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Bleeding

Bleeding and blood loss 3Forward / introduction 2Haemostatic dressings 14Haemostatic dressing use 15Hypovolaemic shock 4Serious bleeding 2Tourniquet 5Tourniquet application 7Tourniquet‐Improvised 9Tourniquet position 10Tourniquet summary 12ControlSeriousBleedingofSafety Publishing LtdPlease note, the booklet contains483 Green Lanes LondonN13 4BSinfo@safetypublishing.co.ukwww.safetypublishing.co.uk©2016 Safety Publishing Ltd. All rights reserved. No part of this publication may be reproduced in any form or byany means without the written permission of Safety Publishing Ltdgraphic images of serious injury.Please be aware of this before usingthe booklet.

Uncontrolled bleeding has been identified as the leading cause of potentiallypreventable death following accidental injury. The effects of losing large volumes ofblood may be very complex and might include the mechanical problems associatedwith reduced circulating blood volume (hypovolaemic / haemorrhagic shock) and alsoreduced clotting ability of the remaining blood due to complex chemical changes.People who suffer these changes are more likely to have significantly increased riskof multiple organ failure and death.The treatment of massive blood loss is also extremely complex but it has been shownthat the simplest way to minimise the damage is to minimise the loss of blood bycontrolling the bleeding in the first instance.Bleeding is usually controlled by the blood’s tendency to congeal or clot.This can be encouraged by slowing down the flow of blood to allow it to happen andthe simplest way of doing this is the application of direct pressure.If bleeding is so severe that this does not work then other means may be employed.This might mean the use of tourniquets or haemostatic dressings.Serious bleeding following traumaIn October 2015 the European Resuscitation Council (ERC) produced new guidelineson first‐aid, particularly on the treatment of uncontrolled, serious or catastrophicbleeding. Within these guidelines they suggested that first aiders, when faced withthis type of bleeding, should be trained in the use of tourniquets and haemostaticdressings.Happily, most first aiders are unlikely to be faced with this type of bleeding butoccasionally there may be circumstances where this type of equipment may berequired. It is likely that this would be linked to particular jobs or trades that haveknown risk factors with regard to bleeding. Forestry, agriculture, deep sea fishing,heavy industry or the use of heavy machinery are areas that come to mind althoughindividual risk assessments may well indicate others.In their guidelines ERC were very specific that people who used this type ofequipment should be properly and thoroughly trained in its use. For this reason wefeltthatratherthanincludesomebasicadviceinageneralfirst‐aidbookwewouldproduce more detailed advice for those that are more likely to need it.The good news is that most bleeding will respond perfectly well to the properapplication of direct pressure. This booklet refers to the very rare occasions whenthat is not the case.Please note, the booklet contains graphic images of serious injury.Please be aware of this before using the booklet.Forward2Serious Bleeding

Bleeding and Blood lossArteryArterioleVenuoleCapillariesVeinBlood vesselsBlood is delivered to the body in high pressurevessels called arteries, it delivers nutrientsand oxygen to the cells via microscopic bloodvessels called capillaries and returns blood totheheart forre‐circulation inlowerpressureblood vessels called veins.Because blood lost from high pressurevessels, such as arteries will be lost morerapidly and because the high‐pressure is  more likely  to prevent the blood fromclottingeasilythenthisisthistypeofbleedingthatismostlikelytocausefirst‐aidersproblems and result in the use of the equipment described in this booklet.Capillary Venous ArterialSteady oozingSteady flowCould be heavySpurting / pulsatingCould be heavyand rapid.Blood volume varies with the size of the individual, but the normal blood volume ofan adult is around 5 to 6 L or 10 to 12 pints.A loss of around 15% of this total is unlikely to cause too many problems. In fact thisis the amount usually donated by blood donors.A 15 to 30% blood loss would produce significant symptoms including a serious dropin blood pressure and the onset of shock.Blood loss of 30% or more could be immediately life‐threatening and 40% ofcirculating volume is almost sure to be fatal unless treatment, probably includingreplacement, is carried out quickly.Effects of blood loss3Serious Bleeding

