Hemorrhage Control: Stopping the Bleed
Uncontrolled hemorrhage is the leading cause of preventable death in trauma. The NREMT emphasizes hemorrhage control as a critical EMT skill, reflected in the XABCDE assessment where eXsanguinating hemorrhage is addressed before airway management.
Types of Bleeding
Arterial: Bright red, spurting blood that corresponds with the heartbeat. This is the most dangerous type of external bleeding because of the high pressure and flow rate. Arterial bleeding can result in death within minutes.
Venous: Dark red, steady flow. Significant venous bleeding (such as from a femoral vein laceration) can also be life-threatening but generally does not spurt.
Capillary: Slow oozing. Rarely life-threatening. Controlled with minor direct pressure and typically stops on its own.
Hemorrhage Control Techniques
Direct Pressure
Apply firm, direct pressure to the wound with a sterile dressing. Maintain continuous pressure for at least 10 minutes before checking the wound. If the first dressing soaks through, apply additional dressings on top without removing the original. Removing the first dressing disrupts clot formation.
Tourniquet Application
Apply a tourniquet for life-threatening extremity hemorrhage that cannot be controlled with direct pressure. Place the tourniquet 2 to 3 inches above the wound, between the wound and the heart. Tighten until bleeding stops and distal pulse is absent. Note the time of application. Do not remove a properly applied tourniquet in the field.
Key NREMT points about tourniquets:
- A tourniquet that does not stop bleeding should be tightened further
- A second tourniquet may be applied proximal to the first if bleeding continues
- Do not apply over joints
- Commercial tourniquets are preferred over improvised ones
- Tourniquets cause pain, which is expected and not a reason to loosen
Wound Packing
For junctional wounds (groin, axilla, neck) where tourniquets cannot be applied, pack the wound with hemostatic gauze or plain gauze, pushing gauze directly into the wound and applying pressure. Pack tightly enough to create tamponade within the wound cavity.
Internal Bleeding
Internal bleeding cannot be controlled in the field but must be recognized. Signs include:
- Mechanism suggesting internal injury (blunt abdominal trauma, pelvic fracture)
- Signs of shock without visible external bleeding
- Rigid, distended, or tender abdomen
- Bruising (ecchymosis) over the abdomen or flanks
- Hematemesis (vomiting blood) or hematochezia (bloody stool)
EMT management of suspected internal bleeding: high-flow oxygen, maintain body temperature, position supine (if no respiratory distress), rapid transport to a trauma center. This patient needs surgery, not field interventions.