

An in-depth understanding of
bleeding, how to control bleeding in
the emergency setting, as well as in a
controlled medical environment

 Control Bleeding and Prevent a Death!

The Apprentice Doctor®

CONTROL BLEEDING
COURSE
 The Apprentice Doctor® The Apprentice Doctor®
Control Bleeding Course and Training Kit Control Bleeding Training Kit

AN IN-DEPTH UNDERSTANDING OF BLEEDING, HOW TO CONTROL ACQUIRE THE SKILLS TO STOP VARIOUS TYPES OF
BLEEDING IN THE EMERGENCY SETTING, AS WELL AS IN A BLEEDING AND SAVE LIVES!
CONTROLLED MEDICAL ENVIRONMENT
For use in conjunction with the Future Doctors Academy’s
Control Bleeding Course
The Apprentice Doctor® Control Bleeding Course developed and compiled by Dr. Anton Scheepers

for the Future Doctors Academy

Aligned with Next Generation Science Standards (NGSS)

YOUR SIMULATION LAB IN A BOX!

Future Doctors
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The Apprentice Corporation, using

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2 3
 THE APPRENTICE CORPORATION:
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The Apprentice Doctor® Control Bleeding Course and accompanying Control Bleeding Training Kit (including all items
and instruments in the kit) are exclusively intended for educational and training purposes. No instrument or item may
be used in a real clinical medical setting (emergency or otherwise).
Some applications in this course are appropriate for use/to be applied by the general public (proof of training within the
past two years required), and some applications should only be used/applied by suitably qualified medical professionals.
The various practical training projects are clearly marked accordingly.
IMPORTANT: members of the public – all people without a formal medical qualification – may open themselves to
medicolegal litigation if applying techniques only appropriate/allowed for qualified medical professionals.
LATEX ALLERGY ALERT! The simulator arm/leg simulation vein and artery tubes contain latex. We do supply latex-free
simulator arms/legs as an alternative on request.
If used in association with colored saline or fake blood—staining on surfaces and clothing may occur if not
adequately protected.
The Apprentice Doctor® Control Bleeding Kit is suitable for students over 12 years of age. Adult supervision is required
for students below the age of 18 years.
Some of the photos/videos in this course are not suitable for sensitive viewers. Parental guidance for students less than
18 years of age is recommended. Not suitable for students 12 years younger.
The kit contains items that could be a choking hazard in the hands of toddlers. Keep out of reach of toddlers and babies!
4 5
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 CONTENTS
SECTION 7 - BLEEDING IN A CONTROLLED ENVIRONMENT 76
Hospital / Field Hospital / Clinic / ER / OR 77

Control Bleeding during Surgery 78

Preface 8

Bleeding in an emergency environment 8

SECTION 8 - RESTORATION OF BLOOD VOLUME 86
Guideline for the management of massive blood loss due to trauma¹ 87
Bleeding in a controlled medical environment 8
Adverse effects 88
Objectives 9
ABO and Rh compatibility 90
The Apprentice Doctor® Control Bleeding Kit 10
Quiz 3 91
List of items in kit 11

SECTION 1 - THE CIRCULATORY SYSTEM 12 PRACTICAL PROJECTS 92

The Apprentice Doctor® Control Bleeding Course Practical Projects 93
Aspects of Safety 16
Project 1: Preparatory Projects 96
The Circulatory System 17
Project 2: Knot tying techniques 103

SECTION 2 - PHARMACOLOGY 28 Project 3: Simulate an emergency/disaster setting 106

Project 4: Set up the simulation arm (Prepare for a workshop) 109

SECTION 3 - VARIOUS SPECIFIC ENTITIES 30 Project 5: Stop Venous Bleeding 113

Project 6: Stop Arterial Bleeding 114

SECTION 4 - VITAL SIGNS 34
The vital signs 35
Quiz 1 36
Project 7: Stop an Amputation Bleed 123
Project 8: Stop an Arteriolar and Venular Bleeding 127
Project 9: Stop Capillary Bleeding 128

Project 10: Clean and store the simulation arm for reuse 129
SECTION 5 - TYPES OF BLEEDING 38
Bleeding in General 39
Directives on when to use which bleeding control method 130
Types of bleeding 41
The legalities of assisting a person in an emergency setting 131
External bleeding 49

Specific common external bleeds 51

Specific common internal bleeds 62

ASSESSMENT AND CERTIFICATION 133
Quiz 2 71

EPILOGUE 134
SECTION 6 - BLEEDING IN AN UNCONTROLLED ENVIRONMENT 72
Bleeding in an uncontrolled environment 73 GLOSSARY 135

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 PREFACE OBJECTIVES
Bleeding in an emergency environment The objectives of the Apprentice Doctor® Control Bleeding Course are:

Trauma is one of the world’s leading causes of death and disability. Around 40% of deaths are due to bleeding or its Members of the public (without medical background/training) should have a good understanding of the various
consequences, establishing hemorrhage as the most common cause of preventable death in the emergency trauma different types of bleeding and the relevant skills to stop or significantly reduce the bleeding.
setting [REF]. There is, therefore, an all-important responsibility placed on the medical and surgical professions to make it
Medical and healthcare professional students will understand the basic principles of bleeding, hemostasis, shock, and
their business to ensure that all medical and healthcare professionals are well trained in the various techniques to control
how to control and or stop bleeding in the emergency as well as in a medical environment.
bleeding. But there is a wider responsibility, and that is to train as many members of the public, young and old, to be able
to slow down or stop excessive bleeding at a disaster or accident scene – at least until emergency medical professionals Stop the Bleed® instructors will have a solid foundation regarding knowledge and skills for conducting Stop the Bleed®
arrive and safely transport the patient to a hospital for definitive treatment of the injuries (or other causes of excessive workshops.
bleeding).
Control Bleeding Course students will gain knowledge and an understanding of:
Recently there has been a national drive toward the above ideal: See HERE
k Vascular anatomy
The Hartford Consensus recommends that an integrated active shooter response should include the critical actions k Physiology of blood, blood volume, blood pressure, and blood clotting
contained in the acronym THREAT: k Methods to control bleeding in both the emergency and controlled medical settings
k Threat suppression k Surgical shock
k Hemorrhage control k Restoring hypovolemia
k Rapid extrication to safety k Relevant pharmacology
k Assessment by medical providers k Various other related subjects
k Transport to definitive care Control Bleeding Course students will gain the following bleeding control skills by applying their knowledge gained in
Life-threatening bleeding from extremity wounds is best controlled initially through the use of tourniquets, while internal The Apprentice Doctor® Control Bleeding Course material and applying it by using The Apprentice Doctor® How to
bleeding resulting from penetrating injuries to the chest and trunk is best addressed through expeditious transport to a Control Bleeding Training Kit.
hospital setting. An optimal response to the active shooter includes identifying and teaching skill sets appropriate to each Methods to stop bleeding in the emergency setting:
level of responder without regard to law enforcement or fire/rescue/EMS affiliation. THREAT incorporates the proven
k Direct pressure
concepts of self-care and buddy-care.
k Packing and bandaging
k Tourniquets
Bleeding in a controlled medical environment
Methods to stop bleeding in the controlled medical environment:
During my surgical residency, I was told that the surgeon has two main enemies: infection and bleeding. While one can
k Direct pressure
argue the list as incomplete, I do have to concede that infection and excessive bleeding are the two most significant
k Packing and bandaging
enemies of all surgeons and associated surgical disciplines.
k Tourniquets
The Apprentice Doctor® has developed the Control Bleeding Course in its own right as part of its top-rated list of medical/
k Clamping bleeding blood vessels
surgical skills simulation training courses and kits [Click Here for more information]. The Apprentice Doctor® Course
serves as supplementary course material to other Stop the Bleed® educational courses and projects. The Apprentice k Tying-off bleeding blood vessels
Doctor® Control Bleeding Training Kit can be used for almost all workshops related to training students and the public k Suturing
to be able to slow down or control bleeding – thus offering patients a viable chance of surviving life-threatening injuries. k A variety of other measures available to the medical professional
Members of the public are generally better positioned to intervene and change the outcome of current trauma statistics,
The final objective is the most important, and that is to enable both the public and all medical
and of course, offer the bleeding individual a fair chance of survival after a life-threatening bleed.
professionals to control and stop bleeding effectively, and as a result, prevent the premature death
of trauma and mass disaster victims.

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 THE APPRENTICE DOCTOR® CONTROL BLEEDING KIT LIST OF ITEMS IN KIT
Minor variation possible due to availability. SKU: AD608-STBA

ITEM COMMENT QUANTITY

Stop the bleed arm Various bleeding scenarios AD608-Arm
Basic upper arm model (Incl. tubes and connectors) 1
Instruments/Reusable Items AD608-RU
Hemostatic forceps Straight (15 cm/6”)/Non-clinical 1
Hemostatic forceps Curved (15 cm/6”)/Non-clinical 1
Sphygmomanometer Aneroid 1 (selected kits only)
Tourniquet CAT Arterial 1
Replenish pack AD608-Refill
Linen savers Protective covers 1
Plastic aprons Waterproof 4
Nitrile gloves Medium 4 pairs
Gauze squares Medium 50
Figure 1. The Apprentice Doctor® Control Bleeding Kit
Ribbon gauze (mutton cloth) Medium 4
The Apprentice Doctor® Control Bleeding Training Kit contains all* the items for practicing the majority of the practical Crepe/ pressure bandage 50 mm (2”) 4

projects contained in The Apprentice Doctor® Control Bleeding Course. (*The Apprentice Doctor® Suturing Kit is Fluid-bag⁴ (empty) Add 1000 ml fake blood 1
Fluid administration line Connected to the fluid bag 1
required for the projects where suturing is required.) The Apprentice Doctor® Control Bleeding Training Kit is also a
Syringe 60 ml Luer lock 1
suitable resource for instructors and participants of the national Stop the Bleed® campaign and associated Stop the
Stitch cutter Long 1
Bleed® workshops [Video].
Balloon Tube form 2
Marker pen Red (non-toxic) 1
Tie suture No needle (1 meter/yard) 1
Items required for workshops Not included in the control bleeding kit Comment
Trays with curved sides Recommended size: >40x50cm (12x16’’) 1 per work station
Funnel (optional) 6-10 cm (2.5–4”) 1 per work station
Gloves (extra) Nitrile – a range of sizes Various boxes
Alcohol hand rub Containers Sufficient number of containers
Absorbent paper towels Rolls Sufficient number of rolls
Rag/old cloth For emergency “make-do” tourniquet One strip
Food coloring dye Red 1 Bottle
¹Apprentice Doctor® Suture Kit Not included in the control bleeding kit 1 AD602-Compact
²Apprentice Doctor® Oximeter Not included in the control bleeding kit 1 AD609-FPOX
³Apprentice Doctor® STB bundle Apprentice Doctor® Control Bleeding Kit, 1 AD608-STBA-Bundle
Suture Kit, and Pulse Oximeter

¹Recommended for completing all projects where suturing is required. Order: Get my Suture Kit, please!

²Recommended for adding value to some of the key projects. Order: Get my oximeter, please!
ORDER YOUR BLEEDING CONTROL KIT HERE! ³Order these three complementary products together at a discounted price.

⁴For filled IV simulation bags: Order here from Wallcur®

The recommended workshop group size is 2 - 4 participants per kit. Table 1: The Apprentice Doctor® Control Bleeding Kit
(Important note: items may vary to some extent depending on availability and other specifics.)

10 11
 SECTION 1
THE CIRCULATORY SYSTEM

James Howard gently awoke his wife and whispered: “Dear... I think someone is
breaking into our house!”
And true, there was unquestionably some noise and movement in the house as burglars were collecting valuables like
TV’s, purses, and mobile phones. The Howard parents kept quiet, fearing for the safety of their two teenage children.

The Howard family had been living in this house for close to 20 years, mostly safe, secure, and without incidents – that is
until recently. Over the past ten months, they’d had three burglaries and had to invest in an alarm system and a rapid
response security company.

12 13
 The security officer was waiting on the outside of the door with a loaded pistol in his hands. When the door opened with
Well, with a panic button installed and now available next to the bed, James quietly turned around and pressed the panic such a commotion, he pulled the trigger, believing that it was the burglars trying to escape in a hurry. The bullet hit James
button, and thus alerting the security company. The Howard parents were now praying that the security officers would in the groin, throwing him to the floor. Severe bleeding was immediately evident and pooled quickly. James, in agony, was
arrive very soon. shouting for help.

After what felt like an eternity, they could hear a car stopping in the street in front of their house, and a few minutes later, Ms. Howard arrived hysterically and tried to apply pressure with a towel, but to little avail. A couple of minutes later, the
a knock on the door. “This is the security company,” he whispered to his wife, and he dashed off in a wild rush, driven by ambulance arrived, and despite aggressive resuscitation measures, James Howard was declared dead on the scene. The
fear, to open the door! cause of death was stated as “massive blood loss due to severance of the femoral artery and vein.”

He plucked open the door, and what happened next was utterly unexpected. The burglars fled the scene using the back door and were never apprehended.

14 15
 ASPECTS OF SAFETY THE CIRCULATORY SYSTEM
YOUR SAFETY IN AN EMERGENCY SETTING ANATOMY
The first step in the effort to control bleeding in an emergency setting is assessment (briefly), and the first thing to assess A thorough knowledge of vascular anatomy is required for managing various vascular bleeds
is your safety. There is a saying amongst emergency workers that a dead hero is of no use, and an injured hero is a nuisance. optimally. Study the following diagrams
You need to be relatively safe and uninjured to be of assistance to the trauma victim/patient. Assess imminent danger, be
it road traffic, or an attacker/terrorist that is still active in the disaster zone.

The helper should always don clean gloves (if available) as a barrier, to avoid introducing pathogenic microbes into the
wounds, and at the same time minimizing the risk of contracting blood-borne diseases from the victim/patient. If there
are no gloves available – do not delay stopping the bleed. Proceed gloveless, as every second count while a patient is
busy bleeding out! Perform proper hand hygiene after the control bleeding procedure.

If blood from the victim/patient splashes onto the helper’s mucous membrane (eyes, mouth, nose or genital area) or if the
helper has a cut, bruise or wound on an ungloved hand, or if any sharp blood-contaminated item cuts the helper), report
to the ER for proper assessment by a medical professional. There are specific protocols to deal with such exposure
incidents, and further assessment and possible management are most definitely required. PEP (post-exposure prophylaxis)
may have to be initiated as a preventative measure.

THE TRAUMA VICTIM/PATIENT’S SAFETY IN AN EMERGENCY SETTING

In the same way, assess the patient’s safety. Consider moving the victim/patient to a safer area, but
keep in mind that a patient with a suspected cervical spine injury should not be moved until qualified
emergency medical workers can assess and stabilize the neck.

YOUR SAFETY IN A CONTROLLED MEDICAL ENVIRONMENT

Wear appropriate personal protective equipment (surgical scrubs, cap, and mask with visor or
protective glasses, clean surgical or sterile gloves). If in the emergency room (ER) or operating room
(OR), perform the procedure with appropriate sterile and aseptic technique, following your hospital/
clinic’s sterility and aseptic technique protocol. Formally scrub and gown for surgery if managing the
injuries in the operating room. See The Apprentice Doctor® Sterility and Aseptic Technique Course
and Kit for more information.

THE PATIENT’S SAFETY IN A MEDICAL ENVIRONMENT

Once the patient is stabilized, ensure that a complete medical history is taken to avoid any unnecessary
risks regarding allergies, hemostasis, previous medical conditions, chronic medication, etc.

Follow the accepted protocol of sterility and aseptic technique. The patient will most probably need
further attention regarding assessing and treating hypovolemia, restoring the blood volume, and
treating any other injuries (e.g., broken bones) more definitively.
Figure 2a. Main blood vessels of the body
Assault and domestic violence patients may need police protection from the assailant.

16 17
 Figure 2b. Veins and arteries of the head and neck

Figure 2c. Arteries of the arm

18 19
 Figure 2d. Veins of the arm

Figure 2e. Arteries of the leg

20 21
 HISTOLOGY
The main differences between arteries and veins are:

k The total wall thickness of an artery is usually greater than that of a vein of a similar size, due to a thicker muscular
layer in the arterial wall,
k The luminal diameter of an artery is usually smaller than that of a vein of the same size,
k Veins are often collapsed or semi-collapsed if empty and
k Some veins have valves.

Figures 3a and 3b. Cross-section of an artery, a vein, and a capillary

PHYSIOLOGY
BLOOD VOLUME

RATIONALE: trauma statistics consistently show that the most common preventable cause of death is bleeding.

The above statement is a reality due to two physiological facts:

1. All individuals have a limited blood volume (Table 2). Losing more than a third of this limited amount causes surgical
shock, and death will become imminent if it remains untreated.

2. The blood in the cardiovascular space is under pressure and will escape if the integrity of this system top-rated. The
normal mean arterial pressure in healthy adult patients is between 70 and 100 mmHg, and the normal central venous
pressure may range from 8-12 mmHg.

AGE MEAN BLOOD VOLUME/WEIGHT EXAMPLE WEIGHT (KG) TOTAL BLOOD VOLUME (ML)
(ML/KG)
6 months 86 7,5 645
1 year 80 10 800
6 years 80 20 1600
10 years 75 32 2400
15 years 71 55 3905
Figure 2f. Veins of the leg
Adult male 71 75 5325
Adult female 70 70 4900
Table 2a. Blood volume by age and weight converter (metric)

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 AGE MEAN BLOOD VOLUME/WEIGHT EXAMPLE WEIGHT (LB.) TOTAL BLOOD VOLUME (PT.) The unit measurement of blood pressure is mmHg (millimeters Mercury) and refers to the height of a
(PT./LB.)
column of Mercury pushed up above the level of the heart. It always given as two numbers:
6 months 0.10 16.5 1.1
1 year 0.08 10 1.4
Systolic Pressure (Contraction phase of the heart cycle)
6 years 0.08 44 2.8 BLOOD PRESSURE =
10 years 0.07 70.4 4.2 Diastolic pressure (Relaxation phase of the heart cycle)
15 years 0.07 121 6.9
Adult male 0.07 165 9.4 STAGE APPROXIMATE AGE SYSTOLIC BP, MMHG DIASTOLIC BP, MMHG

Adult female 0.07 154 8.6 Infants 0 to 12 months 75–100 50–70

Table 2b. Blood volume by age and weight converter (imperial) Toddlers and preschoolers 1 to 5 years 80–110 50–80
School-age 6 to 12 years 85–120 50–80
The adult cardiovascular system contains about 5 liters (9 pints) of blood. This is a preciously small volume in a patient Adolescents 13 to 18 years 95–140 60–90
with an arterial bleed, and bleeding out is possible in a matter of minutes! Adults 18+ 100+ 70+

Table 3. Reference ranges for blood pressure at various age groups

“Bleeding out” is the loss of blood to a degree sufficient to cause death. Depending upon variables like the age, health,
and fitness level, an individual can die from losing half of their blood; a loss of roughly one-third of the blood volume is
considered extremely serious and life-threatening. HYPERTENSION
Hypertension or high blood pressure can lead to serious health problems and increases the risk of
BLOOD PRESSURE
heart disease, stroke, other health problems, and if untreated to premature death.
Blood pressure (BP) is the pressure that circulating blood exerts on the inner walls of blood vessels. Most of this pressure
is due to work done by the heart by pumping blood through the circulatory system. Used without further specification,
SYSTOLIC PRESSURE DIASTOLIC PRESSURE STAGES OF HIGH
“blood pressure” usually refers to the pressure in large arteries of the systemic circulation. (MM HG) (MM HG) BLOOD PRESSURE

140 90 Stage 1
It follows that any discontinuation of the wall of any blood vessel exposed to the external environment (e.g., by trauma),
160 100 Stage 2
arterial blood will pulsate, venous blood will flow, and capillary blood will ooze to the outside while any discontinuation
180 110 Stage 3
of the wall of a blood vessel confined to the internal bodily environment (e.g., the rupture of an aneurysm), blood will
210 120 Stage 4
escape from this discontinuation until pressure equilibrium is reached.
Table 4. Hypertension: blood pressure range for adults

BLOOD’S FUNCTIONS
Blood is a modified fluid type of connective tissue and serves a number of vital functions.

