Emergency bleeding control describes the steps or actions taken to control bleeding

Bleeding

Bleeding, technically known as hemorrhaging or haemorrhaging is the loss of blood or blood escape from the circulatory system...

 from a patient

Patient

A patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider....

 who has suffered a traumatic injury or who has a medical condition which has led to bleeding. Many bleeding control techniques are taught as part of first aid

First aid

First aid is the provision of initial care for an illness or injury. It is usually performed by non-expert, but trained personnel to a sick or injured person until definitive medical treatment can be accessed. Certain self-limiting illnesses or minor injuries may not require further medical care...

 throughout the world, although some more advanced techniques such as tourniquets, are often taught as being reserved for use by health professionals, or as an absolute last resort, in order to mitigate the risks associated with them, such as potential loss of limbs. In order to manage bleeding effectively, it is important to be able to readily identify both types of wounds and types of bleeding.

Types of wounds

Wounds are normally described in a variety of ways. These may deal with a description of wound size (length) and thickness, or also with the plainly visible wound characteristics. Wounds may be categorized as open or closed, or as either acute or chronic in origin. The most common descriptors of wounds are these:

• Incisions: Straight edges to the wound margins, as if sliced with a knife. These can vary in size, and may be caused by a variety of objects, including a scalpel
  Scalpel
  A scalpel, or lancet, is a small and extremely sharp bladed instrument used for surgery, anatomical dissection, and various arts and crafts . Scalpels may be single-use disposable or re-usable. Re-usable scalpels can have attached, resharpenable blades or, more commonly, non-attached, replaceable...
  
  , a knife, any piece of straight, sharp metal, or a piece of glass. Tissue is rarely missing from the wound site, and the margins of the wound may be easily matched from one side of the wound to the other for the purposes of closure.
• Laceration Jagged edges to the wound margins, more closely resembling a tear than a slice. The wounded tissue is random rather than straight in direction, and may have multiple branches. Most often caused by an object with a broken or serrated
  Serrated blade
  A serrated blade is a type of blade used on saws and on some knives or scissors. It is also known as a dentated, sawtooth, or toothed blade.A serrated blade has a cutting edge that has many small points of contact with the material being cut...
  
   edge, such as a piece of broken glass or metal, but may also be caused by a blow from a blunt object to tissue with bone immediately behind it.
• Puncture: Sharp object penetrates the tissue, and travels internally, but does not move laterally in any direction from the point of entry. Such wounds can be misleading, as they may appear quite small on surface examination, but extend quite deeply into the body; even damaging nerves, blood vessels, or internal organs. They may cause substantial internal bleeding
  Internal bleeding
  Internal bleeding is bleeding occurring inside the body. It can be a serious medical emergency depending on where it occurs , and can potentially cause death and cardiac arrest if proper medical treatment is not received quickly....
  
   or secondary injuries, such as a collapsed lung
  Pneumothorax
  Pneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions as well as in those with lung disease , and many pneumothoraces occur after physical trauma to the chest, blast...
  
  , which may not be readily evident during primary assessment. Occasionally, the object causing the injury will remain in the wound as an impaled object. A stab wound from a knife or other sharp object, or a bullet wound would be examples of this type of injury. Medical professionals usually refer to this type of wound as penetrating trauma
  Penetrating trauma
  Penetrating trauma is an injury that occurs when an object pierces the skin and enters a tissue of the body, creating an open wound. In blunt, or non-penetrating trauma, there may be an impact, but the skin is not necessarily broken. The penetrating object may remain in the tissues, come back out...
  
  .
• Abrasion: A scraping or scratching. Generally quite superficial, and affecting only the surface layers of the epidermis. No internal organs, nerves, or blood vessels other than capillaries, are affected. This may be the result of a fall, or of sliding (friction) against rough surfaces. The road rash often suffered by falling motorcyclists is an example of this type of wound.
• Contusion: Simple bruising. In this type of injury, the capillaries in the epidermis and dermis
  Dermis
  The dermis is a layer of skin between the epidermis and subcutaneous tissues, and is composed of two layers, the papillary and reticular dermis...
  
   are damaged, without breaking the skin. Blood oozes out of these vessels into the spaces between cells or interstitial space, causing swelling
  Swelling (medical)
  In medical parlance, swelling is the transient enlargement or protuberance in the body and may include tumors. According to cause, it may be congenital, traumatic, inflammatory, neoplastic or miscellaneous....
  
   and discoloration
  Ecchymosis
  An ecchymosis is the medical term for a subcutaneous purpura larger than 1 centimeter or a hematoma, commonly called a bruise. It can be located in the skin or in a mucous membrane.-Presentation:...
  
