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Haemorrhage control

Arterial bleeding must be stopped immediately.
In an environment where penetrating injuries are common (e.g. tactical medicine & miliatry medicine) this is the reason for changing the approach to CABCDE, with the initial C standing for catastrophic haemorrhage.
It can be recognised because it will be under pressure and, therefore, spurt a distance from the casualty.
Venous bleeding can be serious but will result in a slower rate of blood loss. Its management is therefore less urgent.

Sources of bleeding in trauma

"blood on the floor and four more"
- chest, retroperitoneum, abdomen, pelvis/long bones

In a remote setting bleeding within the chest, retroperitoneum or abdomen following blunt trauma will not normally be stoppable - the emphasis then is on evacuation as rapidly as possible to a surgical facility.

Reducing external haemorrhage

Direct pressure (with gloves on first!) and elevation (where possible) may buy some time by stopping bleeding but cannot be continued during evacuation.
Indirect pressure (i.e. on an artery proximal to the wound) can be used to reduce bleeding while local measures are applied.
This can be achieved using fingers as a first aid manoeuvre - over the femoral artery for a wound in the leg or over the barchial artery in the upper arm for bleeding in the arm. The hip must be extended for femoral pressure to be effective.

Reducing bleeding with pressure over the femoral artery:


A tourniquet is a device that provides indirect pressure on a proximal artery but in a way that does not tie up the rescuer's fingers.
There are specifically designed tourniquets (such as the one in the video below) but they can also be improvised where necessary from clothes or slings.
As a general rule the tourniquet has to be applied proximal to the wound and proximal to the elbow/knee (there is more effective compression of the artery against a single bone).
When a tourniquet is applied, the time of its application must be noted.

Application of a CAT tourniquet

Local measures to control bleeding
Packing wound will reduce bleeding if done correctly. If packing is accompanied by a tight circumferential bandage (but NOT a tourniquet - there should still be a distal pulse) the pressure exerted increases and bleeding will be controlled more effectively.
Special haemostatic dressings can also be used in the wound to reduce bleeding.

Packing a wound to reduce bleeding

When packing a wound it is important that the gauze stands proud of the limb at the end - this means that the application of a circumferential bandage will increase the pressure on the bleeding point.

first step

step 2

Application of an emergency bandage ("Israeli dressing" or "first field dressing")

Presentation on haemorrhage control that includes use of haemostatic dressings

Reducing bleeding from a pelvic fracture

"Open book" pelvic fractures (in which the front (pubis) is split and the two sides hinge at the back (like a book being open - hence the name) can bleed a lot. The theory is that reducing the fracture can limit the bleeding and reduce mortality.
There are ways of improvising this effect, but the SAM sling is easy to use and effective.

Reducing bleeding from a long bone

Splinting a fractured long bone, such as the femur, reduces bleeding.

This video shows the application of the splint I feel is best suited for wilderness use:

Haemorrhage control in tactical setting