Blood:

k Provides the body’s cells with oxygen and transports carbon dioxide from the tissue to the lungs.
k Transports nutrients and various hormones.
k Removes waste products, e.g., carbon dioxide, urea, and lactic acid.
k Transports waste products to the kidneys (excretion) and liver (processing/ detoxification).
k Protects the body from infection due to the white blood cells.
k Transports hormones from one part of the body to another.
k Plays an essential role in regulating the tissue acidity (pH) levels.
k Plays a central role in regulating body temperature.
Chart 1. The blood pressure in the various sections of the circulation [Wikipedia Commons]

24 25
 BLOOD AND OXYGEN
Figure 4a. Blood including blood cells flowing inside a small Figure 4b. Red blood cells and hemoglobin molecules
blood vessel
Hemoglobin, contained within the red blood cells, transports oxygen from the lungs to the tissue cells. It is specifically this
oxygen transport function that makes blood essential for the maintenance of life; and the loss of blood such a serious and
life-threatening condition.
The neurons in the brain are exceptionally dependent on a constant supply of oxygen. Losing a too large quantity of
blood will inevitably lead to cerebral hypoxia (too little oxygen to the brain), with the ultimate outcome of brain damage
and, eventually, brain death. Longer periods of low brain oxygen levels are associated with higher morbidity and mortality.
It follows that controlling excessive bleeding as soon as possible goes a long way to prevent brain damage and eventually
brain death. Oxygen deprivation due to, for example, cardiac arrest, will result in brain damage after about six minutes.
BLOOD CLOTTING
Figure 5. A blood clot with red blood cells, blood platelets, and strands of fibrin
Coagulation, also known as clotting, is the process by which blood changes from a liquid to a gel, forming a blood clot. It
potentially results in hemostasis, the cessation of blood loss from a damaged vessel, followed by repair. The mechanism
of coagulation involves activation, adhesion, and aggregation of platelets, as well as deposition and maturation of fibrin.
Coagulation begins almost instantly after the blood vessel’s endothelium lining has been damaged due to injury.
[Wikimedia Commons]
26
FIBRINOLYSIS
Fibrinolysis is a process that prevents blood clots from growing and becoming problematic. This process has two types:
primary fibrinolysis and secondary fibrinolysis. The primary type is a normal body process, whereas secondary fibrinolysis
is the breakdown of clots due to medicine, a medical disorder, or some other cause.
In fibrinolysis, a fibrin clot (the end product of coagulation) is enzymatically broken down by plasmin by cutting the fibrin
mesh at various places, leading to the production of circulating fragments that are cleared by other proteases or by the
kidney and liver.
Antifibrinolytic preparations, such as aminocaproic acid and tranexamic acid, are used as inhibitors of fibrinolysis. Their
application may be beneficial in patients with hyper-fibrinolysis because they arrest bleeding rapidly if the other
components of the hemostatic system are not severely affected. This may help to avoid the use of blood products such as
fresh frozen plasma with its associated risks of various blood-borne infections or anaphylactic reactions.
HYPOVOLEMIC SHOCK
Hemorrhagic shock is the most common type of hypovolemic shock and can be described as a condition of reduced tissue
perfusion, resulting in the inadequate delivery of oxygen and nutrients essential for the various cellular functions. The
consequence is that oxygen demand on cellular level outweighs its supply, and it results in a patient that is in a state of shock
(“shock” in the pathophysiological sense of the word). For an overview of hypovolemic shock [Wikimedia commons]
HEMORRHAGIC SHOCK
Recognizing the degree of blood loss by assessing and interpreting the patient’s vital signs and mental status is important.
The American College of Surgeons Advanced Trauma Life Support (ATLS) hemorrhagic shock classification links the
amount of blood loss to expected physiologic responses in a healthy 70 kg patient. As total circulating blood volume
accounts for approximately 7% of total body weight, this equals about five liters in the average 70 kg male patient. The
following is a useful classification:
CLASS 1: volume loss up to 15% of total blood volume, approximately 750 ml: heart rate is minimally elevated or normal.
Typically, there is no change in blood pressure, pulse pressure, or respiratory rate.
CLASS 2: volume loss from 15% to 30% of total blood volume, from 750 mL to 1500 ml: heart rate and respiratory rate
become elevated (100 BPM to 120 BPM, 20 RR to 24 RR). Pulse pressure begins to narrow, but systolic blood pressure may
be unchanged to slightly decreased.
CLASS 3: volume loss from 30% to 40% of total blood volume, from 1500 mL to 2000 ml: a significant drop in blood
pressure and changes in mental status occur. Heart rate and respiratory rate are significantly elevated (more than 120
BPM). Urine output declines. Capillary refill is delayed.
CLASS 4: volume loss over 40% of total blood volume: hypotension with narrow pulse pressure (less than 25 mmHg).
Tachycardia becomes more pronounced (more than 120 BPM), and mental status becomes increasingly altered. Urine
output is minimal or absent. Capillary refill is delayed.
Again, the above is outlined for a healthy 70 kg (154 Lb.) individual. Clinical factors must be taken into account when
assessing patients. Read the full article by Nicholas Hooper; Tyler J. Armstrong, on hemorrhagic shock: [Click here]
[StatPearls Publishing LLC. Creative Commons Attribution 4.0 International License Minor adaptations were made in
the above excerpt.]
27
 ANTICOAGULANTS
Helpers and medical professionals should keep in mind that the use of anticoagulant medication, including self-medicating
with, e.g., aspirin, is quite common these days. Oral anticoagulants are taken by many people for a variety of medical/

SECTION 2
surgical reasons.

The most significant risk of anticoagulation therapy is the increased risk of bleeding. In otherwise healthy people, the
increased risk of bleeding during anticoagulant therapy is minimal, but those who have had recent trauma, surgery,
cerebral aneurysms, and other conditions will have an increased risk of uncontrolled bleeding.

PHARMACOLOGY
Generally, the benefit of anticoagulation is the prevention of or reduction of the progression of a disease. Some indications
for anticoagulant therapy with known benefits from therapy include coronary artery disease, deep vein thrombosis,
myocardial infarction, pulmonary embolism, after heart valve replacement surgery, and deep vein thrombosis, to mention
but a few. The use of anticoagulants is a decision based upon weighing up the risks versus benefits of anticoagulation
therapy.

Commonly used anticoagulants include: heparin, warfarin (Coumadin), rivaroxaban (Xarelto), dabigatran (Pradaxa),
apixaban (Eliquis), edoxaban (Savaysa), enoxaparin (Lovenox), fondaparinux (Arixtra) and commonly used antiplatelet
agents include: clopidogrel (Plavix), ticagrelor (Brilinta), prasugrel (Effient), dipyridamole, aspirin (Ecotrin, Cardioaspirin,
and Bayer Aspirin ), dipyridamole plus aspirin (Aggrenox), ticlopidine (Ticlid), eptifibatide (Integrilin).

RISK OF THROMBOTIC INCIDENTS IN A HOSPITAL

It is crucial that patients are evaluated regarding the risk of deep venous thrombosis as a preventative
measure when hospitalized. Risk factors include age, bed rest, congestive heart failure, estrogen,
family history, hematologic cancers, immobility, indwelling catheters, long-distance travel, major
trauma, noninfectious inflammatory conditions, obesity, pregnancy (and postpartum status), prior
venous thromboembolism (VTE), recent surgery, smoking, solid cancers, stroke, and thrombophilias.

See this document from the UK Department of Health on this topic [Click here]

28 29
 HEMATOMA
A hematoma is defined as a collection of (usually clotted) blood outside of blood vessels and inside a bodily cavity or
tissue space. Most commonly, hematomas are caused by an injury to the wall of a blood vessel, causing blood to seep out

SECTION 3
of the blood vessel into the surrounding tissues.

Small hematomas often resolve spontaneously over a period of time as the blood clot is broken down, and the blood is
removed. Larger hematomas usually require surgical evacuation.

VARIOUS SPECIFIC ENTITIES

ECCHYMOSIS

Figure 6. An example of extensive ecchymosis of the forearm

Ecchymosis is the subcutaneous extravasation of blood within the tissues, which results in discoloration of the skin from
damaged small blood vessels and the seepage of blood in the tissues. The discoloration initially may appear red and then
changes to blue-purplish and after a couple of days, will turn into a green-yellowish hue. No treatment is required, and it
will disappear spontaneously. Ultrasound applied by a physiotherapist may speed up the resolution and absorption of an
area of ecchymosis.

To minimize the formation of an area of ecchymosis after injury, apply pressure for 5-10 minutes over the site of injury,
preferably with an ice pack.

HEMANGIOMAS AND VASCULAR MALFORMATIONS

Figure 7a. A small hemangioma of infancy Figure7b. A vascular malformation on a baby’s arm

The above terms are often used interchangeably, but there is a definite difference between these two entities.

30 31
 Have a look at this document for a clear explanation of the differences. ANEURYSM
k A hemangioma is a usually benign vascular tumor derived from blood vessel cell types. The most common form is
infantile hemangioma, known colloquially as a “strawberry mark,” most commonly seen on the skin at birth or in the
first few weeks of life.
k Vascular malformations are usually present at birth, grow proportionally with the child, do not expand rapidly during
infancy, and do not disappear. The blood vessels constituting these entities are usually void of a significant muscular
layer, and since these lesions are exceptionally vascular and blood-rich, surgery involving these lesions may be difficult
and even become life-threatening. Proper planning and special techniques are needed to perform safe surgery
involving these types of lesions. Trauma involving a vascular malformation can become life-threatening.
k [Wikimedia: Commons]

THROMBUS

Figure 10. Types of aneurisms

An aneurysm refers to a weakening of an arterial wall resulting in a bulge, or distention, of the artery. Most aneurysms are
Figure 8. An illustration of a thrombus
asymptomatic and are not dangerous. However, occasionally, one can rupture, leading to life-threatening internal
bleeding.
A thrombus is a blood clot that forms in a blood vessel and remains where it formed.

EMBOLUS DISSEMINATED INTRAVASCULAR COAGULATION (DIC)

Disseminated intravascular coagulation is occasionally seen following massive trauma, certain surgical procedures
(especially lung, brain, and prostate surgery), and septic shock. Inappropriate blood clotting and poor coagulation occur
simultaneously. Multiple small blood clots often arise throughout the cardiovascular system, especially in small blood
vessels and capillaries. These small clots block the blood flow to various parts and organs of the body, restricting the
oxygen supply to these affected parts. The bleeding component of DIC occurs as these multiple micro-clots deplete the
clotting factors in the blood.

DIC differs from normal clotting in 3 ways:

1. It is diffuse instead of localized.

Figure 9. An illustration of deep vein thrombosis (DVT) becoming a pulmonary embolus 2. It a damaging process, unlike normal clotting, which, in essence, is a protective process.
3. It often depletes all the available clotting factors in the blood, causing bleeding.
k An embolus is a blood clot (usually a dislodged thrombus) that travels from the site where it formed to another
location in the body. Emboli can lodge in a blood vessel and block the flow of blood in that location depriving tissues
of normal blood flow and oxygen (e.g., the pulmonary arteries blocking perfusion to the lung/s).

32 33
 THE VITAL SIGNS

SECTION 4
VITAL SIGNS

Figure 11. A typical vital signs monitor

Classically the vital signs for patients 12 years of age or older are listed as the following:
k Heart rate
k Respiratory rate
k Blood pressure
k Body temperature

These elementary measurements give medical professionals a lot of information about the trauma patient’s current status
and prognosis.

Helpers familiar with assessing the vital signs, especially heart rate and respiratory rate, will do well determining these
from the trauma patient being assisted while waiting for emergency medical professionals like paramedics to arrive. As
soon as they arrive, give them this information, it will be valued and appreciated.

WATCH THIS VIDEO: An intra-arterial perspective of blood pressure

34 35
 QUIZ 1 WOULD YOU LIKE TO ATTEND
Are the following statements TRUE or FALSE?
A CONTROL BLEEDING WORKSHOP?
Discuss the statement in a group setting.

Statement 1: The correct way of thinking in a disaster setting is to consider another person’s safety as more important as The Apprentice Doctor® Stop-the-Bleed workshops are great fun and offer
your safety. amazingly realistic simulation training experiences.
Statement 2: A person cannot bleed to death from a venous bleed due to the generally low venous blood pressure.
WATCH THE WORKSHOP VIDEO
Statement 3: The pulmonary artery supplies oxygen-rich blood to the lungs.

Statement 4: An aortic aneurysm is a life-threatening condition.

Statement 5: A patient’s blood-oxygen saturation is not considered as a vital sign.

Answers available at the bottom of the page.

Be sure to wear scrubs and an apron during the workshop - stopping a bleed
can become a messy affair!

 CLICK HERE FOR OUR FACEBOOK PAGE

Workshops venues, dates and times to be announced from time to time.

ANSWERS:
Statement 1: False. One should always consider your safety as the most important. A dead hero is of no use, and an injured hero is a
problem in an emergency setting.
Statement 2: False. The potential for a patient to go into hypovolemic shock is based not only on the pressure in the blood vessel but
also on the volume of blood loss, and this is dictated by both the internal pressure and the diameter of the blood vessel. Veins with large
diameters, like the internal jugular and intrathoracic veins (e.g., the brachiocephalic veins), have diameters sufficiently large to cause a
patient to bleed out within a fairly short time, and die. It is unlikely that a patient will bleed to death from a minor venous bleed, but keep
in mind that many patients are on anticoagulation therapy, and thus the blood loss from even a medium-sized vein may become
life-threatening after some time, if not treated.
Statement 3: False. The pulmonary artery conducts oxygen-poor blood to the lung for oxygenation.
Statement 4: True. Large aortic aneurysms are prone to rupture. A ruptured aortic aneurysm needs urgent intervention and has a grave
prognosis.
Statement 5: True. The classical list of vital signs in an adult trauma patient is the heart rate, the respiratory rate, blood pressure,
and body temperature.

36 37
 BLEEDING IN GENERAL
Fundamental Principle: exerting sufficient pressure - correctly applied to the bleeding point - will always control the bleed.

SECTION 5 Pressure exerted, exceeding the pressure in the bleeding vessel, will reduce or stop the bleeding.

WATCH THIS VIDEO: https://youtu.be/2qv6bP9s9Bg

TYPES OF BLEEDING
Bleeding is the inevitable consequence of the severance of blood vessels. Most bleeds are minor, self-limiting, and the
associated wound heals without professional medical intervention. If the bleeding involves a larger vessel, especially if the
vessel is an artery, then the associated bleed will need intervention to limit blood loss and to stop the bleed.

If you offer assistance at an accident/disaster scene, try to differentiate between bleeds that need intervention and those that
will resolve on their own. Two concepts: the “flow rate” and the “volume” of blood are key to the decisions that you need to
make. Warning signs are (1) continuous bleeding with (2) large amounts of blood with (3) pooling or soaking of clothing.

Figure 12a. A large amount of blood Figure 12b. Pooling of blood Figure 12c. Blood soaked clothing

Assess the blood volume already lost as well as the current flow of blood from the wounds. Classify the blood flow as one
of the following: oozing, slow, moderate, and fast. Imagine how many cups — all the blood that you can visualize, including
all the blood clots and clothing/cloths soaked in blood — would fill. Also, try to differentiate between an arterial bleed
(more urgent) and a venous bleed (less urgent). There is more information on this topic in the section below.

Note the crutch, the loose floor mat, the broken cup, the
bleeding on the floor (and the dog removing some of the
“evidence”). Also, observe the blood marks on the wall next to
the stairs.

Can you guess what happened?

Figure 13. A scene of injury at home. Can you reconstruct the

events in this trauma scene?

38 39
 This is what happened: an elderly female person slipped on the rug with a teacup in her hand. The cup broke and cut into her
hand, and wrist severing the radial artery. She calls a doctor friend for assistance and goes upstairs and washes her hand under TYPES OF BLEEDING
running water.
Bleeding can be classified according to the kind of blood vessel that is involved.

Figure 14. Washing the bleeding hand

She eventual collapsed and was found by her doctor friend in a shocked state on the upper bathroom floor.

Figure 15. Exerting pressure, then inspect for bleeding

The doctor performed emergency stop the bleed procedures with pressure dressings and a bandage and rushed her to the
nearby hospital’s emergency department where she was stabilized. Further management by an emergency physician and a Figure 16. Various types of bleeding

surgeon was required. The patient was hospitalized for three days.
k Arterial bleeding
See Project 48 Prevention of Emergencies – Apprentice Doctor Foundation Medical Course and Kit k Venous bleeding
k Capillary bleeding
k Arteriolar and Venular bleeding

ARTERIAL BLEEDING
Generally, an arterial bleed has a faster flow rate, and it may squirt out of the wound for quite a distance. It is also pulsatile
and bright red in color (exceptions are polycythemia vera and advanced COPD patients’ blood). Arterial bleeding, as a rule,
is difficult to control with applying pressure only and will probably require firm packing or using a tourniquet to minimize/
stop the bleeding.

WATCH THIS VIDEO: Nose bleed - Note the pulsations of the blood in the nasal passage, synchronized with
each heartbeat sound on the monitor.

To stop arterial bleeds, the external pressure exerted by the helper must exceed the systolic arterial blood pressure. A
minimum pressure of 120 mmHg, but probably more, will be required to stop an arterial bleed. The helper should persist
with increasing the direct pressure, packing, or applying a tourniquet until the bleeding stops.

40 41
42 43
 VENOUS BLEEDING CAN ONE BLEED TO DEATH FROM A VENOUS BLEED?

Generally, venous bleeding flows at a slower rate (compared to arterial bleeding); it is not pulsatile and is a darker red As a general rule, the answer to the question is no – but like anything in the medical field, there are some exceptions:
(dark maroon/reddish-purple) in color.
1. Large veins, especially the internal jugular vein. Severance of this vein will lead a bleed-out in a relatively short time,
RESTING VENOUS PRESSURE due to the large diameter and thus volume of blood transported by this vein. It may also cause an air embolism.

The average venous pressure (measured at the ankle in mmHg), varies depending on the person’s posture. These variations
are mainly due to gravity. In a healthy adult of average length, venous pressures measured in the saphenous vein at the
level of the ankle are as follows:

Figure 18. The large blood vessels of the neck

2. Internal bleed-out by severance of large internal veins, for example, the vena cava inferior and superior, the pulmonary
veins, and the brachiocephalic veins.

Figure 19a and 19b. The large blood vessels of the thorax
Figure 17 Venous pressures (a) Lying down. 15 mmHg (b) Sitting. 56 mmHg (c) Standing. 85 mmHg

It follows that lifting a limb will reduce the venous pressure dramatically, and is thus one of the primary methods of
limiting venous bleeding. Lifting the limb, or more accurately, the bleeding area somewhat above the level of the heart
should suffice. It is not necessary to lift the limb to the maximum height.
3. Patients on anticoagulant therapy or who have hemophilia can die from even a medium-sized venous bleed, if there
is no intervention, as the blood will not clot normally after severance, or may not clot at all.
DOES ONE NEED TO STOP VENOUS BLEEDS?

More information: Click Here Yes, although not always a life-saving measure, one should attempt to stop venous bleeds for the following reasons:

1. Some venous bleeds can be life-threatening.

2. So many members of the public are on some type of anticoagulant therapy and will continue bleeding until intervened
by some form of bleeding control measure.
3. Bleeding can cause a mess on clothing and surrounding carpets, furniture, etc.
4. It is the humane thing to do. It is a way to show “I care!”

One can stop most venous bleeds by applying moderate pressure on the bleed point (as little as 20-30 mmHg).

44 45
46 47
 ARTERIOLAR AND VENULAR BLEEDING
EXTERNAL BLEEDING

Figures 20a and 20b. Examples of scalp wounds

Examples of this type of bleeding are: bleeding from a scalp wound, deep skin wounds, bleeding from muscles, and dental
bleeds.

Arteriolar and venular bleeding can be quite daunting, as the blood loss from multiple arterioles and venules bleeding,
adds up to an amazingly strong flow of blood. As in the case of arterial bleeding, pressure exceeding the systolic blood
pressure is recommended.

CAPILLARY BLEEDING

Figure 22. An external bleed of the arm

External bleeding is when blood loss is reaching the external or outside aspect of the body.

Bleeding may originate from:

Figure 21. A finger pad bleed is a good example of capillary bleeding
k One of the extremities
A capillary bleed is generally either a slow or stronger ooze. It is rarely (if ever) life-threatening and will either stop
k A junctional site like the neck, axilla or groin
spontaneously or may need light to moderate pressure for controlling this type of bleed (presuming normal clotting
k The body (torso)
mechanisms and no anticoagulation therapy). It takes as little as 25-45 mmHg to stop most capillary bleeds.
k The head area (face and skull)
WATCH THIS VIDEO: Finger bleed

Another way of classifying bleeding is:

k External bleeding and

k Internal bleeding

48 49
 Skull: members of the public are allowed to apply *hemostatic gauze with moderate pressure,
and place a moderately firm pressure bandage on a bleeding scalp laceration. Caution! Refrain SPECIFIC COMMON EXTERNAL BLEEDS
from excessive pressure over the skull area as one may unintentionally displace a depressed
skull fracture. EMERGENCY MEDICINE
Face: manage a localized bleed in the face with pressure on the bleeding point using gauze or In emergency medicine (paramedics, ER physicians, nurses, trauma surgeons, etc.), stopping bleeding and managing the
a clean cloth. Caution! Do not apply excessive pressure over the eye area. When confronted
sequelae and complications of blood loss is very much what keeps these medical professionals busy for a fair part of their
with bleeding from the nose or mouth: helpers should be cautious not to restrict the airway
days. As blood loss is life-threatening – these individuals work well under pressure, and the more adrenaline (epinephrine),
with inappropriate packing, thereby limiting or blocking the airway.
the more excitement rushes through their veins!
Chest: bleeding originating from the chest wall (including the back) may be controlled by
pressure or packing. Caution! When exerting pressure in the chest region, the helper should
CARDIOPULMONARY RESUSCITATION (CPR) ON A PATIENT WITH AN
ensure that he/she does not interfere with the victim/patient’s normal breathing. Bleeding
originating from inside the thoracic cavity, e.g., from a major blood vessel, or from the heart,
ARTERIAL BLEED
cannot be controlled by pressure or packing and requires specialized medical knowledge to If a patient has both an active bleed, and at the same time, cardiac arrest, stopping the bleed will take priority over CPR.
manage.
One may actually worsen the hypovolemia and level of bleed-out by performing chest compressions on a patient with an
Abdomen: bleeding originating from the abdominal wall (including the back) may be active arterial bleed (internal or external).
controlled by pressure and packing. If the person is bleeding from a large blood vessel within
the abdominal or pelvic cavity (e.g., a stab wound involving a major abdominal blood vessel),
PENETRATING INJURIES
a helper from the public is unlikely to make any difference to the prognosis of the patient, by
exerting pressure (direct or packing) on the external bleeding point.
A fishing trip having gone bad
Junctional sites: pressure and packing are recommended to control bleeding. Caution!
Please do not apply any tourniquets, (especially the neck)!

