UNCLASSIFIED

MASSIVE BLEEDING
MANAGEMENT
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 UNCLASSIFIED

TERMINAL LEARNING OBJECTIVE

M ASSIVE BLEEDING STOPPED

 Hemorrhage is a life threatening condition that requires

IMMEDIATE ATTENTION
 Hemorrhage control is THE FIRST STEP
 THE SURVEY CANNOT PROCEED unless hemorrhage is
controlled
 PERFUSION will not improve in the face of ongoing
hemorrhage (no matter how much oxygen or fluid the
casualty receives)

TAKE WHATEVER ACTION IS NEEDED TO STOP MASSIVE BLEEDING!

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ENABLING LEARNING OBJECTIVES

 The importance of hemorrhage control in preventable
combat deaths
 Anatomy and physiology: blood, vessels and blood
circulation
 Blood loss estimation classes of hemorrhage
 HEMORRHAGE CONTROL METHODS
 DIRECT PRESSURE
 ELEVATION
 PRESSURE POINTS
 TOURNIQUETS
 COMBAT READY CLAMP (CRoC)
 PRESSURE DRESSING
 PACKING DRESSING
NEXT CLASSES
 HAEMOSTATS
 TRANEXAMIC ACID
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REFERENCES

Pre Hospital Trauma Life Support (PHTLS)

Military 7th ed. 2011 ISBN 978-0-323-06503-0
 Chapter 6, pp. 114-115
 Chapter 17, p. 426
 Chapter 25, pp. 602-604
 Chapter 26, pp. 618-619

Tactical Combat Casualty Care guidelines

Special Operations Forces Medical Handbook

US Special Operations Command 2nd ed. 2010 ISBN 978-0-16-084744-8

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COMBAT DEATHS
 KIA: 31% penetrating head trauma
 KIA: 25% surgically uncorrectable torso trauma
 KIA: 7% mutilating blast trauma
 KIA: 10% potentially surgically correctable trauma
 KIA: 9% hemorrhage from extremity wounds
 KIA: 5% tension pneumothorax
 KIA: 1% airway problems
 DOW: 12% mostly from infections & shock complications

SHOCK COMPLICATIONS WILL BE REDUCED IF THE BLEEDING HAS BEEN STOPPED AND/OR
THE CIRCULATION HAS BEEN SUSTAINED
BEFORE THE CASUALTY HAS GONE INTO SHOCK

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PREVENTABLE DEATHS STILL OCCUR

ON THE BATTLEFIELD BECAUSE OF
UNCONTROLLED HEMORRHAGE

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SEVERE BLEEDING IS THE SINGLE

GREATEST PREVENTABLE COMBAT DEATH

 HEMORRHAGE 79 % 91%
 Compressible Extremities 24.5% 13.5%
Junctional 16.6% 19.2%
 NON-compressible (Truncal) 37.9% 67.3%
 AIRWAY 7% 7.9%
 TENSION PNEUMOTHORAX 7% 1.1%
 HEAD INJURY 7%
_____ _____
PREVENTABLE COMBAT DEATHS 100 % 100 %

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HEMORRHAGE – DEFINITION

 Bleeding is the loss of blood, hemorrhage or

haemorrhage is THE MEDICAL TERM FOR BLEEDING

 Although technically hemorrhage means escape of

blood to extra-vascular space, in common usage it
means particularly SEVERE BLEEDING

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BLOOD LOSS ESTIMATION

 SEVERE = when you can actually see blood
flowing out of the wound
 INDICATORS = vital signs
 heart rate
 respiratory rate
 blood pressure
 capillary refill time (CRT) indicator of perfusion
 WRONG ESTIMATION on clothing / ground
 non-porous / appears like a lot
 porous / soaked & seeping
 internal / hidden

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CLASSES OF HEMORRHAGE (ATLS)

CLASS I: < 15% of blood volume

 no change in vital signs
 can be endured in healthy people without any
clinical consequences = fluid resuscitation is
not usually necessary

CLASS II: 15-30% of blood volume

 tachycardia, pale and cool skin
 IF NO RADIAL PULSE PRESENT then fluid
resuscitation is required: 500(+500)ml colloids

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 UNCLASSIFIED

CLASSES OF HEMORRHAGE (ATLS)

CLASS III: 30-40% of blood volume

 heart rate, blood pressure, peripheral
perfusion and mental status worsen
 fluid resuscitation with BLOOD TRANSFUSION
is usually necessary

