First Aid - stopping a major bleed

[Apache]

Following on to a question by caorach I will give you my take on dealing with a serious wound, for example a deep knife cut involving major blood vessels.

The major issue we have is self treatment and the fact that you may well be stalking alone. These are the sort of wounds where you could bleed to death in minutes. Assuming you have a first aid kit you need a decent pressure dressing (ideally) and that kit must be able to be got at one handed (assuming the other is either injured or applying pressure elsewhere) and opened and the contents accessed one handed. Really vital and easily overlooked.

Step 1

Apply direct pressure to the wound. Your coat, tissues hat or even hand will do. Maintain the pressure whilst getting to first aid kit. Open dressing and apply to wound and bandage tightly. A proper pressure dressing is very useful as it will have a pad attached to an elasticated bandage and often a bar to allow extra pressure to be applied. The old 'ambulance dressings' of a pad on a gauze bandage are ok but harder to get tight especially if self treating.

Step 2

Bleeding is continuing. You need to add more material over the existing. Do NOT remove anything from the wound. Anything will do here, hand pressure, elastoplast, even your belt. You need to significantly slow the flow of blood. If it keeps coming through keep adding and getting tighter.

Step 3

You won't find this in any Red Cross or St John's manual but use a tourniquet if wound on an extremity (arm or leg only). Commercially available ones can be bought (CAT are common) and are easy to use, but you can improvise easily with a drag rope, shoelace etc. Best to tie it then use a bar to tighten. IF YOU USE A TOURNIQUET LEAVE IT TIGHT - your arm or leg remain viable for a couple of hours.

Haemostatic agents

They are a tool in your armoury but don't go with just them and nothing else. Initially they generated a lot of heat, but have supposedly been improved now. There can be issues with retention of the product as keeping a granular material in a wound requires a dressing on top. The impregnated gauze looks promising, but I have no experience. If they are used they form a major contaminant that would have to be flushed from the wound in theatre - you are badly contaminating the wound. There is a theoretical risk that if large vessels are compromised the product may be carried elsewhere in the body and act like a clot. Haemostatic agents are better than death, but no substitute for direct pressure. Wounds in the groin are harder to dress and may make you reach for the haemostatic sooner.

Video of pressure bandage application



CAT Tourniquet vid



Nothing beats training and carrying the correct equipment.

 

[Peter Eaton]

You won't find this in any Red Cross or St John's manual but use a tourniquet if wound on an extremity (arm or leg only). Commercially available ones can be bought (CAT are common) and are easy to use, but you can improvise easily with a drag rope, shoelace etc. Best to tie it then use a bar to tighten. IF YOU USE A TOURNIQUET LEAVE IT TIGHT - your arm or leg remain viable for a couple of hours.


If you ever had the above it has to be released every 10 minutes, used to be 15 but everything rounded to 10 mins now. The reason for this is if you starve the limb of oxygen for longer the cells will start to die. Also never cover the torniquet and draw a letter T on the forehead. Touniquets shouldnt really be used unless you have had the training,but as a last resort I would use one but only due to the fact we are taught to use them at work on trauma courses. Regarding knife cuts I have had some deep ones when making knives, I just dry the cut as best as possible and super glue it , stings but works.

 

[finnbear270]

Do NOT remove anything from the wound.

This is THE most common mistake that the average first aider makes........... packing in the wound should remain, as clotting will have usually begun to adhere to it, removing it restarts the flow. This also applies more specifically to head wounds where foreign objects are present.

 

[Apache]

If you ever had the above it has to be released every 10 minutes, used to be 15 but everything rounded to 10 mins now. The reason for this is if you starve the limb of oxygen for longer the cells will start to die. Also never cover the torniquet and draw a letter T on the forehead. Touniquets shouldnt really be used unless you have had the training,but as a last resort I would use one but only due to the fact we are taught to use them at work on trauma courses.

I don't want to get into an argument but the modern thinking is that once a tourniquet is applied it should never be released outside of an environment where advanced care is present (ie hospital). Limbs can survive at least 2 hours without danger of re-profusion injury. They are commonly used in human theatres and are absolutely not released every 10 minutes.

