During the Vietnam War, 50% of battlefield deaths were the result of major haemorrhage. Of these, 80% were torso injuries, which, in the pre-hospital environment, are classed as non-compressible injuries. For the immediate responder these wounds provide us with very little management options and the patient’s immediate need is for treatment by a surgeon. However, 20% of these injuries were to limbs and junctional areas such as the axilla (armpit), groin and neck, which are classed as compressible haemorrhage wounds.
Bleeding from extremity wounds accounted for more than half of the potentially preventable deaths in combat, equating to over 2,500 deaths. Recent conflicts in Iraq and Afghanistan have seen a vast improvement both in recognition and management of catastrophic haemorrhage, although mortality has still been reported as high as 10%-20% from compressible haemorrhage, if the patient isn’t treated effectively within 5 minutes of the injury occurring.
Catastrophic haemorrhage isn’t confined to the battlefield; it is a regular occurrence in the civilian population from multiple causes ranging from road traffic accidents to knife wounds.
RECOGNITION AND EFFECTIVE MANAGEMENT IS VITAL
Not all external bleeding is catastrophic regardless of the mechanism; catastrophic haemorrhage can be defined as:
Severe – obvious heavy bleeding usually free flowing but not necessarily pumping.
Sustained – the bleeding continues unless effectively managed.
Uncontrolled -the wound continues to bleed with initial treatment such as dressing application and elevation.
If a patient presents with an isolated wound, in a safe environment, then the ‘Haemorrhage Control Ladder” should be applied:
Dressing – a good pressure dressing like the Olaes Modular Dressing should be firmly applied, ensuring that the whole wound is covered.
Pressure and elevation – apply direct pressure over the dressed wound and elevate the limb higher than the heart to reduce blood flow.
Second dressing – apply a second pressure dressing over the first (do not remove the first dressing).
Tourniquet – if bleeding continues apply a tourniquet. The two main ones on the market are the SOF-TT W and the CAT but a triangular bandage and stick can be improvised to create the same windlass effect.
In a Care Under Fire situation, or if the patient has multiple injuries, a tourniquet should immediately be applied in order to concentrate efforts and resources on other life threatening injuries or removing the patient to a safer environment. Tourniquets are fast, effective, and easy to apply and are proven to save lives.
TOURNIQUET APPLICATION – THE GOLDEN RULES
- Apply as close to the wound as possible – if this fails to stop the bleeding on an injury below the knee or elbow, then apply a second tourniquet above the joint, this may be more effective as the artery is being compressed against a single bone in comparison to injuries below the joints where the arteries may be compressed between two bones.
- Tighten until the bleeding is significantly reduced. Slight bleeding may still occur from bone ends and small vessels; a dressing will be applied to stop this later on, when assessing the circulation. Tight application can be extremely painful for the conscious patient, however, be aware a loosely applied tourniquet can increase bleeding by acting as a venous rather than arterial tourniquet.
- Reassess the tourniquet frequently and re-tighten if needed. Be aware that the part of the limb below the tourniquet may become less swollen after application and the tourniquet may become loose.
- Always note down the time of application. A tourniquet can stay on a limb for at least 2 hours without detriment.
WOUNDS TO JUNCTIONAL AREAS
Wounds to the neck, axilla and groin are notoriously difficult to manage, both in the pre-hospital and hospital setting. If a large, open wound is present then packing is recommended, ideally with a haemostatic agent like ChitoGauze, then applying direct pressure over the top and holding a dressing in place until the patient reaches definitive care.
REMEMBER NON-COMPRESSIBLE HAEMORRHAGE NEEDS A SURGEON –
COMPRESSIBLE HAEMORRHAGE NEEDS A FIRST AIDER!!
by Dean Bateman