Extremities: all methods – pressure, packing, and tourniquet – are allowed to control bleeding
if appropriately and adequately applied. Helpers should be aptly trained and in possession of a
valid Stop the Bleed card (training remains valid for two years). Caution! Extended periods of
unpaused application of a limb tourniquet will compromise the survival chances of the limb.

*Note: by using a dedicated hemostatic material/dressing (like QuikClot® Z-Fold Hemostatic

Dressing), one can increase the effectiveness of controlling a bleed significantly.

Diagram 1. Various areas of the body with recommendations and cautions to members of the public regarding applying pressure or
packing the bleed.

External bleeding is usually easy to diagnose due to the visibility of the external bodily environment, but keep in mind
that clothing may both obscure and absorb fair amounts of blood. Inspect areas like the axillae and groin as well as below
the patient for blood/blood clots.
Figure 23a and 23b. Photos of a speargun accident and Figure 23c. A CT scan of the impaled spear
Bleeding patients (if conscious) are able to move around and go to the bathroom, for instance, to wash the wound.
Observe blood loss along the bleeding path and take into account that an unknown amount of blood may have been
washed down the drain via the basin. As gross as it may be, sometimes house animals may start licking up some of the WATCH THIS VIDEO: Surgeon removes this impaled object
blood, which serves as evidence of the amount of blood loss. The helper/emergency medical professional needs to
consider all the above when making a blood loss estimate based on the location survey. Try to estimate the amount of A penetrating injury to the body may involve the vasculature (e.g., a knife stab with the knife blade remaining in the
visible blood loss in the number of cups that can be filled with the blood. tissue). The foreign object may actually be occluding a vein or an artery, and on removal, one may cause life-threatening
hemorrhage. It is thus essential to do a full examination, workup, and get specialized imaging in place to assess the risk of
removing the object. Angiography using contrast is especially helpful in this regard.

50 51

Figure 24. An industrial accident at a construction site.
See this interesting case report to illustrate this point: The role of angiography in facial trauma: a case report. [A. Scheepers
M.Dent, FFD (Part-time Consultant) M. Lownie BDS, Dip MFOS, Hons BA (Full-time Consultant) Division of Maxillofacial and Oral Surgery,
Department of Surgery, University of the Witwatersrand, Johannesburg, Republic of South Africa]
Important: always leave an impaled object, e.g., a knife blade or any other foreign object in place following a penetrating
injury. This item is only to be removed after proper medical and surgical evaluation in a controlled environment, usually
an operating room/operating theater.
FOREIGN OBJECTS
As opposed to common public perception, it is not important to get a foreign object like a bullet out of the trauma victim
as soon as possible. On the contrary, removing a foreign object in an uncontrolled environment is highly dangerous, and
one may be causing unnecessary damage, hemorrhage, and as a consequence, the person’s death!
GUNSHOT WOUNDS
Figure 25. A bullet leaving the barrel of a gun
A gunshot wound (GSW) is physical trauma due to a bullet from a firearm. Damage may include bleeding, broken bones,
muscle injury, nerve damage, organ damage, and the loss of a limb or bodily appendages, e.g., fingers or toes. Damage
depends on the part of the body hit, the path the bullet follows through the body, and the type and speed of the bullet.
52
The damage caused by the bullet depends on several factors. From a pure physics point of view, the following equation is
quite relevant:
E = MV²
2
This formula implies that if the mass of the bullet doubles, the energy transferred to the gunshot victim’s body doubles, while
if the speed of the bullet doubles, the energy transfers increases exponentially and thus also so the potential damage.
The caliber of a bullet is a unit of measurement of a bullet’s size, and more specifically, the bullet’s diameter.
Figure 26. Different caliber bullets
The immediate damaging effect of a gunshot wound is typically severe bleeding and with it, the potential for hypovolemic
shock, a condition characterized by inadequate delivery of oxygen to vital organs. In the case of traumatic hypovolemic
shock, this failure of adequate oxygen delivery is due to blood loss, as blood is the means of delivering oxygen to the
various bodily parts. When a bullet strikes a vital organ such as the heart, lungs or liver, or damages a component of the
central nervous system such as the spinal cord or brain, the effects are devastating.
Common causes of death following gunshot injury include bleeding, low oxygen caused by pneumothorax, catastrophic
injury to the heart and major blood vessels, and damage to the brain or central nervous system. Non-fatal gunshot wounds
frequently have mild to severe, long-lasting effects, typically some form of significant disfigurement such as amputation
due to a severe bone fracture, and may cause permanent disability.
[Wikimedia Commons]
PENETRATING CHEST INJURIES
Penetrating injury to the chest includes all penetrating injuries of the thorax bounded superiorly by the lower neck and
inferiorly by the lower costal margin.
Any penetrating injury to the chest must be assumed to have caused internal organ damage until proven otherwise.
These injuries may involve damage to the heart, major thoracic blood vessels, lung, tracheobronchial tree, diaphragm,
esophagus, and the spinal cord.
Penetrating injury to the chest involving the heart or major blood vessels in the chest cavity is an extremely urgent
emergency, and often ends in death, with or without medical intervention.
A bleed originating from the chest wall will respond to direct pressure and packing, but it is utterly futile to try to control
bleeding originating from inside the chest cavity with pressure and of packing on the outside.
53
 PENETRATING ABDOMINAL INJURIES `PNEUMOTHORAX AND HEMOTHORAX
Penetrating abdominal injuries include any penetrating injury that could have entered the peritoneal cavity or
retroperitoneum inflicting damage on the abdominal contents. In general, the entry wound for an abdominal injury may
be as high as the fifth intercostal space or as low as the perineum.

Anterior penetrating abdominal injuries occur when the entry wound is on the anterior abdomen or lower chest
penetrating the peritoneal cavity.

With posterior or flank penetrating abdominal injuries, the entry wound is to the back of the posterior axillary line. These
wounds are different in that the most likely organ to be injured will be in the organs in the retroperitoneum.

Penetrating thoracoabdominal injuries is when both the thoracic and the abdominal cavities are involved. The entry
wound is usually in the region of the lower rib cage, below the fifth intercostal space and above the costal margin. These
injuries are always associated with chest pathology (e.g., hemothorax and pneumothorax).

GUIDELINES TO THE EMERGENCY PHYSICIAN TREATING ABDOMINAL INJURIES:

Follow the ABC’s, and resuscitate patient according to the primary survey findings.

Assess the abdomen looking for entry wounds, bleeding, and peritoneal findings. Make sure that a good chest exam is
performed, since chest injuries can be associated with penetrating abdominal injuries.

Determine if there are symptoms or signs suggestive of immediate need for operative intervention:
Figure 27. A diagram of a pneumothorax
1. Herniated abdominal contents.
2. Massive bleeding from the wound. Pneumothorax refers to a collection of air in the pleural cavity (the space between the lung and the chest wall), while

3. Obvious peritoneal signs consistent with hollow viscus injury or hemoperitoneum. hemothorax refers to a collection of blood within the pleural cavity. The most common cause of a hemothorax is trauma.
The symptoms of a hemothorax include chest pain and difficulty breathing, while the clinical signs include a dull sound
4. Signs of hemodynamic instability associated with an abdominal injury.
on percussion and reduced breathing sounds on the affected side as well as a rapid heart rate.
5. Signs of lower extremity ischemia suggestive of vascular injury.
The treatment of a pneumothorax is the insertion of a chest drain in a procedure called a tube thoracostomy. See video
6. All gunshot wounds with path or other evidence of intraperitoneal penetration or retroperitoneal organ injury.

If any of the above signs are present, then take the patient to the operating room immediately for exploratory laparotomy. To correctly treat the hemothorax, the cause needs to be addressed. Chest drainage may be all that is required for a minor
injury, but for major and persistent bleeds, surgery by a trauma surgeon or a cardiothoracic surgeon will be necessary to
stop the bleeding at its source.

Most moderately sized hemothoraces will require evacuation.

MAXILLOFACIAL INJURIES
The maxillofacial area is blessed with an abundant blood supply. Bleeding from this area can be daunting, and controlling
bleeding has its unique challenges. In addition to a good blood supply, there is also ample collateral blood supply, and
thus merely tying off the source artery may not control the bleed sufficiently. For instance, a bleeding right facial or lingual
artery may still bleed profusely – even after tying off the right external carotid artery – due to the collateral blood supply
from other arteries, like the left carotid artery.

Packing a bleed in this area requires specialized knowledge due to the possibility of compromising the airway or damage
to an important structure like the eye.

54 55
 MAXILLOFACIAL BLEEDS DENTAL BLEEDING
AT THE TRAUMA SCENE Controlling a bleeding tooth socket is relatively simple, but occasionally patients report to the ER with a really problematic
post-extraction bleed.
At the trauma scene/in the field: patients who are conscious and alert will usually position themselves spontaneously in a
position to keep their own airway patent. The patient in the sitting position – somewhat bent forwards seems to work The first step for the ER physician is to call the responsible dentist or the dentist on call to the ER. If this is in the middle of
well. Unconscious patients should be placed in the “recovery” position, and if possible, the head somewhat higher than the night, the chances of successfully getting any dentist in the ER are excessively remote!
the rest of the body. Do not try to stabilize a fractured mandible by applying tight pressure bandages as this may push the
The following practical advice should stop most dental bleeds:
fragmented jaw and tongue backward and thus compromise the airway.
k Soak a cotton wool or gauze swab in ice water and ask the patient to bite on it for 10 - 15 minutes. Repeat another 2-3
times.
k Enquire regarding bleeding tendencies, anticoagulant medication, etc. Check the patient’s Hb, platelet count, and
clotting profile. Rectify/address any specific systemic problems found.
k If bleeding persists, inject local anesthetic around the tooth socket. Add diluted epinephrine (adrenalin) to the cotton
wool swab and repeat the “bite on the bleed” routine.
k If still bleeding after this, one needs to pack the socket with an absorbable hemostatic agent like Surgicel® or
Spongostan™ and then place a number of tight absorbable sutures over the socket.
Figures 28a. Place the patient in the recovery position Figure 28b. The reverse Trendelenburg position
k Give 1-2 grams of Cyklokapron IV and follow with oral medication (adult patients). IMI Vitamin K may also be of some
value if indicated.
IN THE ER

Severe bleeding from maxillary fracture and pan-facial fractures can be controlled as follows: pass a Foleys catheter along
the nasal floor on both sides, so that the balloon is just beyond the posterior nasal aperture then inflate the balloons with
water or saline. Pull the Foleys catheters tightly forward and secure with a clamp or by tying the two catheters together.
Now place nasal tampons or hemostatic sponges in the nasal passages.

WATCH THIS VIDEO: Severe bleeding from maxillary fracture

Penetrating injuries to the maxillofacial area, as well as persistent arterial bleeds: consider angiography and embolization
with interventional radiology/ radiography if indicated.

IN THE OR

Maxillofacial bleeds are best definitively controlled by reducing the various mandibular, maxillary, and other facial bone
fractures.

Sometimes the surgeon struggles to control bleeding when treating gunshot injuries in the maxillofacial area due to
multiple small blood vessels slowly continuing to fill up the wound with blood. The following method may be the little
miracle that the surgeon needs in such a situation:

k Soak an abdominal swab in the boiling water.

k Squeeze out the excess water and immediately pack this into the wound and leave this in place for 4-5 minutes while
applying moderate pressure.
Figure 29a. Oral cancer Figure 29b. Surgicel® packed into the wound after removal of the
It is a remarkable tool to stop this type of bleed, and for some reason, it does not appear to cause any significant heat tooth and adjacent biopsy defect to stop the bleed
damage to the tissue.

56 57
58 59
 ENT (EAR, NOSE, AND THROAT) BLEEDING See professional assistance if the above measures fail.

In the past, tonsillectomies using conventional surgical methods were associated with intraoperative and postoperative Invasive treatment modalities:
bleeding in a significant number of patients. 1. Chemical cauterization

Most modern tonsillectomies are done with a coblator, and the complication rate of post-tonsillectomy bleeding has This method involves applying a chemical such as silver nitrate to the nasal mucosa, which burns and seals off the bleeding.
been reduced dramatically. Patients also report significantly less post-operative pain, compared to conventional
tonsillectomies. See a coblation tonsillectomy [Here]

NOSE BLEEDS

Figure 31. The small blood vessels supplying the nasal mucosa

2. Nasal packing

If pressure and chemical cauterization cannot stop epistaxis, nasal packing is the mainstay of treatment.

3. Surgery

Ongoing bleeding despite good nasal packing is a surgical emergency and can be treated by endoscopic evaluation.
Figure 30. A minor nose bleed
[Wikimedia Commons]
A nosebleed, also known as epistaxis, is noticed when blood flows out of one or both nostrils.

Although the sight of large amounts of blood can be alarming and may warrant medical attention, nosebleeds are rarely
fatal, accounting for only 4 of the 2.4 million deaths in the U.S. in 1999.

The following emergency measures should stop most bleeds:

1. The person should lean slightly forward with the head tilted forward (not leaning back or tilting the head backward).
2. Spit out any blood that may collect in your mouth and throat to prevent nausea or vomiting caused by swallowing a
lot of blood.
3. Gently blow any blood clots out of your nose. This may worsen the nosebleed slightly for a short while.
4. Pinch all the soft parts of the nose together between the thumb and index finger.
5. Press firmly toward the face – compressing the pinched parts of the nose against the bones of the face. Breathe
through your mouth as you do this.
6. Hold the nose for at least five minutes. Repeat as necessary until the nose has stopped bleeding.
7. Sit quietly with the head above the level of the heart. Do not lay down flat or place your head between your legs.
8. Apply ice, wrapped in a plastic bag or towel, to nose and cheeks afterward.
9. Nasal sprays can be used short-term to help with congestion and minor bleeding.
10. Stuffing cotton or tissue into your nose is not recommended.

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SPECIFIC COMMON INTERNAL BLEEDS
Internal bleeding is bleeding that occurs in a bodily cavity (like the abdominal or thoracic cavity) or into a tissue space.
It is difficult to diagnose by mere inspections, and diagnosis is more dependent on correctly interpreting the patient’s
signs and symptoms as well as special imaging techniques like ultrasound and CT scans.
It is essential to achieve hemostasis (stop bleeding) as a matter of urgency, after identifying the cause of the internal
bleeding. As opposed to external bleeds, most internal bleeds cannot be controlled by applying pressure to the site of
injury. Achieving hemostasis in patients with internal bleeding is significantly more specialized and usually a more timeous
process, and thus associated with a higher mortality.
Due to the limited volume of the cranial cavity, any intracranial hemorrhage will soon exert pressure on the brain tissue,
and will need emergency neurosurgical intervention to avoid (or minimize) brain injury and to prevent death. The
intracranial hemorrhage may increase the intracranial pressure, and as a consequence, this may trigger the medullary
ischemic reflex resulting in the following three signs (also called the Cushing’s triad):
k Increase in blood pressure (even >300 mmHg)
k A decrease in heart rate
k Decrease/irregular respiration
SKULL FRACTURE

INTRACRANIAL HEMORRHAGE (ICH)

Figure 33a. The four major types of skull fractures: linear, Figure 33b. An example of a depressed skull fracture.
depressed, comminuted, and basilar.

A skull fracture is a break in one or more of the eight bones that form the cranial portion of the skull, usually occurring as
a result of blunt force trauma. If the force of the impact is excessive, the bone may fracture at or near the site of the impact
and cause damage to the underlying structures within the skull, such as the membranes, blood vessels, and brain. [More]

A closed skull fracture may or may not be associated with bleeding, but an open skull fracture with laceration of the scalp
is often associated with significant bleeding and blood loss. Due to the possibility of forcing a depressed skull fracture
Figure 32. The different types of intracranial bleeds
deeper into the brain, excessive pressure on any bleeding scalp laceration is not recommended in the prehospital setting.
There are four types of ICH: The placement of a dedicated hemostatic agent (powder/sheets/gauze, etc.) and applying a firm pressure dressing or
emergency (temporary) suturing of the wound should slow down the bleeding sufficiently and allow for time to transport
k Epidural hematoma
the patient to a hospital for definitive management.
k Subdural hematoma
k Subarachnoid hemorrhage BASE OF SKULL (BASILAR) FRACTURES
k Intracerebral hemorrhage
Base of skull fractures are usually caused by substantial blunt force trauma. These fractures involve at least one of the
bones that compose the base of the skull, most commonly the temporal bones, but they may also involve the occipital,
WATCH THIS VIDEO: Overview of the various types of intracranial hemorrhage
sphenoid, ethmoid, and the orbital plate of the frontal bone. Several clinical signs are highly suggestive of a base of skull
fracture include hemotympanum, cerebrospinal fluid otorrhea or rhinorrhea, battle’s sign (retro-auricular or mastoid
A berry aneurysm is a small, saccular berry-like distention of the wall of a cerebral artery (most frequently at the junctures
ecchymosis), and raccoon eyes (bilateral periorbital ecchymosis). Base of skull fractures are commonly associated with
of vessels in the circle of Willis). A berry aneurysm is usually the result of a congenital developmental defect and may
other maxillofacial fractures, cervical spine injury, intracranial hemorrhage, cranial nerve injury, and vascular injuries. A
rupture without warning, causing a subarachnoid intracranial hemorrhage.
common complication is meningitis.

62 63
 CARDIAC TAMPONADE BLEEDING HEMORRHOIDS

Figure 34. Acute cardiac tamponade

Cardiac tamponade, also known as pericardial tamponade, is when fluid in the pericardium (the sac around the heart)
builds up, resulting in compression of the heart. Onset may be rapid or gradual. Symptoms typically include those of
cardiogenic shock, including shortness of breath, weakness, lightheadedness, and cough. Common causes of cardiac
tamponade include chest trauma, cancer, kidney failure, and pericarditis.

A cardiac stab wound is a common cause of acute tamponade. An emergency thoracotomy (often in the ER) may be
necessary to save the patient’s life. [ED Thoracotomy]
Figure 36. Internal and external hemorrhoids
GASTROINTESTINAL HEMORRHAGE
Bleeding from hemorrhoids rarely causes any significant amounts of blood loss, but they cause other symptoms like
itching and thus needs management.

Medical treatment modalities include that will cause hemorrhoids to shrink and eventually fall off:

k Rubber band ligation

k Sclerotherapy (injecting a sclerosing agent into hemorrhoids)
k Electrocoagulation

If your bleeding hemorrhoids are more extensive and severe, your doctor may recommend surgery.

k Hemorrhoidectomy is the surgical removal of the prolapsed hemorrhoids.

k Hemorrhoidopexy using specialized surgical staples, changing the blood supply to hemorrhoids, causing them to shrink.
Figure 35. Complications of a bleeding gastric ulcer

Any part of the GI system can bleed for various reasons. Occasionally, a peptic or duodenal ulcer can start bleeding, causing BLOOD IN THE FECES (STOOL)
even a life-threatening hemorrhage. Minor bleeding in an ulcer, however, is usually not as immediately serious and may go
The causes of blood in the stool range from conditions such as enteric infections (e.g., typhoid), hemorrhoids, anal fissures,
unnoticed, but it still requires treatment. Medical professionals should always be aware of the danger of certain anti-
and Crohn’s disease to serious conditions such as rectal and colon cancer.
inflammatory medication in contributing to a bleeding ulcer, especially while in hospital recovering after trauma.

Great informational article [Click Here] on gastrointestinal hemorrhage by the American College of Surgeons Division of
Education https://www.facs.org/~/media/files/education/core%20curriculum/gi_hemorrhage.ashx

64 65
 RUPTURED AORTIC ANEURYSM
Figure 37. An intact aortic aneurism
A ruptured aortic aneurysm (usually the abdominal aorta) will cause massive internal bleeding, which is generally fatal.
About 80 % of patients with a ruptured aortic aneurysm either die before they reach the hospital or don’t survive the
surgery. The most common symptom of a ruptured aortic aneurysm is sudden and severe pain in the abdomen.
Treatment will require urgent emergency intervention, and two prominent techniques are commonly used:
k Open surgical repair and
k Endovascular aneurysm repair
RUPTURED SPLEEN
Figure 38. The structure of the spleen
The spleen is a very vascular organ. It can rupture due to a direct blow or blunt trauma over the abdominal area, for
instance, during a motor vehicle accident. A ruptured spleen occurs when the capsule-like covering of the spleen breaks
open, pouring blood into your abdominal area. Depending on the size of the rupture, a large amount of internal bleeding
can occur. In this case, emergency surgical management is indicated, and a partial or complete splenectomy is often
necessary as a life-saving measure.
66
LIVER TRAUMA
Figure 39. The structure of the liver
The liver is a highly vascular organ located in the right upper quadrant of the abdomen and is susceptible to blunt and
penetrating liver injuries during traumatic events. Most hepatic injuries are relatively minor and heal spontaneously with
non-surgical management, which consists of observation and possibly interventional arteriography with embolization.
Operative intervention to manage the liver injury is needed in only about 14 % of patients. Indications for surgery include
those patients who initially present with hemodynamic instability or those who fail conservative management.
PELVIC GIRDLE FRACTURE
Patients with acute internal bleeding in the abdomen or pelvis after trauma may benefit from the use of a REBOA device
to slow the bleeding.
Figure 40. A REBOA device and how it works (Reference)
ORTHOPEDIC INJURIES
The edges of a long bone fracture can be sharp and may act as a knife, cutting into, or severing arteries, veins, nerves, and
muscles. Blood loss and nerve damage following bone fractures are not rare, and medical professionals should be alert
regarding possible blood loss, even if it is a closed fracture. With all long bone fractures, the medical professional should
assess the distal pulse and scale up the level of emergency status drastically if the distal pulse is absent. Also, check for
peripheral sensory and motor neurological outfall and make notes accordingly.
In addition to this, bone is a vascular type of tissue, and bleeding from a bone can add significant volume to blood loss
after orthopedic injuries. A common misconception is that bone is essentially avascular.
67
 FRACTURED FEMUR AND TIBIA Obstetrical bleeding is bleeding in pregnancy that occurs before, during, or after childbirth. Bleeding may be vaginal or
less commonly into the abdominal cavity. Bleeding which occurs before 24 weeks is known as early pregnancy bleeding.
Bleeding before childbirth by definition occurs after 24 weeks of pregnancy.