Haemorrhagic / hypovolaemic shockThe circulation of the blood is responsible for delivering oxygen and nutrients to thecells and carrying waste products from them. When large amounts of blood is lostpressure within the system is likely to fall, there are fewer red blood cells to deliveroxygen and the circulation overall fails. Because of this the cells are deprived ofoxygen and may stop working and when these cells form part of major organs thenorgan failure will follow. Untreated this will lead to death.The medical treatment for this condition, known as hypovolaemic shock, is tosupport the circulation by replacing lost fluid, ideally with blood transfusion.Priortothecasualtyreceivingthisform alcarethefirst‐aiderwillhavetobealertforand recognise the onset shock and be prepared to offer treatment.Probably the best way to avoid shock starting is to limit the amount of blood lossby controlling external bleeding whenever possible.Skin feels coldand clammyMay be confusedor disorientatedNauseaMay vomitFeels coldand shiveryPale appearanceMay be bluish tinge to lipsRapid shallow breathingRapid weak pulseDry mouth, thirstRecognition of hypovolaemic shockTreatment of hypovolaemic shock◙ Treat the cause where possible,stop the bleeding.◙ Reassure◙ Lay them flat and elevate thelegs, if injuries permit◙ Keep them warm◙ Nil by mouth until seen bymedical professional◙ Moisten the lips if thirsty◙ No smoking or alcohol◙ Ensure early medical attention4Serious Bleeding

Emergency tourniquets used to control bleeding are constricting bands that areplaced around a limb between the bleeding point and the heart. The principle is totighten the constriction to the point where the blood supply to the wound is cut off.TourniquetsHappily most bleeding, even quite severe bleeding, is controllable in the firstinstance by the application of direct pressure. This would normally be the firsttechnique to be used. However, there may be times when the use of the tourniquetwouldbemoreeffectiveandcouldbelife‐saving.◙ Serious or catastrophic bleeding from a limb, that is not responding todirect pressure.◙ Traumatic amputation of a limb.◙ Multiple major injury to a limb or limbs.◙ Serious bleeding from a limb which is trapped or hidden, preventing accessto the bleeding point.◙ In multiple injuries, allowing rapid control of bleeding while the rescuerdeals with problems such as airway or breathing difficulties.◙ In a situation with multiple serious casualties.◙ Where scene safety issues call for rapid evacuation.◙ During emergency transport.◙ Due to inadequate resources.Tourniquet‐indications5Serious Bleeding

The tourniquetA tourniquet may be a purpose made piece of equipment or may be made up fromwhatever is at hand. It should have the following properties:◙ Itshouldideallybemade fromanon‐stretchmate r ial.◙ It should be around 2 inches wide to reduce local tissue damage.◙ It should contain some form of twisting or windlass device to aid tightening.◙ It should be able to be locked in place.Ideally it is better to use a properly designed and tested tourniquet. There areseveral commercially available.If there is no access to a commercial tourniquet then one may be improvised fromother materials that meet the requirement. These improvised tourniquets tend tobemoretime‐consumingtoapplyandlesseffectiveinbleedingcontrol.Where risk assessment suggests that serious or catastrophic bleeding is a potentialoutcome of the work being undertaken then supplying commercially madetourniquetsinfirst‐aidkitswouldbetheideal.The illustration shows the widely used Combat Application Tourniquet orC‐A‐T.Other designs are available but will follow the same principles.If you have a tourniquet in your first aid kit it is YOUR responsibility to ensure thatyou know how it works, before you need it.Windlass rod Windlass locking clipWindlass locking strapSelf adhering(velcro) band6Serious Bleeding

