7.2 Bleeding Control, Shock, Fractures & Airway Obstruction

7.2 Bleeding Control, Shock, Fractures & Airway Obstruction

Quick Summary: Severe hemorrhage, traumatic fractures, and acute airway obstructions represent critical emergencies encountered on industrial, commercial, and construction security posts. Security guards must classify bleeding as arterial (bright red, pulsating spurts), venous (dark red, steady profuse stream), or capillary (slow oozing). First-line bleeding control relies on firm direct pressure with sterile dressings and pressure bandages; catastrophic extremity hemorrhage uncontrolled by pressure requires a commercial tactical tourniquet placed 5 to 7 cm proximal to the wound. Prevent hypovolemic shock by elevating legs 15 to 30 cm, maintaining warmth, and strictly withholding oral fluids. For severe conscious choking, execute alternating cycles of 5 back blows and 5 abdominal thrusts, immediately transitioning to CPR if the victim loses consciousness.

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Classification of External Hemorrhage

Hemorrhage is the loss of blood from the vascular system following traumatic tissue disruption. Rapid blood loss diminishes circulating blood volume, starving vital organs of oxygen. Judge urgency by the amount, speed and persistence of bleeding and the casualty’s condition. Do not delay treatment to identify the vessel or assume dark venous blood is a minor injury.

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Tiered Bleeding Control Protocol

When treating traumatic wounds, security officers must follow an aggressive, tiered intervention sequence, prioritizing immediate physical hemostasis.

Step 1: Universal Precautions and PPE

Before contacting blood, the security officer must don nitrile or latex disposable gloves and safety eye protection from the post first aid kit. Protecting against bloodborne pathogens (including Hepatitis B, Hepatitis C, and HIV) is mandatory. If gloves are unavailable in an immediate life-or-death crisis, use a clean plastic barrier or instruct the conscious casualty to apply direct manual pressure over their own wound.

Step 2: Direct Manual Pressure

• Place a sterile absorbent dressing, gauze pad, or clean cotton cloth directly over the bleeding site.
• Apply firm, uninterrupted manual downward pressure using the flat pads of your fingers or the palm of your hand.
• Maintain firm pressure without repeatedly lifting the dressing. For life-threatening limb bleeding that is not controlled, apply a suitable commercial tourniquet promptly if trained; do not wait out a fixed 5–10-minute interval.
• If bleeding originates from an extremity without suspected skeletal fractures, elevating the limb above heart level while applying pressure helps reduce hydrostatic perfusion pressure.

Step 3: Pressure Bandaging

• Secure the sterile dressing firmly in place using a conforming elastic roller bandage or Israeli trauma dressing.
• Wrap the bandage from the distal extremity toward the proximal body (toward the heart) to maintain even tension.
• Ensure the bandage is tight enough to maintain hemostasis without compromising distal circulation.
• Circulatory Check: Immediately check distal neurovascular status by verifying a palpable distal pulse (e.g., radial pulse for arm injuries, dorsalis pedis for leg injuries), skin warmth, and capillary refill time (pressing a fingernail bed; color must return within 2 seconds). If the extremity turns blue, cold, numb, or loses its pulse, the bandage is too tight and must be slightly loosened.
• Maintain Effective Pressure: Keep the original gauze pad on the wound. If needed, add one pad while maintaining firm direct pressure; do not keep stacking absorbent layers. Ongoing life-threatening limb bleeding needs prompt tourniquet escalation, not repeated bandaging.

Step 4: Tactical Tourniquet Application Guidelines

For life-threatening bleeding from an arm or leg not controlled by direct pressure, including traumatic amputation, a trained first aider should promptly apply a suitable commercial tourniquet. Call 998; do not require bright-red spurting or a diagnosed arterial injury. For other life-threatening wounds, continue firm pressure; use wound packing only if trained and appropriate to the wound. A limb tourniquet must not be placed on the neck or trunk.

