For a discussion of wound management (cleaning, closing, and dressing), see page 260.
Whenever you are going to be exposed to blood or other potentially infectious body fluids, wear sterile latex rubber gloves from your first-aid kit. If you are allergic to latex, use other nonpermeable gloves (such as nonlatex synthetic).
While it is occasionally visually distressing, bleeding can be one of the easiest problems to manage, because the treatment options are so straightforward. The severity of the injury determines the rate of blood loss and what measures you must take to control the bleeding. Evaluate the following considerations:
1. Where is the bleeding? It is important to consider and identify internal bleeding as well as external bleeding. Considerable blood loss can be associated with blunt (nonpenetrating) abdominal injury (liver, spleen), as well as long bone or pelvic fracture (2 quarts, or liters, of blood can rapidly accumulate in the thigh following a broken femur). Examine the entire victim!
2. Is the bleeding from an artery or from a vein? Because arterial blood is under higher pressure, blood loss tends to be more rapid from a severed artery than from a vein. Arterial bleeding can be recognized by its spurting nature and rapid outflow. All blood exposed to air, in the absence of unusual drug intoxications, turns red fairly quickly, so you cannot rely on color to indicate origin.
TREATMENT FOR BLEEDING
First, remove all clothing covering the wound so that you can see precisely where the bleeding is coming from. Almost all external bleeding stops with firm, direct pressure. This should be applied directly to the wound with the heel of your hand, using the cleanest available thick (four or five thicknesses of a 4 in by 4 in—or 10 cm by 10 cm—sterile gauze pad, for instance) bandage or cloth compress (Figure 31). Maintain pressure for a minimum of 10 minutes, to allow severed vessels to close by spasm (an artery contains small amounts of muscle tissue in its walls) and to allow early blood clot formation. Peeking at the wound under the compress interrupts the process and prolongs active bleeding. The application of cold packs or ice packs over the compress (not under it) may hasten the process by initiating spasm and closure of disrupted blood vessels. It is also useful to have the victim lie down, and to elevate the bleeding part above the level of his heart. A scalp wound tends to bleed freely, and may require prolonged pressure or wound closure for control (see page 65).
Figure 31 Firm pressure applied to a bleeding wound.
If direct pressure to the wound does not stop the bleeding, you must make certain that you are applying the pressure in the correct spot. Check quickly to see that you are pressing precisely over the bleeding point. If you are a fraction of an inch off, you can miss the best compression spot for a torn blood vessel; in this case, simply piling on more bandages may not solve the problem. Once you have repositioned your pressure, wait again for 5 to 10 minutes. If the pressure appears to be working, once the bleeding has substantially subsided you can apply a pressure dressing. Do this by covering the wound with a thick wad of sterile gauze pads or the cleanest dressing available, and wrapping the area firmly with a rolled gauze or elastic bandage. Do not apply the dressing so tightly that circulation beyond it is compromised (as indicated by blue fingertips or toes, or by numbness and tingling). Watch the dressing closely for blood soaking and dripping, which indicate continuous bleeding.
A very useful product for bleeding is a nonmedicated BloodStopper gauze bandage. Another alternative is the medicated QuikClot adsorbent hemostatic gauze (Z-Medica Corporation), which delivers a zeolite-based clotting agent. This product is also available in a mesh 3.5 in by 3.5 in “sponge” configuration as QuikClot Sport (with or without silver as an antibacterial agent). BleedArrest (Hemostasis, LLC) particles and sponges utilize a natural biopolymer to control severe external bleeding. Celox (hemostatic granules) is a new high-performance hemostatic material that has been created to control high-volume arterial bleeding. Composed of a proprietary marine biopolymer (including Chitosan), it is poured as a granular mixture into a bleeding wound, where it helps to facilitate blood clot formation without causing any tissue damage. It is thought to do this by aggregating negatively charged red blood cells, which are attracted to the positively charged granules. According to promotional material distributed by Sam Medical Products, the granules assist a clot to form within minutes without generating any heat, burning sensation, or rigid structure formation within the wound. A gelled mass formed by excess granules protects the clot and is easy to remove.
Chitosan is manufactured by chemical modification of chitin, which is the structural element in the exoskeleton (“external” skeleton) of crustaceans (crabs, shrimp, and so forth). It carries a positive charge, wherein lies its value for this particular application. Chitosan is not known to commonly invoke an allergic reaction, and can be sterilized. Notably, it is present in other products designed to control bleeding from wounds, such as bandages (ChitoFlex Hemostatic Dressing) marketed by HemCon Medical Technologies Inc.
Celox works in hypothermic conditions and also on blood that has been heparinized (e.g., a person being treated with this category of “blood thinner” or, presumably, with enoxaparin [Lovenox]). There is no mention of whether or not it has been or would be expected to be effective if a victim is currently taking warfarin (Coumadin), which is a common anticoagulant.
To apply Celox, one pours the granules from a sterilized, sealed packet (15 grams or 35 grams) into the wound and then holds them in place with a gauze bandage for 5 minutes. A compression bandage, such as an elasticized wrap, is then wrapped over the gauze-covered wound and the victim is brought to medical care.
The following are some important things to be aware of with a serious wound:
1. A victim who has lost 25% to 30% of his blood volume may suffer from shock. Treatment is discussed on page 60.
2. Prolonged uncontrollable bleeding is rare unless a major blood vessel or more than one vessel is disrupted, the victim is taking an anticoagulant (blood thinner) medication, or the victim suffers from hemophilia. In such a case, heroic intervention may be lifesaving. The application of extreme compression to “pressure points,” such as the radial, brachial, or femoral arteries, is both difficult and of considerable risk (since the purpose is to cut off all circulation).
