3.2 Bleeding Control & Wound Management
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
Hemorrhage is the number-one preventable cause of trauma death. Rapid identification and control of life-threatening bleeding is one of the most heavily tested EMT skills. The national Stop the Bleed campaign teaches that bleeding control is a skill everyone should have, and EMTs must perform it flawlessly and in the correct order.
Types of Bleeding
| Characteristic | Arterial | Venous | Capillary |
|---|---|---|---|
| Color | Bright red | Dark red | Red |
| Flow | Spurts with each heartbeat | Steady, even flow | Slow oozing |
| Pressure | High | Low | Very low |
| Control | Most difficult | Moderate | Easiest (often self-limiting) |
| Risk | Life-threatening; rapid loss | Can be serious from large veins | Rarely dangerous |
The bright red, pulsatile quality of arterial blood reflects oxygenated blood under systolic pressure. Recognizing arterial bleeding tells you to skip ahead in the control sequence and move quickly toward a tourniquet if direct pressure fails.
Blood Volume and Hemorrhage Classification
The average adult has approximately 5-6 liters of circulating blood (about 70 mL/kg). Losing more than roughly 20% produces clear signs of shock. The four-class system below comes from the trauma literature and is a frequent test reference. Note that blood pressure stays normal until Class III because the body compensates with tachycardia and vasoconstriction first; do not wait for hypotension to recognize serious bleeding.
| Class | Blood Loss | Heart Rate | Blood Pressure | Mental Status |
|---|---|---|---|---|
| Class I | Up to 15% (~750 mL) | Normal | Normal | Alert, mildly anxious |
| Class II | 15-30% (~750-1500 mL) | >100 | Normal (narrowing pulse pressure) | Anxious |
| Class III | 30-40% (~1500-2000 mL) | >120 | Decreased | Confused, anxious |
| Class IV | >40% (>2000 mL) | >140 | Markedly decreased | Lethargic, obtunded |
Bleeding Control Sequence
Step 1 - Direct Pressure. Apply firm, direct pressure with a gloved hand and sterile gauze. Hold continuous pressure; do not lift the dressing to peek, because that disrupts the forming clot. Direct pressure controls the large majority of external bleeding.
Step 2 - Pressure Dressing. Once direct pressure controls the bleed, wrap firmly with roller gauze to maintain compression, then check distal pulses to confirm you have not occluded arterial flow.
Step 3 - Wound Packing. For deep wounds in junctional zones (groin, axilla, neck) where a tourniquet cannot be placed, pack the wound tightly with plain or hemostatic gauze, pressing gauze directly onto the bleeding vessel, then hold firm pressure on top for at least 3 minutes.
Step 4 - Tourniquet. For life-threatening extremity hemorrhage not controlled by pressure, apply a commercial tourniquet high and tight (2-3 inches proximal to the wound, or as high as possible on the limb), tighten until bright bleeding stops and the distal pulse disappears, and write the time of application on the device. Modern guidance has reversed the old fear of tourniquets: they are safe for the several hours of a typical prehospital interval and save lives. Do not loosen or remove a tourniquet once placed; apply a second tourniquet just above the first if one does not control the bleeding.
Hemostatic Agents
Hemostatic dressings such as QuikClot Combat Gauze and Celox are impregnated with agents that accelerate clotting. At the EMT level they are used with wound packing: pack the hemostatic gauze directly into the wound and hold firm pressure for at least 3 minutes. Follow local protocol for the specific approved product.
Types of Wounds
- Abrasion - superficial scraping (road rash); painful but rarely serious bleeding.
- Laceration - jagged tear; can bleed freely if it crosses a vessel.
- Incision - clean, smooth cut from a sharp edge.
- Puncture - small entry, potentially deep; high infection risk; assess for an exit wound.
- Avulsion - flap of tissue torn loose; if still attached, replace it in anatomic position and dress.
- Amputation - control bleeding (tourniquet if needed), wrap the amputated part in moist sterile gauze, seal it in a plastic bag, and keep it cool next to ice rather than directly on ice (direct ice causes frostbite that prevents reattachment).
Impaled Objects
Do not remove impaled objects in the field. Stabilize the object in place with bulky dressings; it may be tamponading a vessel, and removal can unleash uncontrolled hemorrhage. Exceptions where removal is appropriate are objects in the cheek (airway threat) and objects that physically prevent CPR.
Internal Bleeding
Internal bleeding is invisible and must be suspected from mechanism and clinical signs: tachycardia (early), hypotension (late), a rigid/tender/distended abdomen, Grey Turner sign (flank bruising) or Cullen sign (periumbilical bruising), shock signs (pale, cool, diaphoretic skin), blood from orifices, hematemesis, or melena. Management is to treat for shock, give high-flow oxygen, keep the patient warm, and transport rapidly while alerting the receiving facility.
Shock Recognition and the Bleeding Patient
Uncontrolled bleeding leads to hypoperfusion (shock), so the EMT must read shock signs while controlling the source. Compensated shock is the body fighting to maintain perfusion: anxiety or restlessness, tachycardia, tachypnea, pale/cool/clammy skin, delayed capillary refill, and a narrowing pulse pressure - all while the systolic blood pressure is still normal. Decompensated shock appears when compensation fails: a falling blood pressure, declining mental status, and a weak or absent radial pulse. Because hypotension is a late finding, treating only when the pressure drops is treating too late.
Positioning, Warmth, and the Lethal Triad
Keep the bleeding patient warm. Trauma patients are prone to the lethal triad of hypothermia, acidosis, and coagulopathy - and a cold patient clots poorly, which makes bleeding worse. Remove wet clothing, cover with blankets, and warm the patient compartment. The historic routine "Trendelenburg" (head-down) position is no longer recommended; keep the patient supine, treat the cause, and expedite transport. The definitive treatment for serious hemorrhage is surgery and blood products at the hospital, so the most life-saving EMT decision is often rapid transport to an appropriate trauma center.
Tourniquet Conversion and Documentation Pitfalls
Once applied, a tourniquet stays on; EMTs do not loosen or "convert" tourniquets in the field - that is a hospital decision. Document the exact time of application clearly (many services write the time on the device and note it on the patient care report). A common exam trap is choosing to elevate the limb or apply pressure points instead of moving to a tourniquet for clearly life-threatening, spurting extremity hemorrhage; pressure points and elevation are not reliable and should not delay a tourniquet.
Another trap is hesitating to use a tourniquet out of fear of limb loss - current evidence shows tourniquets left in place for the typical prehospital time are safe and save lives.
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