Hemorrhage Control

1

How is massive or life-threatening hemorrhage defined?

There is not a universally accepted definition of massive hemorrhage. It is bleeding that is rapid, large volume, and likely to result in shock with progression to death from exsanguination if not controlled. Examples include wounds associated with pulsatile arterial bleeding and wounds associated with other severe extremity trauma. It is important to recognize that large-volume bleeding is rapidly life threatening. Massive hemorrhage should be controlled even before airway management as it is futile to oxygenate and ventilate without a blood volume to circulate.

2

How common is hemorrhage as cause of death?

Hemorrhage is one of the leading sources of preventable death on the battlefield. It is the second leading cause of death in civilian trauma cases.

3

What are the initial steps to effective control of a hemorrhage?

For most wounds with active bleeding, the initial step should be firm direct pressure with an appropriate dressing if available. Pressure should be directed directly over the source of bleeding. In circumstances where direct pressure on a wound is not feasible or not successful, a tourniquet should be applied. In wounds that are felt to be immediately life threatening due to volume of bleeding or the presence of signs of hemorrhagic shock, tourniquet application as a first-line intervention is appropriate.

4

Have tourniquets been shown to be effective and improve mortality?

In military use, tourniquets have been clearly shown to be effective in controlling hemorrhage. They are issued to every US servicemember in the battlefield setting. Kragh et al., in a landmark paper, showed decreased mortality in military prehospital use. Tourniquet use when shock was absent was associated strongly with increased survival. In cases where tourniquets were indicated but not applied, survival was 0%. This supports the practice of rapid use of tourniquets before significant amount of hemorrhage has occurred. In a civilian setting, tourniquet use has been associated with decreased need for blood products and higher systolic blood pressure (BP) on emergency department (ED) arrival supporting their use.

5

What is the process of tourniquet application?

Current recommendations from military combat casualty care recommend that the tourniquet is applied several inches proximal to the bleeding site. If you cannot rapidly identify the site of bleeding, you should apply the tourniquet as high as possible into the groin or axilla. Tourniquets may be applied over clothes if necessary. Next, you will need to tighten the tourniquet sufficiently to occlude arterial flow. Each device is different and training and practice are important for correct application. In general, the strap must be applied around the extremity, as much slack as possible should be taken up to tighten the device, and then the windlass or other mechanical device should be tightened and secured to prevent loosening. Assess for effectiveness and record application time.

The two broad categories that devices fall into are devices that use a windlass, pneumatic bladder or ratcheting mechanism to provide mechanical advantage and bungee or elastic-type tourniquets. Commercially available products are also recommended over any improvised device. The Committee on Tactical Combat Casualty Care (CoTCCC) publishes a list of recommended devices. Currently none of the bungee or elastic devices on the market today are recommended by CoTCCC. Fig. 75.1 shows several common devices approved by CoTCCC.