11.2 Hemorrhage Control, Shock, Fractures & Dislocations

Quick Answer: For life-threatening external bleeding, press hard, pack deep wounds, and apply a commercial tourniquet for a limb bleed that will not stop — high and tight when the wound is not a single visible site, otherwise 2–3 inches above the wound and not over a joint. Write the time. Do not ice-and-elevate an arterial bleed. True knee (tibiofemoral) dislocation = vascular emergency (ankle-brachial index, EMS). Cover open fractures; do not reduce bone through skin.

Task 0303 is not only the cervical spine. The AT who can hold a head but cannot stop a femoral-shaft bleeder still loses the patient. The American College of Surgeons Stop the Bleed program, Committee on Tactical Combat Casualty Care (TCCC) principles adapted to civilian sport, the 2018 NATA position statement on Immediate Management of Appendicular Joint Dislocations (Rozzi et al., JAT 53(12):1117–1128), and standard trauma teaching on shock and compartment syndrome are the sources.

Catastrophic external bleeding

Bleeding is the leading cause of preventable death after injury. After scene safety and gloves (OSHA bloodborne precautions from Chapter 9), the AT uses the same three actions Stop the Bleed teaches bystanders, executed at a clinical level:

1. Direct pressure. Use gauze or a gloved hand. Stack dressings; do not peel the first layer off a clot. Body weight is allowed on a groin or axillary pack. Hold continuous pressure — peeking every few seconds restarts the bleed.
2. Wound packing. Junctional wounds (groin, axilla, neck base) and deep muscular cavities cannot take a limb tourniquet. Pack hemostatic or plain gauze to bone, then press. Neck packing is directed pressure that does not encircle the neck like a tourniquet.
3. Tourniquet for a life-threatening limb bleed: bright red spurting, a pooling blood volume, an amputation, or a wound that soaks dressings as fast as they go on.

Tourniquet rules the exam actually tests

• Placement. ACS Stop the Bleed / civilian first aid: 2–3 inches (about 5–7.5 cm) proximal to a single visible wound, not over a joint. High and tight (as proximal as possible on the limb, against the skin) is the fail-safe when the wound is under equipment, there are multiple wounds, the limb is mangled, or you cannot see the exact site — the same idea TCCC uses under fire. In sport, high-and-tight is also correct when you must stop bleeding now and will not delay for a perfect measurement.
• Application. Strap tight before the windlass. Twist until bleeding stops and the distal pulse is gone. Secure the windlass. A second tourniquet goes above the first if bleeding continues. Do not place it over a cargo pocket full of keys or over a football thigh pad — get it on skin.
• Time. Note the time on the tourniquet, a marker on the forehead, or the handoff report. Do not loosen every 15 minutes “to let the limb breathe.” Conversion or down-titration is a hospital or EMS decision.
• What a tourniquet is not for. It does not treat a scalp laceration, a solid-organ bleed, or a junctional wound. Those get pressure, packing, and a pelvic binder or surgery.

Exam trap: ice-and-elevate a tourniquet-level arterial bleed. Elevation and a cold pack are adjuncts for routine soft-tissue bleeding after the life threat is gone. They are not the algorithm for spurting femoral or brachial hemorrhage. Delaying a tourniquet to “try RICE first” is how people exsanguinate on a track.

Shock — four buckets, two skin colors

Shock is inadequate end-organ perfusion. The AT does not need a pulmonary-artery catheter; the AT needs skin, pulse, blood pressure, and mechanism.

The comparison the exam loves: a femur-fracture bleeder is pale and tachycardic. A newly quadriplegic athlete can be hypotensive and bradycardic with warm skin. Treating neurogenic shock as “just give more fluids and raise the legs” misses the cord and the airway.

Pelvic binder

An unstable pelvic ring (high-energy hit, instability on gentle compression, shock without a visible limb bleed) can hide liters of retroperitoneal blood. A commercial binder or a sheet is centered over the greater trochanters, then tightened. Binding over the iliac crests is the common error — it does not close an open-book pelvis and can worsen displacement. If groin access is needed later, the binder can be shifted down the thighs and the feet internally rotated/taped. Binders do not replace a tourniquet on a femoral wound.