Apply tourniquet above the bleedingsite. Pass the band around the limb andplace the tip through the inside slit ofthe buckle. Pull the band tight.Pass the tip through the outside slit ofthe buckle. The friction buckle will lockthe band in place.Pull the band very tight and securelyfasten the band back on itself.Twist the rod until the bleeding hasstopped.Place the rod inside the clip; locking it inplace. Check for bleeding. If bleeding isnot controlled, consider additionaltightening or application of a secondtourniquet above the firstSecure the rod inside the clip with thestrap. Prepare the patient for transportand reassess. Record the time ofapplicationApplication of C.A.T.Tourniquet1 234657Serious Bleeding

Adjustment webbingTurn KeyC‐Cuffor chassisApplication time labelAdjustment buckleThe MAT tourniquet◙ Place the tourniquet around the limb◙ Ensure adjustment buckles are connected◙ Pull on adjustment strap to tighten◙ When the tourniquet is tight around the◙ arm the strap will be locked into place.◙ Rotate the tightening key clockwise, this◙ should move easily.◙ Tightening is complete when bleedingstops.◙ Record the time of application on the label.◙ Inform subsequent carers 0r medicalprofessionals of the application.The MAT tourniquet is slightly different in design, although it follows the sameprinciples.Itcanbeusedsingle‐handedbythecasualtyorappliedbyfirst‐aider.8Serious Bleeding

The improvised tourniquetIf you find yourself in a situation where a tourniquet would seem to be necessary butyou don’t carry one in your kit, or possibly you don’t have a kit with you, thenanything which is flexible, not too stretchy and long enough to fit easily around thelimbcan beused toimproviseatourniquet.If youcarry afirst‐aid kittheobviouschoice would be a folded triangular bandage.You will also need something to use as a windlass to tighten the tourniquet. A stick,a pen or any other strong short tubular device that is to hand.Application of an improvised tourniquetAssemble your materials. Look aroundand be creative. A non ‐stretch bandlong enough to encircle the limb andsomething to tighten it with.Tie the band tightly around the limb.Use a knot that won’t slipInsert your windlass between the bandand the limb.Start to twist the windlass, tighteningthe band.Keep twisting until bleeding stops oruntil you cannot twist any more.This will be painful for the casualty, butis necessary to be effective.Once you’re happy it is tight useanother piece of material to lock it intoplace.Re‐assessforeffectivenessandcontinuetore‐assessregularlyuntilhelparrives.Do not slacken or remove thetourniquet once applied1 2349Serious Bleeding

To be effective tourniquets must constrict the artery supplying blood to the injuredarea to prevent further blood flow. This is usually accomplished more easily byapplying the tourniquet to the upper arm or leg, wherever on the limb the injuryoccurs. This is because these upper areas contain only one long bone, allowing youto compress the artery against it. The lower parts of the arm or leg contain twobones and it is very likely that the artery could become shielded between thesebones and not compressed effectively. For the same reason we do not applytourniquets over joints.Tourniquet placementLegArm1For bleeding in the lower part of the limb thetourniquet should be applied 2 to 4 cm above theelbow joint or knee joint (position 1 )For bleeding in the upper part of the limb thetourniquet should be placed as high on the upperlimb as possible (position 2) With this injury ideallyyou should expose the wound and locate thebleeding point so that the tourniquet can be placedjust above it but if this is difficult or too time‐consuming then place the tourniquet as high on thelimb above the injury as possible to ensure that youhave all of the bleeding controlledPlacing the tourniquet on bare skin may preventslipping but you should not hesitate to place it overclothing, particularly where removing clothing wouldbetootime‐consumingorimpossible,asinatrappedvictim.The tourniquet has to be tight to be effective and thiswill undoubtedly be painful for the casualty. You haveto ensure that they understand it is necessary andpotentiallylife‐saving.Do not hesitate to tighten the tourniquet eventhough the casualty may protest.Tourniquets that are not applied tightlyenough may prevent venous return but stillallow arterial supply. This could actuallymake bleeding worse.21210Serious Bleeding