Causes of bleeding before and during delivery include cervicitis, placenta previa, placental abruption, and uterine rupture.
Causes of bleeding after birth include weak contraction of the uterus, retained products of conception, and bleeding
disorders. [Wikimedia Commons]

POSTPARTUM BLEEDING
Postpartum bleeding or postpartum hemorrhage (PPH) is defined as the loss of more than 500 ml of blood within the first
24 hours following childbirth. This is a medical emergency and needs urgent medical /surgical attention to prevent the
patient from progressing to a state of hypovolemic shock.

Treatment is empirical, and these patients are usually managed by an OB-GYN specialist.

Figure 41a. Bilateral fractured femurs. Figure 41b. Bilateral fractured femurs treated with
intramedullary rods. BLEEDING AFTER C-SECTION
In adult patients with fractured femurs, the estimated blood loss for a closed fracture is 1000–1500 ml (2–3 pints), and for The uterus is a very vascular organ, and meticulous suturing of the surgical incision, as well as the other structures of the

a closed fracture of the tibia is 500–1000 ml (1,5–2 pints). These figures can be doubled if the fracture is open. Fractures of abdominal wall, is required. Internal bleeding from the uterus after cesarean section can become life-threatening in a

the lower limb, particularly the femur, should be considered a potential cause of hypovolemic shock, especially if short period of time and should be dealt with as a “code red” emergency.

compound.
POST-OPERATIVE BLEEDING
Control of external hemorrhage should precede fluid resuscitation. Unless hemorrhage is catastrophic (in which case a
tourniquet should be used), control of bleeding should follow a stepwise progression:

k Direct pressure k Indirect pressure

k Elevation k Tourniquet
k Wound packing

Internal bleeding from a long bone fracture, especially in the legs, maybe partially controlled with a tight pressure dressing
or by using a tourniquet. After tourniquet placement, the bleeding should be surgically treated on an urgent basis.

See the full article [Here] Lee C, Porter KM: Prehospital management of lower limb fractures. Emergency Medicine Journal
2005; 22:660-663.
Figure 43. Persistent oozing after the excision of a scalp lesion

OBSTETRICS It is said that the surgeon has two main enemies: postoperative bleeding and postoperative infection. It is of utmost
importance that surgeons take all the necessary care and steps to avoid or minimize the chances of any significant post-
operative bleeding by using appropriate techniques and the required medication. No matter how dedicated and careful,
all surgeons will be confronted with excessive postoperative bleeding from time to time. In these instances, treat it as a
surgical emergency (no matter what time of the day or night) and manage appropriately. If returning to the OR is required,
do this as a matter of urgency, and take extra measures to avoid any further bleeding incidents. Place drains and apply
postoperative pressure dressings if required. Assess the patient’s hemodynamic status/stability on a continuous basis and
rectify problems identified before these develop into further complications and unnecessary emergencies or even demise
of your patient. Arrange a bed in high-care or intensive care if needed.
Figure 42. Placental abruption

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 BLEEDING DURING LAPAROSCOPIC SURGERY
Surgeons performing laparoscopic surgical procedures, despite having a detailed knowledge of the surgical anatomy,
QUIZ 2
sometimes encounter an unexpected massive bleed. If this occurs, the surgeon may have no choice but to convert the Are the following statements TRUE or FALSE?
scope procedure to an open procedure to stop the bleed as soon and as effectively as possible.
Discuss the statement in a group setting.

UROLOGY Statement 1: Two concepts: the “flow rate” and the “volume” of blood are key to the decisions that you need to make in a
disaster zone.

Statement 2: The venous blood pressure in the saphenous vein is the lowest when a person is in the standing position; it
increases as the person sits or lies down.

Statement 3: Pneumothorax refers to a collection of air in the pleural cavity, while hemothorax refers to a collection of
blood within the pleural cavity.
Blood in the urine is called hematuria. Hematuria may be visible or not visible (microscopic).
Statement 4: A fracture long bone is very painful, but as bone tissue has a meager blood supply, losing any significant
Possible causes: amount of blood is unlikely.

k Urinary infection Statement 5: Blood in the urine may be a sign of cancer.

k Kidney or bladder stones Answers available at the bottom of the page.

k Prostate infection or enlargement

k Kidney disease
k Kidney trauma
k Drugs (anticoagulants and anti-inflammatories)
k Bladder cancer (mostly in smokers)
k Kidney cancer

Treatment is empirical, and patients are usually managed by urologists.

ANSWERS:
Statement 1: True. The volume of blood loss within a specific time dictates the urgency of intervening to stop the bleed.
Statement 2: False. False. The average venous pressure in the saphenous vein (at the level of the ankle) is the lowest when lying down
(15 mmHg), higher when sitting (56 mmHg), and highest when standing (85 mmHg).
Statement 3: True.
Statement 4: False. The sharp bone edges of a fractured long bone may cause extensive and even life-threatening bleeding. Bone has a
good blood supply.
Statement 5: True. There are many diverse possible reasons for blood in the urine. It may be due to cancer of the bladder,
although this is not the most common cause.

70 71
 BLEEDING IN AN UNCONTROLLED ENVIRONMENT

SECTION 6 BLEEDING
The American College of Surgeons’ National Stop the Bleed campaign and
associated website has fantastic training resources based on the Hartford
Consensus.

IN AN UNCONTROLLED
WATCH THIS VIDEO: Stop Emergency Bleeds

To download your “Basics of Bleeding” booklet from the BleedingControl.org website, Click here.

ENVIRONMENT
KINDLY NOTE:

k The above information is entirely independent of The Apprentice Doctor® Control Bleeding Course.
k There is no formal association between the Apprentice Doctor and the USA Stop the Bleed program.
k Neither the American College of Surgeons’ nor any of the distinguished partners on the bleedingcontrol.org website
endorses the Apprentice Doctor® Control Bleeding Course or Kit.
k The Apprentice Doctor® Control Bleeding Course is an international independent course. The Apprentice Doctor® is
an accredited member of the IADL (International Association of Distance Learning).

The following is an Apprentice Doctor® summary/outline of the steps to follow in an emergency, where one or many
people are bleeding (details are covered in other parts of this course):

k Assess and Alert

c Assess
~ Life-threatening bleed
~ Safety
• Own safety
• Safety of patient/s
c Alert – Emergency assistance – call 911
k Bleeding
c Life-threatening – Large volume, continuous, pooling
c Source (multiple bleeds, clothing)
c *Classify according to a bodily area (extremity, junctional, torso, head)
k Compress
c Direct pressure
c Packing
c Tourniquet

72 73
 What can you do while you wait:
1. REASSURE PATIENT

As difficult as it might be, be positive and reassure that patient that they will be fine and that you will stay with him/her
until professional medical assistance arrives. Offer general comforting words in a reassuring tone of voice.

READ MORE

2. GATHER INFORMATION* ON:

c What happened?
c Guesstimate on amount blood loss (How many cups?)
3. IF POSSIBLE (IF YOU HAVE THE RELEVANT MEDICAL EQUIPMENT) GET THE FOLLOWING INFORMATION:
c Pulse rate
c Blood pressure
c Respiratory rate
c Blood Oxygen saturation

Hand over to a medical professional

On handing over to the professional first responders, be sure to offer them all the information that you have gathered
above*.

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 HOSPITAL / FIELD HOSPITAL / CLINIC / ER / OR

SECTION 7
It is imperative that the surgeon and the surgical team can accurately visualize
the operative field. The following are key elements of ensuring that the surgeon
can see the surgical field optimally:

BLEEDING IN A CONTROLLED
k Good operative lights

Investing in the best possible operative lights – be it overhead, headlamp, or scope lights – is not negotiable in a
surgical setting. Modern LED lights have lifted operative lighting to a new level. Unlike filament operative lights of the
past, LED lights are cool to work under, the light intensity (and often the frequency) is controllable, and can be fine-
tuned to exact levels.

ENVIRONMENT k Sponging (gauze/swabs)

It is essential always to have sufficient absorbent, sterile sponging material available during surgery. The nurse should
keep count of the exact number of gauze squares and swabs given out to the surgeon. Do not start closusing the
wound before the precise number of guaze squared used are all accounting for. The blood-soaked swabs, properly
displayed on a swab-rack, offer an indication of the amount/volume of blood loss during surgery.

k Suctioning

It is essential to evacuate blood from the operative field effectively. High and low volume suctioning apparatuses are
available. The suction should be able to remove all the blood and fluid used for rinsing from the operative field. A high
volume suction tip could cause tissue damage if it kept sealed and suctioning on friable tissue. Some suction tips
have small side openings to avoid this problem. Blood in the suction bottle should be assessed regarding the volume
of blood loss. The blood in the suction unit can be redirected into a blood cleaning and recycle unit and re-introduced
into the circulation, limiting the need for allogenic blood transfusions.

k Rinsing

Rinsing with saline or sterile water assists with the proper visualization of the operative field. Rinsing also keeps
mechanical apparatuses like a drill and saws cool during bone surgery (orthopedic and maxillofacial surgery). Lastly,
rinsing washes the blood off lenses and mirrors used in scope procedures improving visualization of the operative area.

k Vision

All medical professionals, especially surgeons, should have regular ophthalmological tests. It is sad if a surgeon
compromises his/her patient by allowing suboptimal visual acuity.

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CONTROL BLEEDING DURING SURGERY
Bleeding control is essential for promoting positive outcomes in surgery and
the surgical patient.
Throughout a surgical procedure, bleeding must be well controlled for two main reasons:
k To provide the best view for the surgeon and surgical team of the operative site.
ARTERIAL TOURNIQUETS
Surgical tourniquets are commonly used in limb surgeries, be it orthopedic or plastic surgeries. The tourniquet pressure is
increased above the patient’s diastolic pressure, effectively stopping the arterial blood flow to the limb and offering the
surgeon a virtually bloodless surgical field. A tourniquet should not be used on a patient’s limb for more than 120 minutes.
Specialized surgical modalities:
HARMONIC SCALPEL (ULTRASOUND OR ULTRASONIC SCALPEL)

k To prevent the adverse physiologic sequelae associated with blood loss.
HOW DO SURGEONS MANAGE TO MINIMIZE BLEEDING DURING SURGERY?
The harmonic scalpel is a surgical instrument used to cut and cauterize tissue simultaneously. Unlike electrosurgery,
harmonic scalpels use ultrasonic vibrations instead of electric current to cut and cauterize tissue. It is commonly used in
minimally invasive (scope) surgery. The tip of the harmonic scalpel becomes very hot during use, and junior surgical
residents have to be reminded of this to prevent burn injuries to self or to the patient.

Ways to prevent excessive bleeding: In this study [Ref], the conclusion was: the ultrasonic scalpel can safely seal *arteries up to 8 mm in diameter to prevent or
control bleeding during laparoscopic procedures, even in cases when BP exceeded normal levels. *Most other sources
KNOWLEDGE OF ANATOMY
refer to blood vessels up to 5 mm diameter.
Surgeons need an excellent basic foundation in anatomy, especially the vascular anatomy; thus, a surgeon avoids the
ELECTROSURGERY
larger vessels if at all possible by way of planning the surgical incision and further dissections accordingly.

KNOW THE PATIENT

Avoiding and minimizing bleeding during surgery start with taking a good, comprehensive medical history. All patients
scheduled for surgery should, in addition to the regular medical history, be questioned specifically and in detail regarding
any abnormalities of their blood as well as related diseases, bleeding tendencies, hemophilia, and family history of
hemophilia. Ask about blood platelets and disorders like idiopathic thrombocytopenic purpura or alternatively named
“immune thrombocytopenia” (ITP). So many patients are treated with anticoagulation medication for various conditions
like deep venous thrombosis, after cardiac surgery, etc. Many patients take taken half an aspirin daily, with or without
medical advice, and this will influence hemostasis during surgery. Many anti-inflammatory drugs also affect the function
of blood platelets and thus increase the risk of post-operative bleeding. Also, be alert regarding the use of natural
medicines like arnica, which may increase bleeding during and after surgery.

A number of coagulation factors are manufactured in the liver (fibrinogen (I), prothrombin (II), V, VII, VIII, IX, X, XI, XII, and Figure 44a: Monopolar electrosurgery Figure 44b. Bipolar electrosurgery
(From: Bovie® medical)
XIII); therefore chronic alcoholics with liver damage may have a defective clotting mechanism and thus bleed excessively
during and after surgery. These patients should be well-assessed pre-op, including a full blood count and a clotting profile. Electrosurgery is the application of a high-frequency (radio frequency) alternating polarity, electrical
current to biological tissue as a means to cut, coagulate, desiccate, or fulgurate tissue.
Methods of controlling/reducing bleeding:
ELECTROSURGICAL MODALITIES
HYPOTENSIVE ANESTHETIC
In cutting mode, the electrode touches the tissue, and sufficiently high power density is applied to vaporize its water
One of the essential functions of an anesthesiologist is to keep the blood pressure steady and within normal limits during
content. Since water vapor is not conductive under normal circumstances, electric current cannot flow through the vapor
surgery. Reducing the blood pressure can be advantageous in some settings because it can contribute to a reduction in
layer. Energy delivery beyond the vaporization threshold can continue if sufficiently high voltage is applied (> +/-200 V)
overall blood loss and enhances vision in the surgical field. Controlled hypotension during anesthesia or hypotensive
to ionize vapor and convert it into a conductive plasma. Vapor and fragments of the overheated tissue are ejected, forming
anesthesia is often used in head and neck surgery, including major maxillofacial surgical procedures. Hypotensive
a crater. Electrode surfaces intended to be used for cutting often feature a finer wire or wire loop, as opposed to a more
anesthesia carries the risk of hypoperfusion to vital organs and tissues, mainly the brain, heart, and kidneys, wise patient
flat blade with a rounded surface.
selection is therefore crucial.

78 79
 Coagulation is performed using waveforms with lower average power, generating heat insufficient for explosive
vaporization, but producing a thermal coagulum instead.
Electrosurgical desiccation occurs when the electrode touches the tissue open to the air, and the amount of generated
heat is lower than that required for cutting. The superficial tissue, as well as some of the deeper tissue, dry out and form a
coagulum (a dry patch of dead tissue). This technique may be used for treating nodules under the skin, where minimal
damage to the skin surface is desired.
In fulguration mode, the electrode is held away from the tissue, so that when the air gap between the electrode and the
tissue is ionized, an electric arc discharge develops. In this approach, the burning of the tissue is more superficial because
the current is spread over the tissue area larger than the tip of the electrode.
ELECTROCAUTERY (SURGICAL DIATHERMY)
Electrocauterization is the process of destroying tissue (or cutting through soft tissue) using heat conduction from a metal
probe heated by electric current. The procedure stops bleeding from small vessels (larger vessels being ligated).
Electrocautery applies high-frequency alternating current by a unipolar or bipolar method. It can be a continuous
waveform to cut tissue, or intermittent to coagulate tissue.
Reference and see more: https://en.wikipedia.org/wiki/Electrosurgery
The Colorado microdissection needle is a monopolar electrode with an ultra-sharp tungsten tip for precision cutting,
dissecting and cauterizing of soft tissue.
WATCH THIS VIDEO: Upper Eyelid Blepharoplasty
CHEMICAL CAUTERIZATION
Some cauterizing chemicals, e.g., Silver nitrate and cantharidin, are commonly used in medicine to remove small skin
lesions such as warts or necrotized tissue or for hemostasis, e.g., to treat frequent nose bleeds.
LASER
Laser surgery is a type of surgery that uses a laser instead of a scalpel to cut tissue.
Figure 45: An Diode-pumped Nd:YAG laser (kind permission KLS Martin)
80
Soft-tissue laser surgery is used in a variety of applications in human (general surgery, neurosurgery, ENT, dentistry,
orthodontics, and oral and maxillofacial surgery as well as veterinary surgical fields. The primary uses of lasers in soft
tissue surgery are to cut, ablate, vaporize, and coagulate. There are several different laser wavelengths used in soft tissue
surgery. Different laser wavelengths and device settings (such as pulse duration and power) produce different effects on
the tissue. Some commonly used lasers types in soft tissue surgery include erbium, diode, and CO2. Erbium lasers are
excellent cutters but provide minimal hemostasis. Diode lasers (hot tip) provide excellent hemostasis but are slow cutters.
CO2 lasers are both efficient at cutting and coagulating.
WATCH THIS VIDEO: Laser maxillary frenectomy [Wikimedia Commons]
CLAMPING
Surgeons use a variety of surgical clamps to handle the tissue and to clamp bleeding blood vessels. The types of clamps
used to clamp blood vessels are referred to as hemostats (hemostatic forceps). Once a blood vessel is clamped, it may be
cauterized using an electrosurgical unit on coagulation mode. The surgeon can apply the tip of the bipolar electrosurgical
unit’s handle to part of the hemostat for this purpose, taking great care that the hemostat is not touching any surrounding
tissue or part of the body, to avoid burning tissue unintentionally. Larger blood vessels (more than 5 mm diameter arteries)
should be tied off while the assistant holds the vessel with the hemostatic forceps. Often the surgeon will ask the assistant
to release the hemostat after the first throw of the knot, to assess if there is any residual bleeding.
Figure46a. A straight hemostatic forceps Figure 46b. A curved hemostatic forceps
Click here for a discussion of surgical clamps: http://www.anatomyguy.com/surgical-instruments-clamps/
TIE OFF BLOOD VESSELS
Most surgeons want to be sure that the operative site will not start bleeding after surgery. Small blood vessels can be
closed off using electrosurgical methods, but arteries of 5 mm or more are better tied off. Generally, these sutures will be
dedicated absorbable tie sutures. Surgeons regularly use a one-hand tie technique for this purpose – see Project 2A.
Occasionally the surgeon may cauterize the tied-off blood vessel in addition to tying it off, taking care not to compromise
the integrity of the tied suture.
HEMOSTATIC CLIPS
A variety of hemostatic metal clips are available for both open surgery as well as endoscopic surgical procedures, to
mechanically close the lumen of bleeding blood vessels. One can also clip (close) a blood vessel on both sides of an
intended cut during surgical dissections. [Example]
Surgeons performing incision in the scalp (e.g., bi-coronal flaps) use Raney clips to control the multiple arteriolar and
venular bleeds. Apparently, ordinary sterilized paper clips are equally effective and a lot cheaper! [Ref]
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 PACKING WITH NON-ABSORBABLE MATERIALS FLOWABLE HEMOSTATIC AGENTS

