Key Takeaways
- Arterial bleeding is bright red, spurts with each heartbeat, and is the most difficult to control; venous bleeding is dark red with a steady flow; capillary bleeding oozes and is usually self-limiting
- The bleeding control sequence is: direct pressure first, then pressure dressing, wound packing for junctional wounds, and tourniquet for life-threatening extremity hemorrhage
- Tourniquets should be applied high and tight on the extremity, tightened until bleeding stops, and the time of application must be documented
- Impaled objects should be stabilized in place and NOT removed in the field - removal may worsen bleeding and cause additional tissue damage
- Signs of internal bleeding include tachycardia, hypotension, rigid or distended abdomen, bruising patterns (Grey Turner sign on flanks, Cullen sign around umbilicus), and signs of shock
- Hemostatic agents such as QuikClot or Celox are packed into wounds to promote clotting and are increasingly used at the EMT level
- An average adult has approximately 5-6 liters of blood; losing more than 20% (Class III hemorrhage) produces significant signs of shock
Bleeding Control & Wound Management
Hemorrhage is the #1 preventable cause of trauma death. Rapid identification and control of life-threatening bleeding is one of the most critical EMT skills. The national "Stop the Bleed" campaign has emphasized that bleeding control is a skill every person should have, and EMTs must be expert at it.
Types of Bleeding
| Characteristic | Arterial | Venous | Capillary |
|---|---|---|---|
| Color | Bright red | Dark red | Red |
| Flow | Spurting with each heartbeat | Steady flow | Oozing |
| Pressure | High pressure | Low pressure | Very low pressure |
| Control Difficulty | Most difficult | Moderate | Easiest (often self-limiting) |
| Risk Level | Life-threatening; rapid blood loss | Can be life-threatening if from large vein | Rarely life-threatening |
Hemorrhage Classification
| Class | Blood Loss | Heart Rate | Blood Pressure | Mental Status |
|---|---|---|---|---|
| Class I | Up to 15% (~750 mL) | Normal | Normal | Alert, slightly anxious |
| Class II | 15-30% (~750-1500 mL) | Increased (>100) | Normal | Anxious |
| Class III | 30-40% (~1500-2000 mL) | Increased (>120) | Decreased | Confused, anxious |
| Class IV | >40% (>2000 mL) | Increased (>140) | Significantly decreased | Lethargic, obtunded |
Bleeding Control Sequence
Step 1: Direct Pressure
- Apply firm, direct pressure with a gloved hand and sterile gauze
- Maintain continuous pressure for at least 10 minutes
- Do NOT lift the dressing to check - this disrupts clot formation
Step 2: Pressure Dressing
- If direct pressure controls bleeding, apply a pressure dressing to maintain compression
- Use roller gauze wrapped firmly over the wound
- Check distal pulses after application
Step 3: Wound Packing
- For deep wounds, especially in junctional areas (groin, axilla, neck), pack the wound tightly with gauze or hemostatic gauze
- Pack directly into the wound and apply direct pressure on top
Step 4: Tourniquet
- For life-threatening extremity hemorrhage that cannot be controlled with direct pressure
- Apply high and tight on the extremity (as proximal as possible)
- Tighten until bleeding stops (this is painful - reassure the patient)
- Document the time of application (write "TK" and the time on the tourniquet or patient's forehead)
- Do NOT release the tourniquet once applied
- A second tourniquet may be needed if bleeding continues
Hemostatic Agents
Hemostatic agents (QuikClot Combat Gauze, Celox, etc.) are gauze impregnated with substances that accelerate clot formation. At the EMT level:
- Used in conjunction with wound packing for severe hemorrhage
- Pack the hemostatic gauze directly into the wound
- Apply firm direct pressure for at least 3 minutes
- Follow local protocol for specific products authorized
Types of Wounds
- Abrasion - Superficial scraping of the skin; road rash is a common example
- Laceration - A jagged, irregular cut caused by tearing forces; bleeds freely
- Incision - A smooth, clean cut from a sharp object; edges are even
- Puncture - A small entry wound with potentially deep internal damage; high infection risk
- Avulsion - A flap of skin or tissue torn partially or completely loose
- Amputation - Complete separation of a body part; control bleeding, wrap the amputated part in moist sterile gauze, place in a plastic bag, and keep cool (NOT directly on ice)
Impaled Objects
Critical rule: Do NOT remove impaled objects in the field.
- Stabilize the object in place with bulky dressings
- Shortening the object may be necessary for transport
- Exceptions: objects in the cheek (may compromise airway) or objects that interfere with CPR
- The object may be tamponading (plugging) a blood vessel; removing it can cause uncontrolled hemorrhage
Internal Bleeding
Internal bleeding is not visible and must be suspected based on mechanism and clinical signs:
Signs and Symptoms:
- Tachycardia (early sign)
- Hypotension (late sign - indicates significant blood loss)
- Rigid, tender, or distended abdomen
- Bruising: Grey Turner sign (flank bruising) or Cullen sign (periumbilical bruising)
- Signs and symptoms of shock (pale, cool, diaphoretic skin)
- Blood from body orifices (ears, nose, mouth, rectum)
- Hematemesis (vomiting blood) or melena (dark, tarry stools)
Management: Treat for shock, provide rapid transport, and communicate suspected internal bleeding to the receiving facility.
Which type of bleeding is characterized by bright red blood that spurts with each heartbeat?
When applying a tourniquet for life-threatening extremity hemorrhage, the EMT should:
An EMT encounters a patient with a knife impaled in the abdomen. The correct management is to:
Bruising around the umbilicus (belly button) following abdominal trauma is known as:
A trauma patient presents with a heart rate of 130, blood pressure of 80/60, and confusion. Based on the hemorrhage classification system, this patient is MOST likely experiencing:
Arrange the bleeding control interventions in the correct sequence from first-line to last resort:
Arrange the items in the correct order
Which of the following are signs or symptoms of internal bleeding? (Select ALL that apply)
Select all that apply