  . Blood loss is generally limited, and not of serious consequence. It may, however, act as a signpost, pointing to more serious injuries.
• Avulsion: A full thickness laceration-type wound, often semi-circular in shape. This creates a flap which, when lifted, exposes the deeper tissues to view, or extrudes them from the wound itself. Avulsions often occur in mechanical accidents involving fingers (sometimes referred to as degloving
  Degloving
  A degloving injury is a type of avulsion in which an extensive section of skin is completely torn off the underlying tissue, severing its blood supply. It is named by analogy to the process of removing a glove....
  
  ), and on a more serious note, may affect the orbit
  Orbit
  In physics, an orbit is the gravitationally curved path of an object around a point in space, for example the orbit of a planet around the center of a star system, such as the Solar System...
  
   of the eye
  Human eye
  The human eye is an organ which reacts to light for several purposes. As a conscious sense organ, the eye allows vision. Rod and cone cells in the retina allow conscious light perception and vision including color differentiation and the perception of depth...
  
   or the abdominal cavity
  Abdominal cavity
  The abdominal cavity is the body cavity of the human body that holds the bulk of the viscera. It is located below the thoracic cavity, and above the pelvic cavity. Its dome-shaped roof is the thoracic diaphragm , and its oblique floor is the pelvic inlet...
  
  , exposing the internal viscera. Avulsions are difficult to repair, and no avulsion should ever be considered a minor injury.

Blood vessels affected

External bleeding is generally described in terms of the origin of the blood flow by vessel type. The basic categories of external bleeding are:

• Arterial bleeding: As the name suggests, blood flow originating in an artery
  Artery
  Arteries are blood vessels that carry blood away from the heart. This blood is normally oxygenated, exceptions made for the pulmonary and umbilical arteries....
  
  . With this type of bleeding, the blood is typically bright red in colour, due to the high degree of oxygenation
  Oxygenation (medical)
  Oxygenation occurs when oxygen molecules enter the tissues of the body. For example, blood is oxygenated in the lungs, where oxygen molecules travel from the air and into the blood...
  
  . Blood typically exits the wound in spurts, rather than in a steady flow. The amount of blood loss can be copious, and can occur very rapidly.
• Venous bleeding: This blood is flowing from a damaged vein
  Vein
  In the circulatory system, veins are blood vessels that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated blood to the heart...
  
  . As a result, it will be a darker red to burgundy in colour (due to the lack of oxygen being transported) and will flow in a steady manner. Caution is still indicated; while the blood loss may not be arterial, it can still be quite substantial, and can occur with surprising speed without intervention.
• Capillary bleeding: Capillary bleeding usually occurs in superficial wounds, such as abrasions. The colour of the blood may vary somewhat (distal portion of circulation with oxygenated and unoxygenated blood mixing), and will generally ooze in small amounts, as opposed to flowing or spurting.

External wound management

The type of wound (incision, laceration, puncture etc.) will have a major effect on the way a wound is managed, as will the area of the body affected and the presence of any foreign objects in the wound. The key principles of wound management are:

Elevation

Keeping the wound above the level of the heart will decrease the pressure at the point of injury, and will reduce the bleeding. This mainly applies to limbs and the head, as it is impractical (and in some cases damaging) to attempt to move the torso around to achieve this. Most protocols also do not use elevation on limbs which are broken, as this may exacerbate the injury.