If the bleed originates from a defect or cavitation in the tissue, then packing the cavity with a variety of materials is a very A flowable hemostatic agent consists of a passive and an active hemostatic agent combined into a single application/product.
effective way of controlling a bleed.
SEALANTS
A number of materials will serve the purpose in an emergency setting:
Sealants form a barrier that resists the flow of most liquids. There are four groups of sealants:
k Gauze squares, ribbon gauze, or cotton wool.
k Fibrin sealants
k Part of clothing (a piece of T-shirt, for instance).
k Polyethylene glycol polymers
k A clean cloth (dishcloth).
k Albumin and glutaraldehyde sealants
k QuikClot Combat Gauze® dedicated hemostatic gauze.
k Cyanoacrylates
QuikClot Combat Gauze® is a 3-inch x 4-yard strip of z-folded, soft, white, nonwoven, hydrophilic gauze impregnated with
kaolin, an inorganic mineral that is both safe and effective in accelerating the body’s natural clotting cascade without any BONE WAX
exothermic reactions or use of animal or human proteins. QuikClot Combat Gauze® is supplied in most public areas, in
Unlike common perception, bone is a living, cellular, and vascular type of tissue. Sponge bone (cancellous bone or
Stop the Bleed Therapeutic Kits.
trabecular bone) is quite vascular and can bleed profusely and incessantly.
Important:
Bone wax is a waxy substance used to help mechanically control bleeding from bone surfaces during surgical procedures.
c If possible, try to avoid contaminated cloths (e.g., used, dirty, soiled, or oil-stained cloths). It is generally made of beeswax with a softening agent such as paraffin or petroleum jelly and is smeared across the
c Use a single piece of cloth if possible; try to avoid multiple pieces of cloth. bleeding edge of the bone, blocking the holes and causing immediate bone hemostasis through a tamponade effect.
Bone wax is most commonly supplied in sterile sticks and usually requires softening before it can be applied.
ABSORBABLE HEMOSTATIC AGENTS
VARIOUS PHARMACOLOGICAL PREPARATIONS
There are a large number of absorbable hemostatic agents on the market, each one with its specific indications, advantages,
k Epinephrine (adrenalin)
and disadvantages.
Epinephrine is a hormone, but it is also used as a pharmacological agent. It is a potent vasoconstrictor due to its
PASSIVE HEMOSTATIC AGENTS ability to stimulate the beta receptors in the muscular layer of arteries and veins. The vasoconstriction reduces the
k Collagen-based products. blood flow and thus the bleeding. This action, as well as the action of other vasoactive peptides, may get so intense
that the arterial wall goes into spasm, and the artery closes off completely. Of course, when the spasm lifts, the artery
Collagen-based products are activated on contact with blood and provide a scaffold to which platelets can adhere to,
may re-open and bleeding resumes unless a clot forms in time within the lumen of this artery.
and a stable matrix for clot formation.
k Vitamin K
Absorbable collagen and micro-fibrillar collagen hemostatic sponges are available.
Phytomenadione, also known as vitamin K1 or phylloquinone, is a vitamin found in food and used as a dietary
k Oxidized regenerated cellulose, e.g., Surgicel®. Oxidized regenerated cellulose (ORC) products are available in supplement. As a supplement, it is used to treat certain bleeding disorders, including warfarin overdose, vitamin K
absorbable knitted fabric sheets of various sizes.
deficiency, and obstructive jaundice. It is also recommended to prevent and treat hemorrhagic disease of the
k Gelatins, e.g., Gelfoam® newborn. Use is typically recommended by mouth or injection under the skin. Use by injection into a vein or muscle
k Polysaccharide hemospheres is recommended only when other routes are not possible. When given by injection, benefits are seen within two
hours. [Wikimedia Commons]
ACTIVE HEMOSTATIC AGENTS (CONTAINS THROMBIN)
k Protamine
There are three forms of thrombin products:
Protamine sulfate is a medication that is used to reverse the effects of heparin. It is used specifically in heparin
k Bovine thrombin overdose, in low molecular weight heparin overdose, and to reverse the effects of heparin during delivery and heart
surgery. It is given by injection into a vein. [Wikimedia Commons]
k Pooled human plasma thrombin
k Recombinant thrombin k Vasopressin and derivatives (desmopressin and octapressin)

Vasopressin is a hormone but also synthesized and used as a pharmacological agent. Vasopressin agonists are used

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 therapeutically in various conditions, and its long-acting synthetic analog desmopressin is used for the control of
bleeding, e.g., in some forms of von Willebrand disease, and in mild hemophilia A. Terlipressin and related analogs are
used as vasoconstrictors.
k Lysine analogs, e.g., tranexamic acid (Cyklokapron)
Champions of bloodless surgery do, however, transfuse products made from allogeneic blood, and they also make use of
pre-donated blood for autologous transfusion. Interest in bloodless surgery has arisen for several reasons. Jehovah’s
Witnesses reject blood transfusions on religious grounds; others may be concerned about bloodborne diseases, such as
hepatitis and AIDS. [Wikimedia Commons]

Tranexamic acid (TXA) is a synthetic analog of the amino acid lysine. It acts as an antifibrinolytic agent by reversibly INTRAOPERATIVE BLOOD SALVAGE (IOS) OR CELL SAVING TECHNIQUES
binding a number of lysine receptor sites on plasminogen. It is used to treat or prevent excessive blood loss from
Intraoperative blood salvage (IOS), also known as cell salvage, is a specific type of autologous blood transfusion.
major trauma, postpartum bleeding, surgery, tooth removal, nosebleeds, and heavy menstruation. It is also used for
Specifically, IOS is a medical procedure involving recovering blood lost during surgery and re-infusing it into the patient.
hereditary angioedema. It is taken either by mouth or injection into a vein.
It is a form of auto-transfusion.
k Conjugated estrogens

Orally administered conjugated estrogens (Premarin) effectively improve the bleeding tendency in patients with
chronic renal failure. [Ref ]

BLOOD COMPONENTS (CLOTTING FACTORS, PLATELETS, FFP, ETC.)

Patients with a shortage of any blood clotting factors (hemophiliacs) should be treated by restoring or supplementing the
appropriate clotting factor levels. A detailed discussion of the topic is beyond the scope of this course. For those who need
detailed information, kindly click here.

A shortage of the blood platelets (thrombocytopenia) or pathology of the blood platelets (thrombocytopathy) will require
supplementation with donor platelets, blood platelets concentrate, or fresh frozen plasma. The provision of ABO and Rh
(D) identical platelet transfusion should ideally be performed before transfusion.

LIMB ELEVATION

As bleeding is a pressure-driven process, it is advised that the emergency worker elevate the bleeding limb in an effort to
reduce the bleeding. While this may be somewhat effective with venous bleeds, it is unlikely to make a significant
difference with arterial bleeds, due to the significantly higher pressures found in the arteries. Figure 47. A diagram on how a cell saver works

SEMI-FOWLERS POSITION
The same argument is used for bleeding in the head and neck area, and the same counter-arguments seem to be valid.
Placing a patient in the semi-fowlers position may make a marginal difference and is still commonly practiced to limit
bleeding from the head and neck area. Take care though, with a bleed of one of the large neck veins as elevation may
eventually cause air to enter the vein causing an air embolus.
Other
BLOODLESS SURGERY
Bloodless surgery is a non-invasive surgical method developed by an orthopedic surgeon, Adolf Lorenz, who was known
as “the bloodless surgeon of Vienna.” His medical practice was a consequence of his severe allergy to carbolic acid routinely
used in operating rooms of the era. His condition forced him to become a “dry surgeon.” Contemporary usage of the term
refers to both invasive and noninvasive medical techniques and protocols. The expression does not mean surgery that
makes no use of blood or blood transfusion but refers to surgery performed without transfusion of allogeneic blood.
It has been used for many years and gained increased attention over time as risks associated with allogenic (separate-
donor) blood transfusion have seen more significant publicity and become more fully appreciated. Several medical
devices have been developed to assist in salvaging the patient’s own blood in the perioperative setting. The procedure is
frequently used in cardiothoracic and vascular surgery, during which blood usage has traditionally been high. A greater
effort to avoid adverse events due to transfusion has also increased the emphasis on blood conservation (see bloodless
surgery). [Wikimedia Commons]
RADIOGRAPHIC ASSISTED EMBOLIZATION
Catheter embolization places medications or synthetic materials called embolic agents through a catheter into a blood
vessel to block blood flow to an area of the body. It may be used to control or prevent abnormal bleeding, close off vessels
supplying blood to a tumor, eliminate abnormal connections between arteries and veins, or to treat aneurysms.
Embolization is a highly effective way to control bleeding and is much less invasive than open surgery.

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 GUIDELINE FOR THE MANAGEMENT OF MASSIVE BLOOD

SECTION 8
LOSS DUE TO TRAUMA¹
1. Activate the hospital trauma team prior to patient arrival.
2. The team should have a designated trauma team leader and at least a general surgeon and anesthesiologist.

RESTORATION OF
3. Receive the patient in the emergency room (warm environment).
4. Give oxygen.
5. Primary survey.
6. Establish IV access.

BLOOD VOLUME
7. Send blood for a group and save (type and screen) and crossmatch four units of red cells. Ensure specimens accurately
labeled and hand-deliver it to the blood bank.
8. Start fluid resuscitation prior to further transport (Failure to respond to crystalloid and blood dictates the need for
immediate definitive intervention).
9. Assess injuries and prioritize treatment (aortic injury, head injury).
10. Ensure availability of specialists based on injuries (neurosurgeon, thoracic surgeon obstetrician).
11. Alert clinical lab, blood bank, and hematologist.

¹As recommended by Srikantha Rao* and Fiona Martin, Update in Anaesthesia [Full article]
*Correspondence Email: srao1@psu.edu

THE FOLLOWING FLUIDS ARE COMMONLY USED TO RESTORE THE BLOOD

VOLUME AFTER BLOOD LOSS:
k CRYSTALLOIDS

The most commonly used crystalloid fluid is normal saline, a solution of sodium chloride at 0.9% concentration,
which is close to the level in the blood (isotonic). Ringer’s lactate or Ringer’s acetate is another isotonic solution often
used for large-volume fluid replacement.

k COLLOIDS

Colloids preserve a high colloid osmotic pressure in the blood, while, on the other hand, this parameter is decreased by
crystalloids due to hemodilution. Therefore, they should theoretically preferentially increase the intravascular volume,
whereas crystalloids also increase the interstitial volume and intracellular volume. However, there is no evidence to
support that this results in less mortality than crystalloids. Another difference is that crystalloids generally are much
cheaper than colloids. Common colloids used in the medical context include albumin and fresh frozen plasma.

k BLOOD AND BLOOD COMPONENTS

Blood transfusions and blood components infusions

Blood transfusion should be a last resort, but when done according to acceptable medical and surgical indications
and the relevant hospital unit’s protocols, it is often a life-saving measure.

Blood transfusion is the process of transferring blood or blood products into one’s circulation intravenously.

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 Transfusions are used for various medical conditions to replace lost components of the blood. Early transfusions used
whole blood, but modern medical practice commonly uses only components of the blood, such as red blood cells
(packed red blood cells), white blood cells, plasma, clotting factors, and platelets.
As a general rule massive blood loss will require massive blood transfusions.
ADVERSE EFFECTS
Transfusions of blood products are associated with several complications:
IMMUNOLOGIC REACTION
k Acute hemolytic reactions are defined according to Serious Hazards of Transfusion (SHOT) as «fever and other
symptoms/signs of hemolysis within 24 hours of transfusion; confirmed by one or more of the following: a fall of Hb,
rise in lactate dehydrogenase (LDH), positive direct antiglobulin test (DAT), positive crossmatch.” This is due to the
destruction of donor red blood cells by preformed recipient antibodies. Most often, this occurs because of clerical
errors or improper ABO blood typing and cross-matching, resulting in a mismatch in ABO blood type between the
donor and the recipient. Symptoms include fever, chills, chest pain, back pain, hemorrhage, increased heart rate,
shortness of breath, and rapid drop in blood pressure. When suspected, transfusion should be stopped immediately,
and blood sent for tests to evaluate for the presence of hemolysis. Treatment is supportive. Kidney injury may occur
because of the effects of the hemolytic reaction (pigment nephropathy). The severity of the transfusion reaction is
depended upon the amount of donor’s antigen transfused, nature of the donor’s antigens, the nature, and the amount
of recipient antibodies.
k Delayed hemolytic reactions occur more than 24 hours after a transfusion. These reactions usually occur within
28 days of a transfusion and can be due to either a low level of antibodies present prior to the start of the transfusion,
(which are not detectable on pre-transfusion testing) or development of new antibodies against an antigen in the
transfused blood. Therefore, a delayed hemolytic reaction does not manifest until after 24 hours when enough
amount of antibodies are available to cause a reaction. The red blood cells are removed by macrophages from the
blood circulation into the liver and spleen to be destroyed, which leads to extravascular hemolysis. This process
usually mediated by anti-Rh and anti-Kidd antibodies. However, this type of transfusion reaction is less severe when
compared to an acute hemolytic transfusion reaction.
k Febrile nonhemolytic reactions are, along with allergic transfusion reactions, the most common type of blood
transfusion reaction and occur because of the release of inflammatory chemical signals released by white
blood cells in stored donor blood or attack on donor›s white blood cells by recipient›s antibodies. This type of
reaction occurs in about %7 of transfusions. Fever is generally short-lived and is treated with antipyretics. The
transfusion may be completed as long as an acute hemolytic reaction is excluded. This is a reason for the now-
widespread use of leuko-reduction – the filtration of donor white cells from red cell product units.
k Allergic transfusion reactions are caused by IgE anti-allergen antibodies. Patients may feel itchy or have a rash or
hives. These symptoms are usually mild and can be controlled by stopping the transfusion and giving antihistamines.
k Anaphylactic reactions are rare, life-threatening allergic conditions caused by IgA anti-plasma protein antibodies.
The reaction is presumed to be caused by IgA antibodies in the donor’s plasma. The patient may present with
symptoms of fever, wheezing, coughing, shortness of breath, and  circulatory shock. Urgent treatment
with epinephrine is needed.
88
k Post-transfusion purpura is an extremely rare complication that occurs after blood product transfusion and is
associated with the presence of antibodies in the patient›s blood directed against both the donor›s and
recipient›s platelets HPA (human platelet antigen). Recipients who lack this protein develop sensitization to
this protein from prior transfusions or previous pregnancies can develop thrombocytopenia, bleeding into
the skin, and can display purplish discoloration of the skin, which is known as  purpura. Intravenous immunoglobulin
(IVIG) is the treatment of choice.
k Transfusion-associated acute lung injury (TRALI) is a syndrome that is similar to acute respiratory distress
syndrome (ARDS), which develops during or within 6 hours of transfusion of a plasma-containing blood product.
Fever, hypotension, shortness of breath, and tachycardia often occur in this type of reaction. The treatment is
supportive.
k Transfusion-associated circulatory overload (TACO) is a common, yet underdiagnosed, reaction to blood
product transfusion consisting of the new onset or exacerbation of three of the following within 6 hours of
cessation of transfusion: acute respiratory distress, elevated brain natriuretic peptide (BNP), elevated central
venous pressure (CVP), evidence of left heart failure, evidence of positive fluid balance, and radiographic evidence
of pulmonary edema.
k Transfusion-associated graft versus host disease frequently occurs in immune-deficient patients where the
recipient’s body failed to eliminate donor’s T cells. Instead, the donor’s T cells attack the recipient’s cells. It occurs one
week after transfusion. Fever, rash, and diarrhea are often associated with this type of transfusion reaction. The
mortality rate is high, with 89.7% of the patients dying after 24 days. Immunosuppressive treatment is the most
common way of treatment. Irradiation and leuko-reduction of blood products are necessary for high-risk patients for
preventing T cells from attacking recipient cells.
INFECTION
Since the advent of HIV testing of donor blood in the mid-1980s, the transmission of HIV during transfusion has dropped
dramatically. Prior testing of donor blood only included testing for antibodies to HIV. However, because of latent infection
(the “window period” in which an individual is infectious but has not had time to develop antibodies), many cases of HIV
seropositive blood were missed. The development of a nucleic acid test for the HIV-1 RNA has dramatically lowered the
rate of donor blood seropositivity to about 1 in 3 million units. As transmittance of HIV does not necessarily mean HIV
infection, the latter could still occur at an even lower rate.
The transmission of hepatitis C via transfusion currently stands at a rate of about 1 in 2 million units. As with HIV, this low
rate has been attributed to the ability to screen for both antibodies as well as viral RNA nucleic acid testing in donor blood.
Other rare transmissible infections include hepatitis B, syphilis, Chagas disease, cytomegalovirus infections (in
immunocompromised recipients), HTLV, and Babesia.
INEFFICACY
Transfusion inefficacy or insufficient efficacy of a given unit(s) of blood product, while not itself a “complication” per se, can
nonetheless indirectly lead to complications, in addition to causing a transfusion to entirely or partly fail to achieve its
clinical purpose. [Wikimedia Commons]
89
 ABO AND RH COMPATIBILITY QUIZ 3
In the ABO blood group system, there are four possibilities: A antigen (A blood), B antigen (B blood), both A and B antigen Are the following statements TRUE or FALSE?
(“AB blood”), and lastly, neither A nor B antigens called “O blood.” A person with Type A blood produces antibodies against
the B antigens and vice versa. A person with O blood produces both A and B antibodies. See the illustration below (the Discuss the statement in a group setting.
antigens sticking out are represented by the colored shapes on the surface of the red blood cells).
Statement 1: A profuse bleed from a penetrating chest injury will respond well to external pressure and packing.

Statement 2: Bleeding to death as a result of a nose bleed is not too uncommon, and thus all patients with a nose bleed
need urgent hospitalization.

Statement 3: Anaphylactic reactions are rare, life-threatening allergic conditions.

Statement 4: Individuals with type O, Rh-negative blood are often called universal donors.

Statement 5: Individuals with type AB, Rh-positive blood are called universal recipients.

Answers available at the bottom of the page.

Figure 48: The ABO antigens and antibodies

It varies from country to country, but on average, the general population has the following percentages of blood groups:

O+ A+ B+ AB+ O- A- B- AB-

36 % 28% 21% 5.0% 4% 4% 1.5% 0.5%

Table 5. Prevalence of Blood groups in the general population (approximate global averages)

Genotype (Genetic type) Phenotype (Biochemical expression)

AA or AO A

BB or BO B
ANSWERS:
AB AB Statement 1: False. If the bleeding originates from one of the large blood vessels in the thorax or from a stab wound to the heart,
urgent surgery will be required to save such a patient’s life.
OO O
Statement 2: False. Bleeding to death from a nose bleed is excessively rare. It is commonly managed at home by positioning the patient
Table 6. The ABO Genotype and Phenotype forward and by applying pressure over the nose area.

Statement 3: True. Anaphylactic reactions required urgent treatment and are commonly fatal.
RH BLOOD GROUP SYSTEM
Statement 4: True. These individuals can only receive blood from other type O, Rh-negative donors.
The Rh system (another type of protein that is exposed on RBC is called “Rh-factor”) is the second most significant blood-
Statement 5: True. These individuals may receive donor blood from all other blood groups (O, A, B, AB).
group system in human blood. The most significant Rh antigen is the D antigen. You either have it, or you don’t. The
person who has the D antigen is positive, and one who doesn’t is negative. So, someone could be Type A, B, AB, or O, and
then Rh positive or negative (e.g., A Rh+ or B Rh-). An Rh+ person can donate blood ONLY to another Rh+ person while an
Rh-negative person can donate blood to both an Rh-positive, as well as an Rh-negative person.

90 91
 THE APPRENTICE DOCTOR® CONTROL BLEEDING
COURSE PRACTICAL PROJECTS
PERFECT YOUR SKILLS IN A SIMULATION ENVIRONMENT!

PRACTICAL PROJECTS The Apprentice Doctor® Control Bleeding Training Kit contains *all the items for practicing the majority of the practical
projects contained in The Apprentice Doctor® Control Bleeding Course. (*The Apprentice Doctor® Suturing Kit is
required for the projects where suturing is required). The Apprentice Doctor® Control Bleeding Training Kit is also a
suitable resource for instructors and participants of the national Stop the Bleed® campaign and associated Stop the
Bleed® workshops.

ORDER YOUR BLEEDING CONTROL KIT HERE!

USER DIRECTIVES FOR ALL PRACTICAL PROJECTS

KEYS TO COLORS USED:

Color Meaning
Red Warning
Yellow Caution
Green Permissible/allowed
Cyan Directive/guidance

All individuals and group members proceeding with the practical projects should be well acquainted with the following
directives to be used in all the projects:

92 93
 Key Project√ This project is very important and should not be skipped. WORKSHOP SAFETY
Suggested PPE (personal protective equipment) during simulation workshops

These projects are only allowed in a formal workshop setting with at least one qualified
Supervision√
medical professional present in a supervisory role.
PPE√ Protective clothing and protective equipment are recommended.
Public: Sim√ Members of the public (non-medical professionals) may freely take part in these projects.
Members of the public (non-medical professionals) may take part in these projects, but the
Public: Sim√
skills gained may not be applied/used on real patients.
Members of the public (non-medical professionals) may take part in these projects, and are
Public: Patient√:
allowed to apply the skills gained on real patients in an emergency/disaster situation.
Members of the public (non-medical professionals) may take part in these projects, but the
Public: PatientX:
skills gained may not be used on real patients in an emergency/disaster situation.
When using this technique on a real patient, there is a risk of compromising the survival of the
Limb risk!
limb with tourniquet-on times exceeding 2 hours.
Sharps injury risk! There is a risk of injury with a contaminated needle in a clinical setting.
1. Recommended attire during workshops:
1.1. Scrubs (available from Apprentice Doctor® Website). [Order scrubs]
1.2. Waterproof apron (supplied in the Apprentice Doctor® Control Bleeding Kit).
1.3. Clean gloves (supplied in the Apprentice Doctor® Control Bleeding Kit).
1.4. Protective eyewear, e.g., protective glasses mask with a visor (readily available).
2. Protect your clothes. Since we recommend the use of red-colored water/saline or fake blood, attendees need to wear
scrubs covered by a waterproof apron. Do not wear clothes that you cannot afford to have red stains on after the
workshop.
3. In a clinical setting, proper PPE is recommended to protect the helper against contracting (or possibly transferring) a
blood-borne disease like AIDS or hepatitis B or C from (or to) the victim/patient. It is recommended that workshops
are conducted with all participants pretending a real medical situation in this regard.
RECOMMENDATIONS IN A GROUP SETTING
k The kit works best for groups of 2 - 4 workshop attendees working as a team.
k Allow more than one opportunity for different students in a group to stop the bleed.
k The fluid bag, when half-empty, may have to be folded over on itself within the BP cuff. Refill it when it is empty.
k Ensure that the pressure in the cuff is maintained at the recommended pressure level, as the pressure will tend to
decline as the colored fluid leaves the fluid bag.
k Instructors can raise the “fun level” by setting time limits, for instance:
c “You get three minutes to stop the bleed!” or
c Make it a competition between several groups: “let’s see which group can stop the bleed first – start now!
c Another way is to let the group members compete on who can stop the bleed fist by using a stopwatch.