1. Anatomical Placement: Position the tourniquet band 5 to 7 cm (2 to 3 inches) proximal to the wound (between the injury and the heart).
2. Avoid Joints: NEVER place a tourniquet directly over a joint (elbow or knee). If the wound is located directly below a joint, apply the tourniquet directly above that joint on the upper arm or thigh.
3. Tighten the Windlass: Pull the self-adhering band as tight as possible around the limb before turning the windlass rod. Twist the windlass until the bleeding stops, following the device instructions and practical training.
4. Lock and Secure: Lock the windlass rod firmly inside the plastic windlass clip and secure the Velcro closure strap.
5. Record Application Time: Use an indelible marker to write the exact time of application on the white time strap of the tourniquet or directly on the casualty's forehead (e.g., "T 15:30"). Provide this timestamp directly to arriving Dubai Ambulance paramedics.
6. The Absolute Field Rule: NEVER LOOSEN A TOURNIQUET. Once a tourniquet is applied and locked, it must never be loosened, released, or removed in the field by a first aider. Releasing it can restart life-threatening bleeding. Leave reassessment, release or removal to a healthcare professional under the appropriate clinical protocol; it is not restricted universally to a hospital surgeon.

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Hypovolemic Shock: Pathology, Recognition & Field Management

Shock is a life-threatening physiological state characterized by systemic circulatory collapse, resulting in inadequate cellular perfusion and oxygen delivery to vital organs. In trauma situations, the most common form encountered is Hypovolemic Shock, caused by acute loss of circulating blood volume through severe internal or external hemorrhage.

Clinical Signs and Symptoms of Shock

Security guards must recognize the progressive signs of hypovolemic shock:

• Cardiovascular: Tachycardia (rapid pulse, often >100 bpm) that feels weak and thready; falling systemic blood pressure.
• Integumentary (Skin): Cold, pale, clammy skin; profuse diaphoresis (cold sweats); peripheral cyanosis (bluish tint on lips, earlobes, and nail beds); delayed capillary refill (>2 seconds).
• Respiratory: Tachypnea (rapid, shallow breathing) as the body attempts to compensate for metabolic acidosis.
• Neurological: Extreme anxiety, restlessness, apprehension, agitation, confusion, progressive lethargy, and eventual loss of consciousness.
• Other Indicators: Intense dry thirst, nausea, vomiting, dizziness, and extreme physical weakness.

Field Management Protocol for Hypovolemic Shock

1. Arrest Active Bleeding: Immediately address external hemorrhage using direct pressure or tourniquets. Circulatory support cannot succeed if blood volume continues to leak.
2. Emergency Dispatch: Ensure Dubai Ambulance (998) is dispatched with top priority, specifying that the casualty is in traumatic shock.
3. Maintain Airway and Breathing: Keep the airway open and clear; administer supplemental oxygen if trained and equipped.
4. The Shock Position (Modified Trendelenburg): Lay the casualty flat on their back (supine) on a level surface. Elevate the lower extremities 15 to 30 cm (6 to 12 inches) above the level of the heart, supporting the legs on a folded coat, chair, or equipment box. This uses gravity to pool venous blood from the lower extremities toward the heart, lungs, and brain.
   • Contraindication: DO NOT elevate the legs if the casualty has suspected spinal injuries, pelvic fractures, head trauma, or un-splinted lower leg fractures.
5. Thermal Preservation: Wrap the casualty in a warm blanket, coat, or disposable metallized space blanket. Even in hot UAE climates, shock impairs peripheral vascular vasoconstriction and thermoregulation, causing hypothermia that impairs blood clotting.
6. Strict Prohibition on Oral Intake: NEVER provide oral fluids, water, or food to a casualty in shock, despite complaints of intense thirst. Oral fluids can cause regurgitation and fatal pulmonary aspiration if consciousness declines. Furthermore, trauma casualties frequently require immediate emergency surgery under general anesthesia, which requires an empty stomach.
7. Continuous Monitoring: Reassess the casualty's pulse, breathing rate, and AVPU level every 3 to 5 minutes.

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Musculoskeletal Fractures: Principles of Field Stabilization

A fracture is a structural break or disruption in the continuity of a bone, caused by blunt trauma, falls, or industrial crush impacts.

Types of Fractures

• Closed (Simple) Fracture: The broken bone fragments remain beneath intact skin. While there is no external bleeding, internal hemorrhage and soft-tissue injury can be extensive.
• Open (Compound) Fracture: The broken bone penetrates the skin, or an external wound communicates directly with the fracture site. Open fractures carry extreme risks of catastrophic bacterial infection (osteomyelitis) and severe arterial or venous laceration.

Clinical Presentation

Guards should suspect a fracture if the casualty displays:

• Severe localized pain exacerbated by any attempted movement.
• Obvious physical deformity, shortening, or unnatural rotation of a limb compared to the uninjured side.
• Rapid swelling, edema, and deep ecchymosis (bruising) over the bone.
• Crepitus (a grating or crunching sensation/sound felt or heard when bone ends rub together).
• Loss of distal motor function, numbness, or inability to bear weight.

