Note: This is part two of a two-part series on bleeding control. Read the first part of the series here.
The most common cause of death for individuals age 44 and younger is unintentional injuries, according to CDC data.
This is the premise of the 1966 Accidental Death and Disability: The Neglected Disease of Modern Society report. Though quite dated, this influential white paper published by the National Academy of Sciences almost singlehandedly created modern emergency medical services (EMS) as we know it. And its findings on bleeding control are as relevant today as they were over half a century ago.
Bleeding control and proper patient management is essential to increasing the likelihood of positive patient outcomes.
If you are preparing for certification testing, be advised that some of this information may not yet have been updated by the testing agency, as the textbooks have not yet been updated.
The ABC vs. CAB models
We hear a lot about the new C-A-B (circulation, airway, and breathing) model when it comes to bleeding control. But classes like Prehospital Trauma Life Support (PHTLS) and Advanced Trauma Life Support (ATLS) are more specific with a C-ABCDE model, with the C standing for “control massive hemorrhage.”
Regardless of the mnemonic you choose, patients can bleed out and die within seconds if a major vessel like the femoral artery or vein is injured. Conversely, it takes minutes for a patient to die from an issue associated with an airway injury.
It is estimated that 30% to 40% of trauma-related deaths occur because of the most common form of shock — hemorrhagic — and bleeding play a part in 33% to 56% of trauma-related deaths in the prehospital environment.
This bleeding control model is rooted in the military training program Tactical Combat Casualty Care (TCCC). But this model does not truly translate to the EMS side of treatment.
Military medics commonly work independently — we work in teams. The only time we operate independently is during the initial phase of a mass casualty incident.
So, for EMS, we are truly doing airway and circulation simultaneously. The emergency medical technician (EMT) should immediately move to control severe bleeding because that skill is completely within his or her scope of practice. Plus, the paramedic should move to the airway when he or she needs to perform an advanced airway maneuver.
Bleeding control methods
Direct pressure is still the primary and most effective method of controlling bleeding. The exception to this rule being an appendage amputation.
You should apply your hand or gauze to the wound while you retrieve supplies from the jump bag. The current recommendation is to insert your fingers into the wound and push hard.
Historically, we have been taught to place the palm of our hand over the wound. The issue is this is not enough pressure to control bleeding because there is not enough pressure applied to the injured vessel(s).
Using your fingers decreases surface area by 25 times and increases the pressure applied to the wound by the same ratio.
You should then pack the wound with gauze and continue to pack it until you can’t get more into the wound. After packing, apply very firm pressure for three minutes. The combination of gauze in the wound and finger pressure will stop most bleeding.
After three minutes, reassess for bleeding. If bleeding has stopped initiate transport, start an IV, splint the extremity and apply a cold pack to assist with bleeding control and swelling. If the bleeding continues, you need to pack more dressing into the wound and apply pressure and transport quickly to the appropriate facility.
Tourniquets
Tourniquets are currently recommended for patients with significantly bleeding when direct pressure is not effective. Patients who have a tourniquet applied before they go into hemorrhagic shock have a nine times higher chance of surviving over those who had a tourniquet applied after entering hemorrhagic shock.
Though a tourniquet is almost always recommended for severely injured patients, there are still some noted issues to be aware of:
- Tourniquets do not adequately control bleeding in the truncal areas of the axilla and groin. Use a second tourniquet or a junctional tourniquet in these areas.
- When training is inadequate, tourniquets are commonly not tight enough. The patient should complain of pain from the tourniquet if it’s tight enough.
- Tourniquets do not work well in areas with two bones, forearm and lower leg.
- Reassessment is a must. If the patient’s blood pressure increases to normal after the administration of intravenous (IV) fluids, additional bleeding can occur.
Hemostatic Agents
Hemostatic agents are creeping into some EMS systems, but they are not as effective as perceived.
First of all, these products are expensive and expire. How often have you had to deal with an injury in the civilian world that would have benefited from a hemostatic agent? It is rare.
Commonly, these products sit on the shelves of the ambulance, expire, and go into the trash. The bigger issue is that hemostatic agents only enhance bleeding control by 15%. When I provide this data to students in our continuing education programs, they are surprised that the number is so low.
The other issue is that the product must be packed into the wound. A lot of our protocols have not yet been updated to allow us to pack wounds.
Tranexamic Acid
Tranexamic acid (TXA) has become available within numerous EMS systems for both internal and external bleeding control. The mechanism of action of TXA is that it prevents the breakdown of fibrin.
The medication is recommended for use on patients who have sustained recent trauma and become hypotensive where the paramedic suspects hemorrhagic shock.
The Clinical Randomization of an Antifibrinolytic in Significant Haemorrhage-2 (CRASH-2) study showed that there was a 1.5% decrease of mortality in patients who were bleeding or suspected of bleeding.
The recommended dosing is 1g administered IV over 10 minutes followed by another 1g administered over eight hours.