In a destabilized society, traumatic wounds may be commonplace is scenarios where there is a desperate population and no rule of law. Even routine activities of daily survival may cause injuries that could become life-threatening. Therefore, the family or group medic must always be prepared to deal with bleeding wounds. Some of these, especially those in the abdomen and chest, are likely to be fatal without advanced medical care. In this article, let’s commemorate National Stop The Bleed Month (I’m a certified instructor through the American College of Surgeons) by concentrating on those hemorrhages that are survivable.
Cuts in the skin can be minor or catastrophic, superficial or deep, clean or infected. Significant cuts (also called “lacerations”) penetrate both layers of the skin (dermis and epidermis) and are associated with bleeding, the amount of which depends on the blood vessels disrupted. Knowing how to manage hemorrhagic wounds quickly and effectively will be of paramount importance for the survival medic.
In studies of casualties in recent wars, 50 percent of those killed in action died of blood loss. 25 percent died within the first “golden hour” after being wounded. The golden hour is the time after which a victim’s chance of survival diminishes significantly if untreated, with a threefold increase in death rate for every 30 minutes without care thereafter.
If there is active bleeding and the wrong artery is severed, however, it could take just a few minutes for a person to “bleed out” and be beyond medical help. A severed femoral artery can lose more than a pint of blood a minute. With hemorrhage, the reality should, perhaps, be called the “platinum five minutes” instead.
Venous bleeding manifests as dark red blood that drains steadily from the wound, while arterial bleeding is bright red (due to higher oxygen content) and comes out in spurts that correspond to the pulse of the patient. As the vein and artery usually run together, a serious laceration can have both.
Once below the level of the skin, large blood vessels, muscles, and nerves may be involved. You’ll identify more problems with vessel and nerve damage in deep lacerations and crush injuries. In any case, bleeding control must be achieved.
In response to fatalities due to bleeding in recent military conflicts, the U.S. instituted Tactical Combat Casualty Care (TCCC) guidelines. It is thought that up to one in five deaths from hemorrhage in the field may be prevented with quick action by those at the scene. Civilian and law enforcement authorities have established similar strategies in response to the hard lessons learned by our soldiers; so should the family medic.
It’s worthwhile for the medic who may be dealing with bleeding wounds to know some basics about blood. Blood is a specialized fluid that comprises about 7-8 percent of a person’s total weight. It’s involved in:
• Delivering oxygen to the body from the lungs and eliminating carbon dioxide (a process called “gas exchange”).
• Forming clots that stop hemorrhages.
• Transporting substances that fight infections and disease.
• Delivering waste products to the kidneys and liver.
• Helping to regulate body temperature.
There are four main components to blood:
Red blood cells (RBCs): RBCs are the cells that carry oxygen to body tissues, thanks to a special iron-containing protein called “hemoglobin.” Red cells account for 40-45 percent of total blood volume. They start as immature cells in the bone marrow that mature and are released into the bloodstream. The average lifespan of a red blood cell is about 120 days.
White blood cells (WBCs): These cells account for only about one percent of total blood volume, but are extremely important for fighting infection and disease. There are several types, including short-lived cells deployed for immediate response and longer-lived ones that regulate the function of immune cells, make antibodies, and directly attack infected cells and tumors.
Platelets and other clotting factors: These are small cell fragments that allow bleeding to stop by gathering at the wound site and helping to form a clot. Like RBCs and WBCs, they originate in the bone marrow.
Plasma: A yellow liquid that transports all of the above throughout the body.
Together, these components are referred to as “whole blood.”
PHYSICAL EFFECTS OF BLOOD LOSS
Evaluating blood loss is an important aspect of dealing with wounds. An average size human adult has about 10 pints (4.73 liters or 4730 ml) of blood. The effect on the body caused by blood loss varies with the amount incurred. The American College of Surgeons recognizes four classes of acute hemorrhage, along with expected signs and symptoms:
Class I: Hemorrhage is less or equal to 15 percent of blood volume (1.5 pints/750 ml) in an average adult male. 750 ml is the amount in a bottle of wine. A person donating 1 pint of blood is giving slightly less than 500 ml. At this level there are almost no signs or symptoms, although some may have a slightly rapid pulse and feel vaguely faint or anxious.
