Life-saving First-aid Basics of Hemorrhage Control
First-aid steps for any injury should begin with identifying yourself and reassuring the injured person that you’re there to help.
Whether times are good or bad, everything from everyday accidents to massive disasters can cause injuries and deaths. Some are natural events, such as hurricanes and tornadoes; others are man-made, such as terror attacks and active shooters.
Regardless of how casualties are caused, it’s clear that many deaths occur due to bleeding from traumatic wounds. It’s even clearer that some deaths might be prevented by the quick action of nearby “Good Samaritans.”
In modern times, we have the benefit of emergency medical personnel and high technology. These assets, however, aren’t always just around the corner. An injury causing damage to a major artery can kill a person in just a few minutes. If not treated immediately, some victims will be beyond help by the time professional help arrives.
In survival settings, the situation is even worse: There is no ambulance on the way or rescue helicopter on the horizon. There might not even be a way to contact professionals to get instructions for treating an accident victim.
The Importance of Minimizing Blood Loss
Therefore, individuals at the scene must act, often with limited supplies, if they are to save a life. For someone who isn’t medically trained, it’s a major challenge. Just seeing a good amount of blood or a limb deformed from trauma gives the average person pause and sometimes induces a temporary mental paralysis that could be fatal to the victim. Delay in rendering care makes bleeding control, also called “hemostasis,” more difficult.
The lack of blood volume caused by traumatic hemorrhage has various effects on the body based on the amount lost. The human body contains 9 to 10 pints of blood. It can tolerate the loss of a relatively small amount with little ill effect. For example, you can donate a pint of blood—10 to 11 percent of your total blood volume—to the Red Cross every eight weeks.
Once you lose 15 to 30 percent of your total blood volume, however, physical signs become apparent. The purpose of red blood cells is to deliver oxygen to, and remove carbon dioxide from, the tissues of the body. When there are fewer of them, the cells must travel faster to provide the same amount of oxygen. The heart must beat faster to accomplish this goal, so you’ll notice a rise in the pulse rate. The body begins to feel a lack of oxygen, so the patient breathes faster, as well. Skin begins to pale and is cool to the touch, and some agitation might be noted. If bleeding is stopped, recovery may not require blood transfusion.
From 30 to about 40 percent loss of blood volume, the victim’s ability to compensate for the loss of red blood cells begins to reach maximum capacity. The victim’s blood pressure becomes hard to maintain at normal levels and drops, while the heart rate increases to the point that it might no longer be efficient in pumping blood. The patient becomes confused, lethargic and might lose consciousness.
Blood transfusion is usually required at this point. Beyond 40 percent blood loss, the body can no longer compensate. Blood pressure, heart rate and respiration drop, and death is imminent without major intervention.
Take Action to Stop Blood Loss
What can a medically untrained individual do to stop a major bleed?
For our purposes, we’ll assume the event that caused the injury has passed, and the caregiver is not personally in danger at the moment. Knowing the level of danger is important, just as your personal safety is your highest priority. If there is an active threat, you help no one by becoming the next victim.
DELAY IN RENDERING CARE MAKES BLEEDING CONTROL, ALSO CALLED “HEMOSTASIS,” MORE DIFFICULT.
First-aid steps for any injury should begin with identifying yourself and reassuring the injured person that you’re there to help. Just stating who you are and your purpose will increase the chances the victim will cooperate with your efforts. Ask simple questions such as, “What’s your name?” to get an idea of the level of consciousness and to gauge the ability to follow commands.
The patient should be placed in the “shock” position—that is, lying supine (face up) with the legs elevated above the level of the heart. This might make it more difficult for the heart to pump blood out of the body. If the wound is in the chest or abdomen, however, bend the knees instead of raising the legs.
Expose the wound(s) so you can see their full extent, preferably with an EMT shears or a bandage scissors, which are designed to avoid accidental injury. Don’t direct the victim to remove their own clothes; movement could cause additional injury if there are fractures or might cause unnecessary delay in treatment if the injured party is not fully alert.
Once you’ve cut away clothing and removed loose debris over the wound, evaluate the injury.
Is there an entry wound from a projectile? Is there an exit wound? (Be aware that exit wounds are dependent on the position of the victim at the time of injury and not always directly opposite the entry wound.) Is there a large object embedded in the wound, such as a knife? Objects stuck in the wound should not be removed, because doing so might provoke more bleeding. Don’t probe the wound with, say, your finger. Your job is to stop the hemorrhage.
If there are gloves available, put them on. Use some kind of barrier to try to stop the bleeding—preferably a sterile bandage—or at least a clean cloth. This will protect both the victim and the caregiver. Press the dressing firmly with your palm, one hand over the other, on the bleeding wound. Keep your arms straight, applying pressure directly over the wound itself. Many wounds will cease oozing simply with the application of direct pressure. In large extremity wounds, concentrate your efforts closest to the torso.
IT’S IMPERATIVE TO FREQUENTLY REASSESS THE WOUND. DON’T REMOVE THE GAUZE OR BANDAGE, HOWEVER, UNLESS BLOOD IS OBVIOUSLY SEEPING THROUGH.
In circumstances for which direct pressure fails to stop the hemorrhage, your bandage will soak through, making it clear that a more aggressive response is needed. The placement of a tourniquet 2 to 4 inches above the wound (between the wound and the heart) is indicated for arterial or other life-threatening hemorrhages. Arterial bleeding can be identified by the presence of bright-red blood spurting from the wound.
If you see this or a significant pooling of blood on the ground, placing a tourniquet should be the first course of action. Although tightening a belt or bandanna around a bleeding extremity might suffice, commercial tourniquets such as the CAT (Combat Application Tourniquet) and SOFT-T (Special Operations Forces Tactical Tourniquet), among others, are likely to be more effective.