CLASS IV: >40% of blood volume

 all vital signs worsen
 AGGRESSIVE RESUSCITATION IS REQUIRED

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HEMORRHAGE COMPENSATION
EARLY MECHANISMS
TO COMPENSATE BLOOD LOSS, THE BODY REACTS:

  HEART FREQUENCY

 VASOCONSTRICTION of peripheral blood vessels

 FLUID SHIFT: fluid is flowing from the extra-

vascular space into the intra-vascular space

 FLUID RETENTION (e.g. kidneys, digestive system)

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 UNCLASSIFIED

COAGULATION (CLOTTING)
ESSENTIALS
MAJOR MECHANISM TO STOP & PREVENT BLOOD LOSS

 ACTIVATED PLATELETS
collect on the bleeding site
 a first soft and jelly-like
UNSTABLE RED CLOT

 FIBRIN binds the platelets together trapping the red

cells inside (some serum can still go trough the clot)
 a firm and SOLID WHITE CLOT acts as a plug

Hypothermia affects the clotting process!

Handle with care to preserve the first red clot!
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 UNCLASSIFIED

COAGULATION
BY FAR MORE COMPLEX

BUT

YOU DON’T NEED TO LEARN THIS

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TWO SYSTEMS IN COMPETITION

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COAGULATION SIMPLIFIED

TISSUE FACTOR
(released by damaged tissues/vessels) leads to
THE TRANSFORMATION FROM FIBRINOGEN TO FIBRIN

THIS SYSTEM STARTS FIRST AND AIMS TO THE

DEVELOPMENT OF THE WHITE CLOT

IT WINS AGAINST HIS COMPETITOR

(THE PLASMINOGEN - PLASMIN SYSTEM)
UNLESS THE RED CLOT IS NOT PRESERVED

(e.g. DIRECT PRESSURE RELEASED TOO SOON,

AGGRESSIVE FLUID RESUSCITATION,
IMPROPER HANDLING, etc.)
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TRANEXAMIC ACID
IMPROVES THE CLOT
BY SLOWING DOWN THE CLOT BREAKDOWN

Deaths due to all causes decreased by 9%

Deaths due to bleeding decreased by 15%

The TXA administration I.V. has been included in the

TCCC Guidelines since Apr 2011

Recommended for any trauma patient requiring blood

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 UNCLASSIFIED

TRAUMATIC BLEEDING

 EXTERNAL
e.g. penetrating: knife, GSW, shrapnel, etc. vessels
may be cauterised by hot fragments or projectiles

 INTERNAL
e.g. blunt trauma: blast, assault with a club, fall, MVA, etc.

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 UNCLASSIFIED

Intervention-Based Classification

THE BEST YOU CAN DO

 External hemorrhage
 Limbs Tourniquets (TQ)
 Junctional CRoC, JETT
 Non compressible Packing (Haemostatic gauzes)
Skull, abdomen, chest, etc.

 Internal hemorrhage Clot preservation

 If radial pulse palpable reduce IV fluids
 If available & hemorrhage class > II Blood &TXA
 Additional care Handle with care

 Ongoing research (intraperitoneal foam)

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 UNCLASSIFIED

External hemorrhage is a mix of…

UNCLASSIFIED 20
 UNCLASSIFIED

types of HEMORRHAGES

ARTERIAL, VENOUS OR CAPILLARY BLEEDING

are different because of:

 PRESSURE

 VESSELS ANATOMICAL STRUCTURE

 BLOOD COLOUR (% OF OXYGENATION)

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ARTERIAL bleeding
ARTERIAL BLEEDING IS LIFE-THREATENING
AND DIFFICULT TO CONTROL

 Arteries are blood vessels that carry a HIGH PRESSURE

blood away from the heart

 Arteries have a THICKER & MUSCULAR WALL to stand

the pressure. Because of their tension and elasticity
they contract and retract when cut suddenly

 Arterial bleeding is BRIGHT RED

 The BLOOD "SPURTS" from the wound

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 UNCLASSIFIED

ARTERIAL bleeding

UNCLASSIFIED 23
 UNCLASSIFIED

VENOUS bleeding
VENOUS BLEEDING IS NOT LIFE-THREATENING
UNLESS SEVERE OR NOT CONTROLLED

 Veins are blood vessels that carry a LOW PRESSURE

blood to the heart

 Veins have THIN WALLS and also because of the low

internal pressure they tend to collapse when cut

 Venous bleeding is DARK RED OR MAROON

 The BLOOD FLOWS IN A STEADY STREAM

UNCLASSIFIED 24
 UNCLASSIFIED

CAPILLARY bleeding

 Capillaries are very small blood vessels that carry a

LOW PRESSURE blood to/away from all tissues of
the body

 Capillaries have THINNER WALLS (one layer)

