Uncontrolled bleeding is the most common cause of preventable death in the United States.
We encounter more cases of hemorrhagic shock because it is the most common cause of hypovolemic shock in the prehospital setting than any other form of shock. And in prehospital emergency medicine, we are behind when it comes to providing the best possible care to our trauma patients.
It took years to start using tourniquets to control severe external bleeding. Yes, we were technically allowed to use tourniquets, but we had to make one with a triangular bandage. Plus, we were highly discouraged from applying tourniquets because it virtually guaranteed the patient’s extremity would be amputated.
It is no surprise that we are behind the military regarding trauma treatment. But we should never be behind in the civilian world.
Thanks to the Stop the Bleed organization, civilians are learning to apply direct pressure, pack wounds, and apply tourniquets. The organization states it has trained more than 1 million people. This training program helps would-be bystanders help people who have been involved in an active shooter event.
Before we get into wound packing, lets dispel some long-standing bleeding control myths.
Myth No. 1: Direct Pressure Will Control All Bleeding
This is not to say that direct pressure does not control bleeding — we know that it does. The issue is that we have been taught to use the palm to apply pressure to a patient’s injury.
Direct pressure can be unsuccessful when the palm is used because there is too much surface area, which decreases the pressure applied. We should use our fingers to apply pressure to injuries associated with external bleeding.
When finger pressure is used, it decreases surface area by 25 times and increases the applied pressure by 25 times.
Myth No. 2: When Dressing Is Saturated, Apply Additional Dressings As Needed
When previously applied dressings are removed, we take away natural bleeding control processes from the body.
When the dressing is saturated, the pressure is no longer directly on the source of bleeding. So, applying new dressings to saturated dressings act like a sponge and draw blood and clotting factors from the wound.
Myth No. 3: Tourniquets Control All Extremity Bleeding
Tourniquets are occasionally used in the prehospital setting to control severe bleeding. But there are some identified issues that need to be addressed. Traditional tourniquets do not adequately control bleeding in the truncal areas, axilla, and groin. We should use junctional tourniquets to control bleeding in these areas of the body.
Tourniquets also do not work well in areas with two bones, such as the forearm and lower leg. Effective tourniquet pressure cannot be applied to injured vessels that lie between these bones.
Tourniquets also are commonly not tight enough. When applied correctly, arterial blood flow will stop and the patient, if responsive, will complain of pain from the tourniquet.
Finally, continuous reassessment is a must, especially when intravenous (IV) therapy is administered to the patient. Bleeding can resume on the injury side of the tourniquet as the patient’s blood pressure increases with the administration of IV fluid.
Myth No. 4: Hemostatic Agents Will Control All External Bleeding
Hemostatic agents, when used correctly, only enhance bleeding control by up to 15%. It is misunderstood that these agents make a significant difference when used.
Also, hemostatic agents that are placed on top of wounds will not stop bleeding from traumatic injury. The agents must be packed into the wound and combined with direct pressure for a minimum of three minutes to be effective.
Myth No. 5: Approach to Bleeding Control (ABC)
The ABC model does not take into consideration the time it takes to manage the patient’s airway. Bleeding control can be done in seconds. But it takes minutes to intubate and even more time to progress to and perform an emergency cricothyrotomy.
Because of this, we have adopted the circulation, airway, and breathing (CAB) model and are expected to control the patient’s bleeding first.
This model also was adopted from the military. However, while this has come to be the standard it does not truly represent what we do in the civilian world.
Military medics commonly work independently because there can be numerous causalities that need attention. Civilian healthcare workers tend to take care of one patient at a time and work as a team. So, we should be doing airway management and bleeding control simultaneously.
The one scenario in which we would truly follow the CAB model is when we triage patients at a mass casualty incident.
When to Use Wound Packing
We do not encounter wounds that require packing all that often in the prehospital setting. Obviously, wounds that present with minimal bleeding should not be packed. Wounds in the neck area will only require direct pressure out of concern for the patient’s airway.
Injuries of the chest, abdomen, and pelvis also should not be packed because these injuries tend to be very deep and cannot be reached from outside. Many of these types of injuries require surgical intervention.
How to Pack Wounds
- Immediately apply direct pressure to the injury. You can use your fingers, hand, elbow, or knee to apply pressure, depending on the area of the body involved, while you obtain wound packing supplies from the jump bag.
- Once you obtain the wound packing material you need, insert it into the wound with the fingers of one hand while maintaining direct pressure with the other hand. You are going to continue to pack the wound until you cannot get any more material into the wound.
- After you finish packing, apply very firm pressure to the injury for three minutes.
- After three minutes, place a pressure dressing over the wound and splint the area of injury to ensure the packing does not become dislodged during transport.
- If upon reassessment of the wound it continues to bleed and you have hemostatic agents available, it is recommended you remove the original packing material and insert fresh packing into the wound. The rationale for this is it can be assumed that you either did not pack the wound correctly the first time, or you did not get the original packing deep enough into the wound.
- Follow your local protocols. If you have not been properly trained or your protocols do not reflect this information, do not pack the wound.