4.2 Protocol 21: Hemorrhage / Lacerations

4.2 Protocol 21: Hemorrhage / Lacerations

Quick Answer: Protocol 21 grades external blood loss on a precise MPDS vocabulary. Arterial spurting, pooling blood, or rapidly soaking through multiple heavy towels is DANGEROUS hemorrhage — 21-D-4 (DELTA); SERIOUS hemorrhage is 21-B-2 (BRAVO); POSSIBLY DANGEROUS hemorrhage is 21-B-1; and NOT DANGEROUS or MINOR hemorrhage is 21-A-1 / 21-A-2. Protocol 21's DELTA codes are 21-D-1 Arrest, 21-D-2 Unconscious, 21-D-3 Not alert, 21-D-4 DANGEROUS hemorrhage, and 21-D-5 Abnormal breathing. Patients taking blood thinners (e.g., warfarin or direct oral anticoagulants) face rapid decompensation because normal clotting mechanisms are medically inhibited. The foundational dispatch life support instruction is continuous direct pressure: press down firmly with a clean cloth, and never remove soaked dressings, as doing so strips away early platelet plugs. For catastrophic limb hemorrhage, coach the application of a commercial tourniquet placed 2 to 3 inches above the wound; for junctional bleeding (groin, armpit, neck), coach deep wound packing with manual compression.

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1. Protocol 21 Assessment Architecture: Serious vs. Minor Bleeding

Exsanguinating hemorrhage is the leading cause of preventable trauma death worldwide. When a major artery or vein is lacerated, total circulatory collapse can occur in as little as 90 to 180 seconds. Within the MPDS framework, Protocol 21: Hemorrhage / Lacerations provides rapid clinical discrimination to identify life-threatening blood loss during Case Entry and Key Questions.

Clinical Determinants of Serious Hemorrhage

The EMD must actively screen for signs of DANGEROUS hemorrhage (DELTA 21-D-4) by analyzing the caller's descriptions:

1. Arterial Spurting: Blood exiting under pulsatile systolic pressure, described as "squirting," "spraying," or "shooting across the room." Arterial lacerations cannot form spontaneous clots without external mechanical occlusion.
2. Rapid Pooling: Blood accumulating rapidly on the floor, forming a widening puddle measured in feet rather than inches within seconds.
3. Saturation Velocity: Rapidly soaking through multiple thick bath towels, heavy denim work pants, or bulky winter coats in under one to two minutes.
4. Hemodynamic Instability: In advanced hemorrhagic shock, callers report systemic hypoperfusion signs: profound pallor, cold/diaphoretic skin, confusion, combativeness, or loss of consciousness.

+-------------------------------------------------------------------------+
|                     HEMORRHAGIC SHOCK PHYSIOLOGY                        |
|                                                                         |
|   Class I (<15% loss):   Compensated; normal BP; slight tachycardia     |
|   Class II (15-30% loss):Tachypnea; narrowed pulse pressure; anxiety    |
|   Class III (30-40% loss):Decompensated; marked hypotension; confusion  |
|   Class IV (>40% loss):  Lethal triad; imminent circulatory collapse    |
+-------------------------------------------------------------------------+

Minor Bleeding Characteristics

Minor bleeding (categorized under ALPHA 21-A-1 (NOT DANGEROUS hemorrhage) or 21-A-2 (MINOR hemorrhage), with BRAVO 21-B-1 (POSSIBLY DANGEROUS hemorrhage) one step above) encompasses capillary oozing or low-pressure venous seepage from superficial abrasions or clean lacerations where blood slowly trickles and coagulates readily under simple light pressure.

The Lethal Triad of Trauma

Uncontrolled hemorrhage triggers a lethal physiological feedback loop known as the trauma triad of death:

• Hypothermia: Loss of circulating red blood cells diminishes tissue perfusion and metabolic heat production, dropping core body temperature.
• Metabolic Acidosis: Anaerobic metabolism produces massive lactic acid accumulation, lowering serum pH.
• Coagulopathy: Enzymes in the coagulation cascade become dysfunctional below 35°C (95°F) and in acidic environments. Blood loses its ability to clot, creating catastrophic spontaneous bleeding even from undamaged microvessels.

