5.4 Severe Bleeding, Shock Management & Wound Care

5.4 Severe Bleeding, Shock Management & Wound Care

Core Principle: Acute hemorrhage is the leading cause of preventable trauma death in maritime accidents. Controlling massive arterial blood loss within the first two minutes and aggressively countering the lethal triad of trauma (hypothermia, acidosis, coagulopathy) is essential to preserve life at sea.

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1. Hemorrhage Classification & Pathophysiology

The average adult human body contains approximately 5 liters of blood (roughly 70 mL per kg of body mass). Acute loss of 1 liter (20%) induces clinical shock, while rapid loss of 1.5 to 2 liters (30–40%) causes catastrophic cardiovascular collapse and fatal organ hypoperfusion.

                      VESSEL HEMORRHAGE CHARACTERISTICS

     ARTERIAL BLEEDING           VENOUS BLEEDING          CAPILLARY BLEEDING
     • Bright red (oxygenated)   • Dark red (deoxygenated) • Brick red / mixed
     • Pulsating / spurting      • Steady, rapid flowing   • Slow, oozing drip
     • High pressure             • Low / medium pressure   • Very low pressure
     • Lethal in 60-120 seconds  • Serious volume loss     • Minor; clots easily

Detailed Hemorrhage Profiles

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2. The Hemorrhage Control Escalation Ladder

When managing severe external bleeding, mariners must execute an aggressive, stepped protocol based on the location and severity of the wound.

                     HEMORRHAGE CONTROL ESCALATION LADDER

    [STEP 1: DIRECT PRESSURE]     ──► Continuous firm manual pressure with sterile pad
                 │
    [STEP 2: PRESSURE BANDAGE]    ──► Elastic bandage with built-in pressure bar / knot
                 │
    [STEP 3: WOUND PACKING]       ──► For junctional wounds (groin/axilla): Pack cavity
                                      with hemostatic gauze + hold 3 min manual pressure
                 │
    [STEP 4: ARTERIAL TOURNIQUET] ──► For extremity arterial spurting: Deploy CAT
                                      5-7 cm proximal to wound; tighten windlass

Step-by-Step Tactical Bleeding Interventions

1. Direct Manual Pressure

• Place a sterile dressing (or cleanest available cloth) directly over the bleeding site.
• Apply firm, continuous direct pressure with both hands, using your body weight.
• Maintain unbroken pressure for at least 5 to 10 minutes before checking the wound.

2. Pressure Bandage Application

• Apply an elastic compression bandage (such as an Israeli Emergency Bandage) firmly over the dressing.
• Route the bandage through the pressure bar or tie a firm knot directly over the wound site to exert localized mechanical pressure.
• Neurovascular Check: Verify distal pulse, skin color, and capillary refill (<2 sec) to ensure the bandage does not act as an unintended venous tourniquet.

3. Junctional Wound Packing (Groin, Axilla, Neck Base)

• Junctional zones represent the anatomical transitions where extremities meet the torso; standard tourniquets cannot be applied here.
• Expose the wound and rapidly clear away pooled blood clots.
• Insert hemostatic gauze (e.g., kaolin-impregnated QuikClot or chitosan-impregnated Celox) into the depth of the wound cavity, packing tightly directly against the severed bleeding vessel.
• Pack the cavity completely until gauze extends above the skin surface, then apply unbroken manual pressure for a full 3 minutes (or 5 minutes if using non-hemostatic plain gauze).
• Secure with a tight pressure wrap.

4. Combat Application Tourniquet (CAT) Deployment

                     CAT TOURNIQUET DEPLOYMENT PROTOCOL

  1. PLACEMENT      ──► 5 to 7 cm (2 to 3 inches) proximal to wound (NEVER on joint)
  2. TIGHTENING     ──► Pull band fully tight; turn windlass until spurting & pulse STOP
  3. LOCKING        ──► Secure windlass rod in clip; route remaining band across clip
  4. DOCUMENTATION  ──► Write exact time (e.g., "TK 14:35") on time strap & forehead
  5. CRITICAL RULE  ──► NEVER LOOSEN OR REMOVE without direct medical supervision

• Indications: Severe, life-threatening extremity arterial bleeding, traumatic amputations, or catastrophic blast injuries where direct pressure fails.
• Positioning: Place the tourniquet 5 to 7 cm (2 to 3 inches) proximal (above) the wound on bare skin. If the exact bleeding source cannot be visualized in low light/smoky spaces, place it "high and tight" at the root of the limb.
• Avoid Joints: Never apply a tourniquet directly over a joint (elbow or knee), as underlying bones shield the brachial or popliteal arteries from complete compression.
• Tightening: Rotate the windlass rod until all bright red arterial bleeding ceases AND the distal arterial pulse is obliterated.
• Marking: Record the exact time of application directly on the tourniquet's white time band and write "TK" and the time (e.g., "TK 14:35") on the casualty's forehead with an indelible marker.
• Strict Prohibitions: NEVER loosen, release, or remove a tourniquet once applied. Loosening a tourniquet releases lethal metabolic toxins (lactic acid, potassium, myoglobin) into systemic circulation, causes sudden rebound hemorrhage, and precipitates fatal cardiovascular collapse. Only a physician or authorized medical officer can remove a tourniquet under controlled conditions.