Dealing With Open Wounds
An open wound should be packed tightly with dressings. In the April 2017 issue of the Journal of Emergency Medical Services (JEMS), Dr. Peter Taillac and EMT-P associates Scotty Bolleter and A.J. Heightman put forth their recommendations for the packing of hemorrhagic wounds with plain and/or special blood-clotting gauze such as QuikClot, Celox and others. The American College of Surgeons (of which I am a retired fellow) found these specialized “hemostatic” bandages to be effective in 90 percent of cases.
… IN THESE UNCERTAIN TIMES, HAVING THE KNOWLEDGE AND SUPPLIES TO STOP BLEEDING MAKES SENSE.
If you’re using regular bandages and need to place more to achieve hemostasis, don’t remove the old ones; simply pack the added bandages firmly on top. With blood-clotting gauze, however, old gauze should be removed so you can see where the bleeding vessel is. The hemostatic dressing should be packed directly where the bleeding originates.
Packing of wounds is useful in many situations, but not all. Wounds of the neck are problematic, for instance, due to the risk of compressing airways and affecting the patient’s ability to breathe. Packing injuries in the abdomen, pelvis and chest might not be effective due to the deep nature of the bleeding vessels. This is one reason that in an off-grid setting, the death rate (called “mortality”) from these wounds is so high. For example, statistics from the Civil War put mortality rates for major injuries in these regions at close to 70 percent—a figure that might also be expected in long-term survival scenarios.
According to Dr. Taillac’s team, proper packing of wounds with plain or hemostatic gauze should include the following steps:
Quickly and aggressively apply direct pressure with a gloved hand, a clean dressing or cloth—or even the knee or elbow—while breaking out your supplies.
Find the exact source of the bleeding. Tightly (and I mean, tightly) pack the wound cavity as deeply as you can while continuing to apply pressure directly on the bleeding vessel. Although hemostatic gauze is best, sufficient pressure with plain gauze might be enough in some cases.
Utilizing the presence of nearby bones to pack against might be useful in certain wounds. If there is a knife embedded in the wound, keep it in place and pack around it as best you can until you can get the victim to a more controlled setting.
Maintain pressure on the packed wound for at least three minutes and see if the bleeding has abated. If you’re successful in stopping the hemorrhage, cover the wound securely with a pressure dressing such as the Emergency Bandage (also called the Israeli Battle Dressing), OLAES Bandage or another brand. These are designed specifically to keep pressure on the injury and control bleeding if placed correctly.
At one point or another, the victim should be transported to where further care can be provided, whether it’s a hospital or, in a survival scenario, wherever the bulk of your medical supplies is. Keep in mind that the jostling that might occur during this process could cause bleeding to re-start. Splinting the wound will immobilize it and help decrease movement that could disturb your packing or tourniquet placement. Commercial splints such as the Structural Aluminum Malleable (SAM) can be bent or cut into shape to conform to the injured extremity.
After Stopping the Bleeding
A common issue that occurs in major hemorrhages is the loss of body heat. Keeping a person warm is difficult when they are lying on the cold ground, so a barrier of some sort between the casualty and the ground will help. A Mylar or other blanket should be used to cover the person, as well.
Covering the victim of a bleeding wound to maintain warmth does not mean your vigilance is no longer necessary. It’s imperative to frequently reassess the wound. Don’t remove the gauze or bandage, however, unless blood is obviously seeping through.
Of course, having a medical kit containing the essential items (listed in the First-Aid Kit for Bleeding sidebar below) makes this process much easier. However, simply having medical supplies is not enough. You should practice, for example, using the tourniquet in your kit so you are proficient in its use.
I’ll admit that the likelihood you’ll have to save the life of someone bleeding to death tomorrow, next week or next month might be small. Nevertheless, over the course of a lifetime in these uncertain times, having the knowledge and supplies to stop bleeding makes sense.
Add in your children’s lifetimes, and I think you’ll agree it’s time we instill a culture of medical preparedness in our citizens. If a disaster leaves us without modern medical care, have no doubt: Lives will be saved.
It might be obvious when a victim of a disaster is bleeding externally, but internal bleeding is more difficult to identify. Some signs include:
Distention (swelling) of the abdomen
Blood in the urine or bowel movement
Nausea and vomiting, especially if blood is present
Vaginal bleeding not related to menstruation
For more information about treating hemorrhage from trauma, including knife and gunshot wounds, consider getting the third edition of The Survival Medicine Handbook: The Essential Guide for When Medical Help is Not on the Way (authors Joe Alton, M.D. and Amy Alton, A.R.N.P.)—a winner of the 2017 Book Excellence Award in medicine. The entire book is written as if a disaster has left you, the average citizen, as the highest medical resource left to your family. The goal is to make you effective in that role.
First-Aid Kitfor Bleeding
A good first-aid kit for bleeding will be compact, lightweight and contain the following contents at the minimum:
Nitrile gloves (at least two pairs)
Stainless steel bandage scissors or sturdy EMT shears to help expose wounds and to open packages made slippery by blood
Tourniquets (two is better than one: Sometimes, a second tourniquet must be placed above the first)
Gauze dressings (H&H makes a vacuum-compressed dressing that, when opened, is 4.5 inches wide by 12 feet long)
Hemostatic bandages (QuikClot or Celox products stop even arterial bleeding)
6-inch roller gauze dressings for coverage
Pressure bandage dressings to maintain pressure on treated wounds
Vented chest seals (packaged in one double pack for entry and exit wounds in the chest)
Mylar blankets (to cover the victim and help prevent shock)
Other items, such as nasal airways, might be useful for those with training. You can find examples of several bleeding and gunshot wound kits, including some designed for multiple casualties, at www.DoomandBloom.net.