Should tourniquets be intermittently released? This action was once thought to prevent prolonged ischaemia. This is no longer recommended as a brisk haemorrhage can occur and results in death from ‘incremental exsanguination’

Another quote from the article

However, when using strict clinical criteria as the endpoint, that is, successful application to a bleeding wound where pressure dressings have not worked, in only 5% (3 cases out of 110 in a 5 year period) was the tourniquet actually used to control potentially life-threatening haemorrhage.

A tourniquet is a last resort, if you have the choice of bleeding to death or lose your arm and live I know what I'd chose. Use a pressure dressing first, but if it fails then don't be afraid of placing a tourniquet - unless a surgeon tells you otherwise don't release it!

http://www.ramcjournal.com/2007/mar07/tourniquet_debate.pdf

 

[Moray Outfitting]

Yawn Warning - its a biggie! -

Apache – thank you for posting. Having asked the question about detail in our thread on kits, I can see that the spin off elements would have cluttered things and made it harder to follow - so good call.

For those who haven’t picked up on the First Aid Kit thread, I’d better declare interest at the outset – posted thread to test water regards kits that we sell and product direction. But outside of specific threads dealing with kit we supply, not the intent to in any way push or market anything. Purely entering the debate as believe strongly in the subject.

Agree more or less fully with all you say aside from Torniquets and HaemostaticAgents. The former is just one of those topics in the field where views are polarised – so bound to be differences. The latter I have carried for a number of years, have used once and have several acquaintances who have used ‘in anger’. Further, looked closely at stocking - so waded through more published literature, CE regulations etc than is good for anyone’s sanity! In the end, we are not big enough or well financed enough to carry stock – so relatively neutral.

Your opening post and the response thus far brings in an interesting and crucial element to the equation – differentiating between enthusiasts and users for want of a better term. For the majority, little or no thought is given to their first aid preparation – they are potential users only. I would make it clear that there is nothing wrong with that and completely understand it. Key win is that they carry something useful and are comfortably able to cope with the basics. Statistically that will make a huge difference. If that is taken as a given there is only so much relevant detail they will retain.

Enthusiasts – and they come in all guises – will have the interest to seek out more detailed knowledge and like everything else will show all the classic kit junky symptoms ( not being derogatory and include me in the list! ).

In discussing these things its impossible to avoid erring into enthusiast territory – so I would urge that any reader just wanting to know ‘what to do’ shouldn’t get too hung up on detail like this. If you cannot decide from the information you access, then you should seriously consider proper training and follow the trainers advice.

Dangerously close to areas for other threads to keep things simple and clear; so just my thoughts on the specifics of your posting for now.

Direct pressure/ dressings –

if a deep wound/ crater scrunge up first dressing and pack it in, use second dressing over the top to hold firmly in. Unless seeking tourniquet effect check blood flow to extremity – press down on nail and check colour immediately reappears.

Three separate published A&E/ Trauma centre Doctors have come out to say they cannot recall any case where direct pressure was not sufficient to stem bleeding. I’m not so sure – but I have nowhere near their qualification or experience.

Haemostatic Agents –

There are three main products – QuikClot, Celox and Hemcon. All utilise either a volcanic powder base or chitin ( shell fish shell ) base.
They’ve been out a number of years and are US based – with FDA approval; so you can imagine the testing done on them.

Early Quikclot was exothermic – it could get very hot. Later versions are claimed to get warm – at worst. But the product is issued to the US military and there is field evidence of it stopping blood loss from a damaged carotid artery. I’ve used it and it worked well.

Celox – no heat issue and manufacturers assert specifically will pose no threat in terms of material entering blood stream and causing remote clots. However, ANY clots in the blood – which is what we are trying to achieve – run the risk of breaking free in the bloodstream and causing complications.

Hemcon – much less experience, limited to treated dressings.

Various journal publications supporting first aid support in hazardous areas – eg war zones etc for aid workers, press etc all categorically support the general product in terms of a useful tool of last resort.

Quikclot and Celox come in treated dressings – including sponges, powder and powder applicator forms. Same journals draw not distinction between the application method – saying horses for courses ( my paraphrase ).

Powder tends to be the most flexible – but there is a risk in high winds etc of difficulty getting it to where its needed. And you will definitely be having a bad day if it blows in your eyes! However, makes easier to treat multiple wounds.

Key issue for powder application is that blood flow can wash it out before it becomes effective. The Celox YOUTUBE video ( sorry not savvy enough to insert it ) shows testing on a pig. But you note they leave it sometime and allow blood pressure to fall before applying. I would say that all these products should be utilised in addition to rather than instead of direct pressure – ie bandage etc.

