Basic bleeding control

**Boker** · 10-29-2009, 03:18 PM

Basic bleeding control of the extremities.

“Air goes in and out, blood goes round and round any variation is a bad thing”
-unknown

Basic bleeding control has 4 steps. They are completed in a specific order until the bleeding has stopped. If the bleeding stops you do not continue to the next step.

1. Direct pressure
2. Elevation
3. Pressure points
4. Tourniquet

Direct pressure:

Hold pressure on the wound. Ideally sterile gauze will be used but the cleanest cloth type material will work in an emergency. The bigger the wound the longer you should hold pressure before checking to see if the bleeding has stopped. Apply just enough firm pressure to get the bleeding to stop and loosen up the pressure gradually.

Try not to remove this initial dressing from the wound until after the bleeding has stopped. If the wound bleeds through the dressing, add more layers to the existing dressing. The only 2 times I can think of to remove that initial dressing are that you find a more suitable material to use or the bleeding has been stopped for more than 10 minutes.

If after several minutes the bleeding has not significantly slowed or your dressing continually needs to be reinforced, move to step 2.

Elevation:

Elevate the wound to above the level of the heart. This step can also be started immediately after direct pressure. Assess for other injuries that might complicate manipulation of the affected limb. There may be times that elevation is not possible due to other injuries. If the bleeding remains unchanged move to step 3.

Pressure points.

When direct pressure and elevation fail to control the bleeding holding pressure on key arteries in the body will slow the blood supply to the wounded area make it easier for the body to form a clot.

The arteries in the human body can be thought of like tree branches, the closer to the trunk the bigger the artery. The artery system in the arms and legs have a back up system, if one gets occluded the load is picked up by another branch. For that reason, when using the pressure point method the artery closest to the heart will be the choice spot.

I looked at some diagrams and can’t find an appropriate one to use. For simplicity sake, there are only 2 places you should attempt direct pressure. For arms you want the brachial artery located under the bicep between the body and arm about mid upper arm. For the legs you want the femoral artery located mid groin. Despite the picture, avoid using any pressure points in the neck.

http://www.tpub.com/content/neets/14...14191_21_1.jpg

The use of pressure points carries risk and should only be used if significant blood loss has or is occurring. (Arterial bleed) It’s recommended that pressure only be held for 10 minutes at a time. After 10 minutes if severe bleeding continues move to the next step.

Tourniquets:

The use of tourniquets is often unnecessary and is a last ditch effort. Significant blood loss should have occurred by this time and the previous 3 steps have failed. Signs of initial or advance shock should be present (Restlessness to unresponsive).

The wiki article http:/en.wikipedia.org/wiki/Emergency_bleeding_control#Tourniquet explains the risk better then I can.

“Another method of achieving constriction of the supplying artery is via the use of a tourniquet - a tightly tied band which goes around a limb to restrict blood flow. … The use of the tourniquet is restricted in most countries to professionals such as physicians and paramedics, as this is often considered beyond the reach of first aid and those acting in good faith as a good samaritan. A key exception is the military, where many armies carry a tourniquet as part of their personal first aid kit.

Improvised tourniquets, in addition to creating potential problems for the ongoing medical management of the patient, usually fail to achieve force enough to adequately compress the arteries of the limb. As a result, they not only fail to stop arterial bleeding, but may actually increase bleeding due to the impaired venous blood flow. Some argue that tourniquets should never be used in the pre-hospital setting, not even for amputations. An emergency tourniquet should in any case never be applied to the forearm or lower leg since the arteries in these locations run between bones and can not be compressed.”

It is important that you make sure there are no injuries beneath your tourniquet. For example someone has a slashed wrist and you apply a tourniquet after everything else fails, and they happen to have a broken arm. As you tighten the tourniquet you run the risk of displacing the bone and having it sever the brachial artery (which is much bigger). This will be even more significant if the femoral artery is slashed.

With some reluctant on my part and the warnings stated, there are some key elements for tourniquet applications. The tourniquet should be an inch or 2 wide (Bailing wire or paracord makes a poor tourniquet). Ideally you want the location as close to the wound as possible, keeping in mind that as stated the lower leg/forearm locations will not work. So essentially you are stuck between the shoulder to elbow vs. the groin to knee.