 Capillary bleeding is a MIX OF DARK AND BRIGHT

RED BLOOD

 BLOOD OOZES because of the slow flow (e.g.

abrasions & scraps)

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 UNCLASSIFIED

External Hemorrhage
SIGNS & SYMPTOMS
 BLOOD EXITING AN OPEN WOUND = HEMORRHAGE

 SHOCK = HYPOVOLEMIC SHOCK

 pale & clammy skin
 dizziness / weakness
 level of consciousness
 heart rate = tachycardia
 blood pressure (weak/absent radial) = hypotension
 respiratory frequency = tachypnea
 capillary refill time (CRT)
 urine output

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 UNCLASSIFIED

External Hemorrhage CONTROL

 SAFE APPROACH
 ELEVATE THE EXTREMITY (LIMBS)
 DIRECT MANUAL PRESSURE
 PRESSURE POINTS
 TOURNIQUET
 COMBAT READY CLAMP (CRoC)

 PRESSURE DRESSING
 PACKING DRESSING
NEXT CLASSES
 HEMOSTATS
 TXA

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SAFE APPROACH

Be determined in achieving your goals…

but understand the situation first !!!

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 UNCLASSIFIED

ELEVATION

 Its effect is often UNDERESTIMATED

 Raise the wound (limb) ABOVE HEART LEVEL

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DIRECT PRESSURE

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 UNCLASSIFIED

DIRECT PRESSURE
THE FIRST AND MOST IMPORTANT RESPONSE
IN ANY SETTING, FOR ALL HEMORRHAGES

 Pressure applied ON THE WOUND & AROUND IT can

control most of external bleedings by compressing the
artery against the underlying structures (muscle & bone)

 Maintain pressure for AT LEAST 5 MINUTES before

checking the effectiveness of clotting

 USE ANYTHING that will assist you in applying direct

pressure (gauze, cloth, damp cloth, whatever… the wound is not
sterile, a sterile bandage does not make it sterile)
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 UNCLASSIFIED

DIRECT PRESSURE

IF YOU SEE IT BLEED,

YOU CAN STOP IT WITH DIRECT PRESSURE

DO NOT LET THEM BLEED TO DEATH

while assessing the situation,
deciding on a course of action,
looking for any tourniquet
or haemostatic agent

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PRESSURE POINTS

APPLY PRESSURE
 your team-mate’s or your FIST OR KNEE
 over the casualty’s ARMPIT / GROIN
 IOT OCCLUDE THE ARTERY (brachial or femoral)
BUY TIME by slowing down the hemorrhage from
the extremity
Groin pressure should be regarded as the first procedure to control
bleeding from a high leg amputation, whilst a tourniquet is attempted
and/or other treatments (Hemostatic gauze to pack the wound; field
dressings) are used to stop bleeding.
UK Good practice guide Sep 2010

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PRESSURE POINTS

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PALM vs FINGER TIP pressure

 DIFFUSE PRESSURE is the key (e.g. EMT/hospital TQ)

 more effective due to the surface area covered
 allows for greater pressure to be applied
 able to be maintained over long periods
 less damage to tissues

 FINGER TIP PRESSURE does not ensure full contact

with wound (no artery hunting with finger tips)

 GAUZES / haemostatic gauzes must be in full contact

with the wound / bleeding site to be effective

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 UNCLASSIFIED

Oh, nooo… more tourniquets!

BECAUSE TOURNIQUETS SAVE LIVES

Ibn Sina Hospita, Bagdad, 2006

31 lives saved in 6 months period by the use
of pre-hospital tourniquets, author estimates
2000 LIVES SAVED IN OIF

Kragh, et al, Annals of Surgery, 2009

36
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 UNCLASSIFIED

Oh, nooo… more tourniquets!