Class II: Hemorrhage is 15 to 30% loss of total blood volume (1.5-3 pints/750-1500 ml). The body’s efforts to compensate for less red blood cells at this point results in a faster heartbeat and breathing rate to speed oxygen to tissues. This patient will appear pale and skin will be cool. They’ll feel shaky, weak, and anxious. Blood pressure remains, for now, within normal range. Urine production begins to slow down in order to retain fluid volume.
Class III: Hemorrhage is 30 to 40% loss of blood (3-4 pints/1500-2000 ml). At this point, the heart will be beating very quickly and breathing very fast as the body encounters difficulty getting enough oxygen to tissues. Blood pressure drops. Smaller blood vessels in extremities constrict to keep the body core circulation going. This patient will be confused, pale, and in hypovolemic (low blood volume) shock. Urine decreases significantly. In normal times, blood transfusion is usually necessary.
Class IV: Hemorrhage is more than 40% of total blood volume (greater than 4 pints/2000 ml). The heart can no longer maintain blood pressure and circulation. All parameters are well outside normal range and the patient becomes lethargic due to lack of oxygen and circulation to the brain. Without major resuscitative help at this point, organs like the kidneys fail. The patient loses consciousness. Heart rate and respiration slows and eventually ceases as the patient dies.
ABCDE VS. CABDE
The traditional initial field assessment of a victim usually involves the acronym ABCDE. Although ABCDE may mean different things to different people, one interpretation goes as follows:
Airway: Is the airway open? If the patient can talk, it is.
Breathing: Is the victim breathing?
Circulation: Is the victim bleeding?
Disability: Can the victim feel and move extremities? Can they respond appropriately to questions?
Exposure: Can you see the full extent of the injury? Are there other hidden injuries, such as an exit wound?
This sequence is fine for, say, a heart attack, but must be adjusted in bleeding wound cases to CABDE. In these circumstances, the cause of death is more often hemorrhage. The determination of the victim’s airway, breathing, and even mental status can often be done simultaneously with bleeding control.
It’s important to note that the bleeding may not be coming from the most visible wound. Where there is an entry wound, there is (depending on the projectile) probably an exit wound. This may not be directly on the opposite side of the entrance wound. A bullet may ricochet off a bone and exit in an entirely different direction. Also, the position of the victim when wounded plays a part. If they were in a crouching position when hit in the chest, the exit wound might be in the lower back or buttocks.
Modern strategies for bleeding trauma go beyond ABCDE or CABDE. It pays to remember the mnemonic M.A.R.C.H./P.A.W.S. MARCH is an effective primary survey in situations where serious hemorrhage must be managed. M.A.R.C.H. stands for:
• M Massive Hemorrhage: Establish, continue, or improve the control of life-threatening bleeding by whatever means necessary. Tourniquets, hemostatic agents, pressure dressings, pelvic binders, and more are tools to help stop hemorrhage (known as “hemostasis”).
• A Airway: Establish and maintain a reliable airway via chin lift, jaw thrust, recovery position, oral or nasal airways, and other devices/procedures.
• R Respiration: Seal open chest wounds, decompress tension pneumothoraxes, and ventilate to assure oxygen gets to the lungs. This may be through a bag-valve mask (BVM) and include the use of oxygen if available. In modern times, trained professionals may even place a tube in the windpipe of a casualty, a procedure known as “intubation.”
• C Circulation: In normal times, IV fluids are administered to treat shock. This can involve giving blood or other related products. Improvement in circulation may also be seen by laying a victim flat or in the shock position, and preventing heat loss. Keep the victim warm by covering them with a blanket, if possible, but monitor the site of injury carefully. If the wound is in an extremity, raise their legs 12 inches above the level of the heart. If the wound is in the torso, however, don’t elevate the legs.
• H Hypothermia: Remove wet clothing, cover with blankets, and establish a barrier between the cold ground and the victim. Some also use H to stand for “head”: treatment of traumatic brain injuries.
Of course, you may not have all the materials to fully implement MARCH off the grid. Once you’ve evaluated and treated the issues addressed in MARCH as best you can, it’s time to survey P.A.W.S.:
• P Pain management.
• A Antibiotics for early prevention of infection.
• W Wound reassessment and care.
• S Splinting fractures and providing stabilization to limb dressings.
Although some equipment involved in maximally effecting MARCH will be scarce, the wise medic will likely have some options to implement PAWS. Pain meds, antibiotics, wound dressings, and splints widely available in one form or another for addition to your medical storage.
Next time, I’ll go step-by-step through the process of stopping a possibly life-threatening hemorrhage, including some of the items helpful to succeed.
Joe Alton MD
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