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2. Anticoagulant and Antiplatelet Vulnerabilities

A critical factor in prehospital bleeding triage is whether the patient is taking prescription blood-thinning medications.

Pharmacological Classes and Hemostatic Disruption

• Vitamin K Antagonists: Warfarin (Coumadin) inhibits hepatic synthesis of clotting factors II, VII, IX, and X, drastically prolonging the International Normalized Ratio (INR).
• Direct Oral Anticoagulants (DOACs): Agents such as apixaban (Eliquis), rivaroxaban (Xarelto), and dabigatran (Pradaxa) directly inhibit Factor Xa or thrombin, preventing fibrin clot maturation.
• Antiplatelet Agents: Clopidogrel (Plavix), ticagrelor (Brilinta), and chronic high-dose aspirin permanently inhibit platelet aggregation for the lifespan of the platelet.

Dispatch Implications

In an anticoagulated patient, the normal physiological clotting response is absent. A seemingly innocuous injury—such as a small scalp laceration, a kitchen paring knife cut, a ruptured arteriovenous (AV) dialysis fistula, or a nosebleed (epistaxis)—can cause continuous, uninhibited blood loss culminating in fatal hemorrhagic shock. When a caller confirms anticoagulant therapy, the EMD must maintain high clinical suspicion and treat persistent bleeding with elevated dispatch priority.

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3. Direct Pressure Coaching and Dressing Mechanics

The cornerstone of Dispatch Life Support for bleeding control is scripted, continuous manual direct pressure.

Scripted Direct Pressure Instructions

The EMD must instruct the caller in clear, authoritative language:

"Listen carefully: Get a clean dry cloth or towel. Place it directly over the wound and press down hard and continuously with both hands." "Do not let go, and do not lift the cloth to look. Keep pressing down as hard as you can until the paramedics take over."

                    CARDINAL DIRECT PRESSURE RULE:
       "NEVER remove or lift the initial cloth to check the wound!
            Removing soaked dressings tears away fresh clots.
             Place new cloths directly ON TOP and press harder!"

The Fatal Error of Dressing Removal

Lay callers instinctively want to lift the cloth every 30 seconds to see if the wound is still bleeding. The EMD must explicitly forbid this action. Hemostasis relies on an unstable, microscopic mesh of aggregated platelets and fragile fibrin strands. Peeling away the cloth rips this biological plug directly off the lacerated vessel, re-initiating full-volume hemorrhage. If blood saturates the initial dressing, the caller must be coached to apply additional cloths directly over the saturated material and increase compressive force.

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4. Wound Packing for Junctional Hemorrhage

While extremity wounds can be managed with commercial tourniquets, bleeding occurring at the anatomical junctions of the body cannot be compressed with a circumferential band.

Anatomical Junctional Zones

1. Inguinal Crease (Groin): Lacerations involving the femoral artery or vein.
2. Axillary Fossa (Armpit): Lacerations involving the axillary vasculature.
3. Cervical Base (Neck): Carotid artery or internal jugular vein lacerations.

Dispatch Coaching for Wound Packing

When severe bleeding originates from a junctional cavity where direct surface pressure fails, the EMD provides step-by-step wound packing instructions:

• Direct the caller to take clean gauze, a clean towel, or cloth strips.
• Instruct them to pack the cloth deep into the cavity of the wound, feeding it tightly until the entire wound cavity is firmly filled.
• Coach the caller to place both hands over the packed material and lean their full upper-body weight directly onto the wound, maintaining unrelenting manual compression.

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5. Commercial Tourniquets vs. Improvised Devices

Traumatic amputations, blast injuries, and severe extremity arterial lacerations often require immediate vascular occlusion to prevent death within minutes.