PREVENTABLE COMBAT DEATHS FROM

NOT USING TOURNIQUETS STILL OCCUR
Moughon – Military Medicine, 1970: Vietnam
193 of 2,600
7.4% of total
Kelly – Journal of Trauma, 2008: OIF + OEF
72 of 982
7.8% of total
Eastridge – Journal of Trauma, 2012: OIF + OEF
119 of 4,956
2.6% of total
37
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 UNCLASSIFIED

Tourniquets – PRINCIPLES
 A CONSTRICTING BAND
 single use
 non-elastic
 at least 5cm wide

 ABLE TO STOP THE ARTERIAL FLOW

 ONLY USED ON AN ARM, FOREARM, THIGH OR LEG

NEVER OVER A JOINT, A FRACTURE OR POCKETS

CONTAINING BULKY OBJECTS

38
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 UNCLASSIFIED

Tourniquets – CONSIDERATIONS

 Not all types available have the same EFFECTIVENESS

 PATIENT MUST GET PAIN MEDICATION Tourniquets

are painful when applied but the worse pain comes
when ischemia sets in approx 20 min after application

 They have LIMITATIONS TO LOCATION

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 UNCLASSIFIED

Criteria for tourniquet

EFFECTIVENESS
 Must STOP ARTERIAL BLOOD FLOW in the extremity
 More effective in saving lives when applied BEFORE
THE CASUALTY HAS GONE INTO SHOCK from blood
loss
 IN THE CARE UNDER FIRE PHASE must be applied
first, OVER THE CASUALTY’S UNIFORM, since there is
no time for exposing the wound and for other methods
(they could not be adequate to control the bleeding)

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 UNCLASSIFIED

Tourniquets – TRAINING

 Pick a good one!

 Carry it with you all the time and more than one,
if it is permitted

 Learn how to apply it properly as quick and as

proximal as possible

 Train, buddy aid, self aid, in the darkness…

frequently!

 Use the tourniquet from the casualty

 Eventually convert to pressure bandage

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 UNCLASSIFIED

Tourniquets – MYTH

 DAMAGE TO THE LIMB is rare if the tourniquet is left

on less than two hours. Anyway in the face of massive
extremity hemorrhage it is better to accept a small risk
of damage to the limb than to have a casualty bleed to
death (approximately 3% transient nerve paralysis and
no amputation due to tourniquet use were reported)

 place it 2-3 INCHES ABOVE THE BLEEDING

 A BELT ALONE IS EFFECTIVE

 NEVER LOOSEN IT

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 UNCLASSIFIED

Tourniquets – MISTAKES
 NOT USING ONE WHEN YOU SHOULD
 NOT TIGHTENING IT ENOUGH TO STOP THE
ARTERIAL FLOW
 NOT APPLYING A SECOND ONE SIDE-BY-SIDE IF
THE FIRST IS NOT COMPLETELY EFFECTIVE (BIG
THIGHS OFTEN REQUIRE TWO TQ)

 PUTTING IT ON TOO LOW ON THE EXTREMITY

 PUTTING IT TOO CLOSE TO A JOINT

 USING ONE WHEN YOU SHOULD NOT

 NOT TAKING IT OFF WHEN YOU COULD
 NOT USING THE CASUALTY’S TQ FIRST
UNCLASSIFIED 43
 UNCLASSIFIED

TWO TOURNIQUETS

UNCLASSIFIED
 UNCLASSIFIED

TIME OF APPLICATION

 Some TQ have a TAG where to write down the time

 Write a “T” (for Tourniquet) on the casualty’s FOREHEAD

with an indelible ink marker and the time of application

T 10:45

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CONVERTING the tourniquet

IN THE TACTICAL FIELD CARE PHASE, once you have time to
properly evaluate and treat the casualty
 EXPOSE and re-evaluated the wound
 APPLY a trauma bandage or a pressure dressing
 after applying a pressure bandage, LOOSEN THE TQ BUT
LEFT IN PLACE
 CHECK THE BANDAGE FOR BLEEDING and if any make the
tourniquet tight again
In case of delayed evacuation, to convert the TQ will make it
more likely that the limb can be saved
Never loosen a TQ in case of amputations or if the casualty will
arrive at a hospital in 2 hours or less after application

UNCLASSIFIED 46
 UNCLASSIFIED

Combat Application Tourniquet

(CAT)

47
UNCLASSIFIED
 UNCLASSIFIED

Combat Application Tourniquet

(CAT)
• THE MOST COMMONLY USED AND KNOWN
• Red tip = where to start unpacking it
• Windlass strap may be white (time of application can
be written on it)

