6.1

Hemorrhage Control

Chapter 6

Hemorrhage Control

Stop the Bleeding!

 Hemorrhage is the leading cause of preventable death on the

battlefield.

ο 90% of combat fatalities occur forward of medical care.

ο Half of these casualties bleed to death, 1/5 from extremity

trauma (10%–15% of all deaths).

ο Although bleeding is a main cause of death, the vast

majority of wounds do not have life-threatening bleeding.

Under Fire

Get the patient out of the line of fire — prevent further injury.

Control obvious external bleeding once out from under fire.

If you must remain under fire, stop external bleeding with

use of a tourniquet.

Do not endanger the casualty or yourself with

unnecessary treatment.

Stay engaged in the firefight if necessary.

Keep Your Head Down

Sites of Hemorrhage

 External.

ο Extremity injury (most common cause of massive external

blood loss in combat), scalp, and torso wounds.

ο Usually associated with an open fracture or amputation.

Direct Pressure Is Central to Treatment

 Internal.

♦ Chest, abdomen, pelvis, and closed extremity fractures.

“The hemorrhage that takes place when a main artery is divided is

usually so rapid and so copious that the wounded man dies before

help can reach him.” – COL H.M. Gray, 1919
6.2

Emergency War Surgery

♦ High mortality if the casualty is not expeditiously

transported and salvage surgical procedures performed.

♦ Controlled (hypotensive) resuscitation may be

necessary.

Internal Torso Bleeding Requires Surgical Control

Treatment—First Responder

 External hemorrhage from extremity wounds.

ο Direct pressure at site of injury is the most effective and

preferred method of hemorrhage control.

♦ If direct pressure fails to stop the hemorrhage, it signifies

deep, massive, or arterial injury, and will require surgery

or advanced hemostatic agents.

♦ Hold pressure for at least 5 minutes before looking to

see if it is effective.

♦ Impaled foreign bodies should not be removed because

profuse bleeding may occur.

Pitfall: A Bandage Does Not Equal Direct Pressure!

A bandage may wick blood from the wound without

stopping the bleeding.

A bandage hides ongoing bleeding.

Hemostatic bandages currently being developed may stop

bleeding.

♦ Elevation of the extremity will decrease most

bleeding—this is an under-appreciated technique.

♦ Point compression of the proximal artery.

Pitfalls of Blind Clamping

Blind clamping into the wound is more likely to cause

additional injury than to control bleeding.

Risk–Benefit Decision: Judgment that other measures are

not successful should be exercised before applying clamps

in a wound. Field wound exploration is not recommended.
6.3

Hemorrhage Control

◊ May help slow bleeding while attempting to gain

better control at the wound site.

◊ May require compression at the pressure point for

up to 20 minutes to provide hemostasis.

◊ Table 6-1 shows the recognized pressure points.

Table 6-1. Recognized pressure points.

Bleeding Lower

Site Hand Forearm Arm Leg Thigh

Artery Radial/Ulnar Brachial Axillary Popliteal Femoral

Pressure Wrist Inner Axilla Behind Below

Point upper knee groin

arm crease

Tourniquet May Be First Choice in Combat

♦ A tourniquet should be applied if previous techniques

fail.

◊ Use a tourniquet early, rather than allow ongoing

blood loss. Substitutes for issued tourniquet include

belt, torn cloth, gauze, and rope, among others.

◊ Rapid method to secure hemorrhage control.

◊ Does not require constant attention; allows first

responder to care for others — extends resources.

◊ Tourniquets should not be removed until the

hemorrhage can be reliably controlled by advanced

hemostatic agents or until arrival at surgery.

◊ Tourniquet placement on the forearm or leg may not

compress the vessels, which lie between the double

long bones. Tourniquets on the upper extremity

should be placed on the upper arm and if bleeding

from the lower extremity is not controlled by a

tourniquet on the leg, it should be moved to the thigh

where the vessel may be more easily compressed.
6.4

Emergency War Surgery

Pitfalls of Tourniquet

Application for more than 2 hours may increase limb loss.

Risk–benefit decision: Don’t avoid a tourniquet in order

to save a limb, and then lose a life! Use of tourniquet

does not always lead to limb loss.

♦ Clamping vessels: If there is continued bleeding and a

damaged vessel can be readily identified, a hemostat

may be used to clamp the vessel.

♦ Limb splints will decrease bleeding associated with

fractures and soft tissue injury by aligning, stabilizing,

and returning the limb to length.

♦ Military Anti-Shock Trousers (MAST) possible uses.

◊ Controls hemorrhage from massively injured/

mangled lower extremities.

◊ Provides temporary stabilization of pelvic fractures

to decrease hemorrhage.

◊ Splints fractures of lower extremities.

Pitfalls of MAST

Protracted MAST use leads to compartment syndrome and

ischemic limbs.

Respiratory compromise occurs due to diaphragmatic

elevation.

Increased torso bleeding.

Pressure changes within aircraft (caused by altitude

changes) affect inflation pressure.

Requires close monitoring in aircraft.

♦ Scalp bleeding: can be significant due to the rich

vasculature of the scalp.

◊ Responds to direct pressure.

◊ Compression dressings must be applied if you cannot

provide ongoing direct pressure.

◊ Difficult to apply and maintain direct pressure.
6.5

Hemorrhage Control

◊ Requires circumferential head application.

◊ Vertical mattress suture closure sometimes is

necessary to control bleeding scalp edges.