Direct pressure

Placing pressure on the wound will constrict the blood vessels manually, helping to stem any blood flow. When applying pressure, the type and direction of the wound may have an effect, for instance, a cut lengthways on the hand would be opened up by closing the hand in to a fist, whilst a cut across the hand would be sealed by making a fist. A patient can apply pressure directly to their own wound, if their consciousness

Consciousness

Consciousness is a term that refers to the relationship between the mind and the world with which it interacts. It has been defined as: subjectivity, awareness, the ability to experience or to feel, wakefulness, having a sense of selfhood, and the executive control system of the mind...

 level allows. Ideally a barrier, such as sterile, low-adherent gauze should be used between the pressure supplier and the wound, to help reduce chances of infection

Infection

An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...

 and help the wound to seal. Third parties assisting a patient are always advised to use protective latex

Latex

Latex is the stable dispersion of polymer microparticles in an aqueous medium. Latexes may be natural or synthetic.Latex as found in nature is a milky fluid found in 10% of all flowering plants . It is a complex emulsion consisting of proteins, alkaloids, starches, sugars, oils, tannins, resins,...

 or nitrile

Nitrile

A nitrile is any organic compound that has a -C≡N functional group. The prefix cyano- is used interchangeably with the term nitrile in industrial literature. Nitriles are found in many useful compounds, one example being super glue .Inorganic compounds containing the -C≡N group are not called...

 medical gloves

Medical gloves

Medical gloves are disposable gloves used during medical examinations and procedures that help prevent contamination between caregivers and patients. Medical gloves are made of different polymers including latex, nitrile rubber, vinyl and neoprene; they come unpowdered, or powdered with cornstarch...

 to reduce risk of infection or contamination passing either way. Direct pressure can be used with some foreign objects protruding from a wound, and to achieve this, padding is applied from either side of the object to push in and seal the wound - objects are never removed.

Pressure points

In situations where direct pressure and elevation are either not possible or proving ineffective, and there is a risk of exsanguination

Exsanguination

Exsanguination is the fatal process of hypovolemia , to a degree sufficient enough to cause death. One does not have to lose literally all of one's blood to cause death...

, some training protocols advocate the use of pressure points to constrict the major artery which feeds the point of the bleed. This is usually performed at a place where a pulse

Pulse

In medicine, one's pulse represents the tactile arterial palpation of the heartbeat by trained fingertips. The pulse may be palpated in any place that allows an artery to be compressed against a bone, such as at the neck , at the wrist , behind the knee , on the inside of the elbow , and near the...

 can be found, such as in the femoral artery

Femoral artery

The femoral artery is a general term comprising a few large arteries in the thigh. They begin at the inguinal ligament and end just above the knee at adductor canal or Hunter's canal traversing the extent of the femur bone....

. There are significant risks involved in performing pressure point constriction, including necrosis

Necrosis

Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...

 of the area below the constriction, and most protocols give a maximum time for constriction (often around 10 minutes). There is particularly high danger if constricting the carotid artery

Carotid artery

Carotid artery can refer to:* Common carotid artery* External carotid artery* Internal carotid artery...

 in the neck, as the brain is sensitive to hypoxia

Hypoxia (medical)

Hypoxia, or hypoxiation, is a pathological condition in which the body as a whole or a region of the body is deprived of adequate oxygen supply. Variations in arterial oxygen concentrations can be part of the normal physiology, for example, during strenuous physical exercise...

 and brain damage can result within minutes of application of pressure. Pressure on the carotid artery can also cause vagal tone induced bradycardia, which can eventually stop the heart. Other dangers in use of a constricting method include rhabdomyolysis

Rhabdomyolysis

Rhabdomyolysis is a condition in which damaged skeletal muscle tissue breaks down rapidly. Breakdown products of damaged muscle cells are released into the bloodstream; some of these, such as the protein myoglobin, are harmful to the kidneys and may lead to kidney failure...

, which is a build up of toxins below the pressure point, which if released back in to the main bloodstream may cause renal failure

Renal failure

Renal failure or kidney failure describes a medical condition in which the kidneys fail to adequately filter toxins and waste products from the blood...

Epistaxis

Epistaxis or a nosebleed is a special case, where almost all first aid providers train the use of pressure points. The appropriate point here is on the soft fleshy part of the nose, which should constrict the capillaries sufficiently to stop bleeding, although obviously, this will not stop bleeding which originates in the nasopharynx

Nasopharynx

The nasopharynx is the uppermost part of the pharynx. It extends from the base of the skull to the upper surface of the soft palate; it differs from the oral and laryngeal parts of the pharynx in that its cavity always remains patent .-Lateral:On its lateral wall is the pharyngeal ostium of the...

 or the tear ducts

Tourniquet

Another method of achieving constriction of the supplying artery is via the use of a tourniquet

Tourniquet

An emergency tourniquet is a tightly tied band applied around a body part sometimes used in an attempt to stop severe traumatic bleeding. Tourniquets are also used during venipuncture and other medical procedures. Severe bleeding means the loss of more than 1,000 ml of blood. This flow of blood...