• Windlass rod made of hard plastic = could break

• NOT COMPLETELY RELIABLE WHEN WET OR DIRTY
• Velcro could make the application difficult

48
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 UNCLASSIFIED

Special Operations Forces

Tactical Tourniquet (SOFTT)

49
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 UNCLASSIFIED

Special Operations Forces

Tactical Tourniquet (SOFTT)
• IT IS EFFECTIVE ON LARGER THIGHS
• IT HAS A SECONDARY SECURITY (screw)
• Same basic components
• It has a tag where to write time of application

• LESS SURFACE PRESSURE = MORE TISSUE DAMAGE

Windlass strap is thinner than the CAT one
• HARDER TO SECURE THE ROD THROUGH THE “V” RING
• Metal rod and other metal parts could corrode
• Screw can loosen
50
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 UNCLASSIFIED

Special Operations Forces

Tactical Tourniquet (SOFTT–W )
• Same basic components but THE BUCKLE
• MORE SURFACE PRESSURE = LESS TISSUE DAMAGE
The windlass strap is wider
• Metal rod and other parts made of aluminum

• HARDER TO SECURE THE ROD THROUGH THE “V” RING

51
UNCLASSIFIED
 UNCLASSIFIED

Emergency and Military

Tourniquet (EMT)

52
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 UNCLASSIFIED

Emergency and Military

Tourniquet (EMT)
• HAS BEEN FOUND HAVING THE BEST PERFORM ANCE
and it is strongly suggested in emergency departments
• MORE SURFACE PRESSURE = LESS TISSUE DAMAGE

• THE INFLATABLE RUBBER CUFF MAY DETERIORATE

– prolonged time in the field
– exposed to high / low temperatures
– exposed to shrapnel strikes
• MORE EXPENSIVE
• LARGER PACKAGE SIZE
53
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 UNCLASSIFIED

NATO Tourniquet ZOOM

54
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 UNCLASSIFIED

NATO Tourniquet ZOOM

• LESS COMPONENTS
• EFFECTIVE UNDER ALL WEATHER CONDITIONS
• MORE DURABLE

• HARDER TO USE IN SELF-AID (ARM)

• LESS SURFACE PRESSURE=MORE TISSUE DAMAGE strap
is thinner and could pinch the skin or became string-like
while twisting
• NOT YET “APPROVED”
• NO TAG WHERE TO WRITE TIME OF APPLICATION

55
UNCLASSIFIED
 UNCLASSIFIED

Combat Application Tourniquet

(CAT)

UNCLASSIFIED 56
 UNCLASSIFIED
Special Operations Forces
Tactical Tourniquet (SOFTT)

UNCLASSIFIED 57
 UNCLASSIFIED

WIDER IS BETTER (SOFTT–W)

UNCLASSIFIED 58
 UNCLASSIFIED

IMPROVISED Tourniquet
A preventable death in 2003
This casualty was wounded by an RPG explosion and
sustained a traumatic amputation of the right arm and a
right leg wound. He bled to death from his leg wound
despite the placement of three field-expedient tourniquets

the strings cut skin and muscles without occluding the arterial flow
UNCLASSIFIED 59
 UNCLASSIFIED

IMPROVISED Tourniquet
This casualty was wounded by an IED. The prompt
application of field-expedient tourniquets (T-shirts and
branches) saved his life. The first responder knew what to
do (was he properly trained in how to do it?)

TQs were placed proximally, not tightened or secured enough

The stumps were not dressed at all
UNCLASSIFIED 60
 UNCLASSIFIED

APPLYING an improvised tourniquet – 1/3

GATHER MATERIALS:

 rigid object (WINDLASS) such as a strong stick

 tourniquet band (CRAVAT) AT LEAST 2” WIDE

 SECURING MATERIAL (CRAVAT)

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 UNCLASSIFIED

APPLYING an improvised tourniquet – 2/3

1. Apply band material around the groin / armpit

above wound / amputation
2. Tie band with a half-knot
3. Place windlass rod on top of knot
4. Tie a full knot (square knot) over windlass

UNCLASSIFIED 62
 UNCLASSIFIED

APPLYING an improvised tourniquet – 3/3

5. Twist windlass until pulse (bleeding) has stopped

6. Secure the windlass rod wrapping a second band
around limb or using tying tails in a non-slip knot
so the tourniquet will not unwind