Need Suture Kit√ The Apprentice Doctor® Compact Suture Kit is required for these projects. [Order] c The instructor may ask the workshop attendees to go out of the room, and then he/she opens the roller clamp/s
to start the simulation bleeding, and then instructs the attendees: “go and save some lives!”

The Control Bleeding simulation arm (correctly set up) is necessary for completing these
Need Sim Arm√
projects.

Human volunteer√ A fellow student/friend/family member volunteer is required for these projects.

[Human volunteerX] Do not practice these projects on a fellow student/friend/family member volunteer.

Self√ Persons can perform these projects on their own bodies.

94 95
 PROJECT 1B: MEASURING BLOOD PRESSURE WITH PALPATION
PROJECT 1: PREPARATORY PROJECTS
Public: Patient√: Human volunteer√

PROJECT 1A: PULSE POINTS OF THE BODY

WATCH THIS VIDEO: Project 1B
Public: Patient√: Human volunteer√ Self√
This project will also demonstrate the use of the blood pressure cuff as a pneumatic tourniquet

WATCH THIS VIDEO: Project 1A For a full description of measuring blood pressure with a sphygmomanometer and a stethoscope – see Project 31 in the
Apprentice Doctor® Foundation Medical Course.
Also see: Project 24 of The Apprentice Doctor® Foundation Medical Course
Follow these steps:
Pulse points are usually areas where an artery is close to a bone or crosses a bony prominence in the body.
1. Review the pulse points in the illustration below:
Study the following diagrams:

Figure 50. Some of the pulse points of the body

2. Study the diagram showing the parts of the sphygmomanometer:

Figure 49. Common pulse point of the body (right side) and pressure point on the left side.

1. Identify as many of the pulse points (shown in Figure 49, above) on your own body, using your 2/3 middle digits, and
moderate pressure.
2. Identify the various pulse points (with the exception of the femoral pulse) on a volunteer friend’s body, using your 2/3
middle digits, and moderate pressure.

The distal pulses of the extremities are the radial pulse and the dorsalis pedis pulse. Identification of these two pulse
points is crucial, especially when confronted with patients suffering from orthopedic or vascular injuries of the limbs.

Figure 51. The various parts of the sphygmomanometer

3. Identify the anatomical landmarks: the humerus bone, the biceps muscle, and the brachial artery in the upper arm, as
well as the radial artery in the wrist area.

96 97
 4. Place the cuff snuggly around the upper arm at the level of the heart and about four fingers above the elbow -precisely PROJECT 1C: DETERMINE THE HEART RATE AT THE WRIST (RADIAL) PULSE
the same way as one would do when measuring blood pressure with auscultation. POINT
5. Place the middle 2 or 3 digits of one hand on the brachial artery, distal to the cuff, and palpate the pulsating brachial
artery (one can also palpate the radial artery for the purpose of this project). Public: Patient√: Human volunteer√ Self√

6. Close the pressure control valve and pump the rubber bulb to inflate the cuff about 10-20 mmHg beyond the point
where the artery’s pulse can no longer be felt. WATCH THIS VIDEO: Project 1C

7. Gradually release the pressure by opening the pressure control valve slowly, keeping your finger digits on the brachial/
radial artery.
8. Make a note of the pressure on the sphygmomanometer at the point at which you start feeling the pulse again. This
reading represents the systolic blood pressure.
9. With the test person in the supine position, one can measure the blood pressure in the lower limb, with the femoral
artery and the dorsalis pedis artery as the proximal and distal pulse points, respectively. A dedicated lower limb BP
cuff may be required.
IMPORTANT NOTES:
Also see: Project 24 of The Apprentice Doctor® Foundation Medical Course
Information
Every time the heart contracts, pressure waves occur in the arteries supplying oxygen-rich blood to the tissues of the
body. These pressure waves can be palpated where an artery runs over a bony or firm structure relatively close to the
body’s surface.
k The adult heart normally contracts 70-80 times in one minute during rest. The heart rate is the number of times the
heart contracts in a one-minute period.

1. The touch perception of the fingers is less sensitive than listening with a stethoscope. The first pulsations are noted at k The pulse rate varies with age, for example, the average pulse rate during rest for:
lower pressure in the cuff compared to hearing the first sounds through a stethoscope, and thus the systolic blood c A newborn infant is 140 beats per minute.
pressure reading using the palpation method is usually about 5 to 10 mmHg lower than the pressure measured by the c A 3-year-old is 100 beats per minute.
auscultation method.
c An 11-year-old is 80 beats per minute.
2. It is not possible to measure the diastolic pressure accurately without a stethoscope.
c An adult is 70–72 beats per minute.
3. In hypotensive patients (systolic blood pressure below 80 mmHg), It is difficult (in fact, it is sometimes impossible) to
k The pulse rate varies with physical fitness. A fit person will have a lower pulse rate compared to the average pulse rate.
measure blood pressure accurately, with the palpation method.
k Generally, strong emotions increase the pulse rate, e.g., happiness, fear, anger, etc.
4. Usually, the systolic blood pressure in the legs is about 10% to 20% higher than the arm blood pressure. Blood pressure
readings that are lower in the legs as compared with the upper arms are considered abnormal and should be k The pulse rate decreases during sleep.
investigated regarding peripheral vascular disease. k An increase in the pulse rate is generally the body’s attempt to increase the supply of oxygen-rich blood to the tissues
5. The blood pressure cuff can serve as a pneumatic tourniquet for the upper or lower limbs in an emergency setting. of the body.
If used as a tourniquet, the helper should ensure that the pressure in the cuff remains above the systolic blood k Certain medications, abnormalities, and pathophysiological conditions may cause either an increase or a decrease in
pressure. In a real disaster/emergency situation, if the bleeding starts again, then increase the cuff pressure. the pulse rate.
6. Learn how to determine both the systolic and the diastolic blood pressure using the auscultation method: see project 31 Requirements:
in the Apprentice Doctor® Foundation Medical Course and accompanying medical examination kit [Order Here].
k A stopwatch or timer that measures in seconds.
k A pulse oximeter (optional)

Figure 52. A finger pulse oximeter

98 99
 Follow these steps: PROJECT 1D: CAPILLARY REFILL TIME (CAPILLARY NAIL REFILL) TEST
1. Identify the radial pulse point on your wrist (self-examination or use a suitable volunteer).
Public: Sim√ Public: Patient√: Human volunteer√ Self√
2. Gently press down with the middle three fingers in this area. You may have to move the position of these fingers
slightly over the specific area before feeling the pulse.
WATCH THIS VIDEO: Project 1D
Notes:
The capillary nail refill test is a quick test done on the nail beds.
c Use the middle three fingers to feel for a pulse. Do not feel with the thumb as you may, in fact, be feeling the small
artery pulsating in your own thumb! k Remove colored nail polish before this test.
c The pulse point of the wrist is situated on the thumb’s side of the wrist, as indicated in Figure 49b. k Perform at room temperature (not accurate when the fingers are cold).

k Perform on finger or arm held at heart level (or skin over the sternum in infants).

Follow these steps:

1. Apply pressure to the nail bed until it turns white (blanches). This indicates that the blood has been forced out of the
capillaries. It is called blanching.
2. Once the tissue has blanched, the pressure is instantly removed.
3. Measure the time it takes for the normal pink color to reappear in seconds, indicating that blood has returned into the
capillaries.

Normal results:

If there is proper blood flow to the nail bed, a pink color should return in less than two seconds after pressure is removed.

Figure 53a. The position of the radial artery Figure 53b. The wrist pulse point Abnormal results:

c Use moderate pressure. Do not press too hard as this may block the artery and stop the pulsations. Blanch times that remains after two seconds may indicate:
c The more one practices, the easier it becomes to identify a clear pulse.
k Shock
3. Count the number of beats in one minute. This number is the pulse rate and equals the heart rate for the specific
k Dehydration
person. Alternatively, you may count the number of beats in half a minute and then multiply this number by two to
k Peripheral vascular disease (e.g., Raynaud’s syndrome)
get the pulse rate.
k Hypothermia
Also, take note of the following:

c The forcefulness of each individual beat, e.g., a weak pulse or a strong pulse.
c Is the pulse steady or irregular? PROJECT 1E: RESPIRATORY RATE
4. If you have a pulse oximeter, compare the manually determined pulse rate with the pulse rate determined by the
pulse oximeter. Public: Sim√ Public: Patient√: Human volunteer√ Self√

5. Practice by checking the pulse rate of other people.

WATCH THIS VIDEO: Project 1E
Warnings
c Do not press too hard to find a pulse in the neck. Also, see the Apprentice Doctor® Foundation Medical Course – Project 33

c Do not press on both carotid pulse points at the same time. This may cause fainting! Measure the number of inhalation-exhalation breathing cycles in one minute time period. Respiratory rate unit: breaths
per minute or breathing rate average (BRA).

100 101
 Information
PROJECT 2: KNOT TYING TECHNIQUES
PROJECT 2A: SQUARE KNOT: ONE-HAND TIE
Public: Sim√ Public: PatientX:

WATCH THIS VIDEO: Project 2A

Also, see the knot tying projects in The Apprentice Doctor® Suturing Course

Information

Figure 54. Inhaling and exhaling
The respiratory rate is the number of breaths (inhalation and exhalation cycles) occurring in a one-minute time period. It
varies according to the body’s oxygen requirements. If the body needs more oxygen, the breathing tempo will increase,
and vice versa.
Medical professionals use the one-hand tie technique of tying a square knot to tie off bleeding blood vessels. This is a fast
way of tying a square knot in experienced hands. Occasionally during surgery, seconds may be the difference between life
and death!
Requirements:

k A ±60cm long piece of string or shoelace (not supplied in this kit). Half of it must be colored red and the other half
The respiratory rate will:
white. Use a permanent marker to paint one half of the string/shoelace red.
k Increase with physical exercise. k A small bridge using a ruler, two plastic bottle caps, and sticky tape (see photo below).
k Increase with strong emotions.
k Be influenced by some medications, diseases, and certain pathophysiological conditions, e.g., shock.

Breathing during rest occurs typically through the nose.

The resting respiratory rate of:

k A newborn baby is 30–40 breaths per minute;

k An adult is 12–16 breaths per minute.
Figure 55. A simple bridge constructed for practicing knot tying techniques
Requirement:
Note these, and all the other items that you will need to do a full course in surgical knot tying and basic suturing techniques
k A stopwatch or timer that measures in seconds. are included in the Apprentice Doctor® Suturing Kit.
Follow these steps:
Follow these steps:
1. Place the palm of your hand over the lower mid-chest or upper mid-abdominal area.
1. Prepare a small bridge using a ruler, two plastic bottle caps, and sticky tape (see Figure 51).
2. Count the number of chest rises (the number of times the hand moves up and down during a one minute time period).
2. Slip the string underneath the constructed bridge with the colored end towards you (near side), and the white end
3. Make a note of this number. away from you (far side).
4. Also, note the following: 3. Hold the colored end in your dominant hand between your index finger and thumb, and the white section in your
c Is the breathing shallow or deep? non-dominant hand, in between your middle finger and thumb. Let the white part cross over the palm’s side of the
c Is breathing regular or irregular? open 3rd to 5th fingers of the non-dominant hand with the white tip hanging down past the little finger. Place the index
finger of your non-dominant hand under the white section, and extend the index finger – draping the string over the
c Does the breathing occur through the nose, the mouth, or both of these passages?
tip of the index finger.
c Is it effortless, or does the patient strain to take a breath?
4. Take the colored section to the far side, crossing over the index finger of the non-dominant hand and over the white
c If straining, does the strain happen on inspiration or on expiration? part of string forming an “X”.

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 5. Bend (flex) the index finger of the non-dominant hand around the colored strand and rotate it under the white strand
held by the middle finger and thumb.
6. Open (extend) the index finger making sure that the white section of the string stays on the nail’s side of this finger.
Rotate the hand, pulling the white part of the string through the loop while at the same time letting go of the string
held between the middle finger and thumb.
7. Pull the white section towards you with your non-dominant hand, and the colored end away from you with your
dominant hand and tighten the first throw of the knot.
8. Hold the white end in your non-dominant hand between the tips of your index finger and thumb, and the colored
section in your dominant hand in between your index finger and thumb. Allow the white part to cross over the palm’s
side of the open (extended) 3rd to 5th fingers of the non-dominant hand.
9. Bring the colored section from the far side to the near side, looping it over the 3rd to 5th fingers of the non-dominant
hand, and over the white part of the string to form an “X” shape.
10. Flex the middle finger of the non-dominant hand and hook it around the colored section and beneath the white part
of the string. Extend the index finger again while pulling the white end through the loop in a rotating motion. Take it
now between the tips of the index finger and thumb.
11. Pull the colored end towards you with your dominant hand and the white section away from you with your non-
dominant hand, tightening the second throw of the knot.
Note:
k If required, you may add another loop (by following Steps 3 - 7) or two (by following Steps 3 - 11) again.
k Practice the technique of making a square knot using the one-hand tie method until proficient, before proceeding to
the instrument tie technique.
PROJECT 2B: SURGEONS KNOT: INSTRUMENT TIE
Public: Sim√ Public: PatientX: Need Suture Kit√
WATCH THIS VIDEO: Project 2B
Also, see the knot tying projects in The Apprentice Doctor® Suturing Course
Information
Tying surgical knots with a needle holder is by far the most common form of knot tying done by most medical professionals,
especially those who are involved in any of the surgical disciplines. It is important to master surgical knot tying techniques as
part of any suturing techniques course. The various suturing instruments, in particular, the needle holder become an
extension of the clinician’s hands, making the whole process of suturing more efficient while adding finesse to the procedure.
Requirements:
k A needle holder.
k A ±60cm long piece of string or shoelace. Half of it must be colored (red) and the other half white.
This and all the other items that you will need to do a full course in surgical knot tying and basic suturing techniques
are included in the Apprentice Doctor® Suturing Kit. [Order here]
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Construct a small bridge using your ruler, two plastic bottle caps, and sticky tape (see photo below).
Figure 56. A simple bridge constructed for practicing knot tying techniques
Follow these steps:
1. Color one half of a white string (or shoelace) red using a red felt tip or permanent marker pen. Leave the remaining
half white.
2. Slip the string under the constructed bridge with the colored section towards you (near side) and the white tip away
from you (far side).
3. Hold the needle holder in your dominant hand, and position it parallel to the constructed bridge, with the tip pointing
to your non-dominant hand’s side. The latch mechanism of the needle holder must be unengaged at the stage.
4. Hold the colored section on the near side between the thumb and index finger of the non-dominant hand.
5. The colored section of the string is brought from the near side, over the needle holder, down and back to the near
side, thus completing the first loop of the knot.
Note: To make a surgeon’s knot - loop the string around the needle holder a second time.
6. Open the jaws of the needle holder and grip the white section on the far side, close to the tip of the string. Engage the
ratchet latch mechanism (listen for the first or second “click”).
7. Pull the white section towards you using the needle holder and the colored part away from you using your non-
dominant hand. Tighten the string, thus completing the first throw of the knot.
8. Unclip the latch of the needle holder and release the white tip.
9. Place the needle holder once more parallel to the constructed bridge with the tip pointing to the non-dominant
hand’s side. Hold the colored section on the far side between the thumb and index finger of the non-dominant hand.
10. The colored section of the string is brought from the far side, over the needle holder, down and back to the far side,
thus making the second loop.
11. Open the jaws of the needle holder and grip the white section (now on the near side) close to the tip of the string.
Engage the latch mechanism (listen for the first or second “click”).
12. Pull the white section away from you using the needle holder and the colored part towards you using your non-
dominant hand. Tighten the string, thus completing the second throw of the knot.
13. Unclip the latch lock of the needle holder and release the white tip.
Well done! You have just successfully tied an instrument tie square knot. If you feel comfortable tying a square knot with
a needle holder, go ahead and practice tying a surgeon’s knot. See “Note – Step 5”.
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PROJECT 3: SIMULATE AN EMERGENCY/DISASTER SETTING
PROJECT 3A: HOW TO CREATE A FAKE WOUND
Public: Sim√ Public: Patient√:
WATCH THIS VIDEO: Project 3A:
Instructions:
1. The volunteer should expose one of their limbs (in a comfortable position as this may take a couple of minutes.)
2. Wet the area where you want to create the wound (avoid areas with a rash or previous injuries. Stay a reasonable
distance from the eye/s.) Apply glue to the same area
Human volunteer√ 3. Apply a couple of layers of tissue paper; wet the tissue paper with a diluted glue mixture.
4. Use the paintbrush to apply the skin-colored paint to the periphery of the wound/tissue paper.
5. Create a wound by tearing the middle part of the tissue paper apart.
6. Use a swab of gauze/cotton wool or a tissue paper to mold the wound.
7. Use the red paint to create a bleeding wound effect (use your creativity!)
8. Allow drying somewhat.
9. Pour out some fake blood over the wound (optional.)
10. Position the “patient” in the disaster zone – place a protective liner under the injury.

11. Continue with Project 3B.

After completion of project 3B:

1. Place a wet cloth/towel soaked in warm water over the fake wound for 2-5 minutes. This will make removal of the fake
wound easy and painless (especially if removal from hairy skin).

HOMEMADE GLUE RECIPE:

Items required (not included in the Apprentice Doctor® Control Bleeding Kit): Ingredients:
One can order various simulation trauma moulage kits for this purpose from suppliers, but c 1/2 cup flour
k A volunteer c Water
k Tissue paper c Pinch of salt
k Office glue (or make your own) Instructions:
k Red and skin-colored finger paint (or non-toxic, water-based, quick-dry acrylic paint) c Mix water with flour until it’s sticky and syrupy. Add a bit of water if it becomes too thick, and if it’s too thin, add a
k Paintbrush bit more flour.
k Gauze swab c Mix in a pinch of salt to prevent mold.
k Two toothpicks c Store in a sealed container.
k A waterproof sheet
k Water
k Gloves
k Fake blood (optional)

Notes: The moulage artist, the volunteer, as well as the workshop participants should wear clothes that can be stained.
Surgical scrubs are ideal for this purpose.

When choosing the right room – take furniture, carpets into account as this project has a high risk of causing stains.

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 PROJECT 3B: SIMULATE AN EMERGENCY/DISASTER SETTING
PROJECT 4: SET UP THE SIMULATION ARM
Public: Sim√ Public: Patient√: Human volunteer√

(PREPARE FOR A WORKSHOP)

WATCH THIS VIDEO: Project 3B
Key Project√ PPE√ Public: Sim√ Need Sim Arm√
Important: attendees need to play the part, as if in a real mass shooting incident!

WATCH THIS VIDEO: Project 4

Order The Apprentice Doctor® Control Bleeding Simulation training kit: Click Here

The Apprentice Doctor® Control Bleeding simulation kits include most of the items needed for completing the majority
of the practical projects in the Apprentice Doctor® Control Bleeding course.

You will need the following:

1. The basic Apprentice Doctor® Control Bleeding simulation arm

Figure 67a and Figure 67b. Examples of trauma scenes for you to simulate
2. Connectors/lumen stoppers
Follow these steps:
3. A hemostatic forceps
1. Nominate one participant per group of 3 to 4 attendees, who will be the gunshot victim. 4. The sphygmomanometer (BP meter)
2. Make a simulation gunshot injury on the arm (face or leg) of this volunteer attendee. Feel free to be creative if you 5. The CAT tourniquet
have a moulage kit.
6. A linen saver
3. The other attendees will be playing the part of the helpers.
7. Plastic aprons
4. The instructor plays the “automatic weapon” sound-clip. [Sound clip]
8. Nitrile gloves
5. The gunshot victim should go and lay on the floor.
9. The various packets with gauze and bandages
6. The helpers must try to hide from the shooting until relative safety is perceived then go to aid of the injured person.
10. The fluid bag (empty) with tubing
7. The workshop instructor now guides the groups to follow the A, B, C of bleeding control:
11. The syringe
7.1 “A” (Assess; Alert)
12. The stitch cutter
~ Assess the situation (safety – self and victims, bleeding injuries, type, and seriousness of bleeding).
13. A marker pen
~ Alert – helpers take their mobile phones and fake call 911 or equivalent.
14. The tie suture
7.2 “B” (Bleeding)
You will also need the flowing items not supplied in the kit:
~ Evaluate the bleeding.
~ The helpers quantify the amount of blood loss. 1. Trays with curved sides

7.3 “C” (Control bleeding; Compress) 2. Food coloring dye (preferably red)

~ Consider options for controlling the fake bleeding. 3. Paper towels

~ Take a heart rate and respiratory rate. 4. Funnel (optional)

8. The instructor plays the “ambulance siren” sound-clip. [Sound clip]

9. The instructor ends this project by announcing the arrival of the professional paramedics.

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 Study the diagram of the Apprentice Doctor® Bleeding Control simulation practice arm/leg below: Follow these steps to set up the control bleeding simulation arm:

1. Select a suitable workshop room/lab. Tiled floors are preferred over carpets. Work surfaces/tables should be able to
tolerate spillage and should be easy to clean.
2. Arrange sufficient work stations, each station able to accommodate four workshop attendees.
3. Distribute one Apprentice Doctor® Control Bleeding Kit to all the work stations.
4. Place the tray on the work surface and cover it with a linen saver (absorbing surface facing upwards).
5. Place the simulation arm on the covered tray.
6. Set up the various items, as indicated in the photo below.

