This article describes the the first treatment of a casualty with severe bleeding.
Phil Jevon, BSc, RN, is resuscitation officer/clinical skills lead; Lisa Cooper, MSc, RN, is advanced nurse practitioner, A&E; both at Manor Hospital Walsall.
Classification of wounds
Wounds can be classified as follows:
- Abrasion (graze): superficial injury caused by a ‘ripping’ of the skin. Grazes are often contaminated with foreign bodies, which can cause localised infection;
- Incised wound: cut caused by a sharp object such as a knife or a piece of glass. Damage to the vascular bed can lead to profuse bleeding;
- Laceration: a tearing of the skin that can be superficial or may affect deeper structures. The causes include barbed wire, broken glass and jagged pieces of metal. Profuse bleeding is unlikely;
- Puncture wound: these are usually caused by sharp objects. Causes include insects, marine life, sharp objects and accidental impalement;
- Stab wound: this is a puncture wound caused by a knife or other penetrating object;
- Gunshot wound: caused by a bullet or a missile and usually associated with a small entry and large exit wound;
- Bruise (contusion): blunt injury to the tissues leading to tenderness, swelling and characteristic blue/black discoloration;
- Degloving injury: layers of tissue being torn away, exposing deeper anatomical structures; this is associated with major traumatic injury (Jevon, 2006).
Categories of bleeding
There are three categories of bleeding:
- Arterial: blood is characteristically bright red and typically ‘spurts’;
- Venous: darker than arterial blood and typically trickles or oozes out except in larger veins when it would flood out;
- Capillary: minor in nature.
Historically, the use of tourniquets has been controversial. Following the application of an arterial tourniquet, ischaemic injury will occur after 90 minutes (Jevon, 2006). However, a tourniquet can be life-saving in some situations.
The use of a tourniquet can be considered, but only as a last resort (Cooke, 2007; Greaves and Porter, 2007).
First-aid treatment of severe bleeding
- Ensure that it is safe to approach the casualty;
- If possible, wash your hands using soap and water to minimise the risk of cross-infection;
- If they are available, don gloves (Jevon, 2006);
- Carefully remove any clothing that is covering the casualty’s wound (Fig 1);
- If an object is embedded in the wound, do not remove it;
- Place a sterile dressing pad over the wound. If this is not available, improvise by using a clean piece of non-fluffy material to cover the wound (Fig 2) (St John Ambulance et al, 2006);
- Apply firm pressure to the pad using the fingers or palm of the hand. In some situations, it may be reasonable and practical to ask the casualty to maintain this pressure. Ensure no pressure is applied to an embedded object (St John Ambulance et al, 2006);
- Handle the injured part as carefully as possible, as there may be an associated injury such as a limb fracture;
- If appropriate, raise the injured limb so it is higher than the level of the heart (Fig 3). Gravity will help to reduce the flow of blood to the wound;
- Encourage the casualty to lie down – this will reduce blood flow to the wound and help to minimise the effects of shock (St John Ambulance et al, 2006) (Fig 4);
- Ensure that the emergency services have been alerted (St John Ambulance et al, 2006) (Fig 5);
- Reassure the casualty and stay with them until expert help arrives;
- Make sure to keep the patient warm, for example by placing a blanket or coat over them;
- If you are able to do so, regularly monitor the casualty’s vital signs including respiratory rate, pulse rate and level of consciousness (Fig 6). If possible record the casualty’s blood pressure (if a home sphygmomanometer is available);
- If the casualty’s level of consciousness deteriorates, place them in the recovery position and continue to monitor their vital signs. If the casualty stops breathing, send someone to alert the emergency services again and start resuscitation;
- Where wounds are extensive, effective haemorrhage control may only be achieved by applying indirect pressure over a proximal artery such as the femoral or brachial artery (Greaves and Porter, 2007).
Blood is the single most important source of the transmission of the HIV and hepatitis B viruses. Although this can be difficult in a first-aid setting, great care should be taken to minimise the risk of cross-infection.
This procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols.
Cooke, M. (2007) Pre-Hospital Care. Edinburgh: Churchill Livingstone.
Greaves, I., Porter, K. (2007) Oxford Handbook of Pre-Hospital Care. Oxford: Oxford University Press.
Jevon, P. (2006) Emergency Care and First Aid for Nurses. Oxford: Elsevier.
St John Ambulance et al (2006) First Aid Manual. London: Dorling Kindersley.