LEARNING OBJECTIVES:

LESSON PURPOSE:

Hemorrhage is profuse bleeding and occurs when there is an escape of blood from the circulatory system due to a break in the walls of one or more blood vessels. Profuse bleeding can lead to shock and both are life-threatening conditions. The average body has approximately five liters of blood and the loss of one liter is generally severe enough to have a damaging effect on the body.

a. TERMINAL LEARNING OBJECTIVE:

(1) While functioning as a Combat Lifesaver in a simulated combat situation, without the aid of reference materials, treat an external hemorrhage on a simulated patient.

b. ENABLING LEARNING OBJECTIVE:

Without the aid of reference materials, the student will be able to:

(1) Describe the characteristics of bleeding from the three major kinds of blood vessels of the circulatory system.

(2) Describe two types of hemorrhages.

(3) Describe and demonstrate the use of elevation as a method of external hemorrhage control.

(4) Describe and demonstrate the use of pressure points as a method of external hemorrhage control.

(5) Describe and demonstrate the proper use of a tourniquet to control an external hemorrhage.

(6) Describe first aid measures recommended for the victims of the internal hemorrhage.

I. CONTROL OF THE HEMORRHAGE:

Blood loss can range from very minor to fatal. Determining the severity of blood loss and relating this to the casualty’s condition is very important. Although it is difficult to estimate the exact amount of blood loss, it is important to recognize potentially serious blood loss and the condition of the casualty as a result of this loss. Severe or uncontrolled blood loss will lead to shock and eventual death.

1. THE CIRCULATORY SYSTEM:

a. Three major types of blood vessel: arteries, veins, capillaries

(1) Artery: A blood vessel with a thick, muscular wall that carries freshly oxygenated blood away from the heart.

            a. Arterial blood is bright red in color.           

            b. Arterial blood flows in pulsating spurts when escaping from the vessels.

c. Arterial blood is often profuse and since it is under high pressure, clot formation (which stops bleeding naturally) is difficult.

(2) Vein: A blood vessel that carries blood that has been used by the body back to the heart. Veins contain one-way valves that keep the blood flow in the proper direction.

            a. Venous blood is dark red in color.

            b. Venous blood flows steadily.

c. Venous bleeding sometimes poses special problems since large veins may suck in debris and air bubbles.

(3) Capillary: A microscopic blood vessel where oxygen/carbon dioxide and nutrient waste exchange take place.

            a. Capillary blood is brick red in color.

            b. Capillary blood oozes slowly.

2. TYPES OF HEMORRHAGE:

a. External bleeding: blood escapes from the body.

b. Internal bleeding: bleeding remains inside the body; there is no opening for the blood to escape. Although this blood remains inside the body, it still cannot be used, therefore, perfusion is poor and tissue death results.

3. TREATMENT:

A casualty who is losing blood rapidly may die unless the bleeding is stopped. External hemorrhage is controlled by pressure, elevation, use of pressure points, and tourniquets in that order.

a. Direct Pressure: By far, the most effective, not to mention the simplest, means of controlling external hemorrhage is to apply steady, direct pressure over the wound.

(1) Apply direct pressure using your hand.

a. If the bleeding is life-threatening, use manual pressure with your hand immediately. Do not waste time looking for he proper bandage dressing.

            b. Apply direct pressure with one hand, while gathering the dressing with the other.

            c. Place a dressing over the wound, then reapply direct pressure with your hand.

(2) Apply direct pressure using a dressing.

            a. The term dressing refers to the material that is placed directly over the wound.

b. The dressing absorbs some of the blood and helps a clot to form. The clot “plugs” the wound to stop the bleeding.

            c. The dressing also protects the wound from additional contamination and injury.

i. Expose the wound. Tear, cut, push, or lift the casualty’s clothing from the area around the wound so that you can see the full extent of the injury.                       

ii. Avoid causing additional damage. If clothing is stuck to the wound, cut or tear around the stuck material and leave the part of the clothing stuck to the wound.

                        iii. Do not remove any objects from the wound.

                        iv. Do not attempt to clean the wound.

                        v. Use a battle dressing of appropriate size for the wound.

                                    1. Tear open the dressing.

                                    2. Grasp the folded tails with both hands.

3. Hold the dressing above the wound with white side facing down toward the wound.

                                    4. Place the dressing on the wound.

                                    5. Place one hand on top of the dressing to hold it in place.

6. Wrap the tails around several times and tie in a non-slip knot over the outer edge of the dressing.

7. Check circulation below the wound to ensure dressing not too tight.

b. Elevation:

(1) If the bleeding is from an extremity, elevate the limb.

            a. Ensure the limb is not fractured which would contraindicate elevation.

b. Elevate the limb above the level of the heart to decrease bleeding. Use a pack, log, rock, or other object.

(2) If the wound continues to bleed, reinforce the dressing with a pressure dressing.

a. Place a wad of material on top of the dressing and directly over the wound. The wad can be made from a folded muslin bandage (cravat), a rag, material torn from clothing, or similar material which can be folded several times.