Figure 57.The Apprentice Doctor® Control Bleeding Simulation Arm

Follow these steps to fill the ¹empty fluid bag:

Fill the bag over a tub or basin.

1. Mix about 1liter (2.1 pints) of water with ±3-5 ml of red food dye (available at most grocery outlets).
2. Turn the fluid tube roller clamp to the closed position.
3. Open the lid of the fluid bag and fill the bag up to the 1000 ml mark with the red-colored water (serving as fake blood).
A funnel may make this task easier.
Figure 58. A typical setup for a Stop the Bleed workshop
4. Eliminate the excess air from the bag, and close the lid of the fluid bag. Ensure
that the lid is tightly closed by pressing the lid thoroughly down. 7. Connect the tubing to the fluid bag if it is not already connected.
5. Secure the latch. 8. Open the fluid line roller clamp. Let the fluid fill the drip chamber, and let the liquid run down to the tip of the tube.
6. Place a tight elastic band over the lid to prevent it from opening, thus causing a Allow a few drops of the fake blood to flow out of the tube into a small container, or onto the linen saver.
fluid spillage (see photo and diagram below). 9. Wrap the BP cuff around the filled liquid bag. It should fit snugly.
7. To limit/avoid spillage: 10. Connect the fluid line tip to the relevant vein or artery (according to the guidelines of the specific project). Use a
7.1 Press the lid down firmly. connector if necessary.
7.2 Use the elastic band supplied in the kit, and circle around the neck of the 11. You are ready to start with the various Stop the Bleed projects! Follow the steps according to the specific steps, as in
fluid reservoir bag two or three times. Project 5. It is recommended that students perform the various projects in proper sequence as in the course material.
7.3 On the last loop, hook the elastic band over the latch to secure the latch in place.
8. See the illustration to the right.

¹Note: Alternatively, one can use a 1000 ml IV bag. Draw ±3-5 ml of red food dye up in a syringe, and inject it into the “in”
port of the IV bag. Mix the dye and water thoroughly, and then attach the IV line.

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 1. Set up for venous bleeding.
1.1 Connect the fluid line to the vein- tube on the “inflow” side (blue). PROJECT 5: STOP VENOUS BLEEDING
1.2 Follow the instructions as in Project 5.
2. Set up for arterial bleeding:
PROJECT 5A & 5B: APPLY DIRECT PRESSURE AND APPLY A PRESSURE DRESSING
2.1 Connect the fluid line to the larger artery-tube on the “inflow” side (red and green). PPE√ Public: Sim√ Public: Patient√: Need Sim Arm√
2.2 Follow the instructions as in Project 6 (A to C).
3. Set up for applying an arterial tourniquet: WATCH THIS VIDEO: Project 5

3.1 Connect the fluid line to the smaller artery-tube on the “inflow” side (red).
3.2 Follow the instructions as in Project 6D (1-6). You will need:

4. Set up for amputation bleeding: k One control bleeding simulation arm (or leg, if applicable)
4.1 Connect the fluid line to the smaller artery-tube on the “inflow” side (red). k The fluid bag, filled with colored water or saline, connected to a fluid administration line
4.2 Follow the instructions as in Project 7 (A to C). k The sphygmomanometer (blood pressure meter)
As an alternative to using the fluid bag, order filled 1-liter simulation IV fluid bags here: [Order here] from Wallcur®. Draw k Five to ten gauze squares
up 3-5 ml of red food dye and inject it into the IV bag to serve as fake blood. k A roll of pressure (crepe) bandage

Follow these steps:

1. All participants should don a pair of clean gloves.

2. Identify the vein tube on the simulation arm/leg (marked with blue tape).
3. Identify the wound with the venous bleed (the smaller wound).
4. Close the connector on the outflow side. The connector on the inflow side of the vein should be open.
5. Ensure that the fluid administration line roller clamp is in the closed position.
6. Connect the fluid bag to the inflow side of the simulation arm’s vein via the connector.
7. Close the BP cuff valve and inflate the cuff to around about 20 mmHg (representing the upper limit of peripheral adult
venous pressure).
8. Open the IV tube roller-clamp.
9. The instructor announces, “Stop the bleed!”
10. Observe the blood flowing out of the wound on the simulation arm/leg.
11. Apply moderate finger pressure with your gloved hands directly on the bleeding point.
12. Place a few gauze squares on the bleeding point and re-apply finger/hand pressure.
13. Open the crepe bandage and tightly roll it around the arm over the gauze covering the bleeding point.
14. Inspect the wound to see if there is still any significant bleeding or oozing through the gauze and bandage.
15. Did the pressure bandage reduce or stop the bleeding?
16. If you notice any significant bleeding, apply finger/hand pressure over the bandage.
17. At the end of the project, open the BP cuff valve allowing the cuff to deflate, then close the fluid administration line
roller clamp, and disconnect the IV tube from the simulation arm/leg.

See: [Recommendations in a group setting]

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 Follow these steps:
PROJECT 6: STOP ARTERIAL BLEEDING 1. Review Project 1A, the pulse points of the body (Figure 59).
2. Don clean gloves (optional).
PROJECT 6A: PROXIMAL ARTERIAL PRESSURE POINT
3. Palpate the brachial artery in the mid-upper arm area, between the biceps muscle and the humerus bone, on the
Supervision√ PPE√ Public: Sim√ Public: Patient√: inside of the arm.
4. Using the other hand, palpate the radial artery on the same arm.
Human volunteer√
5. Compress the brachial artery quite firmly against the humerus bone – until the radial pulse disappears.

WARNINGS:
k This project is restricted to official Bleeding Control or Stop the Bleed workshops with at least one qualified medical
professional instructor¹ present as a supervisor.
k Restricting the arterial blood flow for an extended period of time may cause damage to a limb. Keep the period of
arterial obstruction to any limb short and not more than a few minutes.
k Exerting excessive pressure may cause injury to the limb’s nerves or muscles.
¹For example: a qualified paramedic, registered professional nurse (RN/RPN), physician or surgeon, physician assistant (PA).
6. If you have a pulse oximeter, check the disappearance of the peripheral pulse using this apparatus clipped to the
finger of the same arm.
Comments:
k This method can also be used to control arterial bleeding of the leg below the femoral pressure point.
k In an emergency setting, one can control arterial bleeding of the lower arm or hand using this method for a limited
time period. It is difficult to control the artery and maintain sufficient pressure for an extended period of time (the
artery tends to slip to the side); thus the helper may have to use one of the other methods like packing or applying a
tourniquet to control the bleeding for more extended periods of time.

WATCH THIS VIDEO: Project 6A

PROJECT 6B: DIRECT PRESSURE & PROJECT 6C PACKING AND APPLYING A
PRESSURE BANDAGE
Key Project√ PPE√ Public: Sim√ Public: Patient√:

Need Sim Arm√

WATCH THIS VIDEO: Project 6B

WATCH THIS VIDEO: Project 6C

You will need:

k One control bleeding simulation arm (or leg, if applicable)

k The fluid bag, filled with colored water or saline, connected to a fluid administration line
k The sphygmomanometer (blood pressure meter)
Figure 59. The various arterial pressure points
k Five to ten gauze squares
k A roll of pressure (crepe) bandage
You will need: k Cloth for packing

k An adult volunteer
k Gloves

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 Follow these steps: PROJECT 6D: STOP AN ARTERIAL BLEED USING A VARIETY OF TOURNIQUETS
1. All participants should don a pair of clean gloves. There are quite a number of tourniquets available on the market. If needed, one can create an improvised tourniquet.
2. Identify the larger artery tube on the simulation arm/leg (marked with green and red tape).
Warnings applicable to ALL tourniquet projects:
3. Identify the wound with the arterial bleed (the larger wound).
4. Close the connector on the outflow side. The connector on the inflow side of the vein should be open. k This project is restricted to official Bleeding Control or Stop the Bleed workshop with at least one qualified medical
professional instructor¹ present as a supervisor.
5. Ensure that the IV-tubing roller clamp is in the closed position.
k A tourniquet “on” time exceeding 2 hours will compromise the survival of the limb. Tourniquet “on” time on a volunteer
6. Connect the fluid bag to the inflow side of the simulation arm’s artery via the connector.
should be short and restricted to a maximum of a few minutes.
7. Close the BP cuff valve and inflate the cuff to around about 120 mmHg (representing the average adult systolic blood
k Exerting too much pressure may cause injury to one of the sensitive structures of the limb, e.g., muscles or nerves.
pressure).
¹For example: a qualified paramedic, registered professional nurse (RN/RPN), physician or surgeon, physician assistant (PA).
8. Open the IV tube roller-clamp.
9. Stop the Bleed!²
10. Observe the blood spurting out of the wound on the simulation arm/leg.
Project 6D1&2: Tourniquet (CAT)
11. Place your gloved finger inside the wound and apply firm finger pressure directly on the bleed point.
12. Place a few gauze squares on the bleed point and apply finger/hand pressure. Assess the amount of residual bleeding. Key Project√ Supervision√ PPE√ Public: Sim√

13. Close the IV tube roller clamp and remove the gauze squares. Public: Patient√: Limb risk! Need Sim Arm√ Human volunteer√

PROJECT 6C
WATCH THIS VIDEO: Project 6D1
14. Open the roller clamp again.
15. Take the cloth and pack it tightly into the wound while applying pressure. The CAT tourniquet appears to be the “gold standard” of tourniquets. It is essential to use this tourniquet correctly.

16. Open the crepe bandage and tightly roll it around the arm over the packed cloth covering the bleeding point. You will need:
17. If there still is any significant residual bleeding/oozing through the packed cloth and bandage, apply hand pressure k The Combat Application Tourniquet (CAT)
over the bandage.
k The Apprentice Doctor® simulation arm
18. Open the BP cuff valve allowing the cuff to deflate.
Familiarize yourself with CAT Terminology
19. Feel free to simulate bleeding in a hypertensive patient (increase the pressure to 160 mmHg, for instance).
20. At the end of the project, open the BP cuff valve allowing the cuff to deflate, then close the fluid administration line 1. Friction adapter buckle
roller clamp, and disconnect the IV tube from the simulation arm/leg. 2. Windlass rod
21. Repeat steps 7-18 for consecutive students doing this project. 3. Windlass clip
k The fluid bag, when half-empty, may have to be folded over on itself within the BP cuff, and when empty should be 4. Windlass strap
refilled. 5. OMNI-TAPE® band
k ¹Ensure that the pressure in the cuff is maintained at the recommended pressure level, as the pressure will tend to
decline as the colored fluid leaves the fluid bag.
k ²Instructors can raise the fun level by setting time limits, for instance:
Figure 60. A CAT tourniquet
~ “You get three minutes. STOP THE BLEED!” or
Follow these steps to apply the tourniquet on the Apprentice Doctor® simulation arm:
~ Make it a competition between several groups: “Let’s see which group can stop the bleed first – START NOW!

See: [Recommendations in a group setting] 1. All participants should wear a pair of clean gloves.
2. Identify the smaller artery (the tube marked with red tape) on the simulation arm/leg.
3. Identify the simulation arm’s tourniquet zone (see diagram below).

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 12. View the videos below, and then apply the cat tourniquet on one of your own limbs. (You may be the bleeding person
needing help sometime in the future!)
13. Fold up the CAT tourniquet and pack it into the kit.

This is an excellent and comprehensive YouTube video on how to use a CAT tourniquet: https://youtu.be/PMfEls2LC8c
from North American Rescue YouTube channel

Figure 61. The simulation arm’s tourniquet zone

4. The connector on the inflow side of the artery should be open, and there should be no connector on the outflow side.
5. Ensure that the IV-tubing roller clamp is in the closed position.
6. Connect the fluid bag to the inflow side of the simulation arm’s artery via the connector.
7. Close the BP cuff valve and inflate the cuff to around about 120 mmHg (representing the average adult systolic pressure).
8. Open the fluid administration line roller-clamp.
Figure 62. A CAT tourniquet applied in a battle setting
9. Stop the bleed by applying the CAT tourniquet as follows:
In an emergency or disaster setting:
10. Place the simulation arm through the loop of the OMNI-TAPE® band over the tourniquet area (see diagram above).
11. Once placement of the CAT tourniquet is correct, tighten the OMNI-TAPE® band then secure it onto itself with the Velcro. k Place the tourniquet 2-3 inches (5-8 cm) away from the bleeding area (closer to the body). Keep on twisting the
windlass rod until the bleeding stops.
12. Twist the windlass rod until the bleeding stops (about 3-4 times) then insert it into the windlass clip.
k Applying a tourniquet to a conscious patient will cause a lot of pain. Remind yourself that you are trying to save the
13. Thread the excess OMNI-TAPE® band through the windlass clip then secure it using the windlass strap.
victim’s life, despite the pain that you are causing.
14. Enter the time on the strap.
k Place a second tourniquet above the second one (closer to the body) if the bleeding does not stop.
k A tourniquet is just intended for use on a limb (an arm or a leg) and to no other part of the body.
Project 6D2 Demonstrating the CAT tourniquet on a volunteer k Do not release the tourniquet until professional medical help arrives at the scene.
VIDEOS: This is an excellent and comprehensive YouTube video on how to use a CAT tourniquet:
https://youtu.be/PMfEls2LC8c from North American Rescue YouTube channel
Project 6D3: Use a blood pressure cuff as a tourniquet on a volunteer
Follow these steps:
Supervision√ PPE√ Public: Sim√ Public: Patient√:
1. Don a pair of clean gloves (optional).
2. Create a fake bleeding point on a volunteer’s arm or leg with the red marker pen (feel free to be creative). Limb risk! Human volunteer√
3. Place the “injured” extremity through the loop of the OMNI-TAPE® band.
4. Place the CAT approximately 2-4 inches (four fingers) above the injury site. WATCH THIS VIDEO: Project 6D4

5. Once placement of the CAT tourniquet is correct, tighten the OMNI-TAPE® band then secure it onto itself with the Velcro.
6. Twist the windlass rod about three times, and then insert it into the windlass clip.
7. Thread the excess OMNI-TAPE® band through the windlass clip then secure it using the windlass strap.
8. Enter the time on the strap if possible/feasible.
9. Apply a second tourniquet 2-4 inches above the first CAT tourniquet if bleeding is still not controlled.
10. If you have a pulse oximeter, check for the disappearance of the pulse on the heart rate indicator of the pulse oximeter
to monitor the success of the procedure.
11. Remove the CAT tourniquet as soon as possible after completing the project. Avoid extended tourniquet “on” time.
1. Review Projects 1A and 1B.
2. Create a fake bleeding point on a volunteer’s arm or leg with the red marker pen (feel free to be creative).
3. Close the BP bulb valve and inflate the BP cuff to about 20 - 30 mmHg beyond the point where the distal artery’s pulse
can no longer be felt. (In a clinical setting, it will be the pressure where the arterial bleeding stops.)
4. Maintain the cuff pressure for 1 - 2 minutes above the volunteer person’s systolic blood pressure. Monitor the distal
pulse - ensure that it is absent.
5. If the arm is used, place blood pressure cuff over the upper arm and close the brachial artery while monitoring the
radial pulse.

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 6. If the leg is used, place blood pressure cuff over the upper thigh and close the femoral artery by inflating the cuff
above the systolic pressure while monitoring the dorsalis pedis pulse.
7. If you have a pulse oximeter, check for the disappearance of the pulse on the pulse oximeter. When arterial blood
supply stops, the heart rate indicator on the pulse oximeter will disappear, and sometime later, the SpO2 (the
saturation reading) will also disappear.
8. After 2-3 minutes, loosen the BP cuff’s valve and remove the cuff.
Comment: pneumatic tourniquets have the disadvantage that they tend to lose pressure spontaneously, and thus, the
cuff needs to be pumped up periodically to maintain the pressure at the required level for stopping the bleeding.
The SWAT-T Tourniquet from TEMS Solutions is a unique multi-purpose medical device. The wide, elastic band construction
of the SWAT-T has been clinically shown to function effectively at lower pressures than windlass style tourniquets. This
means less potential for injury to the patient and less pain from the tourniquet. The SWAT-T’s unique design allows it to
serve as a tourniquet, pressure dressing, and elastic wrap among numerous other potential uses.
If you have a SWAT-T tourniquet, follow these steps:
1. Study this video on how to apply the SWAT-T tourniquet.
2. Apply the SWAT-T tourniquet on a volunteer person. Check for success by manually feeling the distal pulse and the
disappearance of the distal pulse.
3. Apply the SWAT-T tourniquet on one of your own limbs.

Project 6D4: Tourniquet (RATS/anchor) 4. If you have a pulse oximeter, check for the disappearance of the pulse on the heart rate indicator of the pulse oximeter
to monitor the success of the procedure.
Supervision√ PPE√ Public: Sim√ Public: PatientX: 5. Fold up and place the item in the kit.

Limb risk! Human volunteer√

Project 6D6: Tourniquet (improvised)

WATCH THIS VIDEO: Project 6D5
PPE√ Public: Sim√ Public: Patient√: Limb risk!
The Apprentice Doctor® Control Bleeding Kit does not include a RATS tourniquet. It is available at Amazon.com
Need Sim Arm√
Although the classic anchor tourniquet dates from the Second World War, the redesigned RATS tourniquet works on the
same principle. In a lab setting, one may use a sufficient length of rubber tubing as a make-do tourniquet in a similar fashion.
WATCH THIS VIDEO: Project 6D6
If you have a R.A.T.S. tourniquet, follow these steps:
A mass casualty comes uninvited, and an emergency unannounced! It is unlikely that a disaster zone will have significant
1. Study the video on how to apply the R.A.T.S. (Rapid Application Tourniquet). numbers of medical professionals fully equipped to deal with the numerous bleeds at the disaster site. Helpers need to
2. Apply the R.A.T.S. tourniquet on a volunteer person. Check for success by manually feeling the distal pulse and the improvise and may need to tear clotting in strips to be used as pressure bandages, packing material, or as emergency
disappearance of the distal pulse. tourniquets.
3. Apply the R.A.T.S. tourniquet on one of your own limbs.
With the exception of an evident arterial amputation bleed, applying any type of tourniquet is a last resort. The helper
4. If you have a pulse oximeter, check for the disappearance of the pulse on the heart rate indicator of the pulse oximeter should first attempt to stop bleeding by exerting pressure on the bleeding point, then try packing the wound with gauze/
to monitor the success of the procedure.
cloth and apply pressure, before using a tourniquet.
5. Fold up and place this item in the kit.
WARNING: Applying an improvised tourniquet on the simulation arm can damage the arm. It is recommended that the
student just practice the necessary steps, but take care not over-tighten the makeshift tourniquet. This type of tourniquet
also has a higher tendency to damage internal limb structures like muscles and nerves when used on a real patient.
Project 6D5: Tourniquet (SWAT-T tourniquet)
You will need:
Supervision√ PPE√ Public: Sim√ Public: Patient√:
k A piece of cloth (about two or three times the circumference of the simulation arm), a tie or a ribbon or a strip of
Limb risk! Human volunteer√ clothing. A leather belt should not be the first choice, as it is generally ineffective.
k One of the artery forceps in the kit. Otherwise, a ruler, a stick, or a metal rod can be used.
WATCH THIS VIDEO: Project 6D6
Follow these steps:

This kit does not include a SWAT-T tourniquet. It is available at Amazon.com 1. All participants should don a pair of clean gloves.
2. Identify the smaller artery (the tube marked with red tape) on the simulation arm/leg.

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 3. Identify the simulation arm’s tourniquet zone in the diagram below.
PROJECT 7: STOP AN AMPUTATION BLEED
PROJECT 7A: CLAMPING AN ARTERIAL BLEED
PPE√ Public: Sim√ Public: PatientX: Limb risk!

Need Sim Arm√ [Human volunteerX]

WATCH THIS VIDEO: Project 7A

You will need:

k The simulation arm

Figure 63. The simulation arm’s tourniquet zone k One of the hemostats

4. The connector on the inflow side of the artery should be open. Follow these steps:
5. If the balloon tube is attached to the outflow side of the small artery, proceed with Step 6; if not: 1. Don a pair of clean gloves.
6. Use a pair of scissors to cut off the closed end of the balloon (3-5 mm). 2. Identify the various parts of a hemostat.
7. Pull the balloon securely over the small artery - in the middle of the simulation arm.
8. Ensure that the IV-tubing roller clamp is in the closed position.
9. Connect the fluid bag to the inflow side of the simulation arm’s artery using a connector.
10. Close the BP cuff valve and pump the bulb to around about 120 mmHg (representing the average adult systolic pressure).
11. Open the fluid administration line roller-clamp.
12. Stop the Bleed!
13. Use the strip of clothing and wrap it around the simulation arm in the tourniquet zone.
14. Make half a square knot with this strip of clothing. Figure 65. Parts of a hemostat

15. Place the curved artery forceps with the hinge over the cross-over part of the cloth, the curve facing towards the limb.
3. Hold the hemostat, as demonstrated in the photo.
16. Make a square knot on the artery forceps.
17. Rotate the artery forceps, thus squeezing the cloth
tighter and tighter around the arm. One of the team
members should stabilize the arm during the
tightening process.
18. Keep on tightening until the bleeding stops.
19. Open the jaws of the artery forceps and clip it to part
of the tourniquet cloth. Figure 66. A typical hemostat hold
20. Open the BP cuff valve allowing the cuff to deflate.
4. Open and close the latch mechanism (practice a bit until it feels comfortable).
21. When the last person in the group completed this
5. Identify the smaller artery (the tube marked with red tape) on the simulation arm/leg.
project, close the fluid administration line roller clamp
and disconnect the fluid administration line from the 6. The connector on the inflow side of the artery should be open, and there should be no connector on the outflow side.
Figure 64. An example of an improvised tourniquet used to stop
simulation arm. an arterial arm bleed 7. Ensure that the IV-tubing roller clamp is in the closed position.