UNCLASSIFIED 63
 UNCLASSIFIED

Junctional injuries

 Are becoming more frequent

 Are usually more severe

 Their relevance among the causes of bleeding

is growing since tourniquets became effective
in stopping the bleeding from the extremities

 Researches & development increased

 Devices effectiveness has been tested

 TCCC guidelines currently recommend CRoC

UNCLASSIFIED 64
 UNCLASSIFIED

UNCLASSIFIED 65
 UNCLASSIFIED

JUNCTIONAL HEMORRHAGE
Combat Ready Clamp (CRoC)

UNCLASSIFIED 66
 UNCLASSIFIED

CRoC – instructors’ and students’

COMMENT
• It works: effective in stopping junctional hemorrhage
• It is the only one available / CoTCCC approved
• Heavy for the medic’s bag
• Even after training, it takes time to assemble it
• Difficult to assemble when wet / dirty
• Easily dislodged while handling the casualty

UNCLASSIFIED
 UNCLASSIFIED

JUNCTIONAL HEMORRHAGE
Junctional Emergency Treatment Tool (JETT)

UNCLASSIFIED 68
 UNCLASSIFIED

JUNCTIONAL HEMORRHAGE
Junctional Emergency Treatment Tool (JETT)

UNCLASSIFIED 69
 UNCLASSIFIED

JUNCTIONAL HEMORRHAGE
Junctional Emergency Treatment Tool (JETT)

UNCLASSIFIED 70
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JUNCTIONAL HEMORRHAGE
Junctional Emergency Tactical Tourniquet
JETT
 Belt-effect
 pelvic sling
 infrequent dislodgment
 2 mechanical junctional tourniquets
 pressure applicable on right / left / both sides
at the same time
 cups modeled groin / triangular-shape

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 UNCLASSIFIED

HEMOSTATIC FORCEPS

 NOT YOUR FIRST CHOICE OF ACTION

 ONLY WHEN THE BLEEDING IS:

 LOCAL
 VISIBLE
you can easily locate (see) the ruptured blood vessel
 SUPERFICIAL

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 UNCLASSIFIED

MASSIVE EXTERNAL BLEEDING MANAGEMENT

SUMMARY
 FOCUS needed to understand how to deal with hemorrhage
 BUY SOME TIME to react by rapidly applying good direct
pressure or on pressure points
 DEVISE & COMMUNICATE A PLAN
 NO HESITATION once a course of action is initiated
 ACHIEVE CONTROL of situation quickly: TQ, CRoC, packing
 WORK TOGETHER toward an improvement
 work UNTIL YOU ARE SATISFIED you achieved the objective
 BY MINIMIZING BLOOD FLOW the wound site can be managed
 FURTHERING MANAGEMENT with pressure dressing

REMEMBER THE BASICS!

Basic treatments done well will make the biggest difference
UNCLASSIFIED 73
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INTERNAL HEMORRHAGE

 CHECK ENTIRE BODY, ALL ORIFICES INCLUDED

 CHECK CAVITIES (thoracic, abdominal, pelvic)

they can hide large volumes of blood

 CHECK FOR SIGNS OF SHOCK (compensated / latent)

the assumption that casualties who look good are not
bleeding internally is frequently very wrong

 Continued REASSESSMENT of trauma patients is

essential

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 UNCLASSIFIED

INTERNAL HEMORRHAGE
SIGNS & SYMPTOMS
 SIGNS OF SHOCK
 EXTERNAL BLEEDING THROUGH A NATURAL OPENING
 blood in the STOOL (appears black, maroon, or bright red)
 blood in the URETHRAL MEATUS OR IN THE URINE (appears red,
pink, or tea-colored)
 VAGINAL bleeding (heavier than usual or after menopause)
 blood in the VOMIT (looks bright red, or brown like coffee-grounds)

 PAIN
 TENSION
 SWOLLEN AREA (abdomen, pelvis, chest)

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 UNCLASSIFIED

INTERNAL HEMORRHAGE
EXAMINATION
 INSPECTION (e.g. bruising)
 AUSCULTATION (e.g. bowel sounds reduced )
 PERCUSSION (e.g. dullness)
 PALPATION (detect any tenderness, resistance, reaction,
pain and swelling)
 VITAL SIGNS-SHOCK SIGNS
 Diagnostic peritoneal lavage
 Ultrasound/FAST (Focused Abdominal Ultrasound for Trauma)

YOUR JOB IS TO SUSPECT IT AND TO SUSTAIN THE CIRCULATION

INTERNAL BLEEDING NEEDS SURGICAL TREATMENT!!

