5.2 Severe Bleeding, Shock, Burns and Choking

5.2 Severe Bleeding, Shock, Burns and Choking

Security officers in Abu Dhabi frequently operate in high-risk operational environments—including industrial logistics centers in KEZAD, manufacturing workshops in Musaffah, active commercial development sites, commercial hotel kitchens, and crowded retail complexes. In these environments, traumatic injuries such as acute external hemorrhage, physiological circulatory shock, foreign body airway obstruction (choking), and thermal burns can arise without warning. A security guard's rapid, competent intervention during the initial minutes often determines whether an injured worker survives. This section details the clinical identification and practical operational management of these critical traumatic emergencies in full compliance with PSBD and NSI standards.

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External Haemorrhage Control and Wound Management

Severe external bleeding (haemorrhage) is one of the leading preventable causes of traumatic death. The human adult body contains approximately 5 liters of blood; losing as little as 1 to 1.5 liters can induce life-threatening circulatory collapse. Security officers must instantly recognize the anatomical source of bleeding to deploy the correct intervention.

                         TYPES OF EXTERNAL BLEEDING
┌─────────────────┬───────────────────┬───────────────────┬─────────────────────┐
│ Bleeding Type   │ Vessel Involved   │ Clinical Visuals  │ Pressure & Risk     │
├─────────────────┼───────────────────┼───────────────────┼─────────────────────┤
│ Arterial        │ Severed Artery    │ Bright red,       │ High pressure;      │
│                 │                   │ pulsating spurts  │ fatal in <3 minutes │
├─────────────────┼───────────────────┼───────────────────┼─────────────────────┤
│ Venous          │ Severed Vein      │ Dark red/maroon,  │ Low-medium pressure;│
│                 │                   │ steady flow       │ risk of severe shock│
├─────────────────┼───────────────────┼───────────────────┼─────────────────────┤
│ Capillary       │ Superficial Beds  │ Red, slow oozing  │ Microscopic flow;   │
│                 │                   │ from skin scrapes │ clots spontaneously │
└─────────────────┴───────────────────┴───────────────────┴─────────────────────┘

Universal Infection Control Precautions

Under UAE occupational safety guidelines and PSBD licensing standards, every security guard must treat all human blood, bodily fluids, and contaminated tissues as potentially infectious for bloodborne viruses, including Hepatitis B (HBV), Hepatitis C (HCV), and Human Immunodeficiency Virus (HIV):

• Always don clean disposable nitrile or latex gloves before touching open wounds, broken skin, or blood-soaked apparel.
• If arterial spurting or pressurized fluid is present, wear protective safety goggles and a surgical face mask to avoid mucous membrane splash exposure.
• Wash hands thoroughly with antimicrobial soap and warm running water immediately after peeling off gloves, disposing of all blood-stained materials in marked biohazard waste receptacles.

Step-by-Step Haemorrhage Management Protocol

[Catastrophic External Haemorrhage Identified]
                      │
                      ▼
            [Direct Manual Pressure]
    Apply sterile dressing firmly over wound with gloved hands
                      │
                      ▼
            [Elevate Injured Limb]
    Raise limb above heart level (ONLY IF NO FRACTURE SUSPECTED)
                      │
                      ▼
            [Apply Pressure Bandage]
    Wrap firmly around pad; verify distal pulse & capillary refill
                      │
          ┌───────────┴───────────┐
          ▼                       ▼
   [Bleed Stops]           [Blood Soaks Through]
   Keep immobilized;       DO NOT REMOVE FIRST PAD;
   monitor vital signs     Add 2nd pad on top; firm pressure;
                           Deploy Tourniquet for limb trauma

