23.3 — Severe Bleeding and Wounds

A severed femoral artery can empty a body in under three minutes.

And the treatment is your hands, pressed hard on the wound.

No equipment, no training beyond this page, no drug. Direct pressure stops the large majority of external bleeding, and it works because blood clots when it stops moving long enough (Chapter 7.1) — your job is to hold the edges of the vessel closed until it does.

Uncontrolled bleeding is the leading cause of preventable death in trauma. Preventable is the word that matters: these are people who could have lived.

How much blood there is

An adult has about 5 litres.

Losing 15 percent — around 750 ml — produces little more than a slightly raised heart rate.

Losing 30 percent — around 1.5 litres — produces a rapid heart rate, pale clammy skin, rapid breathing and anxiety.

Losing 40 percent — around 2 litres — produces confusion, collapse and a falling blood pressure. By the time blood pressure drops, a great deal has already been lost.

Which is the key clinical point: blood pressure is a late sign. The body compensates by constricting vessels and speeding the heart, and it holds the pressure up until it can no longer manage — and then it falls fast.

So do not be reassured by a normal blood pressure or by someone talking normally. Look at the pulse, the skin, the breathing and the mental state.

A child has proportionally less blood — around 80 ml per kilogram, so a 20 kg child has about 1.6 litres. The same volume of blood loss is far more serious, and children compensate remarkably well and then collapse suddenly.

The signs of significant blood loss

Early: rapid pulse; pale, cool, clammy skin; anxiety and restlessness — and restlessness is a genuinely useful early sign, because the brain is short of oxygen.

Later: rapid shallow breathing; thirst, sometimes intense; dizziness; nausea; and weakness.

Late and serious: confusion, drowsiness, a weak or absent pulse at the wrist, blue-grey skin, and collapse.

And hidden bleeding is the one that catches people out. Internal bleeding into the abdomen, chest, pelvis or thigh produces all the signs above with no visible blood at all. A fractured femur can hold over a litre. A fractured pelvis can hold several.

Suspect internal bleeding after any significant impact, and treat the signs even without visible blood.

Stopping external bleeding

The sequence, in order.

1. Protect yourself

Gloves if you have them. A plastic bag over your hand if you do not.

Do not let this delay you for more than a couple of seconds in a life-threatening bleed.

2. Direct pressure

This is the treatment. Everything else is a supplement to it.

Press firmly directly on the wound with whatever you have — a dressing, a clean cloth, a folded T-shirt, or your gloved hand.

Press hard. Harder than feels polite. You are compressing a vessel against underlying bone or muscle.

And keep pressing. 10 minutes without lifting to look.

The single commonest reason bleeding continues is that people lift the dressing to check. Every time you lift it, you tear off the clot that was forming and start again.

If blood soaks through: add more dressings on top. Do not remove the first one.

Use a fist or the heel of your hand for a large wound. For a small deep wound, one or two fingertips pressed directly into the wound generate far more pressure than a flat hand and are more effective.

3. Elevate

Raise the injured part above the level of the heart if the injury allows.

It helps modestly, and it is secondary to pressure. Never delay or reduce pressure in order to elevate.

4. Pressure dressing

Once bleeding is controlled, secure the dressing firmly with a bandage.

Tight enough to maintain pressure, not tight enough to cut off circulation.

Check the fingers or toes beyond it: they should stay warm, pink, and have sensation. If they go cold, blue or numb, loosen it slightly.

5. Haemostatic dressing

If you have one — these are gauze impregnated with an agent that speeds clotting.

Pack it firmly into the wound and maintain pressure for at least 3 minutes.

They work, they are increasingly carried in public access bleed kits, and they are a genuine addition to direct pressure rather than a replacement for it.

6. Tourniquet

For life-threatening bleeding from a limb that direct pressure has not controlled.

And the advice on tourniquets has reversed over the past two decades. They were long taught as a last resort that would cost the limb. Military experience in Iraq and Afghanistan changed that: applied properly and released within a couple of hours, they save lives and limb loss from the tourniquet itself is uncommon.

When to use one:

Catastrophic limb bleeding — spurting, pooling, or soaking through dressings.

Traumatic amputation.

Multiple casualties, where you cannot stay and hold pressure.

A trapped casualty you cannot reach properly.

How to apply one:

1. Place it 5 to 7 centimetres above the wound, on bare skin where possible, and never over a joint. If the wound is at or near a joint, go above the joint.

2. Tighten until the bleeding stops. This hurts a great deal, and the person may shout or try to remove it. That is expected. A tourniquet that is not tight enough to hurt is not tight enough to work — and a partially tight tourniquet is worse than none, because it blocks veins while leaving arteries open, increasing bleeding.

3. Secure the windlass.

4. Write the time of application on the tourniquet, on the casualty's forehead, or anywhere obvious. The time is critical information for the hospital.

5. Do not remove it. Removal is done in hospital, with resuscitation ready.

6. If bleeding continues, apply a second tourniquet just above the first.

Improvised tourniquets — a triangular bandage or a strip of cloth at least 4 centimetres wide, with a rigid object as a windlass. They are far less effective than manufactured ones and are worth attempting when there is no alternative. Never use anything narrow like a belt buckle, wire or cord, which cuts rather than compresses.

7. Treat for shock

Lay them down.

Raise their legs about 30 centimetres if there is no leg or spinal injury.

Keep them warm — and this matters more than people realise. Cold blood clots badly. Hypothermia, acidosis and impaired clotting reinforce each other in major trauma, which is why blankets are treatment rather than comfort.

Do not give anything to eat or drink, because they will likely need surgery.

