Basics of Bleeding Control

by Ana Spehonja and Gregor Prosen

Types of wounds

Contusion (Contusio):
It is a result of minor forces, usually over clothes on 90°angle. Capillaries beneath the skin can rupture due to a blunt blow or punch. There can also be a hematoma. Analgesics and RICE (rest, ice, compression, and elevation) will be enough for management.

Abrasion (Excoriation):
It is a result of forces obliquely hit skin. The topmost layers of skin are scraped off, leaving a raw, tender area. Clean the wound, put a sterile bandage, give an analgesic, tetanus protection, and RICE (rest, ice, compression, and elevation) are the parts of management.
If the wound is deep, it may need a surgical consult or referral for better cosmetic healing. Please check the wound care chapter.

Wound (Vulnus):

  • caused by sharp object – vulnus scissum
  • laceration – vulnus lacerum
  • puncture wound – vulnus ictum
  • bite wound – vulnus morsum
  • gunshot wound – vulnus sclopetarium
  • explosive wound – vulnus explosivum
  • contusion – conquassatio

Types are based on time, place, the cause of injury. A clean wound which is not older than 6-8 hours (18-24 hours on face) can be closed right away. Wounds that are older than 8 hours should be thoroughly cleaned and cover with wet gauze. They can be closed after 3-5 days when they are clean, and there is no sign of infection.

If blood vessels affected,

Arterial bleeding

It is a consequence of injury to the artery. The blood is pulsating out of the wound and has a bright red color. If the artery is lacerated through the whole lumen, it will spontaneously shrink and limit the bleeding. However, if there is only injury to the wall of an artery and it is not thoroughly dissected, this cause even more harm.

How to recognize arterial bleeding

Hard Signs

  • No pulses
  • Bruit or thrill
  • Active or pulsatile bleeding
  • Signs of limb ischemia
  • Pulsatile or expanding hematoma

Soft Signs

  • Proximity of injury to vascular structures
  • Major single nerve deficit
  • Non-expanding hematoma
  • Reduced pulses
  • Posterior knee or anterior elbow dislocation
  • Hypotension or moderate blood loss at the scene

Venous bleeding

It is a consequence of injury to the vein. The blood is leaving the wound more slowly and is not pulsating; it has a dark red color.

Capillary bleeding

Damaged subcutaneous capillaries. Slow dotted bleeding.

Assessment and Simple Procedures

Initial evaluation when assessing wounds that are not life- or limb-threatening:

  • past medical history and circumstances surrounding the injury,
  • remove rings or other jewelry that encircle the injured body part,
  • review the mechanism of injury,
  • ask about the presence of a foreign body sensation,
  • determine the time that the injury occurred
  • determine if the wound was the result of intentional, unintentional or workplace event
  • examine nerves’ motor and sensorial function, and tendons.

Assessment of bleeding wounds that are potentially life- or limb-threatening

  • Direct pressure
    • We should provide equal pressure over a gauze that covers the complete wound. It is the first step of immediate bleeding control, and applicable anywhere on the body. Replace skin flaps to their original position, before applying pressure if possible.
    • Some areas of the body can be painful, and it is a limitation for some patients. Direct pressure has time limitations. Therefore, application of pressure bandage may be necessary.
  • Pressure on arteries
    • We can stop blood flow to extremities with pressure on main arteries.
      It is the second step of immediate bleeding control.
      It is useful only on extremities. It is a painful application and has time limitation as direct pressure.
  • Eschmarch tourniquet
    • We can use cuff from blood pressure monitor. It should be inflated with pressure over 250mmHg, especially on lower extremities. However, inflating 20-30 mmHg over the systolic blood pressure levels are also acceptable in most of the bleeding. Use only to stop life-threatening exsanguination or when a tourniquet is needed for a short period of time to create a bloodless field for wound inspection. This technique can be used id above measures are not effective to stop a fast bleeding. It has a time limit up to 2 hours. It is a painful procedure. Apply blood pressure cuff proximal to the bleeding point, inflate it above systolic blood pressure and clamp the tubing with a hemostat. After procedure record the time of application, do a neurological exam and do not leave the tourniquet on for more than 120 minutes.
  • Compression bandage
    • It is very fast, but a temporary bleeding control maneuver. It is less effective than Eschmarch tourniquet. It can limit breathing when applied on the thorax. Lift the injured limb. Place clean gauze over the wound and maintain direct pressure on the wound. Place one bandage over the wound and wrap the other on around the limb. Make sure to have firm and constant pressure. Place the limb in a brace and keep it elevated. Check pulse, mobility, and sensation distal from the dressing. Check the dressing every 5-10 minutes.
  • Clamping and Cauterisation
    • It is fast and on point bleeding control. One of the final steps, if the above measures do not work to stop bleeding. It should not be applied any wound and vessel having an amputation and possible re-anastomosis chance. But it is ideal for continuously bleeding superficial arteries in some wounds. Do not try to clamp deeper vessels because clamping may damage other structures.
    • Cauterization is a final step of bleeding control in the ED, and applied by surgical teams when the other measures used by ER team are not effective to stop bleeding.

References and Further Reading

  • Ahčan, U. Prva pomoč: priročnik s praktičnimi primeri. Ljubljana: Rdeči križ Slovenije; 2007.
  • Smrkoj¸, V. Kirurgija. Celje: Grafika Gracer; 2014.
  • Life in the fast lane [homepage on the Internet]. Trauma! Extremity Arterial Hemorrhage. Available from:: http://lifeinthefastlane.com/trauma-tribulation-030/. Accessed April 1, 2016
  • Rosen, P. M. Rosen’s emergency medicine: Concepts and clinical practice. 8th ed. Philadelphia: Elsevier Saunders; 2014.
  • Herman, S. How to stop the bleeding. Emergency medicine – selected topics 2015. 2015;62-64.

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