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3. Shock Classification & Pathophysiology

Shock is defined as widespread inadequate tissue perfusion resulting in cellular hypoxia, energy production failure (shift from aerobic to anaerobic metabolism), lactic acidosis, and multi-organ failure.

                            THE FIVE TYPES OF SHOCK

  HYPOVOLEMIC SHOCK     CARDIOGENIC SHOCK    ANAPHYLACTIC SHOCK   SEPTIC SHOCK    NEUROGENIC SHOCK
  • Massive blood loss  • Acute MI / pump    • Severe allergic    • Overwhelming  • Spinal cord injury;
  • Severe plasma loss    failure              reaction             bacterial       loss of vasomotor
    from burns          • Fatal arrhythmias  • Massive histamine    infection       sympathetic tone
  • Dehydration         • Blunt cardiac        release & airway   • Systemic      • Hypotension with
                          contusion            edema                vasodilation    bradycardia

Clinical Stages of Hypovolemic Shock

                          STAGES OF HYPOVOLEMIC SHOCK

    COMPENSATED SHOCK        ──► Normal BP, tachycardia (>100 bpm), pale/clammy skin
          │
    DECOMPENSATED SHOCK      ──► Hypotension (systolic <90), marked tachycardia (>120),
          │                      delayed cap refill (>2s), tachypnea, confusion
    IRREVERSIBLE SHOCK       ──► Profound hypotension, bradycardia, multi-organ death

Clinical Manifestations of Shock

• Cardiovascular: Rapid, weak, thready pulse (tachycardia); progressive hypotension (narrowed pulse pressure followed by systolic drop below 90 mmHg); delayed capillary refill time (>2 seconds).
• Integumentary (Skin): Pale, cold, clammy skin; profuse diaphoresis (sweating); peripheral cyanosis (blue/grey lips and nail beds).
• Respiratory: Rapid, shallow respirations (tachypnea) as the body attempts to compensate for metabolic lactic acidosis.
• Neurological: Initial anxiety and restlessness transitioning into disorientation, lethargy, confusion, and eventual coma.
• Gastrointestinal: Intense thirst, dry mucous membranes, nausea, and vomiting.

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4. Emergency Management of Shock

Stabilizing a casualty in shock requires systematic interventions to preserve core organ perfusion and combat the lethal triad of trauma.

                     EMERGENCY SHOCK STABILIZATION PROTOCOL

  1. ARREST HEMORRHAGE   ──► Apply direct pressure, wound packing, or CAT tourniquet
  2. SHOCK POSITION      ──► Supine with lower extremities elevated 15–30 cm (6–12 in)
  3. PREVENT HYPOTHERMIA ──► Thermal blankets, insulate from cold steel deck
  4. HIGH-FLOW OXYGEN    ──► 10–15 L/min via Non-Rebreather Mask
  5. STRICT NPO STATUS   ──► Nil per os (NEVER give oral food, water, or alcohol)

Critical Shock Interventions

1. The Shock Position (Modified Trendelenburg)

• Lay the casualty flat on their back (supine) and elevate the lower extremities 15 to 30 cm (6 to 12 inches).
• Physiological Rationale: Elevating the legs promotes gravity-assisted venous return of pooled blood from the lower extremities back to the heart and core organs (providing an autotransfusion of ~300–500 mL of blood).
• Contraindications: Do NOT elevate the legs if the casualty has:
  • Suspected cervical or thoracic spinal fractures
  • Pelvic fractures or fractured lower extremities
  • Head injuries (increases intracranial pressure)
  • Severe chest trauma or pulmonary edema (worsens dyspnea)

2. Thermoregulation & The Lethal Triad

The Lethal Triad of Trauma consists of Hypothermia, Coagulopathy (impaired blood clotting), and Metabolic Acidosis. When a casualty's core body temperature drops below 35°C (95°F), the body's clotting enzymes are severely inhibited, accelerating uncontrolled internal and external hemorrhage.

• Remove all wet clothing immediately.
• Wrap the casualty in dry thermal space blankets or wool blankets.
• Place insulating foam mats or blankets between the casualty and the cold steel deck plates.

3. Strict NPO Status (Nil Per Os - Nothing by Mouth)

Casualties in shock frequently complain of extreme, burning thirst due to hypovolemia.

• NEVER administer oral water, fluids, or food under any circumstances.
• Risks: Oral fluids induce immediate vomiting due to depressed gastrointestinal motility in shock, leading to fatal pulmonary aspiration. Furthermore, oral intake delays emergency surgical anesthesia.
• Remedy: Moisten the casualty's lips with a damp gauze pad to relieve dryness without swallowing.

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5. Wound Care, Impaled Objects & Traumatic Amputations

• Impaled Objects: Never remove an impaled object (knife, metal shard, shrapnel) lodged in a casualty. Removing the object relieves direct tamponade on underlying severed vessels, causing catastrophic hemorrhage. Stabilize the object in place using bulky rolled dressings secured with tape/bandages.
• Traumatic Amputations:
  • Control stump hemorrhage immediately using a CAT tourniquet.
  • Retrieve the amputated body part (finger, hand, foot).
  • Wrap the severed part in sterile gauze moistened with sterile saline.
  • Place the wrapped part into a clean, waterproof plastic bag and seal it.
  • Place the sealed bag into a container filled with an ice-and-water slurry.
  • Prohibition: NEVER place an amputated part directly in water, and NEVER place it directly on dry ice or bare ice cubes (which causes irreversible freeze necrosis).