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 8. Connect the fluid administration line to the inflow side of the simulation arm’s artery via the connector. Note: it will help if one of the team members stabilizes the artery (balloon) while it is being tied off.
9. Close the BP cuff valve and inflate the cuff to around about 120 mmHg (representing the average adult systolic pressure). 6. Ask one of the team members to open the hemostat after the first loop is securely tied to check for residual bleeding.
10. Open the roller-clamp valve on the fluid administration line. 7. If no residual bleeding, complete the second throw of the square knot.
11. Stop the bleed! 8. Other members of the team now take turns to stop the bleed by tying off the bleeder.
12. One of the workshop attendees takes the artery forceps, opens the beak.
13. Close the clamp’s beak on the bleeding artery (proximal/close to the limb), engaging the ratchet mechanism to the
first or second click. Project 7B2: Simulate an arterial aneurism
14. Check for residual bleeding.
PPE√ Public: Sim√ Need Sim Arm√
15. Other members of the team now get an opportunity to stop the bleed with the hemostat by repeating steps 9-14.

Comment: Easy, wasn’t it? Compare the simplicity of this technique with the relative complexity of stopping an arterial WATCH THIS VIDEO: Project 7B2
bleed with a CAT tourniquet.

Follow these steps, continuing from Step 7 above:

PROJECT 7B: LIGATION 9. Release the pressure in the BP cuff, close the roller clamp, and disconnect the fluid administration line from the artery
in the simulation arm.
Project 7B1: Ligation - method 1 10. Secure the balloon tube on the artery using a circumferential suture or two.
11. Fill the syringe with about 20 ml of fake blood and attach it to the small artery on the inflow side of the simulation arm.
PPE√ Public: Sim√ Public: PatientX: Limb risk!
12. One of the team members needs to take control of the syringe and push the plunger to get the desired distension of
Need Sim Arm√ the balloon (representing the arterial aneurysm).
13. Maintain this distention.
WATCH THIS VIDEO: 14. Rupture the aneurism with the stitch cutter. Take care since the fake blood will splatter outwards.

IMPORTANT NOTES: 15. Continue applying pressure on the syringe’s plunger to simulate continuous bleeding.
16. Stop the bleed by clamping the artery with one of the hemostats on the proximal side (arm side) of the artery.
k To do this project, the students need to review Project 2A and 2B
17. Release the pressure on the plunger of the syringe.
k This Project follows step 15 in Project 7A
Comment: Did you notice the initial large volume of blood loss as the aneurysm ruptured? This is partially the reason
You will need:
why a ruptured aortic aneurysm has such a poor prognosis. The aortic aneurysm may be filled with, for instance, one
k The simulation trainer liter of blood. When it ruptures, the patient loses one liter of blood virtually instantaneously, while the aorta keeps on
k One of the tube balloons pumping blood into the abdominal cavity at quite a fast rate, with the associated massive blood volume loss.

k The hemostat
k The “tie off” silk suture
Project 7B3: Alternative methods of ligating an artery
Follow these steps:
PPE√ Public: Sim√ Public: PatientX: Limb risk!
1. Complete Project 7A, up to Step 15.
2. If the balloon tube is attached to the outflow side of the small artery, go to Step 5; if not, continue with Step 3. Sharps injury risk! Need Suture Kit√ Need Sim Arm√

3. Use a pair of scissors to cut off the closed end of the balloon (3-5 mm).
WATCH THIS VIDEO: Project 7B3
4. Pull the balloon securely over the small artery.
5. Use the silk tie, and tie the artery (not over the rubber tube, but over the softer balloon-only section) using the For successfully completing this project, workshop attendees should be familiar with basic suturing techniques, and will
one-hand tie technique. If unfamiliar with the one-hand tie technique, use the two-hand tie technique, and tie a
need:
secure and tight square knot.

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 You will need:

k The simulation trainer PROJECT 8: STOP AN ARTERIOLAR AND VENULAR BLEEDING

k The hemostats Public: Sim√ Public: Patient√: Human volunteer√
k *A needle holder
k *A tissue forceps WATCH THIS VIDEO: Project 8
k *A pair of scissors
The head and neck have a very rich blood supply, and it follows that patients can lose large quantities of blood from
k *A sachet of suture material injuries in this region. The neck also has large veins and arteries (see the section on Vascular Anatomy). Blood loss due to
*All these items are available in the Apprentice Doctor® Compact Suture Kit [Order here]. trauma to any of these large blood vessels can become life-threatening in seconds to minutes.

Follow these steps: A classic example of this type of bleeding (with bleeding from multiple arterioles and venules) is a laceration of the scalp.
Anyone who has seen this type of bleeding will confirm that it can be daunting for the observer and possibly life-
Note: no balloon required.
threatening to the patient – so it should be treated with respect. A patient can easily go into surgical shock or bleed out
1. Complete Project 7A up to Step 15. from a large laceration of the scalp.

2. Stop an arterial bleed with your resourcefulness using any suturing technique.
VIDEOS:
3. Consider a mattress suture, a Figure 8 suture, or any other type of suturing technique. Top of head: Video1
4. Fold the tip of the artery over on itself and use a modified circumferential suture. Side or back: Video2
5. Check for residual bleeding.
You will need:
6. Other members of the team now take turns to stop the bleed by tying off the bleeder.
k A triangular bandage (not supplied in this kit, but available in most first-aid kits)
k A 75 mm pressure bandage
PROJECT 7C: VARIOUS OTHER SUTURING TECHNIQUES FOR SECURING k A volunteer patient
HEMOSTASIS
Follow the steps, as shown in these videos on a volunteer patient.
PPE√ Public: Sim√ Public: PatientX: Limb risk!
WHAT TO DO AT A TRAUMA SCENE:

Sharps injury risk! Need Suture Kit√ Need Sim Arm√ Public Apply light to moderate pressure (refrain from excessive pressure as one may displace a bone segment
if there is an underlying skull fracture). Use a clean cloth/gauze or dedicated hemostatic gauze (like QuikClot® Combat
Use the simulations arm vein and perform the following suturing techniques for stopping bleeding: Gauze) for this purpose, and then apply a pressure dressing as in Video 1 and Video 2 above. This should at least significantly

Ligation techniques [Demo video] slow down the bleeding if not stopping it. Most probably, the pressure bandage will become soaked with blood in time.
Do not remove the bandage. Apply a second bandage over the first, if necessary.
Suturing techniques [Demo video]
Med Prof Exclude a skull fracture using basic and special examination techniques. Take care of the basics, but give
Horizontal mattress [Demo video] special attention to the neurological part of the examination. With light finger palpation into the wound, feel for any
movement of the underlying skull bone. Follow up with radiographic techniques (a CT scan will most probably be the best
Note: Feel free to sever the vein completely using a pair of scissors.
choice assessing a skull fracture). A variety of hemostatic materials (absorbable powders, sheets, and sponges) are
Feel free to try your own techniques, and have fun! available in the market that can be used to place over or into the wound to reduce/stop the bleeding. If it is confirmed that
there is no skull fracture, one can use the spectrum of pressure techniques to control the scalp bleeding. More definitively,
one can control this type of bleeding by injecting local anesthetic with vasoconstrictor and then selectively clamping and
cauterizing larger bleeders, followed by suturing the wound. A continuous suture works well with most scalp lacerations
as speed is important, and aesthetic considerations in the hair-covered scalp is not a prime consideration. Stapling is a
useful alternative in fairly linear lacerations.

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 PROJECT 9: STOP CAPILLARY BLEEDING PROJECT 10: CLEAN AND STORE THE SIMULATION ARM
Public: Sim√ Public: Patient√: Human volunteer√
FOR REUSE
WATCH THIS VIDEO: Project 9 Key Project√ PPE√ Public: Sim√ Need Sim Arm√

Capillary Bleeding usually stops readily by normal hemostasis, but it may also continue to “ooze” for a period of time WATCH THIS VIDEO: Project 10
(especially so due to anticoagulant therapy and various hemostatic abnormalities).
1. Ensure that the BP cuff is deflated, and the roller clamp of the IV tube is closed.
Sim
2. Disconnect the IV from the simulation arm.
Follow these steps to simulate a capillary bleed on a volunteer patient:
3. Allow the fake blood in the fluid bag and line to empty into a basin.
1. Create a fake-bleed with the red marker pen. Feel free to become creative if you have a moulage set. 4. Rinse the fluid administration line with clean water, empty and allow draining.
2. Gently clean with soap and water. 5. Be sure to leave all the connectors attached to the various arm tubes.
3. Apply direct pressure on the cut or wound with a clean cloth, tissue, or piece of gauze until bleeding stops. 6. Remove the used balloon tube and discard it.
4. Protect the wound by applying a small strapping or and cover with a sterile bandage in the case of larger wounds. 7. Prepare a bowl with clean water.

WHAT TO DO AT A TRAUMA SCENE:
Public Follow the same steps as in the simulation environment. Control capillary bleeding by direct pressure or
pressure packs (see Projects 5A and 5B). Adding ice to the pressure pack will assist in faster control of the bleeding. If there
was any contamination, apply an antiseptic or antibiotic cream to reduce the risk of infection.
Note: Get assistance from a medical professional if the bleeding persists or of pain becomes unbearable or increases.
Med Prof If the bleeding is severe and originates from a large laceration: inject a local anesthetic (no vasoconstrictors
to be injected in toes and fingers) and conservatively coagulate bleeders with diathermy. If the cut is deep, one may need
to suture the wound to stop the bleeding. Remember to address the cause of the bleeding (stop or reduce/reverse
anticoagulant therapy) and consider giving Vitamin K and or Cyklokapron if necessary/indicated. To restore blood platelet
function/numbers, use platelet concentrate infusion or FFP (fresh frozen plasma).
8. Over a basin, rinse all the tubes a number of times using the syringe filled with the clean water from the bowl.
9. Wipe the arm and tubes with a damp cloth.
10. Discard all the used items like the IV bag and line, linen saver, used gauze, and bandages, preferably in a biological
waste bag – for the sake of teaching the correct procedure, but of course, the items are not really contaminated.
11. Discard sharps like the stitch cutter and suture needles (if applicable) in a suitably dedicated sharps waste container.
12. Wipe the tray and the work surfaces with a mild soap solution.
13. Replace all reusable items in the kit.
14. Place a replenish pack in the kit [Order here].
15. Store in an appropriate place (out of reach of babies and toddlers) for future use.
Note:
k The simulation arms can be reused a number of times (if it was not abused during a previous workshop). New
replacement arms (various models and shades) are available: [Order here].
k A new fluid bag and administration line are included in the Apprentice Doctor® Control Bleeding replenish pack
[Order here].
k These items can be reused only for a limited number of times.

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 DIRECTIVES ON WHEN TO USE WHICH BLEEDING THE LEGALITIES OF ASSISTING A PERSON IN AN
CONTROL METHOD EMERGENCY SETTING
Important note: if bleeding stops with simple pressure, apply pressure bandage if available and wait. Most countries of the world and most states in the USA have some form of Good Samaritan laws in place. These laws vary
somewhat in its specifics, but in essence, will protect members of the public offering assistance in good faith in an
k Do not remove the gauze or pressure bandage for any reason. Add more gauze/bandages if required and persist with
emergency situation or a disaster scene.
pressure.
k If oozing occurs, apply hand pressure. There are limitations, though; it does not offer the helper “carte blanche” to go beyond reasonable boundaries. For

k Do not remove the gauze to pack the wound. example, if the helper plays a surgeon and performs a tracheostomy, it will not be covered under the Good Samaritan
laws.
k Do not place a tourniquet if the pressure that you are exerting is effective in stopping the bleed!
k If the bleeding stops after tight packing and the application of a pressure bandage (if available), then wait. If a medical professional offers assistance in an emergency or disaster setting, the situation is different and more complex.

k Do not remove the packing material or pressure bandage for any reason. Read the following article compiled by the Institute of Medicine (IOM) regarding this topic:
k If oozing occurs, apply hand pressure. https://www.ncbi.nlm.nih.gov/books/NBK219958/
k Do not place a tourniquet if the pressure that you are exerting is effective in stopping the bleed! https://www.ncbi.nlm.nih.gov/books/NBK219960/

k Placing a tourniquet is a last resort, but also an essential life-saving measure! IOM (Institute of Medicine). 2009. Guidance for establishing crisis standards of care for use in disaster situations: A letter
k If help is on its way and imminent, do not remove/release the tourniquet. report. Washington, DC: The National Academies Press.

k In areas where help might be hours away, the helper should follow the instructions of the national help center like 911
or guidelines of your regional emergency services/trauma center.
k A tourniquet is a life-saving Stop the Bleed measure. It is also a procedure that may compromise the limb’s survival.
The rationale being: save a life at the possible expense of losing a limb.
Warning: never call 911 or other emergency services if there is no emergency!
As a general rule, medical professionals are expected to stop at any accident disaster scene before the arrival of emergency
services to assess and offer assistance if possible.
With Stop the Bleed (STB) assistance by members of the public are limited to pressure, packing, and applying a tourniquet
– but helpers also need to prove recent training in this regard (attending a registered workshop within the previous two
years).

ASSESS AND ALERT BLEEDING COMPRESS

k Assess k Life-threatening (large volume, k Direct pressure
continuous, pooling)
c Safety k Packing
k Source (multiple bleeds,
~ Own safety clothing) k Tourniquet
~ Safety of patient/s k *Classify according to the
bodily area (extremity,
c Potential life-threatening
junctional, torso, head)
bleed
k Alert – Emergency assistance
– call 911

Diagram 2. The A B C of stopping a bleed

WATCH THIS VIDEO: Click Here

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 Dangers of excessive/
inappropriate pressure,
packing, or tourniquet:
 Skull: pressure may displace an
unstable skull fracture/ intrude a
depressed skull fracture.
 Face: pressure/packing may
interfere with/blocking the airway.
Possible consequences Some notes on patient consent
It is always an ethical principle to explicitly ask a conscious patient over 18 years of age, or the parents of a minor, for
permission to assist.
Brain damage /death
Consent can be expressed, e.g., “Yes, please help me...” or implied (e.g., an unconscious patient). The latter type of consent
is based on the presumption that any reasonable person will request assistance in similar circumstances if they were
conscious and in a position to make a decision. Go ahead and assist.
Brain damage /death
If a patient is conscious and categorically verbally refuse assistance, do not assist. Refer to the next level of medical

Brain damage /death professionals, e.g., paramedics, trauma physicians, etc.

 Neck: in the highly unlikely event of
someone applying a tourniquet to the
neck, it will compromise the brain’s

ASSESSMENT AND CERTIFICATION

blood supply.
 Chest: excessive pressure on the Brain damage /death
chest may interfere with breathing
PREPARE FOR FINAL ASSESSMENT AND CERTIFICATION
– especially with an unconscious
patient.
If you have completed this course, well done!
 Chest: Pushing gauze, bandage, or Loss of gauze, or bandage in the
thoracic cavity* You may now choose to pursue certification by:
cloth into the thoracic cavity.

Sepsis 1. Completing the Apprentice Doctor® Final Control Bleeding Assessment

 Abdomen: excessive packing may
lead to organ damage, e.g., liver.
 Abdomen: packing with
contaminated cloth into the
abdominal cavity.
 Upper limbs: tourniquet properly
applied for an extended period (> 2
hours).
 Lower limbs: tourniquet applied
adequately for an extended period (>
2 hours).
*Use QuikClot® Z-Fold Hemostatic Dressing (or equivalent z-folded dressing) instead of small individual gauze
squares to avoid this complication.
Tension pneumothorax**
Increased bleeding
Peritonitis/abdominal sepsis
The candidate will be required to settle a $29 certification fee (to cover examination and accreditation expenses), and
receive an IADL (International Association of Distance Learning) backed certificate (30 hours of theoretical and practical
Compromise the viability of the arm
training), valid for two years.
and possibly infarction of the arm
Proceed to Final Assessment
Compromise the viability of the arm
and possibly infarction of the arm
OR
2. Attending one of the US National STB Workshops

**The bandage/gauze/cloth my serve as a valve, allowing air to enter but not to escape from the thoracic cavity, and
this will result in the development of a tension pneumothorax.

Tension pneumothorax is a life-threatening condition due to air trapped in the pleural cavity. It causes the
displacement of mediastinal structures, and it compromises cardiopulmonary functions.
Diagram 3. Dangers, when members of the lay public perform Stop the Bleed procedures inappropriately.

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 EPILOGUE GLOSSARY
There is just something about the preciousness of blood. Kindly use the medical dictionary link below
In history, we honor people who were willing to shed their blood for the sake of freedom. Consider the multitudes of  Medical Dictionary
soldiers buying the freedom of their fellow human beings with their blood in the many freedom wars of the past.

Most of the world religions impose substantial importance to the specialness of blood. CREDITS (AND SINCERE APPRECIATION)
The ancient Hebrew Scriptures states that the life of the soul is in the blood. Leviticus 17:11 “...for the life of the body is in PERSON/ENTITY TASK
its blood.” Annette Klut RPN Various aspects of co-development of both the Apprentice Doctor®
Control Bleeding Course as well as the Apprentice Doctor® Control
No wonder that dedicated followers of the Jewish and Muslim religions have elaborate dietary rules and regulations Bleeding Kit.
about not eating blood and only ingesting meat with the blood adequately drained out of the carcass. Thus, as a result of Chris Nutting This colleague at VWR was a key person in the initiation of this project.
this, we get kosher and halal food. Kevin Berry The lovely artwork related to the various real-life stories.
Francisca Gomes An amazingly talented and hard-working videographer, video editor, and
Most religions ascribe some sort of sacredness to human blood. In the Christian and Jewish faith, the sacredness of blood
graphic artist.
is fundamental. This finds expression in the sacredness of human life, “You must not murder.” (Exodus 20:13) and also in
Natalie Scheepers Spanish translation of the course material.
blood’s ability to serve as a sacrifice for blotting out an individual’s sins. Therefore the need for the multitudes of animal
Nataliia Pererva The artistic work and development of the Apprentice Doctor® Control
sacrifices in the history of Israel and later the Jewish people who returned to Palestine after the Babylonian captivity. Bleeding simulation arm.

The ultimate of sacredness in the Christian faith refers to the final sacrifice when the Creator’s son shed His Blood as a Peggy Wendel Proofreading.

ransom for many - indeed the most sacred of all sacredness: the Blood of Jesus. Reg Scheepers Compilation of the course material.
Several authors For various contributions and sharing their knowledge freely under the
Dedicated Christians live with this blood in mind daily: “and they have defeated him by the blood of the Lamb and by their Creative Commons Attribution-ShareAlike License (see list below).
testimony, and they did not love their lives so much that they were afraid to die.” (Revelations 12:11). Several illustrators and photographers Multiple illustrations and photos (see list below).
Table 7. List of credits
Purely biologically speaking, blood is just so immensely precious, and once lost, it is difficult to replace, and impossible
without the multitudes of donors who freely give their blood to save others’ lives – real noble people – all the blood List of topics covered by the Creative Commons Attribution-ShareAlike License:
donors over the world!
TOPIC PAGE LICENSE LINK
Let us, as medical professionals, once more become awe-stricken by the amazing human body, the intricacies of design, Blood pressure 24 Commons https://en.wikipedia.org/wiki/Blood_pressure
and the absolute preciousness of each and every drop of blood that we can so easily become too used to, too familiar with Coagulation 26 Commons https://en.wikipedia.org/wiki/Coagulation
when we see and work with it daily. Hypovolemic shock 27 Commons https://en.wikipedia.org/wiki/Hypovolemic_shock
May members of the public realize that they have a place in preserving this precious fluid and that they can make the final Hemorrhagic shock 27 Commons https://www.ncbi.nlm.nih.gov/books/NBK470382/
difference in fellow human being’s lives. One of the most amazing experiences in life is the joy of saving another person’s life. Hemangioma 32 Commons https://en.wikipedia.org/wiki/Infantile_hemangioma
Gunshot wounds 53 Commons https://en.wikipedia.org/wiki/Gunshot_wound
Nose bleed 61 Commons https://en.wikipedia.org/wiki/Nosebleed
Obstetrical bleeding 69 Commons https://en.wikipedia.org/wiki/Obstetrical_bleeding
Laser surgery 81 Commons https://en.wikipedia.org/wiki/Laser_surgery
Vitamin K 83 Commons https://en.wikipedia.org/wiki/Phytomenadione
Protamine 83 Commons https://en.wikipedia.org/wiki/Protamine_sulfate
Bloodless surgery 85 Commons https://en.wikipedia.org/wiki/Bloodless_surgery
Cell saving 85 Commons https://en.wikipedia.org/wiki/Intraoperative_blood_salvage
Blood transfusions 89 Commons https://en.wikipedia.org/wiki/Blood_transfusion
Table 8. References and acknowledgments regarding the material used under the Creative Common Attribution-ShareAlike Licenses.

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