTTW)

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IMPROVISED Tourniquet
A preventable death in 2003
This casualty was wounded by an RPG explosion and
sustained a traumatic amputation of the right arm and a
right leg wound. He bled to death from his leg wound
despite the placement of three field-expedient tourniquets

the strings cut skin and muscles without occluding the arterial flow
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IMPROVISED Tourniquet
This casualty was wounded by an IED. The prompt
application of field-expedient tourniquets (T-shirts and
branches) saved his life. The first responder knew what to
do (was he properly trained in how to do it?)

TQs were placed proximally, not tightened or secured enough

The stumps were not dressed at all
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APPLYING an improvised tourniquet 1/3

GATHER MATERIALS:
rigid object (WINDLASS) such as a strong stick
tourniquet band (CRAVAT) AT LEAST 2 WIDE
SECURING MATERIAL (CRAVAT)

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APPLYING an improvised tourniquet 2/3

1. Apply band material around the groin / armpit
above wound / amputation
2. Tie band with a half-knot
3. Place windlass rod on top of knot
4. Tie a full knot (square knot) over windlass

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APPLYING an improvised tourniquet 3/3

5. Twist windlass until pulse (bleeding) has stopped
6. Secure the windlass rod wrapping a second band
around limb or using tying tails in a non-slip knot
so the tourniquet will not unwind

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Junctional injuries
Are becoming more frequent
Are usually more severe
Their relevance among the causes of bleeding
is growing since tourniquets became effective
in stopping the bleeding from the extremities
Researches & development increased
Devices effectiveness has been tested
TCCC guidelines currently recommend CRoC

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65

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JUNCTIONAL HEMORRHAGE
Combat Ready Clamp (CRoC)

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CRoC instructors and students

COMMENT
It works: effective in stopping junctional hemorrhage
It is the only one available / CoTCCC approved
Heavy for the medics bag
Even after training, it takes time to assemble it
Difficult to assemble when wet / dirty
Easily dislodged while handling the casualty

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JUNCTIONAL HEMORRHAGE
Junctional Emergency Treatment Tool (JETT)

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JUNCTIONAL HEMORRHAGE
Junctional Emergency Treatment Tool (JETT)

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69

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JUNCTIONAL HEMORRHAGE
Junctional Emergency Treatment Tool (JETT)

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JUNCTIONAL HEMORRHAGE
Junctional Emergency Tactical Tourniquet

JETT
Belt-effect
pelvic sling
infrequent dislodgment
2 mechanical junctional tourniquets
pressure applicable on right / left / both sides
at the same time
cups modeled groin / triangular-shape

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HEMOSTATIC FORCEPS

NOT YOUR FIRST CHOICE OF ACTION

ONLY WHEN THE BLEEDING IS:
LOCAL
VISIBLE
you can easily locate (see) the ruptured blood vessel
SUPERFICIAL

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MASSIVE EXTERNAL BLEEDING MANAGEMENT

SUMMARY
FOCUS needed to understand how to deal with hemorrhage
BUY SOME TIME to react by rapidly applying good direct
pressure or on pressure points
DEVISE & COMMUNICATE A PLAN
NO HESITATION once a course of action is initiated
ACHIEVE CONTROL of situation quickly: TQ, CRoC, packing
WORK TOGETHER toward an improvement
work UNTIL YOU ARE SATISFIED you achieved the objective
BY MINIMIZING BLOOD FLOW the wound site can be managed
FURTHERING MANAGEMENT with pressure dressing

REMEMBER THE BASICS!

Basic treatments done well will make the biggest difference
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INTERNAL HEMORRHAGE
CHECK ENTIRE BODY, ALL ORIFICES INCLUDED
CHECK CAVITIES (thoracic, abdominal, pelvic)
they can hide large volumes of blood
CHECK FOR SIGNS OF SHOCK (compensated / latent)
the assumption that casualties who look good are not
bleeding internally is frequently very wrong
Continued REASSESSMENT of trauma patients is
essential

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INTERNAL HEMORRHAGE
SIGNS & SYMPTOMS
SIGNS OF SHOCK
EXTERNAL BLEEDING THROUGH A NATURAL OPENING
blood in the STOOL (appears black, maroon, or bright red)
blood in the URETHRAL MEATUS OR IN THE URINE (appears red,
pink, or tea-colored)
VAGINAL bleeding (heavier than usual or after menopause)
blood in the VOMIT (looks bright red, or brown like coffee-grounds)

PAIN
TENSION
SWOLLEN AREA (abdomen, pelvis, chest)
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INTERNAL HEMORRHAGE
EXAMINATION
INSPECTION (e.g. bruising)
AUSCULTATION (e.g. bowel sounds reduced )
PERCUSSION (e.g. dullness)
PALPATION (detect any tenderness, resistance, reaction, pain
and swelling)
VITAL SIGNS-SHOCK SIGNS
Diagnostic peritoneal lavage
Ultrasound/FAST (Focused Abdominal Ultrasound for Trauma)