Open fractures

Bone ends that pierce skin are open (compound) fractures. Sideline jobs:

• Control bleeding with pressure around, not into, the bone spike.
• Cover with a sterile dressing (saline-moistened if that is the local protocol).
• Do not reduce bone back through the skin as a convenience move. The exception — and it is narrow — is a limb that is neurovascularly dead (no pulse, pale, insensate) and a directing-physician protocol that authorizes one attempt to restore length/alignment to save the limb. That is not a coach request and it is not “so the athlete looks better for parents.”
• Neurovascular exam before and after any move or splint.
• EMS. Tetanus and antibiotics are hospital care; the AT documents the time, the wound, and the NV status.

Dislocations — NATA 2018, applied on the field

Rozzi et al. (2018) require state-practice-act compliance, written physician standing orders, consent, and a documented neurovascular exam before and after every attempt. Reduction is not entry-level improvisation. If there are signs of fracture, do not reduce onsite. Open physes (adolescents can remain open into the early 20s) raise the fracture risk; NATA 2018 is conservative there except for patella.

Patellofemoral. Usually lateral. Diagnosis is usually obvious. Under physician direction, an AT can reduce an acute patellar dislocation; multiple attempts are not recommended. Osteochondral fracture is common, so reduction is atraumatic, then immobilize and image. This is the dislocation that is “often reducible.”

Glenohumeral (shoulder). Under physician direction, an AT can reduce a first-time or recurrent anterior dislocation when the diagnosis is obvious. Do not reduce if a fracture or posterior dislocation is suspected (seizure, electric shock, locked internal rotation). Multiple attempts are not recommended. After reduction: NV exam (axillary and musculocutaneous nerves), sling, radiographs. Reduce only if trained, protocolized, and there is no fracture suspicion.

Humeroulnar / elbow. Onsite reductions should not be attempted in most cases — associated fractures and neurovascular risk (brachial artery, median and ulnar nerves) are high. If EMS will be delayed and there is no fracture or NV damage, a physician-directed single attempt may be considered. Otherwise splint in the position found and go.

Femoroacetabular (hip). Rare in sport, high-energy. NATA 2018 allows a physician-directed attempt because delayed reduction raises concern for femoral-head ischemia, but fracture is common, sciatic-nerve injury is common, and radiographs are always required. Not a casual sideline pop.

Tibiofemoral (true knee) dislocation. This is the limb-threat. Popliteal-artery injury is reported in a wide range (on the order of 10–64% in the dislocation literature NATA 2018 cites). The peroneal nerve is tethered at the fibular head. Many dislocations spontaneously reduce and present only as a multi-ligament knee — treat those as a dislocation until proven otherwise.

Do not casually reduce a knee dislocation. NATA 2018 allows a physician-directed onsite reduction because prolonged disarticulation can keep the artery stretched, but the BOC-relevant behavior is: this is a vascular emergency, not a “put it back in and tape it” injury. Check popliteal, dorsalis pedis, and posterior tibial pulses and neurologic function before and after. A palpable pulse does not exclude intimal arterial injury. After any reduction (or if already reduced), obtain an ankle-brachial index (ABI) — ankle systolic pressure divided by brachial systolic pressure. ABI < 0.9 is abnormal and warrants urgent vascular imaging. Activate EMS immediately. Splint at about 20–30° of flexion if the joint will accept that position.

Splinting and compartment syndrome

Neurovascular check before and after every splint, reduction, or board. If the limb resists being straightened, splint in the position found. Straightening a fracture through a neurovascular bundle to make a board look textbook is malpractice on an exam item.

Compartment syndrome (leg, forearm, foot, thigh after fracture, crush, or reperfusion): tissue pressure exceeds perfusion. The 6 Ps:

1. Pain out of proportion, and pain on passive stretch of the compartment muscles — earliest and most reliable
2. Paresthesia
3. Pallor
4. Paralysis (late)
5. Pulselessness (late and often absent — do not wait for it)
6. Poikilothermia (the limb is cool)

A tight cast, wrap, or unused tourniquet can create the same emergency. Remove constricting gear, keep the limb at heart level (not high elevation), and emergency fasciotomy is surgical. The AT’s job is recognition and EMS, not waiting for a pulseless foot.

Exam trap: treating a spurting thigh wound with ice, elevation, and a “wait and see” ACE wrap, or reducing a tibiofemoral dislocation in the huddle because the patella “always goes back.”