Once a tourniquet is in place it should only be removed by qualified medical staff. When blood flow is impaired, cells die. As they die enzymes and other chemicals are released. Some of which are toxic, so if the tourniquet has been in place for an extended amount of time once released and blood flow resumed the toxins can be swept through the entire body via the blood stream. This is also the reason it is important to write the approximate time and date that a tourniquet is placed. The clock starts as soon as the bleeding stops.

For most of you, this is just a basic review. I have tried to include the reasons for why the actions are taken, which made this a lot longer then intended. Some items, while technically correct have been simplified for ease of explanation. I’ll provide a print friendly version with what I consider the more important aspects.

Knowing how to control bleeding is important, knowing why and when to control bleeding is also important. Is all bleeding bad? When should you control bleeding? What are the types of bleeding?

Topics for another time if anyone is interested.

Disclaimer: This is not intended to be any type of medical advice. It is simply a collection of information. Sources as noted above.

**Boker** · 10-29-2009, 03:19 PM

Boker’s cheat sheet for bleeding control of the extremities:

1. Direct pressure
2. Elevation
3. Pressure points
4. Tourniquet

Direct Pressure:
• Use cleanest cloth type material available.
• The bigger the wound the longer you should hold pressure.
• Apply just enough firm pressure to stop the bleeding.
• Do not remove the initial dressing until after the bleeding stops
• If the wound bleeds through the dressing, add more layers to the existing dressing.

Elevation:
• Elevate the wound to above the level of the heart.
• There may be times that elevation is not possible due to other injuries.

Pressure Points:
• The use of pressure points carries risk and should only be used if significant blood loss has or is occurring
• Pressure points should only be occluded for 10 minutes at a time.
• Should only be used for artery lacerations.
• The arteries under the bicep muscle and in the groin are the main ones used.
• Never occlude or attempt to occlude the carotid arteries in the neck.

Tourniquets:
• High risk with low benefit potential.
• Last ditch effort.
• Should be several inches wide
• Place as low as possible on upper arm/upper leg
• Never place on lower leg/lower forearm
• Assess for injuries prior to placement. When in doubt don’t.
• Should only be removed by qualified medical staff

**your_comforting_company** · 10-30-2009, 07:04 AM

Thanks Boker! this is exactly what I was looking for.

Good post!

**crashdive123** · 10-30-2009, 07:17 AM

Nice post Boker. If I may add a bit on tourniquets - Just to emphasize that they are an absolute last resort - the limb below the tourniquet will, in most cases, be lost.

**tacmedic** · 10-30-2009, 07:13 PM

Crash- that is a common misconception. The wars in Afghanistan and Iraq have provided the opportunity to do a lot of new studies on trauma care, and they are finding that there is much less incidence of loss of extremity due to tourniquets than previously thought (January 2009 Annals of Surgery, titled "Survival with emergency tourniquet use to stop bleeding in major limb trauma"). I teach advanced PHTLS (prehospital trauma life support) and we are actually teaching now that we shouldn't be waiting so long to apply tourniquets because they have been shown to be beneficial and not as damaging to tissues as once thought.

**crashdive123** · 10-30-2009, 07:24 PM

While it is true that on a battlefield my statement is incorrect. The medivac response times in Iraq and Afghanistan are remarkable. I was thinking more of a wilderness setting or remote location where professional medical help is not so readily available. Thanks for the clarification.

**Boker** · 10-31-2009, 08:03 AM

I once asked an old Vietnam era surgeon how long an extremity could survive (once amputated) and then be successfully reattached. His reply was up to 24 hours under the right conditions. If that is correct then you could say the limb would be viable for up to 24 hours.

There are always exceptions to the 'rules'. I wanted a simple guide on how to stop bleeding out side of the hospital that could be useful to those without training. My intent is to cover the 'how to' aspect. The 'when' aspects could be debated by MDs and never settled. Each situation will be different.