YOUR JOB IS TO SUSPECT IT AND TO SUSTAIN THE CIRCULATION

INTERNAL BLEEDING NEEDS SURGICAL TREATMENT!!
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ABDOMINAL WOUNDS
Apply very gentle pressure to stop the external bleeding
Any penetrating abdominal wound needs URGENT
SURGICAL TREATMENT
Evisceration
do not try to push bowels/organs back into the
abdomen, unless they slide back in by lifting the
wound edges
cover the injury with a moistened cloth or bandage
If signs of hemorrhagic shock after trauma without
external bleeding then suspect the possibility of severe
internal bleeding

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Abdominal blunt trauma The spleen

The spleen is a lymph node (immune system), it has
mechanical functions as well: reservoir of platelets,
retention and removal of old / abnormal RBCs
Rupture of the spleen is responsible for 40% of
internal abdominal bleeding after blunt trauma
(rupture of the liver 20%, rupture of bowel 5%)
The spleen is commonly affected
after blunt trauma to the left lower
chest.

10th rib

A two-stages rupture of the spleen

happens when the capsule of the
organ is initially intact and tears
afterwards leading to a sudden
severe internal bleeding (may be
expected within two weeks)
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The Abdominal Aortic Tourniquet

AAT
Available mid-April 2012
The target of the compression is the AORTIC BIFURCATION
at the abdominal-pelvic junction to occlude blood flow in the
inguinal arteries
It is a circumferential device applied to the mid-abdomen,
tightened and inflated
May remain on for up to an hour safely

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What forward solution?

FOAM - ongoing research (started on 2007)
Two different liquid components are injected at the same time into
the INTAPERITONEAL SPACE, they react with a mild exothermal
chemical reaction (may be beneficial) generating a Styrofoam-like
hydrophobic foam that expands (generates pressure) and solidifies in
less than 60sec in a conformal contact with tissues without adherence
(removable in one piece right after laparotomy)
Doesnt stop the bleeding but slows it down so that more hours are
available before surgery
Prototype : pending questions
How much, affects respiration = pressure against diaphragm
contraindicated in head injury (hypocarbic), retained foam particles,
migration into the pleural space in case of diaphragm lacerations
(more than 2 cm wide), leaking out from holes /wounds (seal them),
suitable for retroperitoneal hemorrhage?
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COMING SOON
SAFE APPROACH
ELEVATE THE EXTREMITY (LIMBS)
DIRECT MANUAL PRESSURE
PRESSURE POINTS
TOURNIQUET
COMBAT READY CLAMP (CROC)
PRESSURE DRESSING
PACKING DRESSING
HEMOSTATS
TXA

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WOUND HEMORRHAGE CONTROL

PACKING (AMPUTATIONS / CAVITIES)

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WOUND HEMORRHAGE CONTROL

PACKING (AMPUTATIONS / CAVITIES)

UNCLASSIFIED

83

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Medics rating

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84

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SUMMARY STOP THE BLEEDING

SAFE APPROACH: secure area and yourself
INITIAL ASSESSMENT M.A.R.
Elevate the extremity (limbs)
Apply direct manual pressure
Apply pressure to pressure points
Tourniquet (convert to pressure bandage when
indicated)
Junctional tourniquets CRoC / JETT
Hemostatic gauzes / Packing dressing
Pressure dressing

at the same time, calm and reassure the victim,

the sight of blood can be very frightening
UNCLASSIFIED

85

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SUMMARY PRESERVE THE CLOT

DO NOT handle the casualty without extreme precaution
DO NOT under estimate the effect of hypothermia
(hypothermia badly affects the clotting process)
DO NOT push I.V. fluids if a radial pulse is present
DO NOT forget to improve the clot with TXA
DO NOT disturb the wound
(remove the gauze, peek at the wound, clean the wound)

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86

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DONT CAUSE EXTRA INJURIES /

RE-BLEEDING
DO NOT probe a wound or pull out any embedded
object from a wound; this will usually cause more
bleeding and harm
DO NOT try to clean a large wound; this can cause
heavier bleeding
DO NOT remove the first dressing if it becomes
soaked with blood (unless if it is a haemostatic
gauze); add a new one on top
DO NOT peek at a wound to see if the bleeding is
stopping; the less a wound is disturbed, the more
likely it is that you'll be able to control the bleeding
DO NOT try to clean a wound after you get the
bleeding under control; get medical help
UNCLASSIFIED

87

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UNCLASSIFIED