All products claim to be wound inert – no issue for medics to subsequently remove in hospital and are sterile as they come from intact package – though risk combining with whatever guck is around the wound – but heavy blood flow is partly intended to flush out the wound and in the field there is not a great deal more you can do – stopping flow is the priority.

My current preference is for Celox and the best powder price I can find so far is www.firstaidwarehouse.co.uk.

So do you put it on straight away – so as to leave any dressing undisturbed? I’d say use for major problems only – if you have a major blood vessel cut, put it on immediately with a pressure dressing straight on top and do not disturb – just add more dressings. Otherwise likely not needed.


Torniquets

Less spoken of than Voldemort for many years in the 1980’s. However, they work. Main issue with them is killing off/ damaging tissue at the site of application and down stream.

There were several incidents in the 1970’s where combat torniquets were applied and basically left on – resulting in lost limbs and associated damage. However they are effective and the wider view was taken that if they saved bleeding to death then risk of tissue damage was worthwhile.

Medical opinion is continuing to evolve/ change on correct use and benefit. Most normal doctors only see medical torniquets which are a rather different beast from combat torniquets. So you will see differing opinions and even completely different opinions. Not making it easy for the lay person to make a call.

Current thinking is heading toward wider straps – even of the current minimum of 1 inch. It is critical that the pressure system – point where you tighten it – does not pinch the skin. With wider strap theory is also the view that complete occlusion of the blood flow is undesirable and they should be set to slow flow/ just cease venous flow. Just try judging that on a dark wet night with a big gash in your arm!

All my experience and training – which is very likely no less nor no more valid than Apache’s - put the preference upon 10 minute application and then loosen for at least 10 minutes. This supposedly is to combat limb morbidity, but also to prevent enzyme and clot build up – similar to rules for crush injury. The intent with this theory is to support other blood cessation methods – pressure dressing etc, reducing flow rate to give clotting a chance.

I carry a tourniquet, but would not directly sell them nor recommend to anyone unless they reach their own decision from training or thorough – not Wikipedia etc – research.

I hope helps rather than muddies!

Of course the main outdoor killer is actually cold…..

 

[trouble]

make your mind up chaps , this is killing me

 

[Tikka-scot]

Tourniquet... If you have any doubts in how to use it dont use it .......Simple
Did loads of training in the Forces and my present job and each case is different if its a good idea to use or not
Carry a mobile instead and always know where you are so you give directions to the Paramedics

 

[Peter Eaton]

Tikka you are quite correct , dont use one unless trained. Like I said earlier we are trained to use them at work , I am actually a wholetime Firefighter and where I am based we are extremely fortunate to have some very advanced kit. Our Tourniquets were taken off the run years ago but if we opted to use one we would substitute something and make one. As regards to not releasing them and leaving them on for hours, the human body need Oxygens, starve any part of the body of oxygen and it will die, that goes for major organs down to cell structure, leave a tourniquet on for longer hours and the flesh will die. The chances of you ever having to use one are very remote even with quite severe bleeeds the ends of maojor arteries restrict when in shock, its the bodies way of coping,simple limb elevation works wonders and direct pressure is very good.
Just another point regarding injured limbs, if you have a crush injury we WILL NOT release the injured limb after 10 minutes, the reason being as with the tourniquet, the blood cells in that area die, if you then release the limb the dead blood cells will rush back into the body and unless drugs are given as this is done renal failure can occur. (as already quoted above)

 

[purdeydog]

Tourniquets if applied should only be used in a catastrophic bleed, where the person is going to bleed out ie die. If applied put just above the wound, and keep on. Generally speaking anything below the tourniquet will be chopped off in surgery.

Indirect pressure should be used before a tourniquet, ie literally squeeze the relevant artery with your hand or foot into the groin. Depending on the wound you can even grab the end of artery with your fingers. If you grab a mates arm, behind the bicep on the inside, press hard, you can notice the effects straight away of the blood flow not getting to where it needs to go.

For a catastrophic bleed
Direct, direct, indirect pressure and tourniquet.

 

[Moray Outfitting]

Trouble - hopefully not from an uncontrolled bleed?