A tourniquet is indicated only in a life-threatening situation and is best applied by an experienced person. Only in the case of torrential bleeding is a tourniquet more advantageous than continuous pressure. The decision to apply a tourniquet is one in which a limb is sacrificed to save a life.
A tourniquet should be applied to the limb between the bleeding site and the heart, as close to the injury as is effective, and tightened just to the point where the bleeding can be controlled with direct pressure over the wound. The reason for placing it close to the bleeding is to preserve as much living tissue (which is “above” the tourniquet) as possible.
To construct a tourniquet, use a 2 to 4 in (5 to 10 cm) bandage—not something thin (such as a string, wire, or cord) that will cut through the skin. Wrap the bandage around the limb several times, and then tie half or an entire square knot, leaving loose ends long enough to tie another knot (Figure 32, A). Place a stick or stiff rod over the knot, and then tie it in place with the loose ends. Twist the stick until the bandage is tight enough to stop the bleeding, and then secure it (Figure 32, B) in place with another cloth, tape, or circular bandage. If you must leave the victim after applying a tourniquet, and therefore can no longer apply direct pressure, be certain to check that the tourniquet is still effective after you have released pressure.
If possible, the tourniquet or a pressure-point occlusion should be released briefly every 10 to 15 minutes to see if it is still necessary. Some authorities recommend loosening it after 5 minutes, which might be all right if the bleeding is not torrential. If the bleeding can now be controlled with direct pressure, don’t retighten the tourniquet, but keep a very close watch on the situation. If the original wound damaged or severed a very large blood vessel, it is likely that you will need to keep the tourniquet in place for more than 10 minutes. Always keep a tourniquet in plain view, so that it doesn’t get left in place longer than necessary just because someone didn’t know or forgot it was there. After a tourniquet has been in place continuously for 6 or more hours, do not remove it until you reach advanced medical care.
3. If the victim has suffered a large wound through which internal organs (such as loops of bowel) (Figure 33, A) or bones (see page 71) are protruding, do not attempt to push these back inside the body or under the skin unless they slide back in without your assistance. Cover extruded internal organs or bones with continually moistened bandages (pads of gauze or cloth) held in place without excess pressure (Figure 33, B). Seek immediate medical attention.
4. If the victim has suffered a severe cut in his neck, take special care to not disturb the wound, because such disturbance might remove a blood clot that is controlling the bleeding from a large blood vessel. Apply a firm pressure dressing (don’t choke the victim with the bandage) and seek immediate medical attention. Continually assess the airway (see page 22), because an expanding blood clot within the neck can compress the throat and windpipe. If the victim begins to have raspy breathing or a changed voice, evacuation is maximally urgent.
5. Bleeding can be quite brisk from a ruptured or torn varicose (dilated) vein in the leg. This can usually be managed with direct pressure, while elevating the leg. Follow this with a pressure dressing.
6. If a foreign object (such as a knife, tree limb, or arrow) becomes deeply embedded (impaled) in the body, do not attempt to remove it, because the internal portion may be occluding a blood vessel that will hemorrhage without this “plug.” Any attempt at removal may create more damage than already exists, which includes increasing the bleeding. This is particularly true with a hunting (broadhead) arrow. Instead, pad and bandage the wound around the object, which should be fixed in place with tape if possible (Figure 34). The external portion of the object may be cut to a shorter length (cut off the shaft of the arrow a few inches above the skin, for example), if necessary, to facilitate splinting and transport of the victim.
7. A gunshot wound may cause severe internal damage that is not readily visible from the surface wound. Any victim who has suffered a gunshot wound should be brought to immediate medical attention, no matter how minor the external appearance.
Figure 32 Application of a tourniquet. A, Wrap the bandage around the limb, and then tie a square knot. Tie a stick in place over the knot. Twist the stick to tighten the tourniquet just until the bleeding stops. B, Secure the stick.
Figure 33 A, Loops of bowel protrude from a laceration in the abdomen. B, These should be covered gently with a moistened bandage or cloth. Don’t try to push them back into the abdomen unless necessary for evacuation (for instance, if the victim must walk out under his own power and such activity is forcing more bowel to extrude from the wound).
Figure 34 Padding and bandages to prevent motion of a penetrating object.
Always disarm the victim. A head-injured or otherwise confused victim carrying a loaded weapon could accidentally create an additional victim. If you don’t know how to handle a gun, move the weapon at least several feet away and point it in the direction where accidental discharge will do the least harm.
8. There are “blood stopper” products that can be used to assist in controlling bleeding (see page 55). These include QuickClot Sport (Z-Medica), which is a porous sack filled with a highly absorbent mineral derived from lava rocks; QR (Biolife LLC), which is a powder composed of tiny plastic beads and potassium salt that is sprinkled on a wound; and bandage and gauze products (such as BloodStop [LifeScience Plus Inc.]) made from cellulose that transform on contact with blood and accelerate clot formation.
9. After the bleeding has stopped, immobilize the injury. Check all dressings regularly to be certain that swelling has not made them too tight.
INTERNAL BLEEDING
If bleeding is internal, such as from a bleeding ulcer, broken bone, injured spleen or liver, leaking abdominal aneurysm, or lung cancer, the victim may suffer from shock. Symptoms of internal (undetected) bleeding are the same as those of external bleeding, except that you don’t see the blood. They include rapid heartbeat, shortness of breath, general weakness, thirst, dizziness or fainting when arising from a supine position, pale skin color (particularly in the fingernail beds and conjunctivae), and cool, clammy skin. Other signs include increasing pain and firmness of the abdomen after an injury, vomiting blood or “coffee grounds” (blood darkened by stomach acid), blood in the urine or feces, or large bruises over the flank or abdomen. Because it is difficult to predict the rate of internal blood loss and because the only effective treatment for many causes of severe internal bleeding is surgery, medical help should be sought immediately.