THE PRESSURE DRESSING IS APPLIED ON TOP OF THE FIELD DRESSING. DO NOT REMOVE OR RETIE THE INITIAL DRESSING OR ANY CLOT THAT HAS BEGUN TO FORM COULD BE DISLODGED AND BLEEDING WILL INCREASE.

            b. Place a bandage over the wad of padding and wrap tightly around the limb.

            c. A non-slip knot should be tied directly over the wound.

c. Pressure Points:

(1) If the wound still continues to bleed, use direct pressure on the pressure point.

a. Pressure point control is not as effective as direct pressure over the wound since it is rare that the bleeding vessel is supplied only by the artery you are compressing.

b. Compression over the artery is unlikely to stop the bleeding altogether, but it may slow the bleeding down to a point where direct pressure over the wound is more effective.

                        i. Locate the appropriate and closest proximal pressure point to control bleeding.

ii. A pressure point is an area where an artery lies over a bone. Pressure on the artery presses it against the underlying bone and reduces the flow of blood.

                        iii. Use as an addition to direct pressure over the wound.

d. APPLY A TOURNIQUET:

(1) If the use of an arterial pressure point does not stop the bleeding, use a tourniquet as a last resort.

a. A tourniquet is a band placed around an upper arm, forearm, thigh, or lower leg, which is tightened to stop the flow of blood below the band.

b. Tourniquets are used immediately (without first using pressure dressings) when there has been a complete amputation of the limb.

(2) Apply a tourniquet.

a. Padding: Place some padding around the limb where the tourniquet band will be applied to protect the skin from being pinched and twisted when the band is tightened.

i. You can smooth the casualty’s shirt sleeve or trouser leg over the tourniquet site.

                        ii. Place the tourniquet band around the tourniquet site.

a. The tourniquet.

1. The band must be made from strong, pliable material and folded into a cravat at least two inches wide.

2. Never use string, shoestrings, wire, rope, or other narrow items that might cut into the skin.

            3. Select a site that is two to four inches above the edge of the wound or amputation site.

            4. If the amputation site is just below the elbow or knee, select a site just above the joint.

            5. Do not apply a tourniquet band over a joint or fracture site.

                        i. Tie the band with a half know (like the first part of tying a shoestring).

b. A rigid object: Use a rigid object, usually a stick, to tighten the tourniquet.

            i. Place the stick on top of the half knot.

            ii. Tie a full knot that will not come undone over the rigid object.

iii. Twist the rigid object until the tourniquet is tight and the bright red bleeding has stopped.

                        1. Venous bleeding may continue to ooze.

                        2. There should be no pulse below the tourniquet.

3. Wrap the tails of the tourniquet band around the end of the rigid object so the object will not untwist.

                        4. Bring the tails under the limb and tie the tails in a non-slip knot.

5. If the rigid object cannot be secured with the tails of the tourniquet band, wrap a piece of material around the limb below the tourniquet, wrap the material around one end of the rigid object so the tourniquet will not unwind, and tie the tails of the material in a non-slip knot.

DO NOT EVER LOOSEN A TOURNIQUET ONCE IT IS IN PLACE. NEVER COVER THE TOURNIQUET; LEAVE IT IN FULL VIEW SO IT CAN BE LOCATED BY MEDICAL PERSONNEL.

c. Dress an amputation: Protect the amputation site from further contamination.

1. Place a dressing made of soft, absorbent material over the end of the stump and secure with bandages.

2. Locate the severed body part, if possible. Transport with the casualty, but make sure to keep it out of the casualty’s sight.

d. Mark the casualty.

1. Write a “T” on the casualty’s forehead with a pen, blood, or mud if nothing else is available.

            2. If possible, include the time and date the tourniquet was applied.

            3. A “T” alerts medical personnel to the presence of a tourniquet.

Key point to remember:

            1. A tourniquet is to be applied to an amputated limb (not part of a hand or foot).

2. When an amputation is not present, a tourniquet is applied only as a last resort when blood loss endangers the casualty’s life and all other methods (direct pressure, pressure dressings, elevation, pressure points) have failed.

3. The portion of the limb below the tourniquet may need to be amputated when the casualty reaches a medical treatment facility.

4. INTERNAL BLEEDING:

a. Internal bleeding can be dangerous for several reasons:

(1) There are many internal organs and large blood vessels under the skin.           

a. Damage to one of these structures can result in the loss of large quantities of blood in a very short time.

(2) This blood loss is hidden.

                        a. External bleeding is easy to identify.

                        b. A person can bleed to death internally without ever spilling a drop.

(3) Severe blood loss can occur internally from an extremity.

a. A fractured femur can cause enough blood loss within the thigh to cause severe shock.

b. Several signs can indicate internal bleeding:

(1) Injuries to the surface of the body from falls or blast injuries, for example, may indicate underlying injury.

(2) Severe bruising, swelling, or pain over vital organs especially in the chest or abdomen.

(3) Painful, swollen, or deformed extremities.

(4) Bleeding from the mouth, rectum, or other body orifice.

(5) Tender, rigid, or distended abdomen.

(6) Vomit that looks like coffee grounds, or bright red vomit.

(7) Dark, tarry stools or bright red blood in the stool.

(8) Signs of shock.

c. There is not too much that can be done in the field about internal bleeding. However, a few measures may help:

            (1) Monitor the casualty’s airway, breathing, and circulation.

            (2) Elevate the casualty’s legs 8-12 inches unless contraindicated.

            (3) Apply a splint to an extremity where internal bleeding is suspected.

            (4) Transport as soon as possible to a higher echelon of medical care.

REFERENCE:

1. First Aid For Soldiers                                                            FM 21-11

2. First Aid                                                                                 MCRP 3-02G