Please look at these discussions as two part - user and enthusiast. Its near unavoidable to not get into deep debate on something that is so contraversial in field. If you are just looking for basic advice/ info then do not get bogged down in these types of threads - nor disheartened.

If you are not aware of these things already, you really arent any better or worse off from sitting tight.

I am looking at the practicalities of some easy reference referal sites and a basic thread to accompany the kit thread.

Unless the Taliban get really shirty in Preston in the next few days, 99.99% of you will be well served by step one of Apaches advice above.

 

[finnbear270]

I have a younger brother who started his training in operating theatres, Anasteasthia (hope that's spelled right!), over the years he moved into heli- med work, & then to teaching para-medics, I have to say he reckons Apache has it correct on the tourniquet topic.

 

[Peter Eaton]

Well just got into work this morning and found out I am on a trauma course. Havent had a good chance to chat to the instructor yet but from the brief chat I had it would appear elements of what we have all are correct with a little blurring around the edges. I will write an updated reply later which should clarify.

 

[User00003]

Rule number one: Tourniquets are not useful for head-wounds, unless you wish to lose conciousness very quickly

 

[Corkonian]

If you're getting the Quick-clot type gauze make sure you get the military version - it has a x-ray visible strip in it.
Not sure why the retail version doesn't have this?

 

[finnbear270]

Probably down to the usual,.... cost?

 

[Peter Eaton]

Had a quick chat to the guys who have just done the course and also a paramedic mate. Seems we are all right but in different situations.

Ok basically tourniquets were taken out of first aid kits and first aid instruction for a couple of reasons. Firstly the likely hood of you ever needing one is very low and with the advice Apache said earlier most bleeds, even major can be controlled in order the injured survive. They were also found to be doing more harm through misuse than good. Which brings me onto the other discussion we were having. Yes they can be left on for 2 hours but that would only be in a complete amputation...ie their is no living limb below they restriction. If there is a limb /flesh that is when training in the use of one is required, ie making sure blood is feb to the living flesh below the restriction, this would be used for example if you lost part of your foot and need to control the bleeding you could, but of course there would be no point starving the rest of the foot or area of the leg above of blood for if the flesh died then it would most likely be amputated ( knida defeat the object ). Once again this is why in that sort of situation training is needed for toxins will develop in the dead flesh if the flow of blood wasnt allowed every 10 mins or the one we all forgot..... blood clots which of course could flow to heart or brain etc.
Regarding the use of them in operating rooms thats a world away from someone with no training using one and with no support,back up be that a team of highly trained staff or the most advanced drugs etc should something go wrong. Hope that all makes sense of what we were discussing

 

[caorach]

Thanks to everyone for the info on this thread, I've been quiet just because I have no experience of knowledge that allows me to do anything more than ask questions.

Given that, and given my take that in terms of first aid while stalking alone then a major cut/bleed situation is about the only one where I could make a serious self help type contribution, what should I carry (normal stalking so small, light and robust) to allow intervention?

 

[Moray Outfitting]

caorach - if you can avoid a major injury for a bit longer - working on a simple/straight forward - and ( to relief of all ) SHORT basic advice - and where to get the stuff sensibly - whether from us or elsewhere.

If urge to juggle a katana is over-whelming then a quality Ambulance dressing - No3 compact size and a No2/No4 or else one of the Emergency Bandages would see you right for 99% of major cuts. If you have a deep wound crumple and stuff first dressing into wound and top/ apply pressure with second. Goof proof and no need to worry bout technicalities. Once on - leave it in place.

 

[Peter Eaton]

I would suppose it would depend on the inujry but I would think the most likely would be a cut from a knife. Even a severe bleed can be stem by just calimg down, sounds daft but very important.Then use a sterile pad on the wound, direct pressure and keep the inury above the heart if possible. It will normelly look far far worse then it is , esp a head wound. I would carry a pad or two large enough to cover your palm that has the bandage attached so you can secure it, also very good an ankle twist. I also have plasters and a roll of plaster to secure dressing. The best thing to remember is your only going to need the first aid kit if you or someone else has done a boo boo, cuts dont just happen but when we rush, use blunt knives, do a galloch to fast etc etc. One important bit of kit, a decent head lamp, great for seeing where your gralloching and so avoiding a cut to yourself at dusk.If you do you have head light....you can have the best first aid kit in the world but your stuffed if you can see to use it.

Safe shooting

Pete