1. Direct Manual Pressure: The primary and most reliable method to arrest external bleeding. Place a sterile wound dressing, clean gauze pack, or trauma pad directly over the bleeding site. Apply firm, continuous, localized pressure using the palm or fingers for at least 10 continuous minutes without lifting the pad to inspect the wound.
2. Elevation: If the hemorrhage is situated on an extremity (arm or leg), elevate the injured limb above the level of the casualty's heart while maintaining continuous direct pressure. Gravitational resistance lowers hydrostatic blood pressure at the wound, facilitating clot stabilization. Critical Rule: Never elevate an injured limb if you suspect an underlying bone fracture, joint dislocation, or spinal trauma, as movement will cause excruciating pain and exacerbate internal vascular tearing.
3. Pressure Bandaging: Secure the sterile dressing firmly in place by wrapping a conforming roller or elastic bandage around the limb. Ensure the bandage is tight enough to maintain constant pressure over the wound, but not so tight that it strangles all distal arterial blood flow.
   • Check Distal Circulation: Test the extremity's circulation immediately after bandaging and every 5 minutes thereafter. Compress the casualty's fingernail or toenail until it blanches white, then release; the healthy pink color must return within 2 seconds (capillary refill test). Palpate for a distal pulse (radial pulse at the wrist, or dorsalis pedis pulse on top of the foot). If the digits turn blue, cold, or numb, loosen the wrapping slightly.
4. Managing Bleed-Through: If blood saturates and seeps through the initial dressing, NEVER REMOVE THE FIRST DRESSING. Removing the first pad tears away the newly formed fibrin mesh and platelet plug forming at the severed blood vessel, provoking renewed catastrophic hemorrhage. Instead, place a second fresh dressing directly over the soaked pad, apply firmer manual pressure, and secure with an additional wrap.
5. Managing Embedded Foreign Objects: In construction accidents, motor vehicle impacts, or industrial mishaps, casualties may present with large glass shards, metal nails, rebar spikes, or knife blades impaled deeply into muscle tissue.
   • THE GOLDEN OPERATIONAL RULE: NEVER REMOVE AN EMBEDDED OBJECT. The foreign object is mechanically plugging the lacerated blood vessels. Removing it unleashes uncontrolled, massive internal and external hemorrhage and inflicts severe secondary trauma on surrounding nerves.
   • Stabilization Technique: Build up bulky, sterile dressings, rolled conforming bandages, or clean towels on both sides of the embedded object (forming a stabilizing "log cabin" or "doughnut" pad). Secure the pads in place by bandaging around the object, applying pressure only to the surrounding tissue and never exerting downward force on the embedded object itself.
6. Emergency Tourniquets: Used exclusively for catastrophic, life-threatening arterial hemorrhage on limbs (such as traumatic amputations or deep blast wounds) where direct manual pressure and pressure dressings fail to stop arterial blood loss.
   • Apply a certified commercial tourniquet (such as a Combat Application Tourniquet / CAT) 5 to 7 cm (2 to 3 inches) above the wound, between the injury and the heart. Never apply a tourniquet directly over a joint (elbow or knee); place it higher on the single-bone segment (upper arm or thigh).
   • Tighten the windlass rod until arterial bleeding ceases completely and the distal pulse disappears, then secure the windlass in the locking clip.
   • Mark the Time: Write the exact time of application (e.g., "TK 14:45") prominently on the casualty's forehead or on the tourniquet label with an indelible marker.
   • Never Loosen a Tourniquet: Once applied, a tourniquet must remain tightened until removed by an emergency physician or paramedic in a hospital operating theater. Loosening a tourniquet releases deadly accumulated metabolic toxins into the bloodstream and induces fatal hemorrhagic relapse.

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Medical Shock (Hypovolemic and Circulatory Shock)

In emergency medicine, shock does not mean emotional fright; it defines a critical, life-threatening physiological collapse where the circulatory system fails to maintain adequate tissue perfusion, depriving the brain, kidneys, and vital organs of oxygen and glucose. In trauma and workplace security incidents, the predominant form encountered is hypovolemic shock, caused by rapid internal or external blood loss or massive fluid plasma depletion from severe burns.

