Every effort should be made to minimise blood loss, maximise clot formation and minimise clot disruption. It is essential to realise the effects of patient handling, packaging and splintage on natural tamponade and to utilise these procedures as a fundamental part of “volume resuscitation”. All fore-shortened fractured femurs should be drawn out to length and splinted. This technique reduces the limb circumference and the soft tissue volume into which bleeding can occur.

Careful handling will minimise clot disruption in the chest wall, peritoneum and pelvis i.e. non-compressible haemorrhage.

Appropriate cutting of clothes and “skin to scoop” packaging are essential elements of this care.

Blood loss can be venous or arterial.  Arterial bleeds are pulsatileand are bright red.  Blood is lost more quickly and it is more difficult to stop the bleeding. If your patient has an external arterial bleed from a limb apply pressure at a proximal pulse point, apply a tourniquet to the thigh or upper arm, and raise the affected area. Venous bleeds ooze and are darker.  Apply direct pressure (preferably with sterile gauze) to a venous bleed (and arterial bleeds of the trunk).  Bandage as well as you can.

Bleeding might not be immediately obvious, check thoroughly for bleeding especially if the patient seems clinically shocked.  Remember waterproof clothing might disguise a bleed.

Visible blood loss through a skin lesion is just one way in which the circulatory system can lose blood.  Blood can also leak into internal cavities.  A way of remembering this is ‘Blood on the floor and four more’. The 4 more are:

  • Abdomen
  • Thorax
  • Long bones
  • Pelvis

You can lose litres of blood into all these body cavities.

Fracture Reduction and Splintage Edit

  • Fractured femur - draw out to length manually and splint, with a Kendrick traction device if available.
  • Fractured pelvis - reduce to anatomical position and apply pelvic splint using minimal movement
  • Fractured tibia/fibula - reduce fracture and splint.
  • Fractured humerus - draw out to length and splint. NB, a KTD can be used to splint a mid-shaft humeral fracture.

Bleeding Wounds Edit

External haemorrhage should be arrested as a matter of priority. Simple techniques such as direct compression with focussed pressure applied accurately should be optimised.

Scalp wounds should be sutured if active bleeding is present. Celox gauze and large dressings will not stop scalp wound bleeding and significant volume of blood loss can be concealed within poor dressings.

Consider indirect pressure e.g. femoral artery / temporal artery compression, proximal to the bleeding site.

Celox gauze can be used to pack into cavities to obtain haemorrhage control e.g. – gunshot wounds, penetrating neck wounds.

Penetrating Wounds to the Limbs Edit

If simple compression using manual pressure or compression bandaging fails to control blood loss the Combat Application Tourniquet may be used.

  • CATs must be applied tightly – turn windlass until it hurts awake patient and then once more.
  • CATs applied to lower limbs should have the loose end doubled through the buckle to prevent slippage. Two CATs may be required in some cases.
  • Time of tourniquet application must be recorded

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