Monitor breathing and consciousness, and be ready to start CPR.

The wounds that need something different

An embedded object — do not pull it out.

**A knife, a piece of glass, a spike, a nail. It may be the only thing plugging a damaged vessel, and removing it can cause immediate catastrophic bleeding. It may also have damaged structures you cannot see.

Instead: apply pressure around the object, not on it. Build up padding on either side, higher than the object, and bandage over the padding without pressing the object further in.

The only exception is an object obstructing the airway.

An open chest wound — a sucking chest wound.

A wound that penetrates the chest wall can let air into the space around the lung with each breath, collapsing it.

Bubbling or a sucking sound at the wound is the sign.

Treatment: a chest seal if available. If not, do not seal it completely with an airtight dressing — leave it open to air, or use a dressing taped on three sides so air can escape but not enter.

Because a completely sealed wound can produce a tension pneumothorax — air accumulating under pressure, pushing the heart and great vessels across and stopping circulation. Signs: severe breathlessness, one side of the chest not moving, neck veins standing out, and collapse. That is a surgical emergency requiring immediate needle decompression by a professional.

Sit them up if they can tolerate it, leaning towards the injured side.

An abdominal wound with protruding organs.

Do not push anything back in.

Cover with a large dressing moistened with clean water or saline, then a dry layer over that to retain warmth.

Lay them down with knees bent, which reduces tension on the abdominal wall.

An amputation.

Control the bleeding at the stump — direct pressure, and a tourniquet if needed.

Then care for the amputated part, because reattachment is sometimes possible:

Wrap it in clean damp gauze.Put it in a sealed plastic bag.Put that bag in a second bag or container of iced water.Never put the part directly on ice or in water — direct contact with ice causes freezing damage that makes reattachment impossible. Label it with the time.Send it with the casualty.

A crush injury.

If someone has been crushed for more than about 15 minutes, releasing them can be dangerous — crushed muscle releases potassium and myoglobin, and when circulation is restored these flood the body, causing cardiac arrest and kidney failure (Chapter 21.6).

Call for professional help and, where possible, do not release a long-standing crush yourself unless there is an immediate danger such as fire. Emergency services can give fluids before release.

And in the specific case of a limb trapped for hours in an inaccessible place, this is one of the few situations where waiting is the correct action.

Bleeding from specific places

Nosebleed.

Sit up and lean forward. Leaning back sends blood down the throat, which causes vomiting and hides how much is being lost.

Pinch the soft part of the nose — not the bony bridge — firmly, for 10 to 15 minutes without releasing to check.

Breathe through the mouth. Spit out blood rather than swallowing.

Seek help if it lasts beyond 20 to 30 minutes, follows a head injury, or if the person takes anticoagulants.

Scalp wounds bleed dramatically because the scalp has a rich blood supply and the vessels are held open by fibrous tissue. Direct firm pressure works well. Always consider head injury underneath (Chapter 23.8).

Mouth and tooth socket — bite down on a rolled gauze pad or clean cloth placed directly on the socket for 10 to 20 minutes.

Vaginal bleeding in pregnancy — any significant bleeding in pregnancy needs urgent assessment. Lie them on the left side, keep any pads for assessment, and call for help.

Coughing up blood, vomiting blood, or passing black tarry stools — all indicate internal bleeding and need emergency assessment. Vomited blood may look like coffee grounds.

Bleeding in someone on anticoagulants — treat the same way and lower your threshold for calling help substantially. Warfarin, apixaban, rivaroxaban, clopidogrel and even aspirin all mean bleeding that would otherwise stop may not (Chapter 22.7).

Ordinary wounds

For anything that is not life-threatening.

Wash your hands and use gloves.

Stop the bleeding with pressure.

Clean it: run clean tap water over it for several minutes. Running water is the most effective wound cleaning available, and drinkable tap water is fine.

Remove visible dirt and gravel with tweezers, cleaned first. Leave anything deeply embedded.

Antiseptic is optional; thorough irrigation matters more. Do not use hydrogen peroxide or alcohol on an open wound — they damage tissue and delay healing.

Dry the surrounding skin and cover with a sterile non-adherent dressing.

Change dressings when wet or dirty.

Wounds that need medical attention:

Deep, gaping, or with edges that will not sit together — these may need closure, and most wounds needing stitches should be closed within 6 to 12 hours.

Anything on the face, where scarring matters.

Anything over a joint.

Puncture wounds, which look trivial and carry infection deep.

Animal or human bites — and human bites are among the most infection-prone wounds there are. Bites are usually not closed with stitches, because sealing bacteria inside is worse than an open wound.

Anything with an embedded object, or a wound in a diabetic person's foot.

Anything showing infection — increasing pain after the first day, spreading redness, swelling, heat, pus, fever, or red streaks tracking from the wound.

Tetanus — caused by a bacterium in soil and dust that produces a toxin causing severe muscle spasm (Chapter 17.4). A booster is needed for a dirty wound if it has been more than 5 years, or for any wound if more than 10 years. Puncture wounds, wounds contaminated with soil or manure, and burns are the high-risk ones.

What to have available

A bleed control kit is a genuinely worthwhile thing to own if you drive, work with machinery, or live somewhere remote:

Gloves. A tourniquet. Haemostatic gauze. Large trauma dressings. A chest seal. Foil blanket. Trauma shears.

Public access bleed kits are appearing alongside defibrillators in many places, for the same reason: the treatment has to reach the casualty in minutes.

What the next page fixes

Chapter 23.4 covers recognising a heart attack and a stroke — the two time-critical emergencies where minutes of delay cost permanent damage, and where the recognition is entirely doable by a bystander.