                  PROGRESSION OF HYPOVOLEMIC SHOCK
┌─────────────────────────────────────────────────────────────────────────────┐
│ Acute Blood Loss ──► Decreased Circulating Volume ──► Vasoconstriction      │
│                             │                                               │
│                             ▼                                               │
│ Rapid Weak Pulse + Pale Clammy Skin + Hyperventilation + Intense Thirst     │
│                             │                                               │
│                             ▼                                               │
│ Blood Pressure Collapse ──► Cellular Hypoxia ──► Multiple Organ Failure     │
└─────────────────────────────────────────────────────────────────────────────┘

Clinical Signs and Symptoms of Shock

• Skin: Cold, clammy, and pale or ashen; cutaneous capillary vasoconstriction shunts blood from the skin to vital organs; cyanosis (bluish discoloration of lips, earlobes, and fingernails).
• Pulse: Rapid (tachycardia >100 bpm) and weak, thready, or difficult to palpate.
• Respiration: Rapid, shallow, and irregular breathing (air hunger).
• Neurological: Anxiety, restlessness, confusion, dizziness, lightheadedness, progressing to lethargy and unresponsiveness.
• General: Intense, desperate thirst; dry mouth; nausea, vomiting; generalized muscle weakness and shivering chills.

Standard First Aid Management for Shock

1. Call the ambulance service (998): Immediately request emergency medical dispatch.
2. Arrest Active Hemorrhage: Apply direct pressure, pressure dressings, or a tourniquet to stop ongoing blood loss.
3. Position the Casualty (Shock Position): Lay the casualty flat on their back (supine) on a level surface. Elevate their lower extremities 15 to 30 cm (6 to 12 inches) above the level of the heart. This modified posture uses gravity to drain venous blood from the legs back into the core circulatory pool, improving perfusion to the brain and heart.
   • Contraindications: Never elevate the legs if you suspect spinal trauma, pelvic fractures, head injury, or unsplinted lower limb fractures. If head injury or breathing difficulty is present, keep the casualty flat or in a semi-reclined position.
4. Preserve Body Temperature: Wrap the casualty in a warm blanket, emergency foil space blanket, or dry coats to combat hypothermia. Insulate them from cold concrete or tile floors. Do not apply direct artificial heat sources (such as hot water bottles or direct heaters), as external heat causes peripheral vasodilation, diverting blood away from core organs.
5. Calm and Reassure: Maintain a reassuring, composed presence. Anxiety accelerates adrenaline discharge, exacerbating cardiovascular strain.
6. THE STRICT ZERO-FLUID RULE: NEVER GIVE FOOD OR DRINK TO A CASUALTY IN SHOCK, regardless of how desperately they beg for water. Circulatory shock shuts down gastrointestinal digestion; ingested fluids sit in the stomach, triggering vomiting and fatal pulmonary aspiration in a semi-conscious casualty. Furthermore, trauma casualties frequently require emergency surgical anesthesia upon arrival at the hospital, and having fluid in the stomach dangerously delays surgical intervention. Moisten dry lips with a damp gauze pad if requested, but permit zero swallowing.
7. Continuous Monitoring: Check airway, breathing, pulse, and skin color every 2 minutes. If the casualty loses consciousness and stops breathing normally, initiate CPR immediately.

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Choking (Foreign Body Airway Obstruction - FBAO)

Choking occurs when a piece of food, a small object, or foreign material lodges in the larynx or trachea, physically occluding the airway. The universal distress signal for choking is the casualty clutching both hands around their throat with wide, panic-stricken eyes.

                 ASSESSMENT OF CHOKING SEVERITY
                               │
               ┌───────────────┴───────────────┐
               ▼                               ▼
      [Mild Obstruction]              [Severe Obstruction]
      • Can speak or cry out          • Cannot speak or vocalize
      • Can cough forcefully          • Silent, ineffective cough
      • Can breathe between coughs    • High-pitched stridor / cyanosis
               │                               │
               ▼                               ▼
      DO NOT INTERVENE                ACT IMMEDIATELY:
      Encourage forceful coughing;    5 Firm Back Blows
      Monitor continuously                     │
                                      5 Abdominal Thrusts (Heimlich)
                                      (Alternate until cleared or unconscious)

