# First Aid/External Bleeding
## Introduction

Bleeding is a common reason for the application of first aid measures and can be internal or external. The principal difference is whether the blood leaves the body – external bleeding can be seen, whereas in internal bleeding, no blood can be seen.
There are many causes of external bleeding, which fall into seven main categories, which are:

### Abrasion

    Also called a graze, this is caused by transverse action of a foreign object against the skin, and usually does not penetrate below the epidermis

### Excoriation

    In common with Abrasion, this is caused by mechanical destruction of the skin, although it usually has an underlying medical cause

### Laceration

    Irregular wound caused by blunt impact to soft tissue overlying hard tissue or tearing such as in childbirth

### Incision

    A clean “surgical” wound, caused by a sharp object, such as a knife

### Puncture Wound

    Caused by an object penetrated the skin and underlying layers, such as a nail, needle or knife

### Gunshot wounds

    Caused by a projectile weapon, this may include two external wounds (entry and exit) and a contiguous wound between the two

## Recognition

Recognizing external bleeding is usually easy, as the presence of blood should alert you to it. It should however be remembered that blood may be underneath or behind a victim. It may be difficult to find the source of bleeding, especially with large wounds or (even quite small) wounds with large amounts of bleeding. If there is more than 5 cups of blood from a wound, then the wound is life-threatening.

## Treatment

As with all first aid situations, the priority is to protect yourself, so put on protective gloves before approaching the victim.
All external bleeding is treated using three key techniques, which allow the body's natural repair process to start. These can be remembered using the acronym mnemonic 'RED':
    Rest
    Elevation
    Direct pressure

### Rest

In all cases, the less movement the wound undergoes, the easier the healing process will be, so rest is advised. Rest will also reduce the pulse rate, thus the severity of the bleeding, especially in the case of arterial bleeding.

### Elevation

Direct pressure is usually enough to stop most minor bleeds, but for larger bleeds, it may be necessary to elevate the wound above the level of the heart (whilst maintaining direct pressure the whole time). This decreases the blood flow to the affected area, slowing the blood flow, and assisting clotting.
Elevation only works on the peripheries of the body (limbs and head) and is not appropriate for body wounds. You should ask the victim to hold their wound as high as possible. You should assist them to do this if necessary, and use furniture or surrounding items to help support them in this position. If it is the legs affected, you should lie them on their back (supine), and raise their legs.

### Direct Pressure

The most important of these three is direct pressure. This is simply placing pressure on the wound in order to stem the flow of blood. This is best done using a dressing, such as a sterile gauze pad (although in an emergency, any material is suitable).
If the blood starts to come through the dressing you are using, add additional dressings to the top, to a maximum of three. If you reach three dressings, you should remove all but the one in contact with the wound itself (as this may cause it to reopen) and continue to add pads on top. Repeat this again when you reach three dressings. The reason for not simply adding more dressings is that it becomes harder to apply the direct pressure which is clearly needed if this much blood is produced.
Where an articulate area of the body is wounded (such as the arms or hands), it is important to consider the position of the area in keeping pressure on the wound. For example, if a hand is cut 'across' from the thumb to halfway across the palm, the wound can be closed with direct pressure by simply clasping the victim's hand shut. However, if the hand was wounded from between the two middle fingers down to the wrist, closing the hand would have the effect of opening the wound, and so the victim should have their hand kept flat.
In most cases, during the initial treatment of the bleed, you will apply pressure by hand in order to stem the flow of blood. In some cases, a dressing may help you do this as it can keep pressure consistently on the wound. If you stop the flow by hand, you should then consider dressing the wound properly, as below.

## Dressing

Once the bleeding is slowed or stopped, or in some cases, to assist the slowing of the blood flow you should consider dressing the wound properly.
To dress a wound, use a sterile low-adherent pad, which will not stick to the wound, but will absorb the blood coming from it. Once this is in place, wrap a crepe or conforming bandage around firmly. It should be tight enough to apply some direct pressure, but should not be so tight as to cut blood flow off below the bandage. A simple check for the bandage being too tight on a limb wound is a capillary refill check; to do this, hold the hand or foot (dependent on what limb is injured) above the level of the heart and firmly pinch the nail. If it takes more than 2 seconds for the pink color to return under the nail, then the bandage is likely to be too tight.
If the blood starts to come through the dressing you have applied, add another on top, to a maximum of three. If these are all saturated, remove the top two, leaving the closest dressing to the wound in place. This ensures that any blood clots that have formed are not disturbed; otherwise, the wound would be opened anew.

## Special cases
### Nosebleeds (epistaxis)

If a person has nosebleed, have them pinch the soft part of the nose firmly between thumb and forefinger, just below the end of the bone. If necessary, do this yourself, but it is preferable to have them do it themselves if they are able to do it effectively.
The victim should lean their head slightly forward and breathe through their mouth. You can also leave the head in a neutral position, but never tilt the head back. Tilting the head forward ensures that blood isn't ingested (as it can cause vomiting) or inhaled (choking hazard).
If you are unsuccessful at stopping the bleeding after 10 minutes of direct pressure, you should assess the blood flow. If the blood flow is minor, you could consider using an ice pack on the bridge of the nose to help stem the flow.
If the nose continues to bleed with a fast flow, you should seek medical assistance, probably from an ambulance.

### Embedded Objects

If there is something embedded in the wound, do not remove it. Instead, apply pressure around the object using sterile gauze as described above. Rolled bandages are perfect for this. Be careful not to disturb the object, as moving it may exacerbate the bleeding. This doesn't apply to superficial splinters and such. A useful rule of thumb: if it's causing bleeding, don't remove it. If it isn't, feel free. Apply pressure and secure with bandages then get medical aid.

### Stab, puncture or gunshot wounds to the body

These wounds are life threatening, and after assessing the ABCs of the victim, you should immediately summon an ambulance. As always, you should check that you are not in danger when approaching these victims (from someone with a knife or gun, for instance). As with all embedded objects, ensure you do not remove the item from the body.
If possible, you should sit the victim up (as blood in the body will go to the lowest point, allowing the heart and lungs to work as efficiently as possible). You should also lean them to the injured side, keeping the healthy side free from incursion by blood.
Assess the victim for open chest wounds or abdominal injuries, and treat accordingly.

### Amputations

If a body part has been amputated, immediately summon ambulance assistance, and treat the wound for bleeding first as above. Cover the amputated part with a moist dressing and place it in a clean plastic bag, and place this bag into a bag of ice and water, sending it with the victim to the hospital (it should be labeled with their name, and where it belongs). You should avoid putting the part in direct contact with ice, as this can cause irreparable damage, meaning that surgeons are unable to reattach it.
If the body part is partially amputated, do not detach, but treat as a wound.