                       [Traumatic Extremity Hemorrhage]
                                      |
                     Does blood SPURT or POOL uncontrollably?
                                      |
                 +--------------------+--------------------+
                 |                                         |
                YES                                        NO
                 |                                         |
     [LIFE-THREATENING BLEED]                     [CONTROLLED / MINOR]
                 |                                         |
     Is a Commercial Tourniquet                   Apply Direct Pressure
     available on scene?                          with Clean Cloth
                 |                                         |
        +--------+--------+                       Does blood soak through?
        |                 |                                |
       YES                NO                      +--------+--------+
        |                 |                       |                 |
    Apply C-A-T /     IMPROVISED DEVICES         YES                NO
    SOFTT 2-3"        STRICTLY DISCOURAGED!       |                 |
    above wound;      Apply intense, two-handed  Add more cloths   Maintain
    tighten windlass  continuous DIRECT PRESSURE on top & press    steady
    until bleed stops directly over wound         harder            pressure

Commercial Tourniquets (C-A-T, SOFTT)

When a factory-manufactured commercial tourniquet (such as a Combat Application Tourniquet or SAM XT) is present on scene, the EMD guides the caller through precise deployment:

1. Placement: Position the tourniquet around the injured limb 2 to 3 inches proximal (above) the bleeding site. Never place a tourniquet directly over a joint (elbow or knee); if the wound is just below a joint, place the tourniquet above the joint.
2. Initial Slack Removal: Pull the self-adhering band as tight as possible before turning the windlass rod. (Failing to pull the strap tight initially is the most common cause of tourniquet failure).
3. Windlass Tightening: Twist the windlass rod until bright red arterial bleeding stops and the distal pulse vanishes.
4. Locking & Timing: Secure the windlass rod into the clip, fasten the strap over it, and record the exact time of application.

The Danger of Improvised Tourniquets

Public folklore encourages using belts, neckties, rope, or shoestrings as makeshift tourniquets. IAED protocols strictly discourage improvised tourniquets:

• Insufficient Width and Pressure: Belts and shoestrings are too narrow and lack the mechanical advantage of a windlass rod. They produce severe focal tissue and nerve necrosis without exerting enough circumferential pressure to occlude high-pressure deep arteries.
• The Venous Tourniquet Catastrophe: An improvised device frequently exerts enough pressure to collapse low-pressure veins (blocking venous return) while leaving high-pressure arterial inflow patent. This perversely increases hydrostatic pressure at the wound, dramatically accelerating blood loss.
• Protocol Directive: Unless the caller has a legitimate commercial tourniquet, the EMD must direct them to focus 100% of their effort on aggressive, continuous manual direct pressure.

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6. Comparative Triage Matrix: Protocol 21 Hemorrhage Management

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7. Realistic Dispatch Dialogue: Arterial Hemorrhage Control

EMD:        "9-1-1, what is the address of the emergency?"
CALLER:     "12 Cedar Ridge Road! Please hurry! My son cut his arm with a circular saw!"
EMD:        "What is the phone number you're calling from?"
CALLER:     "555-0821!"
EMD:        "Okay, tell me exactly what happened."
CALLER:     "The saw kicked back and cut deep into his forearm! Blood is shooting everywhere!"
EMD:        [RECOGNIZES DANGEROUS HEMORRHAGE -> LAUNCHES DELTA 21-D-4 RESPONSE]
            "Is he awake?"
CALLER:     "Yes, but he's pale and shaking!"
EMD:        "Is he breathing normally?"
CALLER:     "Yes, he's breathing!"
EMD:        "Paramedics are on the way. Listen carefully: Do you have a first aid kit with a
            commercial tourniquet in your workshop?"
CALLER:     "No, I don't have a tourniquet! Should I use my leather belt?"
EMD:        "No, do not use a belt. Belts do not stop the bleeding and can make it worse.
            Listen to me: Grab a clean towel right now. Fold it over, put it directly on top of the
            cut, and push down hard with both hands. Put your whole body weight into it."
CALLER:     "Okay, I'm pushing down as hard as I can!"
EMD:        "Hold that pressure continuous and firm. Do not lift the towel to check on the cut.
            Even if blood comes through the towel, keep pressing and put another towel right on top.
            I am staying on the line with you until the paramedics walk through your door."