EMS
80810
Clinically Related
Operations: Bleeding
Chris Weinzapfel, FF, NREMTP(T)
Firefighter/Paramedic/SWAT Medic
Rowlett Fire Rescue
Rowlett, Texas
EMS
80810
Objectives
1.Recognize role of history
in prehospital
hemorrhage treatment.
EMS
80810
Objectives
2.Identify methods/
techniques in prehospital
bleeding control.
EMS
80810
Objectives
3.Indicate common issues
associated with
prehospital bleeding
control.
In the United States
In the United States
• Military Medical Corps –
1862
In the United States
• Military Medical Corps –
1862
–integrated medical
treatment
In the United States
• Military Medical Corps –
1862
–integrated medical
treatment
–evacuation of
personnel
US Special Forces
Combat Medics First Assignments
************
US Army “Special Forces Units”
“Green Beret’s”
Dual Role Operators and Medics
President John F Kennedy
1969 -70
90% of combat deaths
occur on the battlefield
before the casualty ever
reaches a medical
treatment facility.
- Col. Ron Bellamy
The hemorrhage that takes
place when a main artery
is divided is usually so
rapid and so copious that
the wounded man dies
before help can reach
him.
- Col. H.M. Gray, 1919
The overwhelming
cause of preventable
combat death
continues to be
extremity hemorrhage
The American College of
Surgeons and the
Prehospital Trauma Life
Support Guidelines no
longer recommend
elevation and pressure
points for severe
bleeding.
Figure 1
National Registry of
Emergency Medical
Technicians (NREMT) –
February 2009
Figure 2
Internal Hemorrhage
External Hemorrhage
Types of Bleeding to
Consider
Types of Bleeding to
Consider
Types of Bleeding to
Consider
Types of Bleeding to
Consider
• Bleeding from an arm or
leg can usually be
controlled by:
• Bleeding from an arm or
leg can usually be
controlled by:
–trauma dressing
• Bleeding from an arm or
leg can usually be
controlled by:
–trauma dressing
–emergency trauma
dressing
• Bleeding from an arm or
leg can usually be
controlled by:
–manual direct pressure
and elevation
• Bleeding from an arm or
leg can usually be
controlled by:
–manual direct pressure
and elevation
–tourniquet (last resort?)
• In some situations, a
tourniquet is applied first
– since other methods will
not be adequate to control
the bleeding
Hemorrhage and Shock
Hemorrhage and Shock
• What happens when you
start to bleed?
Hemorrhage and Shock
• What happens when you
start to bleed? – it
depends on how much
blood you lose
Normal Adult Blood
Volume
5 Liters Blood Volume
Recognizing Shock
Recognizing Shock
• Most useful in tactical
combat casualty care
(TCCC)
Recognizing Shock
–mental status
–radial pulse
–heart rate (HR)
–blood pressure (BP)
–respiratory rate (RR)
–likelihood of death
Recognizing Shock
• May be difficult to judge
blood loss in combat
except by mental status
and radial pulse
Recognizing Shock
• Heart rate and
respiratory rate may be
affected by exertion and
combat stress as well as
shock
500 cc Blood Loss
4.5 Liters Blood Volume
500 cc Blood Loss
• Mental state – alert
• Radial pulse – full
• Heart rate – normal or
somewhat increased
• Systolic blood pressure
– normal
500 cc Blood Loss
• Respiratory Rate –
normal
• Is he going to die from
this? NO
1000cc Blood Loss
4.0 Liters Blood Volume
1000cc Blood Loss
• Mental state – alert
1000cc Blood Loss
• Mental state – alert
• Radial pulse – full
1000cc Blood Loss
• Mental state – alert
• Radial pulse – full
• Heart rate – 100+
1000cc Blood Loss
• Systolic blood pressure
– normal lying down
• Respiratory rate – may
be normal
• Is he going to die from
this? NO
1500cc Blood Loss
3.5 Liters Blood Volume
1500cc Blood Loss
• Mental state – alert but
anxious
• Radial pulse – may be
weak
• Heart rate – 100+
1500cc Blood Loss
• Systolic blood pressure
– may be decreased
1500cc Blood Loss
• Systolic blood pressure
– may be decreased
• Respiratory rate – 30
1500cc Blood Loss
• Systolic blood pressure
– may be decreased
• Respiratory rate – 30
• Is he going to die from
this? PROBABLY NOT
2000cc Blood Loss
3.0 Liters Blood Volume
2000cc Blood Loss
• Mental state –
confused/lethargic
• Radial pulse – weak
• Heart Rate – 120+
2000cc Blood Loss
• Systolic blood pressure
– decreased
• Respiratory rate – >35
• Is he going to die from
this? MAYBE
2500cc Blood Loss
2.5 Liters Blood Volume
2500cc Blood Loss
• Mental state –
unconscious
• Radial pulse – absent
• Heart rate – 140+
2500cc Blood Loss
• Systolic blood pressure
– markedly decreased
• Respiratory rate – over
35
• Is he going to die from
this? PROBABLY