◊ A readily identified bleeding vessel can be clamped,

but the wound should generally not be explored.

◊ Avoid pushing fragments into brain when applying

pressure, but control hemorrhage even at the expense

of exposed brain.

◊ Protection of exposed brain with nonadherent gauze

or plastic can minimize injury.

♦ Internal bleeding.

◊ Blood loss into the abdomen or chest cannot be

controlled in the field and requires immediate

evacuation for salvage or definitive surgery.

◊ Stabilization of pelvic fracture with MAST garment,

or by wrapping the pelvis tightly with a wide strap

(such as a folded sheet), may reduce pelvic bleeding.

◊ Open torso injuries. If direct pressure does not stop

the hemorrhage, consider inserting a tamponade

with a balloon (Foley) catheter into the wound, and

then with balloon inflated pulling back to compress

the bleeding site.

Dressings, bandages, hemostatic agents, and controlled

hypotension. Dressings promote hemostasis, protect wounds

from mechanical injury and contamination, immobilize tissues,

and provide physical and psychological support to the patient.

 Application of dressings and bandages.

ο Control all bleeding.

ο Assess neurologic status and circulation of extremity before

and after applying a dressing or bandage.

ο Immobilize suspected fractures.

ο Keep dressing as clean as possible.

ο Dressings should cover the entire wound.

ο Bandages should cover the entire dressing.

ο Avoid skin-to-skin contact.

ο Leave fingers and toes exposed.
6.6

Emergency War Surgery

ο Reinforcement.

♦ If at all possible, do not remove the first dressing.

♦ If the dressing becomes thoroughly saturated,

reevaluate the wound for a source of bleeding amenable

to direct pressure, and consider advanced hemostatic

agents or a proximal tourniquet. Blood loss into the

dressing can be estimated from Table 6-2.

Table 6-2. Blood loss.

Size designation Small Medium Large ABD

Measurement (inch) 4 x 7 7.5 x 8 11.75 x 11.75 18 x 22

Saturation (mL) 300 750 1,000 2,500

ο Coagulopathy. Blood loss, massive fluid resuscitation, and

drop in body temperature may lead to inability to form clot.

♦ Keep patient warm (above 34°C).

♦ Use warm fluids.

♦ Use crystalloid fluids sparingly.

♦ Transfuse with fresh whole blood (less than 24 h old).

ο Hemostatic agents: new products and bandages are

available in several forms:

♦ Powders: placed in wound, then covered with a

dressing.

♦ Dressings: impregnated with hemostatic agents.

♦ Injectables.

◊ Intravenous: augment clotting cascade of body.

◊ Intracavitary: through wounds to control internal

bleeding.

♦ Two=component “glues”.

♦ If an advanced hemostatic agent is used after a

tourniquet has been placed, the tourniquet may be

carefully removed after the agent has achieved

hemostasis and the wound observed for hemorrhage.

If hemorrhage recurs, return to the tourniquet.
6.7

Hemorrhage Control

Two Field Hemostatic Agents

 Two agents are recommended by the US Tactical

Combat Casualty Care Committee: 1) HemCon, 2)

QuikClot.

 If standard measures such as elevation and pressure

dressings do not control bleeding, it is recommended

that tourniquet be used and that the first agent be

HemCon. If this dressing fails, it should be removed

and QuikClot used if the bleeding is life threatening.

 If the bleeding is external and not at a site where a

tourniquet can be applied, HemCon and QuikClot can

be used if conventional pressure dressings fail.

 Both products are to be used only on external sources

of hemorrhage.

 HemCon dressing is a firm 4 x 4 inch dressing that is

sterile and individually packaged. It works by

adherence to the bleeding wound and has some

vasoconstrictive properties. The blood and clot in the

wound should be removed before application.

Hemostatic Agents

Product Source Mechanism Advantages Disadvantages

Hem- Shrimp Sticks to FDA approved,

Con shell poly- blood inexpensive

saccharide forming

& vinegar plug

Quik- Volcanic Acts as a FDA approved, Thermal

Clot rock selective inexpensive, injury,

sponge for easy to store, requires

water/ long shelf life removal

dehydrates from wound

blood

Fibrin Fibrinogen/ Activates Natural Not FDA

bandage thrombin clotting clotting approved,

mechanism mechanism allergic

reactions expensive
6.8

Emergency War Surgery

 QuikClot is a granular zeolite that absorbs fluid and

causes hemostasis. It has handling properties similar

to sand. When applied it can generate significant heat

during the absorption process. Blood and clot should

be wiped out of the wound prior to application.

 Remember, pressure must be applied for 3–5 minutes

at the bleeding site, after application of a hemostatic

dressing.

Field Hemostatic Dressings Considerations

Use should be delayed until after a trial of conventional

dressings.

Do not use on minor injuries.

Use on internal wounds is not yet recommended.

Must apply pressure to the bleeding site after application.

Risk of inadequate contact of HemCon to the bleeding

tissues in deep wounds.

Heat generation from QuikClot.

ο Controlled resuscitation (hypotensive resuscitation).

♦ Resuscitation as a method of hemorrhage control. The

needs of organ perfusion must be carefully balanced

against the risk of increased bleeding as blood pressure

rises. Excessive fluid resuscitation may increase

bleeding and rebleeding. Prior to definitive hemorrhage

control, a lower-than-normal blood pressure may be

accepted. Small volumes of resuscitation fluid are still

required in those casualties with decreased mentation

due to hypotension (ie, decreased or absent radial

pulse).