Conscious Adult Choking Protocol

• Mild Obstruction: If the casualty can speak, cry out, and cough forcefully, do not touch them or strike their back. The physiological cough reflex generates air velocities far higher than manual chest or back thrusts. Stand beside them, encourage them to keep coughing, and monitor for sudden deterioration.
• Severe Obstruction: If the casualty cannot speak, cannot cough, struggles frantically for breath with high-pitched wheezing (stridor), or begins turning blue, intervene immediately:
  1. 5 Firm Back Blows:
     • Stand to the side and slightly behind the casualty.
     • Support their upper chest firmly with one hand and lean their torso well forward, so that any dislodged obstruction exits the mouth rather than slipping deeper down the airway.
     • Deliver up to 5 sharp, distinct blows squarely between the shoulder blades (scapulae) using the heel of your other hand.
  2. 5 Abdominal Thrusts (The Heimlich Manoeuvre):
     • If 5 back blows fail to clear the blockage, stand directly behind the casualty.
     • Wrap both arms around their upper abdomen.
     • Clench one hand into a tight fist. Place the flat thumb-side of your fist against the casualty's abdomen in the midline, just above the navel (umbilicus) and well below the lower tip of the breastbone (xiphoid process).
     • Grasp your fist firmly with your other hand.
     • Pull sharply inward and upward into the abdomen in a rapid, forceful J-shaped thrust. This compresses the diaphragm, forcing residual lung air upward to blast the obstruction out of the trachea.
     • Deliver up to 5 distinct abdominal thrusts.
  3. Continuous Alternation: Continue alternating 5 back blows and 5 abdominal thrusts until the foreign object is expelled or the casualty loses consciousness.
  4. Special Adaptation for Pregnancy or Severe Obesity: Do not perform abdominal thrusts on a visibly pregnant woman or an individual with severe abdominal obesity, as this can rupture internal organs or harm the fetus. Instead, stand behind them, place your arms under their armpits, position your fist in the center of their breastbone (sternum), and deliver rapid, sharp chest thrusts straight backward.

Protocol for the Unconscious Choking Casualty

If a choking casualty loses consciousness and goes limp:

1. Carefully lower them onto their back on the floor, protecting their head and neck.
2. Ensure the ambulance service (998) is dispatched immediately.
3. Begin CPR immediately, starting with 30 chest compressions. Downward compressions compress the thoracic cavity, generating high intrathoracic pressures that can force the obstruction out of the trachea.
4. Before attempting rescue breaths, open the airway (head-tilt, chin-lift) and look inside the mouth:
   • If the foreign object is clearly visible and loose, perform a hooked finger sweep with a gloved finger to extract it.
   • NEVER PERFORM A BLIND FINGER SWEEP. Poking blindly into the back of an adult's throat can push a partially dislodged object back down into the laryngeal inlet, converting a partial block into an irreversible complete obstruction.
5. Attempt 2 rescue breaths. If the chest does not rise, re-tilt the head and attempt 2 breaths again. Continue standard CPR cycles (30:2) until professional medics take over or the casualty recovers normal breathing.

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Burn Management and Triage

Burns represent severe tissue trauma caused by thermal heat, open flame, electrical currents, hazardous chemicals, or solar radiation. In Abu Dhabi security settings, thermal burns frequently occur in commercial kitchens, industrial mechanical workshops, and generator plants.

                      BURN DEPTH CLASSIFICATION
┌─────────────────┬───────────────────┬───────────────────┬─────────────────────┐
│ Burn Depth      │ Layer Affected    │ Clinical Signs    │ Pain Characteristics│
├─────────────────┼───────────────────┼───────────────────┼─────────────────────┤
│ First Degree    │ Epidermis only    │ Red, dry, mild    │ Painful, tender;    │
│ (Superficial)   │ (outer layer)     │ swelling; NO acne │ heals in 3-7 days   │
├─────────────────┼───────────────────┼───────────────────┼─────────────────────┤
│ Second Degree   │ Epidermis &       │ Bright red, raw,  │ Extremely painful   │
│ (Partial Thk.)  │ Dermis (deep)     │ blisters, weeping │ due to exposed      │
│                 │                   │ fluid             │ intact nerve endings│
├─────────────────┼───────────────────┼───────────────────┼─────────────────────┤
│ Third Degree    │ All skin layers;  │ Charred black,    │ Center is painless  │
│ (Full Thickness)│ fat, muscle, bone │ leathery, waxy    │ (nerves destroyed); │
│                 │                   │ white, dry skin   │ outer edges painful │
└─────────────────┴───────────────────┴───────────────────┴─────────────────────┘