 - a tightly tied band which goes around a limb to restrict blood flow. Tourniquets are routinely used in order to bring vein

Vein

In the circulatory system, veins are blood vessels that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated blood to the heart...

s to the surface for cannulation, although their use in emergency medicine is more limited. The use of the tourniquet is restricted in most countries to professionals such as physician

Physician

A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...

s and paramedic

Paramedic

A paramedic is a healthcare professional that works in emergency medical situations. Paramedics provide advanced levels of care for medical emergencies and trauma. The majority of paramedics are based in the field in ambulances, emergency response vehicles, or in specialist mobile units such as...

s, as this is often considered beyond the reach of first aid

First aid

First aid is the provision of initial care for an illness or injury. It is usually performed by non-expert, but trained personnel to a sick or injured person until definitive medical treatment can be accessed. Certain self-limiting illnesses or minor injuries may not require further medical care...

 and those acting in good faith as a good samaritan

Good Samaritan law

Good Samaritan laws are laws or acts protecting those who choose to serve and tend to others who are injured or ill. They are intended to reduce bystanders' hesitation to assist, for fear of being sued or prosecuted for unintentional injury or wrongful death...

. 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 bloodflow. Some argue that tourniquets should never be used in the pre-hospital setting, not even for amputations.

Clotting agents

Some protocols call for the use of clotting accelerating agents, which can either by externally applied as a powder, gel or pre-dosed in a dressing, or as an intravenous injection.
These may be particularly useful in situations where the wound is not clotting, which can be due to external factors, such as size of wound, or medical factors such as haemophilia

Haemophilia

Haemophilia is a group of hereditary genetic disorders that impair the body's ability to control blood clotting or coagulation, which is used to stop bleeding when a blood vessel is broken. Haemophilia A is the most common form of the disorder, present in about 1 in 5,000–10,000 male births...

.

Internal wound management

Internal wounds (usually to the torso

Torso

Trunk or torso is an anatomical term for the central part of the many animal bodies from which extend the neck and limbs. The trunk includes the thorax and abdomen.-Major organs:...

) are harder to deal with than external wounds, although they often have an external cause. The key dangers of internal bleeding include hypovolaemic shock (leading to exsanguination

Exsanguination

Exsanguination is the fatal process of hypovolemia , to a degree sufficient enough to cause death. One does not have to lose literally all of one's blood to cause death...

, causing a tamponade

Tamponade

Tamponade is the closure or blockage as if by a tampon especially to stop bleeding.Tamponade is a useful method of stopping a hemorrhage...

 on the heart or a haemothorax on the lung. The aortic aneurysm

Aortic aneurysm

An aortic aneurysm is a general term for any swelling of the aorta to greater than 1.5 times normal, usually representing an underlying weakness in the wall of the aorta at that location...

 is a special case where the aorta

Aorta

The aorta is the largest artery in the body, originating from the left ventricle of the heart and extending down to the abdomen, where it branches off into two smaller arteries...

, the body's main blood vessel, become ruptured through an inherent weakness. This is one of the most serious medical emergencies

Medical emergency

A medical emergency is an injury or illness that is acute and poses an immediate risk to a person's life or long term health. These emergencies may require assistance from another person, who should ideally be suitably qualified to do so, although some of these emergencies can be dealt with by the...

a patient can face, as the only treatment is rapid surgery, although exertion, raised blood pressure or sudden movements could cause a sudden catastrophic failure.

In the event of the bleeding being caused by an external source (trauma, penetrating wound), the patient is usually inclined to the injured side, in order to ensure that the 'good' side can continue to function properly, without interference from the blood inside the body cavity.

The treatment of internal bleeding is beyond the scope of simple first aid, and should be considered by any first aider to be potentially life threatening. The definitive treatment for internal bleeding is always surgical treatment, and medical advice must be sought urgently for any victim of internal bleeding.