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 UNCLASSIFIED

ABDOMINAL WOUNDS
 Apply very gentle pressure to stop the external bleeding
 Any penetrating abdominal wound needs URGENT
SURGICAL TREATMENT
 Evisceration
 do not try to push bowels/organs back into the
abdomen, unless they slide back in by lifting the
wound edges
 cover the injury with a moistened cloth or bandage
 If signs of hemorrhagic shock after trauma without
external bleeding then suspect the possibility of severe
internal bleeding

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Abdominal blunt trauma – The spleen

 The spleen is a lymph node (immune system), it has
mechanical functions as well: reservoir of platelets,
retention and removal of old / abnormal RBCs
 Rupture of the spleen is responsible for 40% of
internal abdominal bleeding after blunt trauma
(rupture of the liver 20%, rupture of bowel 5%)
 The spleen is commonly affected 10th rib

after blunt trauma to the left lower

chest.
A two-stages rupture of the spleen
happens when the capsule of the
organ is initially intact and tears
afterwards leading to a sudden
severe internal bleeding (may be
expected within two weeks)

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The Abdominal Aortic Tourniquet

AAT™
 Available mid-April 2012
 The target of the compression is the AORTIC BIFURCATION
at the abdominal-pelvic junction to occlude blood flow in the
inguinal arteries
 It is a circumferential device applied to the mid-abdomen,
tightened and inflated
 May remain on for up to an hour safely

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What forward solution?

FOAM - ongoing research (started on 2007)
Two different liquid components are injected at the same time into
the INTAPERITONEAL SPACE, they react with a mild exothermal
chemical reaction (may be beneficial) generating a Styrofoam-like
hydrophobic foam that expands (generates pressure) and solidifies in
less than 60sec in a conformal contact with tissues without adherence
(removable in one piece right after laparotomy)
Doesn’t stop the bleeding but slows it down so that more hours are
available before surgery
Prototype : pending questions
How much, affects respiration = pressure against diaphragm
contraindicated in head injury (hypocarbic), retained foam
particles, migration into the pleural space in case of diaphragm
lacerations (more than 2 cm wide), leaking out from holes /wounds
(seal them), suitable for retroperitoneal hemorrhage?
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COMING SOON

 SAFE APPROACH
 ELEVATE THE EXTREMITY (LIMBS)
 DIRECT MANUAL PRESSURE
 PRESSURE POINTS
 TOURNIQUET
 COMBAT READY CLAMP (CROC)

 PRESSURE DRESSING
 PACKING DRESSING
 HEMOSTATS
 TXA

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WOUND HEMORRHAGE CONTROL

PACKING (AMPUTATIONS / CAVITIES)

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WOUND HEMORRHAGE CONTROL

PACKING (AMPUTATIONS / CAVITIES)

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Medics’ rating

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SUMMARY – STOP THE BLEEDING

 SAFE APPROACH: secure area and yourself
 INITIAL ASSESSMENT M.A.R.
 Elevate the extremity (limbs)
 Apply direct manual pressure
 Apply pressure to pressure points
 Tourniquet (convert to pressure bandage when
indicated)
 Junctional tourniquets CRoC / JETT
 Hemostatic gauzes / Packing dressing
 Pressure dressing

at the same time, calm and reassure the victim,

the sight of blood can be very frightening
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SUMMARY – PRESERVE THE CLOT

 DO NOT handle the casualty without extreme precaution

 DO NOT under estimate the effect of hypothermia

(hypothermia badly affects the clotting process)

 DO NOT push I.V. fluids if a radial pulse is present

 DO NOT forget to improve the clot with TXA

 DO NOT disturb the wound

(remove the gauze, peek at the wound, clean the wound)

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DON’T CAUSE EXTRA INJURIES /

RE-BLEEDING
 DO NOT probe a wound or pull out any embedded
object from a wound; this will usually cause more
bleeding and harm
 DO NOT try to clean a large wound; this can cause
heavier bleeding
 DO NOT remove the first dressing if it becomes
soaked with blood (unless if it is a haemostatic
gauze); add a new one on top
 DO NOT peek at a wound to see if the bleeding is
stopping; the less a wound is disturbed, the more
likely it is that you'll be able to control the bleeding
 DO NOT try to clean a wound after you get the
bleeding under control; get medical help
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