Immediate First Aid Protocol for Thermal Burns

1. Ensure Scene Safety: Isolate the heat source. If the incident involves electrical contact, do not touch the casualty until the electrical current is completely isolated at the main distribution board.
2. Cool the Burn Immediately (The 20-Minute Rule):
   • Cool the affected area immediately under clean, running cool or lukewarm tap water for a minimum of 20 continuous minutes.
   • Cooling is therapeutically effective if initiated within 3 hours of the injury. It halts the inward thermal progression of heat into deep tissue layers, reduces localized edema, and delivers profound pain relief.
   • If running tap water is unavailable, immerse the burn in clean cool water or apply clean, wet towels, replacing them constantly as they absorb heat.
3. Critical Prohibitions in Burn Treatment (EXAM MANDATES):
   • NEVER APPLY ICE OR ICE-COLD WATER: Extreme cold causes intense cutaneous vasoconstriction, halting blood flow, deepening tissue ischemia, and converting a second-degree burn into irreversible full-thickness necrosis. Ice also triggers rapid systemic hypothermia.
   • NEVER APPLY BUTTER, OIL, TOOTHPASTE, FLOUR, OR OINTMENTS: Traditional household remedies trap heat within the skin, exacerbate thermal tissue destruction, and introduce dangerous bacterial contaminants that cause severe wound sepsis.
   • NEVER BURST OR POP BLISTERS: The intact epidermal blister roof provides an airtight, sterile biological barrier protecting the exposed raw dermis. Popping blisters exposes the tissue to airborne bacterial pathogens.
4. Remove Constrictive Items:
   • Rapidly and gently remove rings, wristwatches, tight jewelry, belts, and tight shoes from the burned limb before inflammatory swelling develops. If swelling locks tight rings on fingers, arterial gangrene can result.
   • Clothing Rule: Gently remove loose clothing around the burn. DO NOT PEEL OFF CLOTHING THAT HAS MELTED OR ADHERED TO BURNED FLESH. Carefully cut around the stuck fabric with trauma shears, leaving the melted material in place for surgical debridement in the hospital.
5. Dressing the Burn:
   • Cover the cooled burn loosely with a sterile, non-adherent wound dressing, or use clean plastic cling film (food wrap).
   • Apply plastic cling film in flat sheets laid loosely over the burn; never wrap cling film circumferentially or tightly around a limb, as subsequent tissue swelling will turn the wrap into a dangerous constriction band. Cling film is sterile on the roll, non-adherent, prevents fluid evaporation, shields exposed nerves from air currents to relieve pain, and allows physicians to inspect the burn without painful dressing removal.
6. Prevent Hypothermia: While cooling a localized burn, keep the rest of the casualty dry and warm with a clean blanket, especially pediatric, elderly, or extensively burned casualties.
7. When to Call the ambulance service (998) for Burns:
   • Any third-degree (full-thickness) burn, regardless of size.
   • Any second-degree burn exceeding 10% of the body surface area in an adult (the casualty's palm represents ~1% of their body surface area).
   • Burns involving critical anatomical areas: face, airway, eyes, hands, feet, groin, major joints, or circumferential burns around limbs or torso.
   • All electrical, high-voltage, or chemical burns.
   • Any casualty showing signs of inhalation burn injury: singed nasal hairs, soot around nostrils/mouth, hoarse voice, coughing black sputum, or respiratory stridor.

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Practical UAE Operational Scenario

The Incident

Officer Dawoud is on security patrol at a major steel fabrication workshop in Musaffah Industrial Area, Abu Dhabi. At 11:20, an industrial abrasive cutting wheel shatters on a workbench. A 28-year-old fabricator suffers a deep laceration across his right forearm, with a 6-cm jagged shard of composite wheel embedded deeply in the wound, accompanied by dark, heavily flowing venous blood. In his panic, the fabricator trips backward, spilling a bucket of boiling degreasing water across his left thigh and lower leg, screaming in agony as massive blisters rapidly erupt across the skin.