Expose the Wound
Expose the Wound
• Push or cut away loose
clothing
Expose the Wound
• Push or cut away loose
clothing
• DO NOT remove
clothing that is stuck to
the wound
Expose the Wound
• DO NOT attempt to clean
the wound
Expose the Wound
• DO NOT attempt to clean
the wound
• DO NOT probe the
wound in order to
remove an object from
the wound
Expose the Wound
Apply a Bandage or
Combined Trauma
Bandage
Apply a Bandage or
Combined Trauma
Bandage
• Israeli bandage/pressure
dressing
Apply an Emergency
Trauma Dressing
Apply an Emergency
Trauma Dressing
Apply Pressure Dressing
Over First Aid Dressing
Apply Pressure Dressing
Over First Aid Dressing
• When blood continues
to seep from the field
first aid dressing
Apply an Agent to a Wound
ChitoFlex™ Hemostatic
Bandage
Chitosan (ki’ to san)
Dressing
Addition to Chitosan
Dressing
Addition to Chitosan
Dressing
• Apply manual pressure
Addition to Chitosan
Dressing
• Apply manual pressure
• A bandage may be
applied to the chitosan
dressing to prevent it
from being dislodged
Wound Stat
Civilian Accessible
Agents
®
QuikClot
CELOX™
Figure 3
Apply Digital Pressure
Apply Digital Pressure
• Uses pressure from the
fingers, thumbs, or the
heel of the hand applied
to an artery supplying
the wound
Apply Digital Pressure
• Temporal
• Carotid
• Brachial
• Radial
• Femoral
• Posterior/anterior
tibialis
Tourniquet
Tourniquet
• A constricting band
placed around an
extremity to stop arterial
bleeding
Tourniquet
• A constricting band
placed around an
extremity to stop arterial
bleeding
• Only used on an arm,
forearm, thigh, or leg
Tourniquet
• Used when there is no
time to control bleeding
• Used on an amputation
of the arm, forearm,
thigh, or leg
Applying a Combat
Application Tourniquet
(CAT)
Applying a CAT
Marking the Casualty
T
Dressing an Amputation
Dressing an Amputation
• Place a dressing
(soft/absorbent) over the
end of the stump
• Secure the dressing with
bandages
Dressing an Amputation
• Prevents contamination
• Protects from additional
injury
Applying an Improvised
Tourniquet
Applying an Improvised
Tourniquet
• Gather materials
Applying an Improvised
Tourniquet
• Rigid object (windlass)
such as a strong stick
Applying an Improvised
Tourniquet
• Rigid object (windlass)
such as a strong stick
• Tourniquet band (cravat)
at least two inches wide
Applying an Improvised
Tourniquet
• Rigid object (windlass)
such as a strong stick
• Tourniquet band (cravat)
at least two inches wide
• Securing material
(cravat)
Applying an Improvised
Tourniquet
• Twist windlass until
bright red bleeding has
stopped
• Wrap second cravat
around limb
Applying an Improvised
Tourniquet
• Wrap tails around end of
windlass so the
tourniquet will not
unwind
• Tie tails in a non-slip
knot
Ranger Ratchet
Tourniquet
The Special Operations
Forces Tactical
Tourniquet (SOFT)
Are any of the pre-fabbed
tourniquets available
outside the military?
Have you ever used a
blood BP cuff as a
tourniquet?
Wound Packing
Wound Packing
• Slow the bleeding first
with point pressure or
tourniquet, depending
on the location of the
insult
Wound Packing
• Pack and pack and pack
until there is no more
room, filling all the
voids you can
Wound Packing
• Using a gauze with a
blood stopping agent
will make the pack more
effective
Wound Packing
• Using a gauze with a
blood stopping agent
will make the pack more
effective
• Check and recheck
during transport or with
movement
Wound Packing
• Wound packing with a
clotting agent can be
helpful
Summing It All Up
Summing It All Up
• NREMT skill change
Summing It All Up
• NREMT skill change
• Civilian accessible
hemostatic agents
Summing It All Up
• Techniques and
equipment used in
management of major
bleeding
Questions
Are the blood clotting
agents better for a trauma
surgeon or emergency
room doctor than they
used to be – no more
concrete clots?
Will the clotting agents
help control femoral artery
bleed?
Have the heat effects of
some clotting agents
improved?
Is there any push-back
from surgeons?
Do these clotting agents
have FDA (Food and Drug
Administration) approval?
Can you put Celox™ in the
wound, bandage it, and
release the patient?
Conclusion
EMS
80810
Clinically Related
Operations: Bleeding
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EMS
80810
Release Date:
04/01/2010
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program can be found by
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EMS
80810
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