First Aid Management Rules for Fractures

1. Golden Rule: Support As Found: Never attempt to push protruding bone fragments back beneath the skin, and never attempt to straighten, align, or reduce a deformed fracture. Splint and immobilize the injured bone in the exact abnormal anatomical position in which it was discovered.
2. Manage Open Wounds First: For open fractures, control severe bleeding by applying gentle pressure around the wound perimeter. Cover the exposed bone and wound with a sterile, moist dressing. Do not apply pressure directly onto protruding bone ends.
3. Splinting the Fracture: If trained to apply splints (e.g., SAM splints, rigid wood splints, or anatomical body splinting):
   • Immobilize the joint above and the joint below the fracture site (e.g., for a tibia/fibula fracture, immobilize both the knee and the ankle).
   • Pad rigid splints with soft cloth to avoid pressure necrosis.
   • Secure splints with roller bandages or triangular bandages tied with square knots, avoiding ties directly over the fracture site.
4. Neurovascular Assessment (PMS Check): Always assess Pulse, Motor function, and Sensory response (PMS) distal to the fracture site before applying a splint and immediately after splinting. If the pulse disappears or the foot/hand becomes cold, pale, or numb after splinting, loosen the splint bindings immediately.

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Foreign Body Airway Obstruction (Choking) Protocol

Choking occurs when a foreign object (typically food, chewing gum, or dental appliances) becomes lodged in the larynx or trachea, physically preventing ventilation.

Managing Severe Choking in a Conscious Adult

Call 998 or direct a helper to call while you act. Do not wait for the person to collapse.

1. Deliver 5 Sharp Back Blows:
   • Stand slightly behind and to the side of the choking casualty.
   • Support the casualty's chest firmly with one hand and lean the casualty forward so that if the obstructing object is dislodged, it falls out of the mouth rather than sliding down the airway.
   • Using the heel of your free hand, deliver up to 5 sharp, forceful blows in the middle of the back between the shoulder blades.
   • Check after each individual back blow to see if the obstruction has cleared.
2. Deliver 5 Abdominal Thrusts (The Heimlich Maneuver):
   • If 5 back blows fail to clear the obstruction, stand directly behind the casualty.
   • Wrap both your arms around the casualty's upper abdomen.
   • Lean the casualty slightly forward.
   • Make a firm fist with one hand and place the flat, thumb-side of your fist against the casualty's abdomen, midway between the navel (belly button) and the xiphoid process (lower tip of the breastbone).
   • Grasp your fist firmly with your other hand.
   • Pull sharply inward and upward into the abdomen in a quick, distinct jolt. This thrust pushes the diaphragm upward, compressing air in the lungs to forcefully pop the foreign object out like a cork from a bottle.
   • Deliver up to 5 abdominal thrusts, checking after each thrust.
   • Special Modification: If the person is in late pregnancy or you cannot encircle their abdomen, use chest thrusts instead of abdominal thrusts. Instead, deliver chest thrusts by positioning your hands around the lower sternum (as in chest compressions).
3. Repeat Cycles: Continue alternating between 5 back blows and 5 abdominal thrusts until the foreign object is dislodged or the casualty loses consciousness.

Transition to Unconsciousness

If the choking casualty loses consciousness and collapses:

1. Support the casualty carefully and lower them safely to a flat, firm floor.
2. Immediately shout for an assistant to call Dubai Ambulance (998) and bring an AED.
3. Begin CPR immediately, starting with 30 chest compressions. Compressions increase intrathoracic pressure and can dislodge foreign objects.
4. Before attempting rescue breaths, open the casualty's mouth and LOOK inside: if a foreign object is clearly visible and loose, perform a hooked finger sweep to remove it.
5. NEVER PERFORM A BLIND FINGER SWEEP. Poking blindly into the pharynx can push a partially lodged foreign body deeper into the laryngeal inlet, causing complete irreversible obstruction.
6. Attempt 2 rescue breaths, adjusting the airway after the first ineffective attempt. Do not keep repeating breaths if the chest fails to rise; return promptly to compressions.
7. Resume 30 chest compressions, repeating the cycle with visible-object checks before breaths. Continue until the person responds/breathes normally, professional help takes over, you are exhausted or the scene becomes unsafe. Anyone treated with abdominal thrusts or chest compressions needs medical assessment, even if the obstruction clears.