11:20 Workshop Incident ──► Fabricator with embedded wheel shard in right arm;
                            Boiling water burn across left leg
           │
           ▼
Officer Dawoud PPE ────────► Dons nitrile gloves & protective eye goggles
           │
           ▼
Manage Life Threats First ─► Embedded Object in Arm:
                             • DOES NOT REMOVE SHARD
                             • Pads both sides with bulky rolled gauze
                             • Bandages firmly around shard; bleed slows
           │
           ▼
Manage Severe Burn ────────► Directs coworker to run clean, cool water over
                             blistered left leg for 20 minutes;
                             Forbids popping blisters or applying pastes
           │
           ▼
Shock Management ──────────► Worker turns pale, cold, clammy, shivers, dizzy;
                             Dawoud lays him flat, elevates legs 20 cm,
                             wraps torso in blanket, refuses water for thirst
           │
           ▼
Ambulance Handover ► 998 arrives at 11:29; structured clinical pass-down

Applied Actions

1. Safety and Universal Precautions: Dawoud verifies the machine switch is isolated. He immediately dons nitrile gloves and protective safety glasses from his duty belt pouch.
2. Triage and Life-Threat Prioritization: Dawoud recognizes that active hemorrhage takes absolute priority over a burn. Inspecting the right arm, he observes the composite shard protruding from the muscle.
3. Embedded Object Management: Dawoud remembers the golden rule: never pull out an embedded object. He takes two bulky sterile roller bandages from the workshop first aid kit, places one on each side of the protruding shard to bracket and stabilize it, and wraps an elastic bandage diagonally around the arm, securing the pads without pressing downward on the shard. The heavy venous flow is controlled, and distal pulse is verified.
4. Burn Intervention: Dawoud guides the fabricator to the emergency eye-wash/safety shower station. He directs a clean stream of cool running water across the worker's blistered left leg, setting a watch timer for 20 minutes. He instructs coworkers: "Do not touch the blisters, and do not put ice, butter, or grease on that skin!"
5. Shock Prevention: At 11:25, the fabricator turns ashen pale, breaks into a cold clammy sweat, shivers uncontrollably, and slurs his speech, complaining of intense thirst and dizziness. Dawoud identifies hypovolemic shock. He seats the worker safely on the floor, lays him flat on his back, and elevates his uninjured right leg on a toolbox 20 cm high. He wraps the worker's upper body in a clean cotton sheet and blanket to preserve core warmth. When the worker desperately begs for cold water, Dawoud refuses calmly: "I know you are thirsty, brother, but you have lost blood and may need urgent surgery. Swallowing water can make you vomit into your lungs. I will moisten your lips with a damp cloth."
6. Professional Handover: the ambulance service (998) arrives at 11:29. Dawoud delivers a concise operational handover to the lead paramedic: "28-year-old male, sustained deep right forearm laceration with embedded cutting disc shard at 11:20; stabilized with bracketing pads. Second-degree thermal scald to left lower limb; cooled under running water for 9 minutes. Casualty displayed signs of shock at 11:25; laid flat, leg elevated, warmth maintained, zero oral fluids administered." Paramedics praise Dawoud's exceptional composure and textbook execution.

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Section Summary Review Checklist for the PSBD Exam

• Bleeding Classification: Arterial (bright red, pulsating/spurting, life-threatening), Venous (dark red, steady flow), Capillary (slow oozing).
• Hemorrhage Control Steps: Direct manual pressure on wound, elevate limb (only if no fracture), apply pressure bandage, check distal capillary refill (<2 sec).
• Bleed-Through Rule: Never remove a blood-soaked dressing; apply a second pad directly on top and maintain pressure.
• Embedded Objects: Never remove an embedded object; stabilize with bulky padding on both sides and bandage around it.
• Tourniquets: Applied 5-7 cm above limb wound (never on joints) for catastrophic arterial bleed; mark application time ("TK 14:30"); never loosen.
• Shock Management: Pale/cold/clammy skin, rapid weak pulse, shallow breathing, thirst; lay flat, elevate legs 15-30 cm (if no trauma), maintain warmth, ZERO food or drink.
• Choking Protocols: Mild = encourage coughing; Severe conscious = 5 back blows alternating with 5 abdominal thrusts (Heimlich); Unconscious = start CPR (30 compressions), check mouth before breaths, never perform blind finger sweep.
• Burn Protocols: Cool with clean running cool/lukewarm water for at least 20 minutes; never use ice, butter, or oils; never pop blisters; cover loosely with clean cling film or non-adherent dressing.